What you need to know

July 28, 2017

CMS has posted a survey and certification memo extending the deadline for compliance regarding annual testing requirements for doors.

CMS has released S&C 17-38-LSC which adds an additional six months for facilities to comply with annual testing requirements for all rated fire door assemblies (2010 NFPA 80). It clarifies an expectation that non-rated doors, which are not part of the NFPA 80 codes, are also required to be inspected annually. To comply, facilities should

  1. Use requirements from NFPA 80 2010 edition as a guide to determine what aspects of the door assemblies are inspected and tested.
  2. Document the inspection, testing, and any maintenance performed for the survey team.

June 20, 2016

CMS has posted a survey and certification memo to address concerns regarding the implementation of a revised survey process to include review of the 2012 NFPA 101 Life Safety Code (LSC) and the 2012 NFPA 99 Health Care Facilities Code (HCFC). The memo includes the following important information:

  • CMS has adopted by regulation the 2012 NFPA 101 LSC and the 2012 HCFC. The regulation effective date is July 5, 2016.
  • Buildings constructed before July 5, 2016 can meet Existing Occupancy requirements. In addition, buildings that receive design approval or building permits for construction before July 5, 2016 can meet Existing Occupancy requirements. All other building construction must meet New Occupancy requirements.
  • CMS will begin surveying for compliance with the 2012 LSC and HCFC on November 1, 2016. 

June 8, 2016

Accrediting organizations received notice today from CMS regarding implementation of the final rule regarding the 2012 Life Safety Code. This notice outlines the timeframe by which CMS expects that state surveyors will be able to survey against the updated regulations. AAAHC must submit its planned changes to align with CfC 416.44 (see below, entry for May 4) for approval no later than August 8, 2016. AAAHC cannot implement any changes to its process until after approval is received.

May 23, 2016

We’re receiving lots of questions about the 2012 NFPA 101 and the 2012 NFPA 99. To clarify: These are different documents–“code sets”–that address different but related issues.

NFPA 101 The Life Safety Code consists of occupancy-based requirements that assure safety under normal and emergency conditions.

NFPA 99 Health Care Facilities addresses physical plant features unique to facilities that provide patient care.

Last week, our physical environment consultant, Bill Lindeman, AIA, NCARB, spoke about physical environment requirements during the 2016 ASCA Annual Meeting.  Bill received numerous questions about limits on the size of trash and soiled linen containers. More

May 6, 2016

NEW Standard: 416.44(b)(6) Doors to hazardous areas, per 2012 Ed. NFPA 101

Beginning July 5, 2017, an ASC must be in compliance with Chapter, Doors to hazardous areas.

This change draws attention to a requirement for closers on doors to hazardous areas in both new and existing ASCs. More

May 4, 2016

It’s official! CMS has revised the Standards under Condition for Coverage (CfC) 416.44 Physical Environment to include an updated reference to the 2012 edition of NFPA 101 The Life Safety Code®. The revisions are significant and will affect how existing and new ASCs are reviewed for physical plant requirements.

We are committed to updating existing resources and providing additional tools to support our accredited ASCs. We will use this page and email communications to direct you to information as it becomes available. Among the many pieces that will be created or updated, are the Physical Environment Checklist (PEC) and Chapter 8 Facilities and Environment of the Accreditation Handbook for Medicare Deemed Status.

Refer frequently to this page and help us stay in touch by ensuring that we have accurate contact information on file. (Send changes to notify@aahc.org.)