Vol. 79 Wednesday, 

No. 73 April 16, 2014 

Part III 

Department of Health and Human Services 

Centers for Medicare & Medicaid Services 

42 CFR Parts 403, 416, 418, et al. 

Medicare and Medicaid Programs; Fire Safety Requirements for Certain 

Health Care Facilities; Proposed Rule 


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21552 Federal Register / Vol. 79, No. 73 / Wednesday, April 16, 2014 / Proposed Rules 

DEPARTMENT OF HEALTH AND 

HUMAN SERVICES 

Centers for Medicare & Medicaid 

Services 

42 CFR Parts 403, 416, 418, 460, 482, 

483, and 485 

[CMS–3277–P] 

RIN 0938–AR72 

Medicare and Medicaid Programs; Fire 

Safety Requirements for Certain Health 

Care Facilities 

AGENCY: Centers for Medicare & 

Medicaid Services (CMS), HHS. 

ACTION: Proposed rule. 

SUMMARY: This proposed rule would 

amend the fire safety standards for 

Medicare and Medicaid participating 

hospitals, critical access hospitals 

(CAHs), long-term care facilities, 

intermediate care facilities for 

individuals with intellectual disabilities 

(ICF–IID), ambulatory surgery centers 

(ASCs), hospices which provide 

inpatient services, religious nonmedical health care institutions 

(RNHCIs), and programs of all-inclusive 

care for the elderly (PACE) facilities. 

Further, this proposed rule would adopt 

the 2012 edition of the Life Safety Code 

(LSC) and eliminate references in our 

regulations to all earlier editions. It 

would also adopt the 2012 edition of the 

Health Care Facilities Code, with some 

exceptions. We are providing the LSC 

citation, a description of the 2012 

requirement, and an explanation of its 

benefits for health care facilities, 

patients, staff, and visitors over the 2000 

version in each occupancy section. 

DATES: To be assured consideration, 

comments must be received at one of 

the addresses provided below, no later 

than 5 p.m. on June 16, 2014. 

ADDRESSES: In commenting, please refer 

to file code CMS–3277–P. Because of 

staff and resource limitations, we cannot 

accept comments by facsimile (FAX) 

transmission. 

You may submit comments in one of 

four ways (please choose only one of the 

ways listed): 

1. Electronically. You may submit 

electronic comments on this regulation 

to http://www.regulations.gov. Follow 

the ‘‘Submit a comment’’ instructions. 

2. By regular mail. You may mail 

written comments to the following 

address only: Centers for Medicare & 

Medicaid Services, Department of 

Health and Human Services, Attention: 

CMS–3277–P, P.O. Box 8010, Baltimore, 

MD 21244–8010. 

Please allow sufficient time for mailed 

comments to be received before the 

close of the comment period. 

3. By express or overnight mail. You 

may send written comments to the 

following address only: Centers for 

Medicare & Medicaid Services, 

Department of Health and Human 

Services, Attention: CMS–3277–P, Mail 

Stop C4–26–05, 7500 Security 

Boulevard, Baltimore, MD 21244–1850. 

4. By hand or courier. Alternatively, 

you may deliver (by hand or courier) 

your written comments only to the 

following addresses prior to the close of 

the comment period: 

a. For delivery in Washington, DC— 

Centers for Medicare & Medicaid 

Services, Department of Health and 

Human Services, Room 445–G, Hubert 

H. Humphrey Building, 200 

Independence Avenue SW., 

Washington, DC 20201. 

(Because access to the interior of the 

Hubert H. Humphrey Building is not 

readily available to persons without 

Federal government identification, 

commenters are encouraged to leave 

their comments in the CMS drop slots 

located in the main lobby of the 

building. A stamp-in clock is available 

for persons wishing to retain a proof of 

filing by stamping in and retaining an 

extra copy of the comments being filed.) 

b. For delivery in Baltimore, MD— 

Centers for Medicare & Medicaid 

Services, Department of Health and 

Human Services, 7500 Security 

Boulevard, Baltimore, MD 21244–1850. 

If you intend to deliver your 

comments to the Baltimore address, call 

telephone number (410) 786–9994 in 

advance to schedule your arrival with 

one of our staff members. 

Comments erroneously mailed to the 

addresses indicated as appropriate for 

hand or courier delivery may be delayed 

and received after the comment period. 

For information on viewing public 

comments, see the beginning of the 

SUPPLEMENTARY INFORMATION section. 

FOR FURTHER INFORMATION CONTACT: 

Kristin Shifflett, (410) 786–4133. 

Danielle Shearer, (410) 786–6617. 

SUPPLEMENTARY INFORMATION: Inspection 

of Public Comments: All comments 

received before the close of the 

comment period are available for 

viewing by the public, including any 

personally identifiable or confidential 

business information that is included in 

a comment. We post all comments 

received before the close of the 

comment period on the following Web 

site as soon as possible after they have 

been received: http://

www.regulations.gov. Follow the search 

instructions on that Web site to view 

public comments. 

Comments received timely will also 

be available for public inspection as 

they are received, generally beginning 

approximately 3 weeks after publication 

of a document, at the headquarters of 

the Centers for Medicare & Medicaid 

Services, 7500 Security Boulevard, 

Baltimore, Maryland 21244, Monday 

through Friday of each week from 8:30 

a.m. to 4 p.m. To schedule an 

appointment to view public comments, 

phone 1–800–743–3951. 

I. Background 

A. Overview of the Life Safety Code and 

the Health Care Facilities Code 

The Life Safety Code (LSC) is a 

compilation of fire safety requirements 

for new and existing buildings, and is 

updated and published every 3 years by 

the National Fire Protection Association 

(NFPA), a private, nonprofit 

organization dedicated to reducing loss 

of life due to fire. The LSC regulations 

adopted by Centers for Medicare & 

Medicaid Services (CMS) 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 Medicare and Medicaid 

regulations have historically 

incorporated by reference these 

requirements, along with Secretarial 

waiver authority. The statutory basis for 

incorporating NFPA’s LSC for our 

providers and suppliers is the 

Secretary’s authority to stipulate health 

and safety regulations for each type of 

Medicare and (if applicable) Medicaidparticipating facilities, as well as the 

Secretary’s general rulemaking authority 

set out at sections 1102 and 1871 of the 

Social Security Act (the Act). 

In our regulations, issued pursuant to 

the Act, we have stated that we believe 

CMS has the authority to grant waivers 

of some provisions of the LSC when 

necessary; for instance, to hospitals 

under section 1861(e)(9) of the Act, and 

to LTC facilities at sections 

1819(d)(2)(B) and 1919(d)(2)(B) of the 

Act. Currently, the Secretary may waive 

specific provisions of the LSC for any 

type of facility, if application of the rule 

would result in unreasonable hardship 

for the facility, and if the health and 

safety of its patients would not be 

compromised. 

We do not consider it always 

necessary for a facility to be cited for a 

deficiency before it can apply for or 

receive a waiver. This is particularly the 


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case when we have evaluated specific 

provisions of the LSC, determined that 

a waiver would arguably apply to all 

similarly-situated facilities with respect 

to the LSC requirement in question, and 

issued a public communication 

describing the specifics of such a 

categorical waiver, including any 

particular requirements that must be 

met in order for the waiver to apply to 

a facility. Waiver approval in these 

instances would be subject to a review 

of documentation maintained by the 

facility, verification of the applicability 

of the waiver, and confirmation that the 

terms and requirements of the waiver 

have been implemented by the facility. 

In most cases such verification occurs 

when an onsite survey of the facility is 

conducted. We plan to continue this 

approach, but would like to clarify that 

in those cases where we have issued a 

prior public communication providing 

for a categorical waiver, an advance 

recommendation from a state survey 

agency or accrediting organization (as 

applicable), is not required in order for 

a waiver to be granted. We have issued 

categorical waivers of LSC requirements 

when newer editions of the LSC 

provided equally effective means of 

ensuring life safety compared to 

requirements of earlier LSC editions. 

When CMS has evaluated the alternative 

(such as examining the new fire safety 

research and technology), and 

concluded that the specific alternative 

would improve or maintain the safety of 

the residents or patients of the facility, 

CMS may defer to newer editions of the 

LSC. CMS requires that providers 

comply with applicable provisions of 

the version of the LSC referenced in the 

categorical waiver. 

In addition, the Secretary may accept 

a state’s fire and safety code instead of 

the LSC if CMS determines that the 

protections of the state’s fire and safety 

code are equivalent to the protections 

offered by the LSC. Further, the NFPA’s 

Fire Safety Evaluation System (FSES), 

an equivalency system, provides 

alternatives to meeting various 

provisions of the LSC, thereby achieving 

the same level of fire protection as the 

LSC. These flexibilities mitigate the 

potential burdens of applying the 

requirements of the LSC to all affected 

health care facilities. 

On January 10, 2003, we published a 

final rule in the Federal Register (68 FR 

1374) adopting the 2000 edition of the 

LSC. In this final rule, we required that 

all affected providers and suppliers 

meet the provisions of the 2000 edition 

of the LSC, with certain exceptions. One 

of the exceptions to the 2000 edition of 

the LSC is the code’s use of roller 

latches on corridor doors in buildings 

that are fully protected by a sprinkler 

system. We believe that roller latches 

are a safety hazard under all 

circumstances and prohibit their use in 

all Medicare and applicable Medicaid 

facilities. We also removed references to 

all previous editions of the LSC. 

In 2002, the Centers for Disease 

Control and Prevention (CDC) published 

an initial set of hand hygiene guidelines 

for health care settings on its Web site 

(http://www.cdc.gov/handhygiene/

Guidelines.html). The guidelines 

recommended the use of alcohol-based 

hand rub (ABHR) dispensers. On 

September 22, 2006 we published a 

final rule (71 FR 55326), to allow certain 

health care facilities to place ABHR 

dispensers in exit corridors under 

specified conditions. To accommodate 

the placement of ABHR dispensers in 

health care facilities, the NFPA 

retroactively amended the 2000 edition 

of the code. When CMS adopts an 

edition of the LSC, it adopts that edition 

as it existed on the day of publication 

of the final rule. Since the changes to 

the 2000 edition of the LSC occurred 

after publication of the January 2003 

final rule that adopted the 2000 edition 

of the LSC, CMS was required to use the 

notice and comment rulemaking process 

to adopt the amendment that the NFPA 

made to the code. 

The September 2006 final rule also 

required that LTC facilities, at a 

minimum, install battery-powered 

single station smoke alarms in resident 

rooms and common areas if their 

buildings were not fully sprinklered, or 

if the building did not have systembased smoke detectors. A Government 

Accountability Office (GAO) report 

entitled ‘‘Nursing Home Fire Safety: 

Recent Fires Highlight Weaknesses in 

Federal Standards and Oversights’’ 

GAO–04–660, July 16, 2004, (http://

www.gao.gov/products/GAO-04-660) 

examined two LTC facility fires 

(Hartford and Nashville) in 2003, that 

resulted in 31 total resident deaths. The 

report examined Federal fire safety 

standards and enforcement procedures, 

as well as results from the fire 

investigations of these two incidents. It 

specifically cited requiring smoke 

detectors in these facilities as one way 

to strengthen the requirements. We 

agreed with the GAO findings and 

added this smoke alarm requirement in 

response to the GAO report. 

On August 13, 2008, we published a 

final rule (73 FR 47075), to require all 

LTC facilities to install automatic 

sprinkler systems throughout their 

buildings in accordance with the 

technical provisions of the 1999 edition 

of NFPA 13—Standard for the 

Installation of Sprinkler Systems, and to 

test, inspect, and maintain sprinkler 

systems in accordance with the 

technical requirements of the 1998 

edition of NFPA 25—Standard for the 

Inspection, Testing and Maintenance of 

Water-Based Fire Protection Systems. 

The August 2008 final rule required all 

LTC facilities to be equipped with 

sprinkler systems by August 13, 2013. 

This rule was also in response to the 

July 2004 GAO report on nursing home 

fire safety. In addition to its findings 

related to smoke alarms, the GAO 

recommended that fire safety standards 

for unsprinklered LTC facilities be 

strengthened, and cited sprinklers as the 

single most effective fire protection 

feature for LTC facilities. 

On October 24, 2011, we published a 

proposed rule (76 FR 65891), to reform 

hospital and critical access hospital 

conditions of participation. Many of the 

public comments received during the 

comment period strongly encouraged 

CMS to adopt the 2012 edition of the 

LSC. The commenters stated that the 

newest edition of the LSC would clarify 

several issues and would be beneficial 

to facilities. 

B. 2012 Edition of the Life Safety Code 

The 2012 edition of the LSC includes 

new provisions that we believe are vital 

to the health and safety of all patients 

and staff. Our intention is to ensure that 

patients and staff continue to experience 

the highest degree of fire safety possible. 

The term ‘‘Patient(s)’’ will be globally 

used throughout this document, and 

refers to patient, clients, residents and 

all other terms used to describe the type 

of individuals cared for in each provider 

type. The use of earlier editions of the 

code can become problematic due to 

advances in safety and technology, and 

changes made to each edition of the 

code. Newer buildings are typically 

built to comply with the newer versions 

of the LSC because state and local 

jurisdictions, as well as non-CMSapproved accreditation programs, often 

adopt and enforce newer versions of the 

code as they become available. 

Therefore, a health care facility that is 

constructed or renovated in 2013 would 

likely be required by its state and local 

authorities to comply with a more 

recent edition of the LSC, while also 

being required to comply with the 2000 

edition of the LSC to meet the Medicare 

and applicable Medicaid regulatory 

requirements. Requiring compliance 

with two different editions of the LSC 

at the same time can create unnecessary 

conflicts, duplications, and 

inconsistencies that increase 

construction and compliance costs 

without any fire safety or patient care 

benefits. For example, the 2000 edition 


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of the LSC limits ABHRs to gel form, 

whereas the 2012 edition of the LSC 

expands to allow aerosol and gel 

ABHRs. Limiting the choice of ABHRs 

creates barriers to improve hand 

hygiene, which has been shown to 

reduce the number of health care 

associated infections. We believe that 

adopting the 2012 LSC would simplify 

and modernize the construction and 

renovation process for affected health 

care providers and suppliers, reduce 

compliance-related burdens, and 

allowing for more resources to be used 

for patient care. 

The 2012 edition of the LSC contains 

several significant changes from the 

2000 edition. First, the format of the 

LSC has been altered. The LSC has 

eliminated the use of ‘‘exceptions’’ 

throughout the entire code to provide 

more consistency and easier reading. 

There was also a change in 

measurement systems, from centimeters 

to millimeters. Using a smaller unit of 

measurement allows for more precision 

and consistency throughout the LSC. 

The 2000 LSC requires minor 

renovation projects to meet the same 

stringent requirements as those applied 

to completely new construction. 

