Document Category:
State: Alabama
Subject Matter: CMS Proposes Adoption of Updated Life Safety Code
Document Title:


morning, the Centers for Medicare & Medicaid Services (CMS) issued a
proposed rule regarding adopting the 2012 edition of the Life Safety Code
(LSC). CMS states the updated code contains new provisions that are vital to
the health and safety of all patients and staff. To see the full rule, click


CMS applies the fire safety standards set out in the 2000 edition of the LSC.
CMS states the 2012 edition is better aligned with international building codes
and will make compliance across codes simpler for Medicare and
Medicaid-participating facilities.

Health Care Facilities Code (HCFC) contains more detailed provisions specific
to health care and ambulatory care facilities. It is a cross-referenced
document in the LSC. The HCFC provides minimum requirements for the
installation, inspection, testing, maintenance, performance and safe practices
for health care facility materials, equipment and appliances.

new edition of the LSC applies to hospitals, long-term care facilities (LTC),
critical access hospitals (CAHs), ambulatory surgical centers (ASC),
intermediate care facilities for individuals with intellectual disabilities
(ICF-IIDs), hospice inpatient care facilities, programs for all- inclusive care
for the elderly (PACE) and religious non-medical health care institutions

Proposed Rule

changes for hospitals, LTC facilities, CAHs, ASCs, hospice inpatient facilities
and ICF-IIDs include:

  • Increased size of
    sleeping suites
    . Newly-constructed
    sleeping suites can be up to 7500 square feet. 
  • Use of sprinklers in high-rise
    . All high-rise buildings over
    75 feet tall must have automatic sprinklers installed throughout the
    building. Existing facilities have 12 years to install automatic
  • Controlled access doors. Facilities may lock interior doors where patients’
    special needs require specialized protective measures. The ability to lock
    interior doors is subject to five requirements.
  • Sprinkler system
    . If a sprinkler system
    is out of service for more than four hours, the building must be
    evacuated, or a person or persons must monitor the facility for a fire and
    notify appropriate individuals in an emergency. 

changes for ASCs: 

  • Interior nonbearing
    . Interior nonbearing walls
    must have a minimum 2 hour fire resistance rating if constructed of
    fire-retardant treated wood that is enclosed within noncombustible or
    limited combustible materials. Walls with fire-retardant treated wood
    cannot be used as shaft enclosures. 
  • Doors. All doors to hazardous areas must be self-closing or
    close automatically

changes for ICF-IIDs:

  • Sprinklers. New facilities must install sprinkler systems in all
    habitable areas, closets, roofed porches, balconies and decks. 
  • Attics. New and existing facilities must protect attics with
    an approved automatic sprinkler system if the attic is used for living
    purposes, storage or housing of fuel-fired equipment. If the attic is used
    for other purposes, or not used, then it must meet one of four
    requirements listed in the LSC. 
  • Means of escape. Facilities must ensure designated means of escape are
    continuously free of all obstructions or impediments.
  • Smoke alarms. Newly-constructed facilities must install approved
    smoke alarms in and around sleeping areas and on all levels within a
    residential unit. 
  • Access-controlled egress
    . New and existing facilities
    are permitted to have access-controlled egress doors that meet the
    requirements in the LSC. Doors may be equipped with electronic locks to
    prevent egress. 
  • Hazardous areas. Smoke partitions must separate hazardous areas from
    other parts of the building. This provision applies to existing facilities
    with impractical evacuation capabilities.
  • Emergency forces
    . Existing facilities
    with a new or replaced fire alarm system must notify emergency forces in
    accordance with the LSC. 


Essentially, this
proposed rule will mean major changes to the fire safety requirements a health
care facility must follow, if adopted. The comment period for the proposed rule
closes on June 16, 2014 . If you are interested in this area and would like
more information or the opportunity to comment on the proposed rule, Baker
Donelson can assist you. Sheila Burke, chair of the Government
Relations and Public Policy group, or any of our attorneys and policy advisors
in our Health Law and Long
Term Care
groups are ready to help identify issues and answer

Document Author: Shelia Burke
Firm/Company: Baker Donelson
Document Date: February 25, 2020
Search Tags: CMS
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