The changing of the guard – CMS adoption of 2012 LSC


After much anticipation, on July 5, 2016 the Centers for Medicare and Medicaid Services (CMS) adopted the 2012 edition of the Life Safety Code (NFPA 101) and the 2012 edition of the Health Care Facilities Code (NFPA 99). While this long-awaited adoption was vital to ensuring that health care facilities meet current standards, there is still confusion among those that must adhere to these regulations.

One source of this confusion is the rule modifications that CMS made when they adopted the 2012 edition.  While most of these are not deviations from existing CMS requirements, they are also not included in the requirements of the 2012 LSC. Included in these are:

  1. All patient sleeping room must have an outside window or door. The sill of patient sleeping room windows for new construction must be less than or equal to 36” above the finished floor. However, there are exceptions for newborn nurseries, special care nurseries and atriums.
  2. Roller latches are not allowed on corridor doors or rooms that contain flammable or combustible materials. However, they are still permitted for auxiliary rooms such as toilets and bathing rooms
  3. All health care occupancies that provide care to one or more patients would be required to comply with the relevant requirements of the 2012 LSC. The 2012 LSC classifies a health care occupancy as a facility that houses fewer than four occupants as inpatients.
  4. Hospital outpatient surgical departments must comply with chapter 20 or 21 due to the requirement of one or more patient
  5. Projections into the corridor shall not exceed 4” when located between 27” and 80” aff

Additionally, CMS did not wholly adopt the 2012 edition of the Health Care Facilities Code.  Chapters 7 (Information Technology and Communications Systems), 8 (Plumbing), 12 (Emergency Management) and 13 (Security) would not apply to hospitals or ambulatory surgical centers.  That is, of course, provided that the local or state jurisdiction have not adopted them independently. 

To add to the lack of clarity, the release of the 2018 edition of the Life Safety Code is pending. While CMS will not likely adopt a newer version of the life safety code soon, there is a possibility that state or local jurisdictions will. This could result in the potential of, once again, comparing various editions and following what is perceived to be the most stringent requirements.

With all the varying codes that are applicable to the health care environment, it is imperative to thoroughly understand which regulations are imposed upon each facility and which edition of each code will be enforced. Knowing and analyzing this information early in your project could prevent future issues from ever arising.