However, the 2012 edition of the LSC 

contains a new chapter entitled, 

‘‘Chapter 43—Building Rehabilitation.’’ 

This new chapter replaces the 

requirements that all modernizations/

renovations meet the requirements for 

new construction. The degree to which 

requirements for new construction must 

be met now varies with the 

rehabilitation work category. This 

chapter sets out different types of 

building rehabilitation work (that is, 

repair, renovation, modification, 

reconstruction, change of use, change of 

occupancy and addition) to which 

different standards apply. We believe 

that this clarification will assist health 

care facilities by reducing costs for 

minor construction projects. 

Buildings that have not received all 

pre-construction governmental 

approvals required by the jurisdiction(s) 

in which the building is to be built 

before the rule’s effective date, or those 

buildings that begin construction after 

the effective date of this regulation, 

would be required to meet the New 

Occupancy chapters of the 2012 edition 

of the LSC. Buildings constructed before 

the effective date of this regulation 

would be required to meet the Existing 

Occupancy chapters of the 2012 edition 

of the LSC. Changes made to buildings 

would be required to comply with 

Chapter 43—Building Rehabilitation, 

which could require compliance with 

the New Occupancy chapters, 

depending on the changes being made. 

In instances where mandatory LSC 

references do not include existing 

chapters, existing occupancies must 

ensure buildings and equipment are in 

compliance with provisions previously 

adopted by CMS at the time they were 

constructed or installed. 

Health Care Occupancies 

The following are provisions that 

appear in the 2012 edition of the LSC, 

but that did not exist in the 2000 edition 

of the LSC, for Chapter 18, ‘‘New Health 

Care Occupancies,’’ and Chapter 19, 

‘‘Existing Health Care Occupancies.’’ 

We are providing the LSC citation, a 

description of the 2012 requirement, 

and an explanation of its benefits for 

health care facilities, patients, staff, and 

visitors over the 2000 version. 

Both the 2000 and 2012 editions of 

the LSC classify a ‘‘Health Care 

Occupancy’’ as a facility having 4 or 

more patients on an inpatient basis. 

However, CMS does not apply this LSC 

standard with respect to patient census 

numbers. Unless specifically noted, the 

requirements, conditions of 

participation, and conditions for 

coverage for all Medicare and Medicaidparticipating health care providers and 

suppliers subject to these rules would 

apply on a facility basis, regardless of 

the size of the facility or the facility’s 

patient census. These basic 

requirements are established to assure a 

core level of safety and quality for all 

patients, regardless of where they 

receive health care services. We believe 

that patients in small facilities should 

be assured the same level of fire safety 

as those in larger facilities. Therefore, 

the LSC exception for health care 

occupancy facilities with fewer than 

four occupants/patients would be 

inapplicable to the Medicare and 

Medicaid facilities affected by this 

proposed rule. All health care 

occupancies that provide care to one or 

more patients would be required to 

comply with the relevant requirements 

of the 2012 edition of the LSC. 

Sections 18.2.3.4 (2) and 19.2.3.4(2)— 

Corridor Projections 

This provision requires 

noncontinuous projections to be no 

more than 6 inches from the corridor 

wall. In addition to following the 

requirements of the LSC, health care 

facilities are also required to follow the 

requirements of the Americans with 

Disabilities Act (ADA). Section 307 of 

the ‘‘ADA Accessibility Guidelines for 

Buildings and Facilities’’ (http://

www.ada.gov/regs2010/

2010ADAStandards/

2010ADAstandards.htm#c4) requires 

that projections be no more than 4 

inches from the corridor wall. 

Therefore, while the LSC allows 

facilities to have 6 inch projections, so 

long as the ADA standard is 4 inches 

then facilities should only have 4 inch 

projections to comply with the more 

stringent requirement set forth by the 

ADA. 

Sections 18.2.5.7 and 19.2.5.7—Suites 

This new provision has enlarged the 

size of permissible sleeping suites for 

patients to potentially allow ‘more 

comfort and space for patients’ if the 

facilities choose to use the larger size 

patient rooms. The provision requires 

that new construction sleeping suites 

cannot exceed 7500 square feet. 

Previously sleeping suites could not 

exceed 5000 square feet. Sleeping suites 

greater than 7500 square feet, and not 

exceeding 10,000 square feet, may be 

permitted where there is direct visual 

supervision and a complete smoke 

detection system. This change allows 

health care facilities to have more 

patients in a single area, reducing the 

number of staff that are necessary to 

visually monitor patients and allowing 

facilities to accommodate additional 

pieces of medical equipment or visitor 

space. This could improve facility 

staffing flexibility and reduce costs by 

allowing this increase in size thereby 

reducing the number of suites to treat 

the same number of patients. 

Sections 18.7.5.7.2 and 19.7.5.7.2— 

Recycling 

This new provision requires that 

containers used solely for recycling 

clean waste be limited to a maximum 

capacity of 96 gallons. If the recycling 

containers are located in a protected 

hazardous area, container size will not 

be limited. In the 2000 edition of the 

LSC, the container size was limited to 

32 gallons. The larger containers 

allowed in the 2012 edition of the LSC 

require less frequent emptying, which 

could reduce housekeeping costs. 

Sections 18.3.6.3.9.1 and 19.3.6.3.5— 

Roller Latches 

A roller latch is a type of door 

latching mechanism to keep a door 

closed. The 2012 edition of the LSC 

requires corridor doors to be provided 

with a means for keeping the door 

closed that is acceptable to the authority 

having jurisdiction. The LSC permits 

roller latches capable of keeping the 

door fully closed if a force of 5 pounds 

is applied at the latch edge or roller 

latches in fully sprinklered buildings. 

However, we would not adopt these 

standards from the 2012 LSC. Through 

fire investigations, roller latches have 

proven to be an unreliable door latching 


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mechanism requiring extensive 

maintenance to operate properly. Many 

roller latches in fire situations failed to 

provide adequate protection to residents 

in their rooms during an emergency. 

Therefore, roller latches would be 

prohibited in existing and new Health 

Care Occupancies, and corridor doors 

would be required to have positive 

latching devices. 

Sections 18.4.2 and 19.4.2—Sprinklers 

in High-Rise Buildings 

This is a new provision for existing 

health care occupancies. This provision 

requires buildings over 75′ (generally 

greater than 7 or 8 stories) in height to 

have automatic sprinkler systems 

installed throughout the building. The 

2012 LSC allows 12-years from when 

the authority having jurisdiction (which 

in this case is CMS) officially adopts the 

2012 edition of the LSC for existing 

facilities to comply with the sprinkler 

system installation requirement. 

Therefore, those facilities that are not 

already required to do so would have 12 

years following publication of the final 

rule adopting the 2012 LSC to install 

sprinklers. We propose to adopt this 

new provision because high-rise 

buildings require more time to evacuate, 

and sprinklers would very likely allow 

additional time to safely evacuate a 

facility. 

We believe that this provision would 

mainly affect hospitals. However, we are 

specifically soliciting public comment 

to determine if other provider types are, 

or may be, located in a high-rise 

building. We would also like to solicit 

public comments regarding the phase-in 

period of 12 years, including if 12-years 

is enough time for the installation of 

sprinklers in high-rise buildings. 

Sections 18.2.2.2.5.2 and 19.2.2.2.5.2— 

Door Locking 

This new provision requires that, 

where the special needs of patients 

require specialized protective measures 

for their safety, door-locking 

arrangements are permitted. This 

provision allows interior doors to be 

locked to reduce the risk of infant 

abductions and individuals who may 

wander, subject to the following 

requirements: (1) All staff must have 

keys; (2) smoke detection systems must 

be in place; and (3) the facility must be 

fully sprinklered; (4) the locks are 

electrical locks that will release upon 

loss of power to the device and (5) the 

locks release by independent activation 

of the smoke detection system and the 

water flow in the automatic sprinkler 

system. This provision would improve 

the security of health care facilities with 

specialized needs and improve patient 

safety. 

Sections 18.3.2.6 and 19.3.2.6—Alcohol 

Based Hand Rubs (ABHRs) 

This provision now explicitly allows 

aerosol dispensers, in addition to gel 

hand rub dispensers. The aerosol 

dispensers are subject to limitations on 

size, quantity, and location, just as gel 

dispensers are limited. Automatic 

dispensers are also now permitted in 

health care facilities, provided that the 

following requirements are met: (1) 

They do not release contents unless they 

are activated; (2) the activation occurs 

only when an object is within 4 inches 

of the sensing device; (3) any object 

placed in the activation zone and left in 

place must not cause more than one 

activation; (4) the dispenser must not 

dispense more than the amount required 

for hand hygiene consistent with the 

label instructions; (5) the dispenser is 

designed, constructed and operated in a 

way to minimize accidental or 

malicious dispensing; and (6) all 

dispensers are tested in accordance with 

the manufacturer’s care and use 

instructions each time a new refill is 

installed. The provision further defines 

prior language regarding ‘‘above or 

adjacent to an ignition source’’ as being 

‘‘within 1 inch’’ of the ignition source. 

These new provisions would allow for 

more hand hygiene dispenser options 

for all facilities. 

Sections 18.3.5 and 19.3.5— 

Extinguishment Requirements 

This provision is related to sprinkler 

system requirements and cross 

references section 9.7 of the LSC, 

‘‘Automatic sprinklers and other 

extinguishing equipment.’’ Section 9.7 

further cross references the 2011 edition 

of NFPA 25, Standard for the 

Inspection, Testing and Maintenance of 

Water-based Fire Protection Systems. 

Section 9.7.5 of the LSC states ‘‘All 

automatic sprinkler and standpipe 

systems required by this Code shall be 

inspected, tested and maintained in 

accordance with NFPA 25. . . .’’ 

Section 15.5.2, of the 2011 edition of 

NFPA 25, which is cross-referenced by 

the 2012 edition of the LSC, requires the 

evacuation of a building or the 

instituting of an approved fire watch 

when a sprinkler system is out of 

service for more than 10 hours in a 24- 

hour period until the system has been 

returned to service. However the 1998 

edition of NFPA 25, which is crossreferenced by the 2000 edition of the 

LSC, has the same requirement when a 

sprinkler system is out of service for 

only 4 hours. Because of the increased 

reliance upon a facility sprinkler 

protection system in the 2012 edition of 

the LSC, and to ensure a facility is 

adequately monitored when a sprinkler 

system is out of service, we propose to 

retain the requirement for evacuation or 

a fire watch when a sprinkler system is 

out of service for more than 4 hours. 

This provision is set out in the 

applicable sections of this proposed 

rule. 

Section 18.3.2.3 and 19.3.2.3— 

Anesthetizing Locations 

This provision requires that 

anesthetizing locations be protected in 

accordance with the 2012 edition of 

NFPA 99, Health Care Facilities Code. 

The 2012 edition of NFPA 99 eliminated 

an important requirement that was in 

the 1999 edition of NFPA 99. The 1999 

edition of NFPA 99, which is crossreferenced in the 2000 LSC, requires a 

smoke control ventilation system in 

anesthetizing locations (for example, 

Operating Rooms). The 1999 edition of 

NFPA 99 requires that supply and 

exhaust systems for windowless 

anesthetizing locations must be 

arranged to automatically vent smoke 

and products of combustion to prevent 

the circulation of smoke originating 

from within and outside the operating 

room(s). The smoke control is intended 

to protect the anesthetizing location 

until surgical procedures can be 

completed and patients can be safely 

evacuated from the operating rooms. As 

fires in operating rooms continue to 

occur, we propose to retain the 

requirement for smoke control in 

anesthetizing locations, notwithstanding 

the lower standard in the 2012 LSC. 

http://www.fda.gov/ForConsumers/

ConsumerUpdates/ucm282810.htm. 

Sections 18.2.3.4 and 19.2.3.4— 

Corridors 

This new provision allows for storage 

of medical equipment in the corridors. 

Any equipment that is in use, including 

medical emergency equipment, and 

patient lift and transportation 

equipment is permitted to be stored in 

the corridors for more timely patient 

care. This provision also allows 

facilities to place fixed furniture in the 

corridors. This creates resting points in 

the corridors for patients and families in 

facilities and makes for a more homelike setting. 

Sections 18.3.2.5.3 and 19.3.2.5.3— 

Cooking Facilities 

This provision is a new section, 

which further supports a more homelike setting in health care facilities. 

Cooking facilities are allowed in a 

smoke compartment where food is 

prepared for 30 individuals or fewer (by 


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21556 Federal Register / Vol. 79, No. 73 / Wednesday, April 16, 2014 / Proposed Rules 

bed count). The cooking facility is 

permitted to be open to the corridor, 

provided that the following conditions 

are met: 

• The area being served is limited to 

30 beds or less; 

• The area is separated from other 

portions of the facility by a smoke 

barrier; 

• The range hood and stovetop meet 

certain standards— 

++ A switch must be located in the 

area that is used to deactivate the cook 

top or range whenever the kitchen is not 

under staff supervision 

++ The switch also has a timer, not 

exceeding 120-minute capacity that 

automatically shuts off after time runs 

out 

• Two smoke detectors must be 

located no closer than 20 feet and not 

further than 25 feet from the cooktop or 

range. 

Sections 18.7.5.1 and 19.7.5.1— 

Furnishings & Decorations 

This provision has been revised to 

allow combustible decor in any health 

care occupancy as long as they are 

flame-retardant or treated with 

approved fire-retardant coating that is 

listed and labeled, and meet fire test 

standards. The de ́cor (such as 

photographs, paintings and other art) 

may be attached directly to the walls, 

ceilings, and non fire-rated doors as 

long as it does not interfere with the 

operation of the doors. Additionally, 

decor may not exceed—(1) 20 percent of 

the wall, ceiling and doors, in any room 

that is not protected by an approved 

automatic sprinkler system; (2) 30 

percent of the wall, ceiling and doors, 

in any room that is not protected by an 

approved, supervised automatic 

sprinkler system; and (3) 50 percent of 

the wall, ceiling and doors, in any room 

with a capacity of 4 people (the actual 

number of occupants in the room may 

be less than its capacity) that is not 

protected by an approved, supervised 

automatic sprinkler system. These 

changes would allow individuals to 

bring in their own furnishings and 

decor, which helps to provide a more 

home-like setting. 

Sections 18.5.2.3 and 19.5.2.3— 

Fireplaces 

This provision has been revised to 

allow direct-vent gas fireplaces in 

smoke compartments without the 1 hour 

fire wall rating. Fireplaces must not be 

located inside of any patient sleeping 

room. Solid fuel-burning fireplaces are 

permitted and can be used only in areas 

other than patient sleeping rooms, and 

must be separated from sleeping rooms 

by construction of no less than a 1 hour 

fire resistance wall rating. This 

provision allows for more options for 

the location of fireplaces in health care 

facilities, which makes the facilities feel 

more home-like. 

