September 2013 CMS memo on exemptions

On August 30, 2013, CMS released a Survey and Certification Memo detailing a new set of categorial waivers for current Life Safety Code requirements. A categorical waiver is a way for an ASC to acknowledge that it does not meet a particular code requirement but is still able to provide a safe environment. A set of exemptions released last year pertain only to inpatient settings. This recently releases memo includes some waivers that may apply to ASCs.

Using a waiver

An ASC electing to use a waiver must document that it is being used prior to the surveyor noting the deficiency. Once the surveyor (AAAHC, state agency or other) notes the deficiency, the facility should be able to produce appropriate documentation that it had recognized the deficiency prior to the survey and is electing to use the specific waiver. After finding a code deficiency, a surveyor may not suggest that the ASC elect to apply the appropriate categorical waiver.

Description of the waivers

There are five waivers in the CMS survey and certification memo described briefly below that may apply to ASCs. The numbers correspond to the waiver number in the memo.

1. Medical Gas Master Alarms

This categorical waiver may apply to ASCs that have a level 1 piped medical gas system; for example, ASCs that receive piped gas from a hospital on the same campus.

2.Openings in Exit Enclosures

This categorical waiver may apply to ASCs that are in older building shells in which the exiting access meets the described conditions.

3. Emergency Generators and Standby Power Systems

This categorical waiver may apply to ASCs that use diesel powered generators.

6. Extinguishing Requirements

This categorical waiver may apply to ASCs that have a supervised automatic sprinkler system.

7. Clean Waste & Patient Record Recycling Containers

This categorical waiver may apply to ASCs meeting the described criteria and using large trash collection containers.