Fire Safety Requirements

The final rule was recently adopted for the health care industry as it relates to theCenters for Medicare and Medicaid.

Those of you involved in the U.S. health care industry are probably aware that on May 3, 2016, the Centers for Medicare and Medicaid (CMS) issued a final rule entitled “Medicare and Medicaid Programs; Fire Safety Requirements for Certain Health Care Facilities.” The final rule, which became effective on July 5, adopts the 2012 edition of NFPA 101 Life Safety Code. It also adopts the 2012 edition of NFPA 99 Health Care Facilities Code, with some exceptions. Until this change, CMS was on the 2000 edition of NFPA 101 and the 1999 edition of NFPA 99.”    

From the final rule:

“(These) regulations … apply to hospitals, long-term care facilities (LTC), critical access hospitals (CAHs), ambulatory surgical centers (ASC), intermediate care facilities for individuals with intellectual disabilities (ICF-IIDs), hospice inpatient care facilities, programs for all-inclusive care for the elderly (PACE) and religious non-medical health care institutions (RNHCIs). … The statutory basis is the Secretary of the Department of Health and Human Services … authority to stipulate health and safety regulations for each type of Medicare and (if applicable) Medicaid-participating facility, as well as the … general rule-making authority, set out at sections 1102 and 1871 of the Social Security Act (the Act).” 

This month we will look at NFPA 99. The 2012 edition of NFPA 99 contains the following new chapters:

  • Chapter 4: Fundamentals 
  • Chapter 7: Information Technology and Communications Systems for Health Care Facilities
  • Chapter 8: Plumbing 
  • Chapter 9: Heating, Ventilation and Air Conditioning (HVAC)
  • Chapter 13: Security Management
  • Chapter 15: Features of Fire Protection

As noted, CMS adopted NFPA 99 2012 edition with exceptions. Of the new chapters in NFPA 99, CMS indicates that Chapters 7, 8 and 13 do not apply to facilities covered by the rule. Also, CMS indicates that Chapter 12: Emergency Management also does not apply.

A significant change with the 2012 NFPA 99 is the requirement to follow a risk-based approach to achieve compliance. The new Chapter 4 requires building systems to meet requirements based on the applicable risk category. There are four risk categories:

  • Category 1: Facility systems in which failure of such equipment or system is likely to cause major injury or death of patients or caregivers
  • Category 2: Facility systems in which failure of such equipment is likely to cause minor injury to patients or caregivers
  • Category 3: Facility systems in which failure of such equipment is not likely to cause injury to patients or caregivers, but can cause patient discomfort
  • Category 4: Facility systems in which failure of such equipment would have no impact on patient care

These risk categories are to be applied to Chapters 5 through 11. Chapters 12, 13, 14 and 15 do not use the risk categories. Neither NFPA 99 nor CMS specifies the risk assessment methods to be used. The final CMS rule states:

“CMS does not require the submission of risk assessment methods to CMS. However, CMS, will confirm that facilities are using risk assessment  methodologies when conducting onsite surveys. We did not propose to require the use of any particular risk assessment procedure. However, if future situations indicate the need to define a particular risk assessment procedure, we would pursue that through a separate notice and comment rulemaking.” 
The annex in NFPA 99, Section A.4.2 provides some guidance for risk assessment procedures and provides the all-important recommendation that the “procedure should be documented and records retained.” 

One key change is the change of the term “wet location” to “wet procedure locations,” and a clarification of what areas would be considered wet procedure locations. 

Beyond that, I am not going to get into the nuts and bolts of Chapter 5 through 14, as that would take me a bit out of my zone of expertise. I would like to address some of the items in the new Chapter 15.

Chapter 15: Features of Fire Protection, in large part, extracts material from NFPA 101 and some other NFPA codes and standards. There are other provisions in this chapter not contained in NFPA 101 that one should be aware of. (CMS will certainly be looking at compliance with these items). 

Section contains special provisions for fire alarm occupant notification, where the health care facility uses a defend-in-place fire safety strategy. In general, these provisions would apply where there are two or more smoke compartments on a floor. 

There is a requirement for fire alarm zones to coincide with the boundaries of smoke compartments: “A provisions that private mode signaling shall be permitted to be used in health care and ambulatory care occupancies; and a requirement for the notification signal to readily identify the smoke zone or the floor area, floor and building in need of staff response.” 

Also, in this section, visual alarm notification may be used in lieu of audible alarm notification in critical care areas. Also, visual alarms may be omitted from surgical operating rooms, patient sleeping rooms or psychiatric care areas where their operation would interfere with patient treatment. Visual alarms may also be omitted from exam rooms, special procedure rooms, dressing rooms and nonpublic toilet rooms where staff is required to respond to those areas in accordance with the facility fire plan.

Paragraph calls for sprinkler system zones to coincide with smoke compartment boundaries, or be in accordance with the facility fire plan. To try to avoid confusion on this issue, refer to the associated annex note which states: “A. It is not the intent of this paragraph to require sprinkler system zones to coincide with smoke compartment boundaries, provided that the facility fire plan addresses the differences between sprinkler systems zones and building smoke compartments.”

Chapter 15 also contains some special provisions applicable to compact storage and compact mobile storage.

Next time, we will address NFPA 101 and the final rule of CMS. 

It really is about time that, after 16 years, CMS has been able to update to a more current set of documents. Let us hope they can continue to be more current in the future. I would not bet on it (as I did not bet on the UH Warriors beating the 41 point spread in their game at “The Big House” last month, final Score 63-3). The 2018 edition of NFPA 101 will be out towards the end of 2017, and at that time CMS will already be lagging the current code by six years.

Samuel S. Dannaway, P.E., FSFPE, is a licensed fire protection engineer and mechanical engineer with bachelor’s and master’s degrees from the University of Maryland Department of Fire Protection Engineering. He is a past president and fellow of the Society of Fire Protection Engineers. He is vice president of Fire Protection Technology at Coffman Engineers Inc., a multidiscipline engineering firm with over 360 employees across eight offices. Sam can be reached at

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