Outside Window or Door Requirements 

The 2000 edition of the LSC required 

that every health care occupancy patient 

sleeping room shall have an outside 

window or outside door, with new 

health care occupancies having an 

allowable sill height not to exceed 36 

inches above the floor with certain 

exceptions. This requirement no longer 

exists in the 2012 edition of the LSC; 

however, as outside windows and doors 

may be used for smoke control, building 

entry, patient and resident evacuation, 

and other emergency forces operations 

during an emergency situation, we 

propose to retain this requirement. We 

propose the following exceptions to the 

outside window or door requirement, as 

included in the 2000 edition of the LSC: 

• Newborn nurseries and rooms 

intended for occupancy for less than 24 

hours have no sill height requirements. 

• Windows in atrium walls shall be 

considered outside windows for the 

purposes of this requirement. 

• The window sill height in special 

nursing care areas shall not exceed 60 

inches above the floor. 

Ambulatory Health Care Occupancies 

The following are new provisions in 

the 2012 edition of the LSC from 

Chapter 20, ‘‘New Ambulatory Health 

Care Occupancies’’ and Chapter 21, 

‘‘Existing Ambulatory Health Care 

Occupancies.’’ We are providing the 

LSC citation, a description of the 

requirement, and an explanation of its 

benefits for health care facilities, 

patients, staff, and visitors. 

Both the 2000 and 2012 edition of the 

LSC define an ‘‘Ambulatory Health Care 

Occupancy’’ as a facility capable of 

treating 4 or more patients 

simultaneously on an outpatient basis. 

CMS regulations at 42 CFR § 416.44 

require that all ASCs meet the 

provisions applicable to Ambulatory 

Health Care Occupancy, regardless of 

the number of patients served. We 

believe that hospital outpatient surgical 

departments are comparable to ASCs 

and thus should also be required to 

meet the provisions applicable to 

Ambulatory Health Care Occupancy 

Chapters, regardless of the number of 

patients served. 

Sections 20.1.6.4 and 21.1.6.5—Interior 

Nonbearing Walls 

This new provision allows all interior 

nonbearing walls that are required to 

have a minimum 2 hour fire resistance 

rating to be constructed of fire-retardant 

treated wood enclosed within 

noncombustible or limited combustible 

materials, provided that these walls are 

not used as shaft enclosures. The use of 

fire-retardant treated wood allows for 

more flexibility during construction and 

could reduce the cost of construction. 

Sections 20.3.2.1 and 21.3.2.1—Doors 

This new provision requires all doors 

to hazardous areas to be self-closing or 

close automatically. This provision was 

added to provide an extra level of 

protection for all patients. Adding this 

provision aligns the requirements for 

both ASCs and Health care occupancies 

to assure the same basic level of 

protection for all patients. 

Sections 20.3.2.6 and 21.3.2.6—ABHRs 

This provision now explicitly allows 

aerosol dispensers, in addition to gel 

hand rub dispensers. The aerosol 

dispensers are subject to limitations on 

size, quantity, and location, just as gel 

dispensers are. Automatic dispensers 

are also now permitted in health care 

facilities, provided, among other things, 

that—(1) they do not release contents 

unless they are activated; (2) the 

activation occurs only when an object is 

within 4 inches of the sensing device; 

(3) any object placed in the activation 

zone and left in place must not cause 

more than one activation; (4) the 

dispenser must not dispense more than 

the amount required for hand hygiene 

consistent with the label instructions; 

(5) the dispenser is designed, 

constructed and operated in a way to 

minimize accidental or malicious 

dispensing; (6) all dispensers are tested 

in accordance with the manufacturer’s 

care and use instructions each time a 

new refill is installed. The provision 

further defines prior language regarding 

‘‘above or adjacent to an ignition 

source’’ as being ‘‘within 1 inch’’ of the 

ignition source. These new provisions 

allow for more hand hygiene dispenser 

options for all facilities. 

Sections 20.3.5 and 21.3.5— 

Extinguishment Requirements 

This provision is related to sprinkler 

system requirements and cross 

references section 9.7 of the LSC, 

‘‘Automatic sprinklers and other 

extinguishing equipment.’’ Section 9.7 

also cross references the 2011 edition of 

NFPA 25, ‘‘Standard for the Inspection, 

Testing and Maintenance of Waterbased Fire Protection Systems.’’ Section 

9.7.5 of the LSC states, ‘‘All automatic 

sprinkler and standpipe systems 

required by this Code shall be 

inspected, tested and maintained in 

accordance with NFPA 25. . . .’’ 


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Section 15.5.2, of the 2011 edition of 

NFPA 25, which is cross-referenced by 

the 2012 edition of the LSC, requires the 

evacuation of a building or the 

instituting of an approved fire watch 

when a sprinkler system is out of 

service for more than 10 hours in a 24- 

hour period until the system has been 

returned to service. The 1998 edition of 

NFPA 25, which is cross-referenced by 

the 2000 edition of the LSC, has the 

same requirement when a sprinkler 

system is out of service for only 4 hours. 

With the increased reliance upon a 

facility sprinkler protection system in 

the 2012 edition of the LSC, and to 

ensure a facility is adequately 

monitored when a sprinkler system is 

out of service, we propose to retain the 

requirement for evacuation or a fire 

watch when a sprinkler system is out of 

service for more than 4 hours. 

Section 20.3.2.3 and 21.3.2.3— 

Anesthetizing Locations 

This provision requires that 

anesthetizing locations be protected in 

accordance with the 2012 edition of 

NFPA 99, Health Care Facilities Code. 

The 2012 edition of NFPA 99 eliminated 

an important requirement that was in 

the 1999 edition of NFPA 99. The 1999 

edition of NFPA 99, which is crossreferenced by to the 2000 LSC, requires 

a smoke control ventilation system in 

anesthetizing locations (for example, 

Operating Rooms). The 1999 edition of 

NFPA 99 requires that supply and 

exhaust systems for windowless 

anesthetizing locations must be 

arranged to automatically vent smoke 

and products of combustion to prevent 

the circulation of smoke originating 

from within and outside the operating 

room. The smoke control is intended to 

protect the anesthetizing location until 

surgical procedures can be completed 

and patients can be safely evacuated 

from the operating rooms. As fires in 

operating rooms continue to occur, we 

propose to retain the requirement for 

smoke control in anesthetizing 

locations. 

Residential Board and Care Occupancies 

The LSC requirements for residential 

care facilities are differentiated based on 

the evacuation capability of the facility 

in question. The term ‘‘evacuation 

capability’’ refers to the ability of 

occupants, residents, and staff as a 

group either to evacuate a building, or 

to relocate from one point of occupancy 

to a point of safety. An ‘‘impractical 

evacuation capability’’ means that a 

group is unable to reliably move to a 

point of safety in a timely manner. A 

‘‘prompt evacuation capability’’ means 

that a group is able to move reliably to 

a point of safety in a timely manner that 

is equivalent to the capacity of a 

household in the general population. A 

‘‘slow evacuation capability’’ means that 

a group is able to move reliably to a 

point of safety in a timely manner, but 

not as rapidly as members of a 

household in the general population. 

The LSC requirements for a facility that 

has a prompt evacuation capability may 

be different from those for a facility that 

has an impractical evacuation 

capability. Those differences are 

reflected in the following provisions. 

Both the 2000 and 2012 editions of 

the LSC classify ‘‘board and care’’ as a 

facility ‘‘used for lodging or boarding of 

4 or more patients not related by blood 

or marriage to the owners or operators, 

for the purpose of providing personal 

care services.’’ However, for CMS 

regulatory purposes, unless specifically 

noted, the conditions of participation 

and conditions for coverage for all 

affected health care providers and 

suppliers apply to all patients in a 

facility, regardless of the number of 

patients served. These basic 

requirements are established to assure a 

core level of safety and quality for all 

patients, regardless of where they 

receive health care services. We 

continue to believe that patients in very 

small facilities should be assured the 

same level of fire safety as those 

residing in very large facilities. 

Therefore, the LSC ‘‘4 or more’’ criteria 

would not apply to any Medicare and 

applicable Medicaid certified facilities. 

All residential board and care 

occupancies that provide care to one or 

more patients would be required to 

comply with the relevant requirements 

of the 2012 edition of the LSC. 

The following are provisions that 

appear in the 2012 edition of the LSC, 

but that did not exist in the 2000 edition 

of the LSC, for Chapter 32, ‘‘New 

Residential Board and Care 

Occupancies’’ and Chapter 33, ‘‘Existing 

Residential Board and Care 

Occupancies.’’ We are providing the 

LSC citation, a description of the 

requirement, and an explanation of its 

benefits for health care facilities, 

patients, staff, and visitors. 

Section 32.2.3.5.3.2—Sprinklers 

This revised provision has been 

expanded to require that sprinkler 

systems be installed in all habitable 

areas, closets, roofed porches, balconies 

and decks of new facilities. Although 

this section of the LSC does not apply 

to existing facilities, we strongly 

encourage all existing facilities be 

sprinklered in all habitable areas in the 

same manner that newly constructed 

facilities are required to be sprinklered. 

Sections 32.2.3.5.7 and 33.2.3.5.7— 

Attics 

This new provision requires attics of 

new and existing facilities to be 

sprinklered. The attics of new board and 

care facilities are required to be 

protected in accordance with sections 

32.2.3.5.7.1 or 32.2.3.5.7.2 of the LSC. 

The attics of existing board and care 

facilities are required to be protected in 

accordance with sections 33.2.3.5.7.1 or 

33.2.3.5.7.2 of the LSC. For both new 

and existing board and care facilities, if 

the attic is used for living purposes, 

storage, or housing of fuel fired 

equipment, it must be protected with an 

automatic approved sprinkler system. If 

the attic is used for other purposes or is 

not used, then it must meet one of the 

following requirements: (1) Have a heat 

detection system that activates the 

building fire alarm system; (2) have 

automatic sprinklers; (3) be of 

noncombustible or limited-combustible 

construction; or (4) be constructed of 

fire-retardant-treated-wood. We are 

requesting public comment on the 

length of time needed to install 

sprinklers in attics. This provision was 

added after fire investigations 

demonstrated that fires in attics pose a 

high hazard in this type of occupancy. 

For example, one well-known case 

would be the fire in a board and care 

facility in Wells, New York on March 

21, 2009. The fire started on the 

screened porch and spread to the 

unsprinklered attic where it quickly 

engulfed the facility. Despite the prompt 

evacuation by staff, 4 of the 9 clients 

perished in the fire. (http://

www.prevention1st.org/documents/

Wells_Fire_GrandJuryReport.pdf.) 

Sections 32.2.2 and 33.2.2—Means of 

Escape 

This new provision requires 

designated means of escape to be 

continuously maintained free of all 

obstructions or impediments to full 

instant use in the case of a fire or 

emergency. This provision was added 

because there were no provisions within 

the occupancy chapter to prohibit an 

obstructed means of escape, and to 

emphasize that all means of escape are 

required to be free of obstructions to 

allow use without delay. 

Section 32.3.3.4.7—Smoke Alarms 

This new provision would only affect 

newly constructed facilities. Approved 

smoke alarms are required to be 

installed in accordance with 9.6.2.10 of 

the LSC inside every sleeping room, 

outside every sleeping area, in the 

immediate vicinity of the bedrooms, and 

on all levels within a resident unit. This 


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requirement is located in Chapter 32, 

which only applies to newly 

constructed facilities. We are soliciting 

public comments about whether or not 

CMS should also require existing 

facilities to have smoke alarms that meet 

the requirements of this section. 

Sections 32.7.6 and 33.7.6—Staff 

This new provision for both newly 

constructed and existing facilities 

requires staff to be on duty and in the 

facility at all times when residents 

requiring evacuation assistance are 

present. This provision was added 

because staff assistance during 

evacuation is a necessity in this 

occupancy. This would increase safety 

for patients that are unable to 

independently exit the building in an 

emergency situation. 

Sections 32.3.2.2.2 and 33.3.2.2.2— 

Access-Controlled Egress Doors 

New and existing facilities must be 

permitted to have access-controlled 

egress doors that are in accordance with 

7.2.1.6.2 of the LSC. When using the 

term ‘‘egress,’’ we are describing, for 

example, hallways or corridors, interior 

and exterior stairways, entrance ways or 

lobbies, and escalators. Section 7.2.1.6.2 

of the LSC permits means of egress to 

be equipped with electrical lock 

hardware to prevent egress. This 

provision was added to improve safety 

while allowing for more flexibility. 

Section 33.3.3.2.3—Hazardous Areas 

This new provision is for existing 

facilities with impractical evacuation 

capabilities. All hazardous areas must 

be separated from other parts of the 

building by smoke partitions, and also 

in accordance with section 8.4 of the 

LSC. Section 8.4 of the LSC addresses 

the continuity of smoke partitions and 

requires that they be placed 

appropriately. We are requesting public 

comment on the length of time needed 

to install smoke partitions in hazardous 

areas. This new provision provides a 

higher level of safety for facilities with 

impractical evacuation capabilities, and 

allows more time for individuals using 

facilities with slower evacuation 

capabilities to exit the building. 

Section 33.3.3.4.6.2—Emergency Forces 

Notification 

This new provision is only for 

existing facilities. Where a new fire 

alarm system is installed, or the existing 

fire alarm system is replaced, 

notification of emergency forces must be 

handled in accordance with section 

9.6.4 of the LSC, which states that, 

where required by another section of 

this code, notification of emergency 

forces should alert the municipal fire 

department and fire brigade (if 

provided) of fire or other emergency. 

This new provision would increase 

safety for residents and staff by assuring 

that the appropriate emergency force is 

quickly notified of an emergency 

situation, enabling the emergency force 

to arrive in the fastest time possible to 

aid residents and staff. 

Waiver Authority 

We are proposing to retain our 

existing authority to waive provisions of 

the LSC under certain circumstances, 

further reducing the exposure to 

additional cost and burden for facilities 

with unique situations. A waiver may be 

granted for a specific LSC requirement 

if we determine that—(1) The waiver 

would not adversely affect patient/staff 

health and safety; and (2) it would 

impose an unreasonable hardship on the 

facility to meet a specific LSC 

requirement. We do not consider it 

always necessary for a facility to be 

cited for a deficiency before it can apply 

for or receive a waiver, and we have 

periodically issued communications 

regarding specific provisions of the LSC 

that we evaluated and for which we 

have determined that a waiver would 

generally apply, subject to 

documentation maintained by the 

facility and verification of the 

applicability of the waiver when a 

survey of the facility is conducted. We 

plan to continue this approach. 

