CMS Categorical Waiver - TJC Traditional Equivalency
When and how do CMS categorical waivers apply to TJC standards?
Any examples are for illustrative purposes only.
Many of the Categorical Waivers (CW) that CMS issued in the past related to the Life Safety Code became no longer needed when they adopted NFPA 101-2012 and NFPA 99-2012, effective July 5, 2016.
The Joint Commission still recognizes S&C 13-25-LSC & ASC related to Relative Humidity in Anesthetizing Locations.
The organization must strictly comply with the provisions of the CMS waiver document. The organization is to document invocation of the CW in their EC Committee meeting minutes or in the applicable management plan(s). When documenting invocation of a CW, the CW must be identified (S&C letter/subject), the locations of applicability, and there is to be an attestation that the organization has reviewed and is in compliance with the referenced content of the of the applicable NFPA code.
The S&C letter requires the organization to notify the survey team of the CW at the beginning of the survey (the entrance conference). The survey process will field-validate that the requirements of the CW have been met.
Additional Resources
For the text of S&C 13-25-LSC & ASC click here
For a full list of CMS S&C letters click here
Many of the Categorical Waivers (CW) that CMS issued in the past related to the Life Safety Code became no longer needed when they adopted NFPA 101-2012 and NFPA 99-2012, effective July 5, 2016.
The Joint Commission still recognizes S&C 13-25-LSC & ASC related to Relative Humidity in Anesthetizing Locations.
The organization must strictly comply with the provisions of the CMS waiver document. The organization is to document invocation of the CW in their EC Committee meeting minutes or in the applicable management plan(s). When documenting invocation of a CW, the CW must be identified (S&C letter/subject), the locations of applicability, and there is to be an attestation that the organization has reviewed and is in compliance with the referenced content of the of the applicable NFPA code.
The S&C letter requires the organization to notify the survey team of the CW at the beginning of the survey (the entrance conference). The survey process will field-validate that the requirements of the CW have been met.
Additional Resources
For the text of S&C 13-25-LSC & ASC click here
For a full list of CMS S&C letters click here
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
Go Above and Beyond with Certification
Certifications from The Joint Commission represent the most stringent, comprehensive and evidence-based proof of the success of your program available.
Additional Resources
Train your staff with a tool to quickly and efficiently assess standards compliance with our Hospital Compliance Assessment Workbook.
Hospital Webinars
Keep learning with our Hospital Breakfast Briefings Webinar Series. Get a deep dive into our standards, chapter-by-chapter, individually or as a team.
Joint Commission Virtual Assistant