Life Safety Code - CMS Minimum Requirement

What is the minimum requirement to be compliant with the Centers for Medicare/Medicaid Services?

Any examples are for illustrative purposes only. 

Beginning July 5, 2016 the Center for Medicare and Medicaid Services (CMS) adopted NFPA 101 (2012 edition) Life Safety Code and NFPA 99 (2012 edition) Health Care Facilities Code.  Facilities that were designed and approved for construction by the authority having jurisdiction (AHJ) before this date are considered “existing” occupancies by the Life Safety Code.  Facilities that were approved after that date are considered “new” occupancies.  These codes include other NFPA documents by reference which are enforced as long as there is a code path from NFPA 101 or NFPA 99.

The Joint Commission standards in the Comprehensive Accreditation Manuals are based on CMS’s Conditions of Participation and have been approved by CMS.  The Conditions of Participation that relate to the Life Safety Code standards are §482.41 for Hospitals, §482.41 and §485.623 for Critical Access Hospitals, §416.44 for Ambulatory facilities, §483.90 for Nursing Care Centers, and §418.110 for Home Care.  Even though Behavioral Health facilities have life safety standards in The Joint Commission Comprehensive Accreditation Manual, there are no CoPs for these standards.

You may view the Joint Commission standards that apply to your organization, and view whether each standard is related to a CMS CoP on your Extranet site under the Resources and Tools tab, E-dition.  The standards may be filtered by the Life Safety Chapter on the left side. By clicking on the CoP number that is listed next to the Element of Performance (EP), you will see the language of the CoP. 
Last updated on May 15, 2020
Manual: Behavioral Health
Chapter: Life Safety LS

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