In cases where a provider or supplier 

has been cited for a LSC deficiency, the 

provider or supplier may request a 

waiver from its State Survey Agency or 

Accrediting Organization (AO) with a 

CMS-approved Medicare and applicable 

Medicaid accreditation program. The 

State Survey Agency or AO reviews the 

request and makes a recommendation to 

the appropriate CMS Regional Office. 

The CMS Regional Office would review 

the waiver request and the 

recommendation and make a final 

decision. A waiver cannot be granted if 

patient health and safety is 

compromised. 

The LSC recognizes alternative 

systems, methods, or devices approved 

as equivalent by the authority having 

jurisdiction as being in compliance with 

the LSC. CMS, as the authority having 

jurisdiction for certification, will 

determine equivalency through the 

waiver approval process. 

State Fire Codes 

In addition to the proposed waiver 

option, a state may request that its state 

fire safety requirements, imposed by 

state law, be used in lieu of the 2012 

edition of the LSC, which we are 

proposing to adopt in this rule. The 

state must submit the request to the 

appropriate CMS Regional Office, and 

the Regional Office would forward the 

request to CMS central office for final 

determination. We would retain our 

authority to apply the Fire Safety 

Evaluation System (FSES) as an 

alternative approach to meeting the 

requirements of the LSC. 

C. 2012 Edition of the Health Care 

Facilities Code 

The 2012 edition of the NFPA 99, 

‘‘Health Care Facilities Code’’, addresses 

requirements for both health care 

occupancies and ambulatory care 

occupancies, and serves as a resource 

for those who are responsible for 

protecting health care facilities from fire 

and associated hazards. The purpose of 

this Code is to provide minimum 

requirements for the installation, 

inspection, testing, maintenance, 

performance, and safe practices for 

health care facility materials, equipment 

and appliances. This Code is a 

compilation of documents that have 

been developed over a 40-year period by 

NFPA, and is intended to be used by 

those persons involved in the design, 

construction, inspection, and operation 

of health care facilities, and in the 

design, manufacture, and testing of 

appliances and equipment used in 

patient care areas of health care 

facilities. It provides information on 

subjects such as medical gas and 

vacuum systems, electrical systems, 

electrical equipment, and gas 

equipment. 

The NFPA 99, which is a crossreferenced document in the LSC, has 

undergone some significant changes. 

The NFPA 99 has been upgraded from 

a standard to a code. A code, as used by 

the NFPA describes what to do, whereas 

a standard describes how to comply 

with the code. In addition to the 

upgrade, the format of the code has 

changed from specific provisions that 

are directed by different chapters in the 

NFPA 99 to provisions that apply to all 

health care facilities. The applicability 

of any specific provision is determined 

in accordance with the results of a risk 

based methodology. Previous editions 

utilized occupancy chapters to 

determine which systems were required 

in a health care facility. Requirements 

were applied based upon the facility 

type (that is, Hospital, Nursing Home, 

Limited Care Facility, Other Health Care 

Facilities). In the 2012 edition, 

requirements are based upon the 

possible risks to patients and residents, 

regardless of the type of facility. 

Although NFPA 99 is a reference 

document of the 2012 edition of the 


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LSC, the health care occupancy chapters 

of the LSC do not reference NFPA 99 

requirements for all areas within a 

health care facility. In order to ensure 

the minimum level of protection 

afforded by NFPA 99 is applicable to all 

patient and resident care areas within a 

health care facility, CMS is proposing 

the adoption of the 2012 edition of 

NFPA 99, with the exception of chapters 

7, 8, 12, and 13. In the following 

section, we describe the key provisions 

within the NFPA 99. 

The first three chapters of the NFPA 

99 address the administration of the 

NFPA 99, the referenced publications 

and also definitions. 

Chapter 4—Fundamentals 

Chapter 4 is new to the 2012 edition 

and provides guidance on how to apply 

NFPA 99 requirements to health care 

facilities based upon ‘‘categories’’ 

determined when using a risk-based 

methodology. A risk-based approach 

allows for the application of 

requirements based upon the types of 

treatment and services being provided 

to patients or residents rather than the 

type of facility in which they are being 

performed. This approach will ensure 

that patients and residents in all types 

of health care facilities are provided 

with a minimum level of protection. In 

addition, the risk-based approach will 

allow a facility to determine the 

appropriate level of protection required 

in individual areas throughout a facility 

based upon each area’s risk to patients 

or residents, and would no longer 

require the facility to implement 

requirements in discriminately 

throughout an entire facility. Based 

upon a risk assessment conducted by 

qualified facility personnel, 

implementation of less stringent 

requirements may be appropriate for 

areas presenting a lower risk to patients 

or residents, while implementation of 

more stringent requirements is reserved 

for areas presenting a higher risk. This 

will allow health care facilities to apply 

the most appropriate level of protection 

in an efficient and economical manner. 

There are four categories utilized in 

the risk assessment methodology, 

depending on the types of treatment and 

services being provided to patients or 

residents. Section 4.1.1 of NFPA 99 

describes Category 1 as, ‘‘Facility 

systems in which failure of such 

equipment or system is likely to cause 

major injury or death of patients or 

caregivers . . . .’’ Section A.4.1.1 

provides examples of what a major 

injury could include, such as 

amputation or a burn to the eye. Section 

4.1.2 describes Category 2 as, ‘‘Facility 

systems in which failure of such 

equipment is likely to cause minor 

injury to patients or caregivers . . . .’’ 

Section A.4.1.2 describes a minor injury 

as one that is not serious or involving 

risk of life. Section 4.1.3 describes 

Category 3 as, ‘‘Facility systems in 

which failure of such equipment is not 

likely to cause injury to patients or 

caregivers, but can cause patient 

discomfort . . . .’’ Section 4.1.4 

describes Category 4 as, ‘‘Facility 

systems in which failure of such 

equipment would have no impact on 

patient care . . . .’’ 

Section 4.2 would require that each 

facility that is a health care or 

ambulatory occupancy define its risk 

assessment methodology, implement the 

methodology and document the results. 

We do not propose to require the use of 

any particular risk assessment 

procedure. Section A.4.2 provides 

examples of appropriate risk assessment 

procedures, such as ISO/IEC31010, Risk 

management—Risk Assessment, or 

NFPA 551, Guide for the Evaluation of 

Fire Risk Assessments. 

Chapter 5—Gas and Vacuum Systems 

The hazards addressed in Chapter 5 

include the ability of oxygen and 

nitrous oxide to exacerbate fires, safety 

concerns from the storage and use of 

pressurized gas, and the reliance upon 

medical gas and vacuum systems for 

patient care. Adopting Chapter 5 would 

ensure a minimal level of the 

performance, maintenance, installation, 

and testing of piped medical gas and 

vacuum systems in all patient and 

resident care areas (for example, 

operating rooms, intensive care units, 

critical care units, procedure rooms, and 

sleeping rooms). Chapter 5 would not 

mandate the installation of any systems; 

rather, if they are installed or are 

required to be installed, the systems 

would be required to comply with 

NFPA 99. 

Chapter 5 covers the performance, 

maintenance, installation, and testing of 

the following: 

• Nonflammable medical gas systems 

with operating pressure below a gauge 

pressure of 300 psi; 

• Vacuum systems in health care 

facilities; 

• Waste anesthetic gas disposal 

systems (WAGD); and 

• Manufactured assemblies that are 

intended for connection to the medical 

gas, vacuum, or WAGD systems. 

The NFPA 99 defines key terms that 

are used frequently throughout this 

chapter as follows: 

Section 3.3.108—Medical Gas Systems 

Medical gas systems are an assembly 

of equipment and piping for the 

distribution of nonflammable medical 

gases such as oxygen, nitrous oxide, 

compressed air, carbon dioxide, and 

helium. 

Section 3.3.110—Medical-surgical 

Vacuum 

Medical-surgical vacuum systems are 

used to provide a source of drainage, 

aspiration, and suction in order to 

remove body fluids from patients. 

Section 3.3.183—Waste Anesthetic Gas 

Disposal Systems (WAGD) 

A WAGD system is the process of 

capturing and carrying gases vented 

from the patient breathing circuit during 

the normal operation of gas anesthesia 

or analgesia equipment. 

Section 3.3.111—Medical-Surgical 

Vacuum System 

A medical-surgical vacuum system is 

an assembly of central vacuumproducing equipment and a network of 

piping for patient suction in medical, 

surgical, and WAGD applications. 

Section 3.3.102—Manufactured 

Assembly 

A manufactured assembly is a factoryassembled product that contains 

medical gas or vacuum outlets, piping, 

or other devices related to medical gas. 

Chapter 5 is organized by category as 

described in Chapter 4. The NFPA 

Technical Committee on Medical Gas 

did not find there was a need for 

Category 4 requirements, as Category 4 

facilities would not ordinarily have 

piped medical gas or vacuums. Chapter 

5 includes several sections, described 

below, which are significant to 

managing the hazards associated with 

gas and vacuum systems. 

Section 5.1.3—Category 1 Sources 

This section includes information on 

the management of the sources for the 

medical gas, vacuum, WAGD, and 

instrument supply systems. It requires 

facilities to identify and label storage 

containers and other system 

components. It also contains 

requirements related to areas used to 

store gas and equipment, and how to 

handle gas cylinders and containers. 

Facilities would be required to design 

and construct systems and storage 

locations in accordance with the 

requirements for this section. This 

section also regulates the requirements 

for construction materials and 

placement of system components, and 

requirements for emergency power and 

quality assurance. 


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Section 5.1.9—Category 1 Warning 

Systems 

This section includes information on 

the requirements for warning systems 

that monitor piped gas and vacuum 

systems. Warning systems monitor and 

alert the facility if a condition exists that 

could have a negative effect on the 

health and safety of patients, staff, and 

visitors. This section regulates the 

functions, capabilities, placement, 

labeling, emergency power, wiring, 

computer systems, initiating devices, 

and monitoring requirements for master, 

area, and local alarm systems. 

Section 5.1.10—Category 1 Distribution 

This section includes information on 

the requirements for the piping system 

for medical gas, vacuum, and WAGD 

systems. It regulates piping system 

installation, location, assembly, 

cleaning, and materials of construction, 

inspection, and installer qualifications. 

Section 5.1.14—Category 1 Operation 

and Management 

This section includes information on 

the operation and maintenance of 

medical gas, vacuum, WAGD and 

support gas systems. Issues addressed in 

this section include system limitations, 

maintenance programs, inspection and 

testing, management of flexible 

connections, piping and valve labeling, 

and recordkeeping. This section allows 

facilities flexibility in meeting the 

maintenance program requirements by 

focusing on the basic goals, timing, and 

qualifications for performing the work. 

NFPA 99 would not require a specific 

schedule, allowing a facility to 

determine the frequency of maintenance 

based on the original quality, age and 

longevity, and known characteristics of 

the equipment. 

Section 5.2 Category—2 Piped Gas and 

Vacuum Systems and 5.3 Category 3 

Piped Gas and Vacuum Systems 

Category 2 requirements apply to 

facilities treating patients who might 

require the gases occasionally, but 

ordinarily would not require them. 

When the use of gas is required for 

patient care, the need is short term. The 

provisions for Category 2 are virtually 

the same as for Category 1, except some 

equipment is permitted to be simplex 

rather than duplex. Category 3 applies 

to office-based care, where gases are 

used in such a manner that the life of 

the patient is never at issue in the event 

of failure of gas. Many requirements in 

the Category 3 section are similar to the 

requirements in Category 1 and Category 

2. 

Chapter 6—Electrical Systems 

The hazards addressed in Chapter 6 

are related to the electrical power 

distribution systems in health care 

facilities, and address issues such as 

electrical shock, power continuity, fire, 

electrocution, and explosions that might 

be caused by faults in the electrical 

system. Although these threats are 

present in any facility, the 

vulnerabilities of patients or residents in 

health care facilities, coupled with the 

complexity of the systems involved, 

create a need for distinct considerations. 

Chapter 6 covers the performance, 

maintenance, and testing of both the 

normal and essential electrical systems 

(EES) in health care facilities. The 

normal electrical system is comprised of 

a normal power supply, typically 

provided by a public utility, connected 

to the facility electrical distribution 

system and ancillary equipment. The 

normal electrical system supplies power 

to the health care facility under normal 

operating conditions. An EES is 

comprised of an alternate source of 

power, typically a generator, connected 

to the facility’s separate essential 

electric distribution systems and 

ancillary equipment. An EES is 

designed to ensure continuity of 

electrical power to designated areas and 

functions of a health care facility during 

a disruption of the normal power 

sources, and also to minimize 

disruptions with the internal wiring 

system (3.3.48). 

Certain provisions in Chapter 6 

related to the normal power system are 

defined by category as described in 

Chapter 4; however, all EES provisions 

are organized by ‘‘Type.’’ Category 1 

systems are the most reliable and 

complex, because patients being served 

by these systems are the most 

dependent on this system to function 

properly and will be at the greatest risk 

if the system fails. Category 2 systems 

are a step down from Category 1 

systems, and Category 3 systems are 

another step down. Critical care rooms 

(Category 1) would be required to be 

served by a Type 1 EES, general care 

rooms would be required to be served 

by a Type 1 or Type 2 EES, and basic 

care rooms and non-patient care rooms 

are not required to be served by any 

EES. 

Chapter 6 includes several sections, 

which are significant to managing the 

hazards associated with the normal 

electrical system. Subject areas include: 

Section 6.3.1—Sources 

This section requires each linepowered electrical appliance in a health 

care facility to be supported by sources 

and distribution systems that provide 

power adequate for each service. 

Section 6.3.2—Distribution 

This section includes information on 

the electrical distribution systems 

within a health care facility. Some of the 

issues addressed include: 

• Electrical system installation; 

• Specific requirements for patient 

care rooms (circuits, overcurrent 

protection, receptacles, wet locations); 

• Ground-fault protection; and 

• Isolated power systems. 

Section 6.3.3—Performance Criteria and 

Testing 

This section includes information on 

electrical system performance criteria. 

Electrical systems that support patient 

rooms would be required to be tested in 

order to ensure that they are safe and 

reliable. Some of the issues addressed 

include: 

• Grounding system testing; 

• Voltage measurements; 

• Impedance measurements; 

• Testing equipment; 

• Receptacle testing; 

• Isolated power systems testing; and 

• Ground-fault protection testing. 

Section 6.3.4—Administration of 

Electric System 

This section includes information on 

the frequency of electrical system 

component testing and record keeping 

requirements. Where hospital-grade 

receptacles are required at patient bed 

locations and in locations where deep 

sedation or general anesthesia is 

administered, testing must be performed 

after initial installation, replacement, or 

servicing of the device. Receptacles not 

listed as hospital-grade must be tested 

in intervals not exceeding 12 months. 

The minimum acceptable 

documentation would identify what was 

tested, when it was tested, and whether 

it performed successfully. 

