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NFPA 101 2012 - References For Life Safety Code/Environment of Care Compliance

What references are used by CMS and TJC for Life Safety Code and Environment of Care compliance?

Any examples are for illustrative purposes only. 

For deemed organizations, the Centers for Medicare & Medicaid Services (CMS) requires compliance with NFPA 101-2012 Life Safety Code and NFPA 99-2012 Health Care Facilities Code, including the mandatory references in each edition, for fire safety, construction and operations requirements. 

The Joint Commission's Elements of Performance in the Accreditation Manuals reference these same editions of the NFPA documents.  

Variations in adopted code editions are required to be followed by the organization's controlling authorities (e.g. the state health care licensing entity) can be handled by reconciling the requirements of the code editions and complying with the most strict requirements. 

For other federal organizations like the Veterans Administration, the Department of Defense, the Indian Health Service, etc., those entities decide the NFPA code editions that they will use and TJC will survey to those standards. 

For non-CMS deemed organizations, like a state institution, they must arrange with TJC for the editions of NFPA to be used; if there is no previous arrangement, the 2012 edition of NFPA 101 and NFPA 99 is used.
Manual: Hospital and Hospital Clinics
Chapter: Life Safety LS
First published date: April 11, 2016 This Standards FAQ was first published on this date.
This page was last updated on October 26, 2021

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