Life Safety (LS) (Hospital and Hospital Clinics / Hospitals)
NFPA 101 2000 - References For Life Safety Code/Environment of Care Compliance
Publish | January 01, 0001
What references are used by CMS and TJC for Life Safety Code and Environment of Care compliance?
At this time, Centers for Medicare/Medicaid Services (CMS) requires compliance with the 2000 edition of NFPA 101 Life Safety Code for fire safety construction and operations criteria. The Joint Commission standards are aligned with CMS requirements, therefore NFPA 101 (2000) is used until CMS adopts a later edition. Mandatory References found in Chapter 2 of NFPA 101 are used. NFPA 99 (1999 edition) is used in total. Some TJC standards specifically refer to later editions of various codes, therefore are to be used. Variations in adopted code editions required to be followed by other of the organization's controlling authorities (like their state health care licensing entity) can be handled by either reconciling the requirements of the code editions and complying with the most strict requirements, or by using the TJC traditional equivalency process (instructions are in your organization's electronic Statement of Condition, in the PFI section). Traditional Equivalencies are reviewed by TJC on an issue-by-issue basis, and if recommended for approval, they are forwarded to CMS for final approval. If approved, the deficiency caused by code edition variation is not subject to a finding during the survey process. TJC also recognizes Categorical Waivers issued by CMS through Survey and Certification (S&C) letters, where criteria from later editions of NFPA 101 and its mandatory references are allowed under specified circumstances. 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 no previous arrangement, the 2000 edition of NFPA 101 is used.
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