Chapter 6 also includes several 

sections related to managing the hazards 

associated with the EES, including but 

not limited to: 

Section 6.4.1—Sources (Type 1 EES) 

This section includes specific 

information for on-site generators used 

as an alternate source of power. 

Generator requirements focus on design 

considerations, generator types, 

allowable uses, generator placement and 

protection, capacity, rating, heating, 

cooling, ventilating, battery 

maintenance, fuel supply, and generator 

monitoring. In addition, this section 

addresses batteries used as alternate 

sources of power, as permitted. 


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Section 6.4.2—Distribution (Type 1 

EES) 

This section includes information on 

the EES distribution systems and 

ancillary equipment in a health care 

facility. It covers topics such as transfer 

switches; division of distribution system 

into three branches—life safety, critical, 

and equipment; and wiring 

requirements. 

Section 6.4.3—Performance Criteria and 

Testing (Type 1 EES) 

This section includes information on 

EES performance criteria to assure that 

the EES is safe and reliable. It includes 

a requirement that all functions of the 

life safety branch and critical branches 

must be automatically restored to 

operation within 10 seconds after 

interruption of the normal power 

source. It also includes specific transfer 

switch requirements related to 

placement, voltage drop, load transfer, 

and normal power restoration. 

Section 6.4.4—Administration (Type 1 

EES) 

This section includes general 

information on the maintenance, 

inspection and testing of the EES 

alternate power source, including 

generator testing criteria, test 

conditions, and testing personnel 

qualifications. Specific maintenance, 

inspection and testing requirements are 

also required through reference to NFPA 

110, Standard for Emergency and 

Standby Power Systems. In addition, 

this section addresses the maintenance 

and testing of EES circuitry and record 

keeping requirements. 

Section 6.5—Essential Electrical System 

Requirements—Type 2 

Section 6.5 addresses Type 2 EES 

requirements, which share many of the 

Type 1 EES requirements related to 

maintenance, inspection, and testing. 

The major difference between a Type 1 

and Type 2 EES is that a Type 2 EES 

only requires two separate branches—a 

Life Safety branch and an Equipment 

branch. A Type 2 EES does not require 

a branch to supply a limited amount of 

lighting and power service that is 

considered essential for life safety and 

effective operation to critical care areas 

during the time the normal electrical 

service is interrupted. 

Section 6.6—Essential Electrical System 

Requirements—Type 3 

Section 6.6 addresses Type 3 EES 

requirements, which share many of the 

Type 1 EES requirements related to 

maintenance, inspection, and testing. 

The major difference between a Type 1 

or Type 2 EES and a Type 3 EES system 

is that a Type 3 EES system comprises 

only one electrical branch to supply a 

limited amount of lighting and power 

service that is considered essential for 

life safety and orderly cessation of 

procedures during the time normal 

electrical service is interrupted. Type 3 

EES systems are not permitted in areas 

where surgery is performed. In addition, 

the alternative power for a Type 3 

system can be a generator, battery 

system, or self-contained battery integral 

with the equipment. 

Chapter 9—Heating, Ventilation, and 

Air Conditioning (HVAC) 

Chapter 9 is a newly added chapter to 

the 2012 edition of the NFPA 99 and 

requires HVAC systems serving spaces 

or providing health care functions to be 

in accordance with the American 

Society of Heating, Refrigeration and 

Air-Conditioning Engineers (ASHRAE) 

Standard 170—Ventilation of Health 

Care Facilities (2008 edition) (http://

www.ashrae.org). The purpose of a 

HVAC system is to create acceptable 

indoor air quality. Heating is the process 

of bringing heat to different spaces using 

a variety of sources. Ventilating is the 

process of removing or changing air in 

a space to create a different temperature 

or to reduce or remove moisture, odors, 

smoke, dust, gases and microbes within 

a space. Air conditioning is the removal 

of heat from a space. 

Chapter 9 does not apply to existing 

HVAC systems, but would apply to the 

construction of new health care 

facilities, and the altered, renovated, or 

modernized portions of existing systems 

or individual components. Chapter 9 

would ensure minimum levels of 

heating, ventilation and air conditioning 

performance in patient and resident care 

areas. Some of the issues discussed in 

Chapter 9 are: 

• HVAC system energy conservation; 

• Commissioning; 

• Piping; 

• Ductwork; 

• Acoustics; 

• Requirements for the ventilation of 

medical gas storage and trans-filling 

areas; 

• Waste anesthetic gases; 

• Plumes from medical procedures; 

• Emergency power system rooms; 

and 

• Ventilation during construction. 

Chapter 9 includes several sections, 

which are of significant importance to 

managing the hazards associated with 

HVAC systems, including but not 

limited to: 

Section 9.3.1—Heating, Cooling, 

Ventilating, and Process Systems 

The purpose of this section is to 

define design requirements for 

ventilation systems in order to assure an 

environment that is comfortable and 

clean, and that minimizes odors in 

health care facilities. These 

requirements also apply to patient care 

areas and other related support areas 

within a health care facility. This 

section considers chemical, physical 

and biological contaminants that can 

affect the delivery of medical care to 

patients, the recovery of patients, and 

the safety of patients, health care 

workers, and visitors. 

Section 9.3.3—Commissioning 

This section requires HVAC system 

commissioning to follow ASHRAE 

Guideline 0, The Commissioning 

Process, and ASHRAE Guideline 1.1, 

HVAC & R Technical Requirements for 

the commissioning process, or other 

publically viewed documents 

acceptable to the authority having 

jurisdiction. Commissioning is a 

quality-oriented process for verifying 

new HVAC systems and assemblies 

meet performance objectives and 

criteria. For purposes of this rule, we 

would consider ASHRAE Guideline 0 

and ASHRAE Guideline 1.1 as the only 

acceptable documents guiding the 

commissioning process. 

Section 9.3.5—Ductwork 

This section requires health care 

facilities to use ductwork systems that 

comply with NFPA 90, Standard for the 

Installation of Air-Conditioning and 

Ventilation Systems or other mechanical 

codes. NFPA 90 covers the construction, 

installation, operation, and maintenance 

of HVAC systems to protect life and 

property from fire, smoke, and gases 

resulting from a fire. NFPA 90A is also 

cross-referenced in the 2012 edition of 

the LSC. 

Section 9.3.7—Medical Gas Storage or 

Transfilling 

This section addresses the ventilation 

requirements for both medical gas 

storage and transfilling areas. 

Transfilling is the process of transferring 

a medical gas in gaseous or liquid state 

from one container or cylinder to 

another container or cylinder (3.3.176). 

Some of the requirements included in 

this section are for natural and 

mechanical ventilation. 

Section 9.3.8—Waste Gas 

This section requires the removal of 

gases vented from the patient breathing 

circuit during the normal operation of 

gas anesthesia or analgesia equipment 

by a WAGD system, as described in 

chapter 5, or by an active or passive 

scavenging ventilation system. 


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Section 9.3.10—Emergency Power 

System Room 

This section requires operation of the 

emergency power supply to be in 

accordance with NFPA 110, Standard 

for Emergency and Standby Power 

Systems. NFPA 110 addresses 

ventilation requirements including, 

maintaining room temperature, 

adequate supply of air for generator 

combustion and cooling, air supply 

quality, and generator radiator and 

exhaust discharge. NFPA 110, in its 

entirety, is also cross-referenced in the 

2012 edition of the LSC. 

Chapter 10—Electrical Equipment 

Chapter 10 covers the performance, 

maintenance, and testing of electrical 

equipment in health care facilities. 

Much of this chapter applies to 

requirements for portable electrical 

equipment in health care facilities, but 

there are also requirements for fixedequipment and information on 

administrative issues. There has been an 

increased need for electrical equipment 

safety requirements due to the increase 

in the use of electrical circuits and 

multiple appliances that are located 

close to the patient’s body, including 

situations where they enter the patient’s 

body (such as internal defibrillators, and 

neurostimulators). Chapter 10 includes 

several sections, which may reduce the 

instances of patient injuries and death 

due to electrical appliances and 

equipment, including, but not limited 

to: 

Section 10.2—Performance Criteria and 

Testing for Patient Care—Related 

Electrical Appliances and Equipment 

This section includes information on 

the connection of equipment, grounding 

of equipment, power cords, and the 

proper use of electrical plug adapters 

and extension cords. This section also 

discusses the proper materials to use to 

ensure electrical safety. 

Section 10.3—Testing Requirements— 

Fixed and Portable 

This section discusses the proper 

testing procedure for patient care 

electrical equipment, both visually and 

physically, to ensure that leakage 

currents, which may cause electrical 

shocks, are minimized or eliminated. 

Section 10.4—Nonpatient Electrical 

Appliances and Equipment 

This section discusses the proper 

testing procedure of equipment that may 

not be patient care related, but may be 

in the vicinity of the patient and could 

pose an electrical hazard to the patient, 

if not properly inspected. Nonpatient 

electrical appliances may include: 

Entertainment devices, computers, 

displays and such. 

Section 10.5—Administration 

This section requires facilities to 

ensure that there are policies in place 

for the testing and maintenance of 

equipment, for the proper use of 

electrical equipment in the 

administration of oxygen therapy, and 

for the proper use of electrical 

equipment in an oxygen enriched 

environment. This section also includes 

requirements for the use, inspection, 

and maintenance of equipment found in 

laboratories. Section 10.5.6 requires that 

a facility would keep records related to 

the performance testing and repairs of 

patient care equipment. Section 10.5.8 

would require that equipment be used 

and maintained by qualified and trained 

personnel. 

Chapter 11—Gas Equipment 

The hazards addressed in Chapter 11 

relate to general fire, explosions, and 

mechanical issues associated with gas 

equipment, including compressed gas 

cylinders. Fire and explosions may be 

caused by incidents involving oxygen, 

frequently used in health care facilities, 

or nitrous oxide, frequently used as an 

inhalation anesthetic. Many materials 

commonly used in health care facilities 

are not flammable in room air, but 

become flammable or extremely 

flammable when the concentration of 

oxygen is raised in a room. Mechanical 

hazards are often associated with 

compressed gas cylinders, which are 

generally under high pressures and are 

very heavy in weight. The cylinders can 

cause injury, if not property secured or 

mishandled. If there is physical damage 

to regulators or valves, such damage 

may cause escaping gas to propel the 

cylinder. Use of Chapter 11 would 

ensure a minimal level of performance, 

maintenance, testing, storage, and 

management of gas equipment in all 

patient and resident care areas. 

Chapter 11 includes several sections, 

which may reduce the instances of 

patient injuries and death due to gas 

equipment. The following are important 

provisions of this section: 

Section 11.1—Applicability 

This section includes information on 

the types of medical gases included in 

this chapter such as nonflammable 

medical gases, and vapors and aerosols. 

Section 11.2—Cylinder and Container 

Source 

This section includes information on 

the proper connection of regulators and 

gauges to various types of gas sources to 

prevent cross connections and leakage. 

Section 11.3—Cylinder and Container 

Storage Requirements 

This section includes information on 

the proper storage of cylinders and 

containers, including cryogenic liquid 

containers. It discusses the types of 

enclosures required for storage and 

signage that facility must display. 

Section 11.4—Performance Criteria and 

Testing 

This section includes information on 

the proper testing of portable patient 

care gas equipment that is found in 

health care facilities, proper handling of 

gas containers for respiratory therapy, 

and non-patient gas equipment safety 

procedures. The section also addresses 

special requirements regarding the 

proper handling of gas equipment in 

laboratories. 

Section 11.5—Administration 

This section includes requirements 

for the elimination of potential sources 

of ignition, as well as the servicing and 

maintenance of equipment. There are 

also special handling requirements in 

this section for gases in cylinders, 

liquefied gases in containers, and 

transfilling of cylinders, including the 

transfilling of liquid oxygen. 

Section 11.6—Operation and 

Maintenance of Cylinders 

This section includes requirements 

for the proper procedures for safe 

handling of cylinders and containers. 

This section also requires special 

precautions for handling oxygen 

cylinders and manifolds, and making 

cylinder and container connections. 

Section 11.7—Liquid Oxygen 

Equipment 

This section includes information on 

the safe storage and handling of liquid 

oxygen portable containers and base 

reservoir containers. 

Chapter 14—Hyperbaric Facilities 

Hyperbaric facilities house hyperbaric 

chambers and auxiliary equipment. 

Hyperbaric medicine is the medical use 

of oxygen at a level higher than 

atmospheric pressure. The hyperbaric 

chamber is necessary to adjust the 

ambient pressure required for 

hyperbaric oxygen therapy. Chapter 14 

addresses the hazards associated with 

hyperbaric facilities in health care 

facilities, including electrical, explosive, 

implosive, as well as fire hazards. 

Chapter 14 sets forth minimum 

safeguards for the protection of patients 

and personnel administering hyperbaric 

therapy and procedures. 

Chapter 14 contains requirements for 

hyperbaric chamber manufacturers, 


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hyperbaric facility designers, and 

personnel operating hyperbaric 

facilities. It also contains requirements 

related to construction of the hyperbaric 

chamber itself and the equipment used 

for supporting the hyperbaric chamber, 

as well as administration and 

maintenance. Many requirements in this 

chapter are applicable only to new 

construction and new facilities. 

However, there are some requirements, 

ones that are generally operational in 

nature, that are applicable to existing 

facilities. The 2000 edition of the LSC 

required that all occupancies containing 

hyperbaric facilities must comply with 

NFPA 99; therefore, Chapter 14 is not 

expected to impose a significant burden 

upon existing health care facilities. 

Hyperbaric chambers are classified 

according to the number of human 

occupants in order to establish 

appropriate minimum safeguards in 

construction and operation. Class A 

chambers have multiple occupants, 

Class B chambers are single occupancy, 

and Class C chambers are for animals 

only (no human occupancy ever). 

Chapter 14 includes several sections, 

which are important to managing the 

hazards associated with hyperbaric 

facilities, including, but not limited to: 

Section 14.2—Construction and 

Equipment 

This section includes information on 

the construction and management of 

hyperbaric facilities and hyperbaric 

chambers, including topics such as: 

• Fabrication of the hyperbaric 

chamber; 

• Illumination; 

• Ventilation; 

• Fire protection; 

• Electrical wiring; 

• Electrical equipment; 

• Communication systems; 

• Gas detection and monitoring; and 

• Chamber equipment and fixtures. 

Section 14.3—Administration and 

Maintenance 

This section includes information on 

the administration and maintenance of 

hyperbaric facilities and hyperbaric 

chambers, including topics such as: 

• Recognition of hazards associated 

with hyperbaric facilities; 

• Establishing programs and 

assigning responsibilities to ensure 

safety; 

• Restrictions on ignition sources; 

• Limitations on flammables; 

• Antistatic procedures and 

grounding; 

• Limitations on combustibles; 

• Restrictions and compatibility of 

equipment; 

• Proper handling of gases; 

• Installation, inspection, and 

maintenance of chamber equipment; 

and 

• Electrical and electrostatic 

safeguards. 

