CMS Adopts 2012 Life Safety Code Effective July 05, 2016

  • Tuesday, May 03, 2016 7:38 PM
    Message # 4001159
    Al Moon (Administrator)

    Advocacy Alert: CMS Adopts 2012 Life Safety Code

    The Centers for Medicare & Medicaid Services (CMS) has adopted the 2012 edition of NFPA 101: Life Safety Code®. The final rule adopting the 2012 edition will be published in the Federal Register on May 4 but is currently available on the Federal Register’s public inspection site. The document includes about 100 pages of background material, but ASHE has extracted the final rule from the larger document to more easily show the relevant Conditions of Participation for hospitals, ambulatory surgical centers, and other health care facilities; that information is on the ASHE website.


    The change is effective July 5 and comes after years of CMS considering the change to the more updated standard. In its rule, CMS adopts the 2012 edition of the Life Safety Code and the 2012 edition of NFPA: Health Care Facilities Code—but makes several changes to the codes. For example, the chapters of NFPA 99 on the following topics are not included in the adoption: information technology (Chapter 7), plumbing (Chapter 8), emergency management (Chapter 12), and security (Chapter 13). CMS had previously proposed its own emergency preparedness rules separate from NFPA 99 requirements.

    The rule will also make several changes for hospitals, including:

    • Corridor doors and doors to rooms containing flammable or combustible materials must be provided with positive latching hardware. Roller latches are prohibited on such doors under the CMS rule.
    • In consideration of a recommendation by the state survey agency or accrediting organization, CMS may waive specific provisions of the Life Safety Code that would result in unreasonable hardships but only if the waiver will not adversely affect the health and safety of the patients.
    • Hospitals may install alcohol-based hand rub dispensers in its facility if the dispensers are installed in a manner that adequately protects against inappropriate access. This requirement from CMS differs from the Life Safety Code, which doesn’t have any requirements against inappropriate access.
    • When a sprinkler system is shut down for more than 10 hours, hospitals must either evacuate the building or portion of the building affected by the system outage until the system is back in service or establish a fire watch until the system is back in service.
    • Buildings must have an outside window or outside door in every sleeping room, and for any building constructed after 60 days past the publication date of the rule, the sill height must not exceed 36 inches above the floor. Windows in atrium walls are considered outside windows for the purposes of this requirement. The sill height requirement does not apply to newborn nurseries and rooms intended for occupancy for less than 24 hours. The sill height in special nursing care areas of new occupancies must not exceed 60 inches.

    ASHE had encouraged CMS to adopt the 2012 edition, and applauds CMS for taking this step toward more current codes. The 2012 edition of the Life Safety Code includes several advantages compared to the 2000 edition, which is currently required by CMS. The 2012 edition reduces conflicts with other codes, including the International Building Code, meaning hospitals will use fewer resources trying to comply with conflicting codes. The 2012 edition also reflects the needs of modern health care facilities, such as larger critical care patient rooms.

    ASHE has several resources available—and new resources coming soon—for members responsible for addressing these regulatory changes in their facilities. Resources include:

    • An ASHE monograph exploring the specific differences between the 2000 and 2012 editions of the Life Safety Code. ASHE members can download the monograph for free.
    • A webinar series explaining code changes in the 2012 edition of the Life Safety Code. All webinars in the series are free for ASHE members, and recordings of previous webinars in the series are available for free to ASHE members.
    • An e-learning course on the applications of NFPA 99 in health care facilities. The course covers the 2012 edition of NFPA 99, including the important shift to a risk-based approach. Learn more about the course online.

    ASHE will continue to keep members informed about this change through advocacy alerts and the ASHE Insider weekly electronic newsletter.



    Last modified: Wednesday, July 20, 2016 12:39 PM | Al Moon (Administrator)
  • Tuesday, May 03, 2016 7:46 PM
    Reply # 4001161 on 4001159
    Al Moon (Administrator)

    CMS has adopted the 2012 Life Safety Code, effective July 5, 2016. You can download a PDF of the Final Rule here:


  • Wednesday, May 04, 2016 6:22 PM
    Reply # 4003174 on 4001159

    I do not know enough about this subject, so I want to ask for help...

    According to document, all existing hospitals and ambulatory surgery centers (if receiving Medicare/Medicaid dollars) must comply with Life Safety Code NFPA 101, 2012 edition.  They also have to comply with NFPA 99, 2012 edition (Chapter 5, specifically).

    ......unless they submit a waiver specifying hardship, and the waiver is approved.

    Is this correct?

    Does anyone have access to an previously approved waiver to know how they are written?  It would be interesting to see how specific the waiver has to be.  


16339 Kranker Drive, Stilwell, KS 66085