The hazards involved in the use of 

hyperbaric facilities can be mitigated 

successfully only when all of the areas 

of hazard are fully recognized by all 

personnel and when the physical 

protection provided is complete and is 

augmented by attention to detail by all 

personnel of administration and 

maintenance having any responsibility 

for the functioning of the hyperbaric 

equipment. This section addresses the 

administration and maintenance of the 

hyperbaric chamber with requirements 

such as the having a Safety Director, 

developing management policies and 

emergency procedures, and fire training 

of personnel involved with the use of 

the chamber. This section also includes 

policies describing what types of 

medical devices or equipment can be 

used in the chamber, along with the safe 

use of medical gases, electrical 

equipment, and fire protection 

equipment used within the chamber 

itself. 

Chapter 15—Features of Fire Protection 

Chapter 15 covers the performance, 

maintenance, and testing of fire 

protection equipment in health care 

facilities. Issues addressed in this 

chapter range from the use of flammable 

liquids in an operating room to special 

sprinkler protection. These fire 

protection requirements are 

independent of the risk-based approach, 

as they are applicable to all patient care 

areas in both new and existing facilities. 

Chapter 15 has several sections taken 

directly from the NFPA 101, including 

requirements for the following: 

• Construction and 

compartmentalization of health care 

facilities; 

• Laboratories; 

• Utilities; 

• Heating, ventilation and air 

conditioning systems; 

• Elevators; 

• Escalators; 

• Conveyors; 

• Rubbish Chutes; 

• Incinerators; 

• Laundry Chutes; 

• Fire detection, alarm and 

communication systems; 

• Automatic sprinklers and other 

extinguishing equipment; 

• Compact storage including mobile 

storage and maintenance; and 

• Testing of water based fire 

protection systems. 

These sections have requirements for 

inspection, testing and maintenance 

which would apply to all facilities, as 

well as specific requirements for 

existing systems and equipment that 

would also apply to all facilities. 

Section 15.13 addresses fire loss 

prevention in operating rooms. This 

section includes requirements for a 

hazard assessment, fire prevention 

procedures, procedures for handling 

flammable germicides and antiseptics, 

emergency procedures, and orientation 

and training. This section sets out 

requirements that may reduce the risk of 

surgical fires, as described below: 

Section 15.13.1—Hazard Assessment 

This section includes information on 

the assessment of hazards that a facility 

could encounter during a surgical 

procedure, and the periodic review of 

surgical operations and procedures. 

Section 15.13.2—Fire Prevention 

Procedures 

This section requires that fire 

prevention procedures be established in 

facilities, but does not prescribe any 

particular procedures. The exact 

procedures to be used are left to the 

discretion of each facility based on its 

unique circumstances, features, and 

needs, and applicable State licensure 

laws and local ordinances 

Section 15.13.3—Germicides and 

Antiseptics 

This section includes information on 

the procedures for the safe handling of 

flammable materials in operating rooms. 

This section also outlines operational 

procedures to address the fire hazards of 

these flammable materials, including 

packaging and material handling, 

removing solution-soaked materials, 

preventing pooling of material, 

preoperative ‘‘time-out’’ period to allow 

for drying before patient draping, and 

establishing policies and procedures to 

outline safety precautions. 

Section 15.13.3.9—Emergency 

Procedures 

This section requires emergency 

procedures to be in place in case of fire, 

or chemical spills in the operating room, 

as well as the procedures for alarm 

activation, evacuation and equipment 

shutdown. 

Section 15.13.3.10—Orientation and 

Training 

This section includes requirements 

for the orientation and training of new 

operating room/surgical suite staff for 

issues such as: 

• Safe practices related to the area 

and equipment; 

• Continuing education; 

• Incident reviews; 


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• Procedure updates; and 

• Fire drills. 

II. Proposed Requirements for Health 

Care Facilities 

This section details the specific 

regulatory changes for each affected 

provider and supplier. Due to the 

similar content and structure of the 

regulations for the various providers 

and suppliers, most of the information 

presented repeats for each provider. 

1. Religious Nonmedical Health Care 

Institutions: Condition of Participation: 

Life Safety From Fire (§ 403.744) 

We propose to maintain most of the 

current provisions for Religious 

Nonmedical Health Care Institutions 

(RNHCI) published in the Federal 

Register on January 10, 2003 (68 FR 

1374), except if it conflicts with the 

2012 LSC and the requirements are not 

within the provisions detailed in 

Section I of this preamble regardless of 

the number of patients the facility 

serves. 

Specifically, we propose to retain the 

requirements at § 403.744(a)(1)(ii) 

related to the prohibition of roller 

latches in health care facilities. We 

propose to update the LSC chapter 

reference from ‘‘19.3.6.3.2 exception 

number 2’’ to ‘‘19.3.6.3.5 numbers 1 and 

2 and 19.3.6.3.6 number 2’’. 

We propose to modify the 

requirements specific to ABHRs since 

most of the requirements in our 

regulation are now included in the 2012 

edition of the LSC. Therefore, we 

propose to remove the requirements at 

§ 403.744(a)(4)(i), (ii), (iv) and (v). We 

propose to retain the requirements at 

§ 403.744(a)(4)(iii) related to protection 

against inappropriate access, and would 

redesignate it at § 403.744(a)(4). 

We propose to add a new requirement 

at § 403.744(a)(5) that would require a 

facility with a sprinkler system that is 

out of service for more than 4 hours in 

a 24-hour period to evacuate the 

building or portion of the building 

affected by the system outage, or 

establish a fire watch until the system 

is back in service, notwithstanding the 

lower standard of the LSC. 

We also propose to add a new 

requirement at § 403.744(a)(6) that 

would retain the 36 inch window sill 

requirement that was in the 2000 

edition of the LSC. 

In addition, we propose to retain the 

requirement at § 403.744(b) related to 

the Secretary’s waiver authority and 

state imposed codes. We do not propose 

to make any changes to this section. 

Furthermore, we propose to remove 

the requirements at § 403.744(c) related 

to the phase-in period for compliance 

with emergency lighting. In the 2003 

final rule, we allowed facilities until 

March 13, 2006, to upgrade their 

emergency lighting equipment. This 

phase-in period has now expired and all 

facilities should be in compliance. 

Therefore, this phase-in provision is no 

longer a necessary regulatory 

requirement. 

We are proposing to add a new 

Condition of Participation at § 403.745 

that would require RNHCIs to comply 

with the 2012 edition of the NFPA 99. 

We propose that chapters 7, 8, 12, and 

13 would not apply to RNHCIs. We also 

propose to allow for waivers of these 

provisions under the same conditions 

and procedures that we currently use for 

waivers of applicable provisions of the 

LSC. 

2. Ambulatory Surgery Centers: 

Condition for Coverage: Environment 

(§ 416.44) 

We propose that all ASCs meet the 

provisions applicable to Ambulatory 

Health Care Centers in the 2012 edition 

of the LSC, except as detailed in section 

I of this preamble, regardless of the 

number of patients the facility serves. 

We believe the protection provided in 

the Ambulatory Health Care Centers 

chapter is necessary to protect the 

health and safety of patients who are 

incapable of caring for themselves at 

any point in time. However, we do not 

believe that the Business Occupancy 

chapter of the LSC (applied by some 

authorities having jurisdiction to ASCs 

treating fewer than 4 patients at a time) 

affords an adequate level of protection 

to patients in an ASC. 

Specifically, we propose to retain the 

provision at § 416.44(b)(2) and (3) 

related to the Secretary’s waiver 

authority and state imposed codes. We 

do not propose to make any changes to 

this section. 

We propose to remove the 

requirements at § 416.44(b)(4) related to 

the phase-in period for compliance with 

emergency lighting. In the 2003 final 

rule, we allowed facilities until March 

13, 2006, to upgrade their emergency 

lighting equipment. This phase-in 

period has now expired and all facilities 

should be in compliance. Therefore, this 

phase-in provision is no longer a 

necessary regulatory requirement. 

We propose to modify the 

requirements specific to ABHRs since 

most of the requirements are now 

included in the 2012 edition of the LSC. 

Specifically, we propose to remove the 

requirements at § 416.44(b)(5)(i), (ii), 

(iv), (A) through (G), and (v). We also 

propose to retain the requirements at 

§ 416.44(b)(5)(iii) related to protection 

against inappropriate access, and would 

redesignate it at § 416.44(b)(4). 

We propose to add a new requirement 

at § 416.44(b)(5) that would require a 

facility with a sprinkler system that is 

out of service for more than 4 hours in 

a 24-hour period to evacuate the 

building or portion of the building 

affected by the system outage, or 

establish a fire watch until the system 

is back in service, notwithstanding the 

lower standard of the 2012 LSC. 

We propose to add a new requirement 

at § 416.44(b)(6) that would require 

facilities with windowless anesthetizing 

locations to have a supply and exhaust 

system that automatically vents smoke 

and products of combustion, prevents 

recirculation of smoke originating 

within the operating room, and prevents 

the circulation of smoke entering the 

system intake. 

We are proposing to add a new 

paragraph at § 416.44(c) that would 

require ASCs to comply with the 2012 

edition of the NFPA 99. We propose that 

chapters 7, 8, 12, and 13 would not 

apply to ASCs. We also propose to allow 

for waivers of these provisions under 

the same conditions and procedures that 

we currently use for waivers of 

applicable provisions of the LSC. 

3. Hospice Care: Condition of 

Participation: Hospices That Provide 

Inpatient Care Directly (§ 418.110) 

We propose that all inpatient hospice 

facilities meet the provisions applicable 

to health care occupancies in the 2012 

edition of the LSC, with the exceptions 

discussed in section I of this preamble, 

regardless of the number of patients 

they serve. We note that this is not a 

change in requirements, but merely a 

clarification that, for LSC purposes, an 

inpatient hospice facility is considered 

a health care occupancy. The LSC does 

not apply to hospice care that is 

provided in a patient’s home. 

We propose to retain the requirements 

at § 418.110(d)(1)(ii) related to the 

prohibition of roller latches in health 

care facilities. We are proposing to 

update the LSC chapter reference from 

‘‘19.3.6.3.2 exception number 2’’ to 

‘‘19.3.6.3.5 numbers 1 and 2 and 

19.3.6.3.6 number 2.’’ In addition, we 

propose to retain the provision at 

§ 418.110(d)(2) and (3) related to the 

Secretary’s waiver authority and state 

imposed codes. We do not propose to 

make any changes to this section. 

We also propose to modify the 

requirements specific to ABHRs because 

most of the requirements are now 

included in the 2012 edition of the LSC. 

Specifically, we propose to remove the 

requirements at § 418.110(d)(4)(i), (ii) 

and (iv). We also propose to retain the 


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requirements at § 418.110(d)(4)(iii) 

related to protection against 

inappropriate access, and would 

redesignate this requirement at 

§ 418.110(d)(4). 

We propose to add a new requirement 

at § 418.110(d)(5) that would require a 

facility with a sprinkler system that is 

out of service for more than 4 hours in 

a 24-hour period to evacuate the 

building or portion of the building 

affected by the system outage, or 

establish a fire watch until the system 

is back in service, notwithstanding the 

lower standard of the 2012 LSC. 

We also propose to add a new 

requirement at § 418.110(d)(6) that 

would retain the 36 inch window sill 

requirement that was in the 2000 

edition of the LSC. 

We are proposing to add a new 

paragraph at § 418.110(e) that would 

require hospices to comply with the 

2012 edition of the NFPA 99. We 

propose that chapters 7, 8, 12, and 13 

would not apply to hospices. We also 

propose to allow for waivers of these 

provisions under the same conditions 

and procedures that we currently use for 

waivers of applicable provisions of the 

LSC. 

4. Programs of All-Inclusive Care for the 

Elderly (PACE): Condition of 

Participation: Physical Environment 

(§ 460.72) 

We propose to retain most of the 

provisions of the existing final 

regulation for Programs of All-Inclusive 

Care for the Elderly (PACE) published in 

the Federal Register on January 10, 

2003 (68 FR 1374), regardless of the 

number of patients the PACE facility 

serves. PACE providers would continue 

to be required to meet LSC 

specifications for the type of facilities in 

which the programs are located (that is, 

hospitals, and office buildings). 

Specifically, we propose to retain the 

requirements at § 460.72(b)(1)(ii) related 

to the prohibition of roller latches in 

health care facilities. We are proposing 

to update the LSC chapter reference 

from ‘‘19.3.6.3.2 exception number 2’’ to 

‘‘19.3.6.3.5 numbers 1 and 2 and 

19.3.6.3.6 number 2.’’ 

We propose to retain the provision at 

§ 460.72(b)(2)(i) and (ii) related to the 

Secretary’s waiver authority and state 

imposed codes. We do not propose to 

make any changes to this section. 

We propose to remove the 

requirement at § 460.72(b)(3) related to 

the phase-in period for compliance with 

emergency lighting. In the 2003 final 

rule, we allowed facilities until March 

13, 2006, to upgrade their emergency 

lighting equipment. This phase-in 

period has now expired and all facilities 

should be in compliance. Therefore, this 

phase-in provision is no longer a 

necessary regulatory requirement. 

We also propose to remove the 

requirements at § 460.72(b)(4) related to 

the prohibition of roller latches in 

health care facilities. In the 2003 final 

rule, we allowed facilities until March 

13, 2006, to replace their existing roller 

latches. This phase-in period has now 

ended, and all facilities should be in 

compliance. Therefore, this phase-in 

provision is no longer a necessary 

regulatory requirement. 

We propose to modify the 

requirements specific to ABHRs because 

most of the requirements are now 

located in the 2012 edition of the LSC. 

Specifically, we proposed to remove the 

requirements at § 460.72(b)(5)(i), (ii), (iv) 

and (v). In addition, we propose to 

retain the requirements at 

§ 460.72(b)(5)(iii) related to protection 

against inappropriate access, and would 

redesignate it at § 460.72(b)(3). 

We propose to add a new requirement 

at § 460.72(b)(4) that would require a 

facility with a sprinkler system that is 

out of service for more than 4 hours in 

a 24-hour period to evacuate the 

building or portion of the building 

affected by the system outage, or 

establish a fire watch until the system 

is back in service, notwithstanding the 

lower standard of the 2012 LSC. 

We are proposing to add a new 

paragraph at § 460.72(d) that would 

require PACE centers to comply with 

the 2012 edition of the NFPA 99. We 

propose that chapters 7, 8, 12, and 13 

would not apply to PACEs. We also 

propose to allow for waivers of these 

provisions under the same conditions 

and procedures that we currently use for 

waivers of applicable provisions of the 

LSC. 

5. Hospitals: Condition of Participation: 

Physical Environment (§ 482.41) 

We propose that the hospital must 

meet the health care occupancy 

provisions of the 2012 edition of the 

LSC, regardless of the number of 

patients the hospital serves. There can 

be multiple occupancy classifications 

within a single hospital. Therefore, 

multiple chapters of the code may be 

applied to a single hospital in 

accordance with the Multiple 

Occupancies provisions in 18.1.3 and 

19.1.3. In addition, we believe that 

hospital outpatient surgical departments 

are comparable to ASCs and thus should 

be required to meet the provisions 

applicable to Ambulatory Health Care 

Occupancy chapters, regardless of the 

number of patients served. 

We propose to retain most of the 

provisions from the existing final 

regulation for hospitals published in the 

Federal Register on January 10, 2003 

(68 FR 1374). Specifically, we propose 

to retain the requirements at 

§ 482.41(b)(1)(ii) related to the 

prohibition of roller latches in health 

care facilities. We are proposing to 

update the LSC chapter reference from 

‘‘19.3.6.3.2 exception number 2’’ to 

‘‘19.3.6.3.5 numbers 1 and 2 and 

19.3.6.3.6 number 2.’’ 

We propose to retain the provision at 

§ 482.41(b)(2) and (3) related to the 

Secretary’s waiver authority and state 

imposed codes. We do not propose to 

make any changes to this section. 

We propose to remove the 

requirements at § 482.41(b)(4) related to 

the phase-in period for compliance with 

emergency lighting. In the 2003 final 

rule, we allowed facilities until March 

13, 2006, to upgrade their emergency 

lighting equipment. This phase-in 

period has now ended, and all facilities 

should be in compliance. Therefore, this 

phase-in provision is no longer a 

necessary regulatory requirement. 

We propose to remove the 

requirements at § 482.41(b)(5) related to 

phase-in period of the prohibition on 

roller latches in health care facilities. 

This provision allowed hospitals a 3 

year period to replace all existing roller 

latches. This phase-in period has now 

expired and all facilities should be in 

compliance. Therefore, this phase-in 

provision is no longer a necessary 

regulatory requirement. 

We propose to retain the requirements 

at § 482.41(b)(7) through (b)(8), and 

would redesignate them at § 482.41(b)(4) 

through (b)(6), without changes. 

In addition, we propose to modify the 

requirements specific to ABHRs since 

most of the requirements are now 

located in the 2012 edition of the LSC. 

We proposed to remove the 

requirements at § 482.41(b)(9)(i), (ii), (iv) 

and (v). We propose to retain the 

requirement at § 482.41(b)(9)(iii) related 

to protection against inappropriate 

access, and would redesignate it at 

§ 482.41(b)(7). 

We are proposing to add a new 

requirement at § 482.41(b)(8) that would 

require a facility with a sprinkler system 

that is out of service for more than 4 

hours in a 24-hour period to evacuate 

the building or portion of the building 

affected by the system outage, or 

establish a fire watch until the system 

is back in service, notwithstanding the 

lower standard of the 2012 LSC. 

We are also proposing to add a new 

requirement at § 482.41(b)(9) that would 

require facilities with windowless 

anesthetizing locations to have a supply 

and exhaust system that automatically 

vents smoke and products of 


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combustion, prevents recirculation of 

smoke originating within the surgical 

suite, and prevents the circulation of 

smoke entering the system intake. 

We also propose to add a new 

requirement at § 482.41(b)(10) that 

would retain the majority of the 36 inch 

window sill requirement that was in the 

2000 edition of the LSC. Newborn 

nurseries and rooms intended for 

occupancy for less than 24 hours, such 

as those housing obstetrical labor beds, 

and recovery beds would be exempt 

from the window sill height 

requirement. The 2000 edition of the 

LSC allowed for observation beds in the 

emergency department to be exempt 

from the 36 inch window sill 

requirement. However, we do not 

propose to incorporate an exemption for 

observation beds, because they are 

frequently occupied for greater than 24 

hours. Therefore, observation beds 

would be required to meet the 36 inch 

window sill requirement. Window sills 

in special nursing care areas, such as 

those housing an intensive care unit, 

critical care unit, hemodialysis, and 

neonatal patients, would not exceed 60 

inches. 

We are proposing to add a new 

paragraph at § 482.41(c) that would 

require hospitals to comply with the 

2012 edition of the NFPA 99. We 

propose that chapters 7, 8, 12, and 13 

would not apply to hospitals. We also 

propose to allow for waivers of these 

provisions under the same conditions 

and procedures that we currently use for 

waivers of applicable provisions of the 

LSC. 

6. Long-Term Care Facilities: Condition 

of Participation: Physical Environment 

(§ 483.70) 

We propose to retain most of the 

provisions of the existing final 

regulation for long-term care facilities 

published in the Federal Register on 

January 10, 2003 (68 FR 1374) regardless 

of the number of residents the facility 

serves. We propose to retain the 

requirements at § 483.70(a)(1)(ii) related 

to the prohibition of roller latches in 

health care facilities. We are proposing 

to update the LSC chapter reference 

from ‘‘19.3.6.3.2 exception number 2’’ to 

‘‘19.3.6.3.5 numbers 1 and 2 and 

19.3.6.3.6 number 2.’’ 

We propose to retain the provision at 

§ 483.70(a)(2) and (3) related to the 

Secretary’s waiver authority and state 

imposed codes. We do not propose to 

make any changes to this section. 

We propose to remove the 

requirements at § 483.70(a)(4) related to 

the phase-in period for compliance with 

emergency lighting. In the 2003 final 

rule, we allowed facilities until March 

13, 2006, to upgrade their emergency 

lighting equipment. This phase-in 

period has now expired and all facilities 

should be in compliance. Therefore, this 

phase-in provision is no longer a 

necessary regulatory requirement. 

We also propose to remove the 

requirements at § 483.70(a)(5) related to 

the phase-in period for the prohibition 

of roller latches in health care facilities. 

In the 2003 final rule, we allowed 

facilities until March 13, 2006, to 

upgrade their door latching equipment. 

This phase-in period has now ended 

and all facilities should be in 

compliance. Therefore, this phase-in 

provision is no longer a necessary 

regulatory requirement. 

We propose to modify the 

requirements specific to ABHRs since 

most of the requirements are now 

included in the 2012 edition of the LSC. 

Specifically, we propose to remove the 

requirements at § 483.70(a)(6)(i), (ii), (iv) 

and (v). We propose to retain the 

requirement at § 483.70(a)(6)(iii) related 

to protection against inappropriate 

access, and would redesignate it at 

§ 483.70(a)(4). 

We propose to retain the requirements 

at § 483.70(a)(7)(i), (ii), (iii), (A) and (B) 

related to installation, inspection, 

testing and maintenance of battery 

operated single station smoke alarms, 

without changes. We are proposing to 

redesignate these requirements at 

§ 483.70(a)(5) (i), (ii), (iii) (A) and (B). 

In addition, we propose to retain the 

requirements at § 483.70(a)(8)(i) and (ii) 

related to the installation of supervised 

automatic sprinklers and the testing, 

inspection and maintenance of the 

sprinkler system. We propose to 

redesignate these requirements as 

§ 483.70(a)(6)(i) and (ii), without 

changes. 

We also propose to add a new 

requirement at § 483.70(a)(7) that would 

retain the 36 inch window sill 

requirement that was in the 2000 

edition of the LSC. 

We are proposing to add a new 

paragraph at § 483.70(b) that would 

require LTCs to comply with the 2012 

edition of the NFPA 99. We propose that 

chapters 7, 8, 12, and 13 would not 

apply to LTCs. We also propose to allow 

for waivers of these provisions under 

the same conditions and procedures that 

we currently use for waivers of 

applicable provisions of the LSC. 

7. Intermediate Care Facilities for 

Individuals With Intellectual 

Disabilities: Condition of Participation: 

Physical Environment (§ 483.470) 

We propose to retain most of the 

provisions of the existing regulation for 

ICFs/IID. ICFs/IID would continue to be 

permitted to meet either the Residential 

Board and Care Occupancies chapter or 

the Health Care Occupancy chapter of 

the LSC, as appropriate, regardless of 

the number of patients the facility 

serves. 

However, we propose not to adopt the 

provisions at Chapters 32.3.2.11.2 and 

33.3.2.11.2, related to ‘‘lockups.’’ This is 

a new provision that has not been 

addressed in this chapter in prior 

editions of the LSC. Lock-ups are 

incidental use areas where occupants 

are secluded or restrained, and; 

therefore, incapable of self-preservation 

in any emergency situation because of 

security measures and other 

circumstances no longer under the 

person’s control. We do not believe that 

lock-ups as described in the LSC are 

appropriate under any circumstances for 

board and care facilities. 

In addition, we propose to retain the 

requirements at § 483.470(j)(1)(ii) 

related to the prohibition of roller 

latches in health care facilities. We are 

proposing to update the LSC chapter 

reference from ‘‘19.3.6.3.2 exception 

number 2’’ to ‘‘19.3.6.3.5 numbers 1 and 

2 and 19.3.6.3.6 number 2.’’ 

We propose to retain the requirements 

at § 483.470(j)(2), (3), and (4). We do not 

propose any changes to the content of 

these sections. 

We propose to remove the 

requirements at § 483.470(j)(5) related to 

the phase-in period for compliance with 

emergency lighting. In the 2003 final 

rule, we allowed facilities until March 

13, 2006, to upgrade their emergency 

lighting equipment. This phase-in 

period has expired and all facilities 

should be in compliance. Therefore, this 

phase-in provision is no longer a 

necessary regulatory requirement. 

We propose to remove § 483.470(j)(6) 

related to the phase-in period for the 

prohibition of roller latches in health 

care facilities. In the 2003 final rule, we 

allowed facilities until March 13, 2006, 

to upgrade their door latching 

equipment. This phase-in period has 

now ended and all facilities should be 

in compliance. Therefore, this phase-in 

provision is no longer a necessary 

regulatory requirement. 

We also propose to retain the 

provision at § 483.470(j)(7)(A) and (B) 

related to the Secretary’s waiver 

authority and state imposed codes. We 

propose to redesignate these provisions 

at § 483.470(j)(5)(A) and (B) without 

change. 

In addition, we propose to modify the 

requirements specific to ABHRs since 

most of the requirements are now 

included in the 2012 edition of the LSC. 

Specifically, we proposed to remove the 

requirements at § 483.470(j)(7)(ii)(A), 


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(B), (D) and (E). We propose to retain the 

requirements at § 483.470(j)(7)(ii)(C) 

related to protection against 

inappropriate access, and would 

redesignate it at § 483.470(j)(5)(ii). 

We propose to add a new requirement 

at § 483.470(j)(5)(iii) that would require 

a facility with a sprinkler system that is 

out of service for more than 4 hours in 

a 24-hour period to evacuate the 

building or portion of the building 

affected by the system outage, or 

establish a fire watch until the system 

is back in service, notwithstanding the 

lower standard of the 2012 LSC. 

We are proposing to add a new 

paragraph at § 483.470(j)(5)(iv) that 

would require ICF–IIDs to comply with 

the 2012 edition of the NFPA 99. We 

propose that chapters 7, 8, 12, and 13 

would not apply to ICF–IIDs. We also 

propose to allow for waivers of these 

provisions under the same conditions 

and procedures that we currently use for 

waivers of applicable provisions of the 

LSC. 

8. Critical Access Hospitals: Condition 

of Participation: Physical Plant and 

Environment (§ 485.623) 

We propose to retain most of the 

provisions of the existing final 

regulation for Critical Access Hospitals 

(CAHs) published in the Federal 

Register on January 10, 2003 (68 FR 

1374), regardless of the number of 

patients the facility serves. Specifically, 

we propose to retain the requirements at 

§ 485.623(d)(1)(ii) related to the 

prohibition of roller latches in health 

care facilities. We are proposing to 

update the LSC chapter reference from 

‘‘19.3.6.3.2 exception number 2’’ to 

‘‘19.3.6.3.5 numbers 1 and 2 and 

19.3.6.3.6 number 2.’’ 

We propose to retain the requirements 

at § 485.623(d)(2) through (d)(4). We do 

not propose to make any changes to 

these sections. 

We propose to remove the 

requirement at § 485.623(d)(5) related to 

the phase-in period for compliance with 

emergency lighting. In the 2003 final 

rule, we allowed facilities until March 

13, 2006, to upgrade their emergency 

lighting equipment. This phase-in 

period has now expired and all facilities 

should be in compliance. Therefore, this 

phase-in provision is no longer a 

necessary regulatory requirement. 

We propose to remove the 

requirement at § 485.623(d)(6) related to 

the phase-in period of the prohibition 

on roller latches in health care facilities. 

This provision allowed CAHs a 3 year 

period to replace all existing roller 

latches. This phase-in period has also 

expired and all facilities should be in 

compliance. Therefore, this phase-in 

provision is no longer a necessary 

regulatory requirement. 

In addition, we propose to modify the 

requirements specific to ABHRs since 

most of the requirements are now 

incorporated in the 2012 edition of the 

LSC. Specifically, we proposed to 

remove the requirements at 

§ 485.623(d)(7)(i), (ii), (iv) and (v). We 

propose to retain the requirement at 

§ 485.623(d)(7)(iii) related to protection 

against inappropriate access, and would 

redesignate it at § 485.623(d)(5). 

We are proposing to add a new 

requirement at § 485.623(d)(6) that 

would require a facility with a sprinkler 

system that is out of service for more 

than 4 hours in a 24-hour period to 

evacuate the building or portion of the 

building affected by the system outage, 

or establish a fire watch until the system 

is back in service, notwithstanding the 

lower standard of the 2012 LSC. 

We are proposing to add a new 

requirement at § 485.623(d)(7) that 

would require facilities with 

windowless anesthetizing locations to 

have a supply and exhaust system that 

automatically vents smoke and products 

of combustion, prevents recirculation of 

smoke originating within the surgical 

suite, and prevents the circulation of 

smoke entering the system intake. 

We also propose to add a new 

requirement at § 485.623(d)(8) that 

would retain the 36 inch window sill 

requirement that was in the 2000 

edition of the LSC. With the exception 

of newborn nurseries and rooms 

intended for occupancy for less than 24 

hours, every sleeping room must have 

an outside window or outside door, and 

the sill height must not exceed 36 

inches above the floor. Special nursing 

care areas shall not exceed 60 inches. 

Windows in atrium walls are considered 

outside windows for the purposes of 

this requirement. 

We are proposing to add a new 

paragraph at § 485.623(e) that would 

require CAHs to comply with the 2012 

edition of the NFPA 99. We propose that 

chapters 7, 8, 12, and 13 would not 

apply to CAHs. We also propose to 

allow for waivers of these provisions 

under the same conditions and 

procedures that we currently use for 

waivers of applicable provisions of the 

LSC. 

III. Collection of Information 

Requirements 

This proposed rule does not impose 

any new reporting, recordkeeping or 

third-party disclosure requirements. 

However, this proposed rule does 

reference the NFPA 99 that has several 

recordkeeping requirements for medical 

gas and vacuum systems, and electrical 

equipment. We believe that 

documenting maintenance and testing is 

a usual and customary business practice 

in accordance with 5 CFR 1320.3(b)(2), 

and would not impose any additional 

information collection burden beyond 

that associated with the normal course 

of business. Consequently, it need not 

be reviewed by the Office of 

Management and Budget under the 

authority of the Paperwork Reduction 

Act of 1995. 

IV. Response to Comments 

Because of the large number of public 

comments we normally receive on 

Federal Register documents, we are not 

able to acknowledge or respond to them 

individually. We will consider all 

comments we receive by the date and 

time specified in the DATES section of 

this preamble, and, when we proceed 

with a subsequent document, we will 

respond to the comments in the 

preamble to that document. 

V. Regulatory Impact Statement 

In accordance with the provisions of 

Executive Order 12866, this regulation 

was reviewed by the Office of 

Management and Budget. 

A. Overall Impact 

We have examined the impacts of this 

rule as required by Executive Order 

12866 on Regulatory Planning and 

Review (September 30, 1993), Executive 

Order 13563 on Improving Regulation 

and Regulatory Review (January 18, 

2011), the Regulatory Flexibility Act 

(RFA) (September 19, 1980, Pub. L. 96– 

354), section 1102(b) of the Social 

Security Act, section 202 of the 

Unfunded Mandates Reform Act of 1995 

(March 22, 1995; Pub. L. 104–4), 

Executive Order 13132 on Federalism 

(August 4, 1999) and the Congressional 

Review Act (5 U.S.C. 804(2). 

Executive Orders 12866 and 13563 

direct agencies to assess all costs and 

benefits of available regulatory 

alternatives and, if regulation is 

necessary, to select regulatory 

approaches that maximize net benefits 

(including potential economic, 

environmental, public health and safety 

effects, distributive impacts, and 

equity). Executive Order 13563 

emphasizes the importance of 

quantifying both costs and benefits, of 

reducing costs, of harmonizing rules, 

and of promoting flexibility. A 

regulatory impact analysis (RIA) must 

be prepared for major rules with 

economically significant effects ($100 

million or more in any 1 year). The 

overall economic impact for this rule is 

estimated to be $41,437,279 in the first 

year of implementation and $7,109,914 


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1The following states submitted data regarding 

the sprinkler status of high-rise buildings 

containing health care facilities—Arizona, 

Arkansas, California, Colorado, Delaware, Hawaii, 

Idaho, Iowa, Kansas, Louisiana, Maine, Maryland, 

Massachusetts, Minnesota, Missouri, Montana, 

Nebraska, Nevada, New Hampshire, New Mexico, 

North Dakota, Oklahoma, Pennsylvania, Rhode 

Island, South Dakota, Texas, Utah, Virginia, 

Washington, and Wyoming. 

after the first year of implementation, 

and annually thereafter for an 11 year 

period. Therefore, this is not an 

economically significant or major rule. 

B. Alternatives Considered 

We could have chosen not to update 

our fire safety provisions. We believe 

that this is not an acceptable alternative 

because many health care facilities 

complete unnecessary work and incur 

unnecessary expense without any gain 

in fire safety by continuing to comply 

with the 2000 edition of the Life Safety 

Code. Many states have adopted 

subsequent editions of the Life Safety 

Code. This has caused confusion for, 

and imposed additional burdens on, 

health care facilities, that must request 

waivers or modify designs to meet the 

requirements of both the state- and 

federally-adopted editions of the LSC. 

Updating the LSC would not only 

relieve the regulatory burden on health 

care providers, but also assist in 

ensuring the health and safety of 

patients and staff. 

We considered proposing an 

alternative phase-in period for the 

requirement to install sprinklers in high 

rise health care occupancies. The LSC 

allows for a 12-year phase-in period, 

which would begin on the day a final 

rule is published. We considered 

shortening this period in order to 

accelerate compliance. However, based 

on our recent experience with requiring 

long term care facilities to install 

sprinklers within 5 years, and the 

difficulties that several facilities have 

faced in meeting this deadline, we have 

learned that a shorter phase-in period is 

not always feasible for facilities. We also 

considered proposing a longer phase-in 

period, but believe that extending 

beyond 12 years set out in the LSC may 

not sufficiently convey the importance 

of this requirement to improving patient 

and staff safety in these buildings. 

Therefore, we have proposed to 

maintain the phase-in length that is 

already part of the LSC, and we are 

specifically requesting public comment 

on the appropriateness of this 

timeframe. 

We considered not proposing separate 

requirements for anesthetizing 

locations, out-of-service sprinkler 

systems, and window sill heights. 

Although the NFPA has removed these 

requirements from the LSC, we felt that 

these were important issues that still 

needed to be required for the safety of 

patients, visitors, and staff. We believe 

that smoke detection systems in 

anesthetizing locations are important 

because there continue to be operating 

room fires and this requirement will 

maintain the safety in operating rooms 

for staff and patients. CMS believes that 

allowing a sprinkler system to be out of 

service for 12 hours before evacuating 

patients or establishing a fire watch is 

too long. Therefore, CMS will continue 

to require the shorter 4 hour timeframe 

that was in the 2000 edition of the LSC. 

Lastly, window sill height requirements 

were eliminated from the 2012 edition 

of the LSC. We believe that this 

requirement is essential to allow easier 

access for emergency personnel in the 

event of a fire or other emergency 

situation. 

We considered not proposing the 

adoption of the NFPA 99 Health care 

Facilities code. However, many 

requirements of the LSC already cross 

reference the NFPA 99, therefore we 

decided to propose adopting the NFPA 

99 because it addresses additional 

building safety topics that are related to 

important fire safety issues. 

We also considered proposing 

adoption of chapters 7, 8, 12, and 13 of 

the NFPA 99, related to information 

technology, plumbing, emergency 

management, and security management. 

We believe that information technology, 

plumbing and security management are 

not within the scope of the conditions 

of participation and conditions for 

coverage. In addition, emergency 

management topics are addressed in our 

December 27, 2013 proposed rule, 

‘‘Medicare and Medicaid Programs: 

Emergency Preparedness Requirements 

for Medicare and Medicaid Participating 

Providers and Suppliers’’ (78 FR 79081). 

C. Anticipated Effects 

1. Hospitals 

Section 19.4.2 of the LSC requires that 

all existing high-rise buildings 

containing health care occupancies be 

protected throughout by an approved, 

supervised automatic sprinkler system. 

This provision was added to the LSC in 

2012 and we anticipate that there would 

be a cost associated with installing the 

sprinklers. Since this is a new provision 

for the 2012 edition of the LSC, only 3 

states have adopted this requirement, 

accounting for 21 high-rise facilities. 

To develop the most accurate estimate 

possible for this provision, we requested 

data from all 50 states regarding the 

sprinkler status of high-rise buildings 

containing health care occupancies, and 

the average square footage needing to be 

sprinklered. Of the 50 states, we 

received some data from 30 states.1 We 

calculated the average number of highrise hospitals for all of the states that 

responded. Overall, 15.64 percent of 

hospitals were located in high-rise 

buildings. We also used the data 

submitted to determine the average 

number of fully, partially and nonsprinklered high-rise buildings in each 

state for which we have data. First, we 

calculated the percentages of fully, 

partially, and non-sprinklered hospitals 

for each state. We then averaged the 

percentage of fully, partially and nonsprinklered buildings across all states 

for which there was data, with a result 

of 84.66 percent of hospitals in high-rise 

buildings being fully sprinklered, 14.6 

percent being partially sprinklered and 

0.74 percent being non-sprinklered. 

Next, we applied these percentages to 

the states that did not respond to our 

data request or that provided a limited 

amount of data. For example, Alabama 

has a total of 125 hospitals. Based on the 

data from states that submitted 

information, we know that, on average, 

15.64 percent of hospitals have high-rise 

buildings, for an estimated 20 high-rise 

hospitals in Alabama. We used this 

same methodology to estimate the 

average number of high-rise hospitals in 

all of the states that did not respond to 

our data request or that provided only 

a limited amount of data, for a total of 

386 high-rise hospitals. Of the 386 

estimated high-rise hospitals in states 

that did not respond, we estimate there 

are 339 fully sprinklered, 56 partially 

sprinklered, and 3 non-sprinklered. We 

note that these numbers do not directly 

match because there was limited actual 

data available for the state of 

Massachusetts. The number of high rise 

hospitals in Massachusetts is included 

in the count of states for which we have 

reported data. However, because we did 

not receive a breakdown of those highrise hospitals by their current sprinkler 

status, we used the methodology 

described above to estimate the 

distribution of fully sprinklered, 

partially sprinklered, and nonsprinklered high-rise hospitals in that 

state. 

We combined this information with 

the information from the states that 

submitted data to develop an estimate of 

858 high-rise facilities with health care 

occupancies throughout all 50 states 

(472 high-rise facilities in states that 

submitted data + 386 estimated highrise facilities in states that did not 

submit data). We estimate that 682 of 

those high-rise facilities are fully 


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2The following states provided data regarding the 

average square footage for partially sprinklered 

high-rise facilities containing health care facilities— 

California, Hawaii, Iowa, Kansas, Nebraska, 

Pennsylvania, Virginia, and Washington. 

3The following states provided data regarding the 

average square footage for non-sprinklered high-rise 

facilities containing health care facilitiesCalifornia, Hawaii, and Iowa. 

sprinklered, 169 are partially 

sprinklered, and 7 are not sprinklered. 

We also requested that the 50 states 

submit information regarding the area 

(measured in square feet) per partially 

sprinklered and non-sprinklered facility 

that does not currently have sprinklers. 

Only 8 states supplied data regarding 

the area to be sprinklered in partially 

sprinklered facilities.2 In addition, 3 

states supplied data regarding the area 

to be sprinklered in non-sprinklered 

facilities.3 We did not specify size and 

age data. Of the states that responded 

with square footage data, we estimate 

that an average partially sprinklered 

facility would need to install sprinklers 

to protect 37,173 square feet, and an 

average non-sprinklered facility would 

need to install sprinklers to protect 

127,667 square feet. Regardless of the 

square footage, any facility in a high-rise 

building 75’ and over is required to be 

sprinklered. We recognize that these 

averages are based on very limited data 

submitted by the states, and we 

welcome public comment and/or 

additional data submission that would 

help us improve the accuracy of these 

estimates. 

We applied all of the data submitted 

and averages calculated to figure out the 

total average area that will need to be 

sprinklered in all partially sprinklered 

facilities and non-sprinklered facilities, 

and the cost associated with that 

installation. Based on the information 

provided by the public in comments 

received on the hospital conditions of 

participation (76 FR 65891), the cost per 

square foot to install sprinklers is 

approximately $11. We estimated that 

there are 169 partially sprinklered 

facilities that would install sprinklers to 

cover an average of 37,173 square feet 

per facility, for a total of 6,282,237 

square feet. At an estimated cost of $11 

per square foot to install sprinklers, we 

estimate a total cost of $69,104,607 for 

all partially sprinklered facilities 

(6,282,937 square feet × $11 per square 

foot). We estimate that an average 

partially sprinklered facility would 

spend $408,903 to complete the 

sprinkler installation (37,173 square feet 

per facility × $11 per square foot). 

We estimated that there are 7 nonsprinklered facilities nationwide, and 

that an average non-sprinklered facility 

would install sprinklers for, 127,667 

square feet, for a total of 893,669 square 

feet (7 facilities × 127,667 square feet 

per facility). At an estimated cost of $11 

per square foot to install sprinklers, we 

estimate that it would cost $9,830,359 

for all non-sprinklered facilities to 

install sprinklers in their facilities. We 

estimate that an average non-sprinklered 

facility would spend $1,404,337 per 

facility (127,667 square feet × $11 per 

square foot). 

We estimate the total cost associated 

with the installation of sprinklers in 

partially sprinklered and nonsprinklered facilities to be $78,934,966 

($69,104,607 for all partially sprinklered 

facilities + $9,830,359 for all nonsprinklered facilities). This cost would 

be distributed over a phase-in period of 

12 years, per the phase-in period 

established within the LSC, or an 

average yearly cost of $6.6 million. 

2. Ambulatory Surgical Centers 

Sections 20.3.2.1 and 21.3.2.1 of the 

LSC requires all doors to hazardous 

areas to be self-closing or automatic 

closing. This provision was added to the 

LSC in 2003, and we anticipate that 

there would be a cost associated with 

installing the self-closing or automatic 

closing doors. Since 2003, 35 states have 

adopted this requirement, accounting 

for 4,149 ASCs. As of December 2012, 

there were 5,444 total Medicare and 

applicable Medicaid participating ASCs. 

The 1,295 remaining facilities would be 

required to upgrade their door closing 

mechanisms to meet this requirement. 

The estimated cost per door is $349, and 

we would assume the average facility 

has 3 hazardous areas that would 

require a replacement door closing 

mechanism for a total cost of $1,047 per 

facility. The anticipated cost is 

$1,355,865. 

3. Intermediate Care Facilities for 

Individuals With Intellectual 

Disabilities 

Sections 32.2.3.5.7 and 33.2.3.5.7 of 

the LSC requires attics of new and 

existing facilities to be sprinklered if the 

attic space is used for living purposes, 

including storage and fuel fired 

equipment. Facilities that do not use 

their attics for living purposes may 

choose to install a heat detection system 

in place of the sprinklers. This 

provision was added to the LSC in 2012. 

Since this is a new provision for the 

2012 edition of the LSC, only 3 states 

have adopted this requirement, 

accounting for 78 ICF–IIDs. We are not 

including those 78 facilities in our 

analysis. For purposes of this analysis 

only, we assume that about 10 percent 

(639) of facilities will install a heat 

detection system because they do not 

use the attic for living purposes. As of 

December 2012, there were 6,460 total 

Medicare participating ICF–IIDs. After 

excluding those facilities located in 

states that have already adopted this 

requirement and those that would 

install a heat detection system instead of 

sprinklers, the 5,743 remaining facilities 

would be required to install sprinklers 

in their attics to meet this requirement. 

Installing sprinklers into an unfinished 

attic is less complicated than installing 

sprinklers in a finished hospital, 

therefore the cost per square foot would 

be less to install in attics than hospitals. 

The estimated cost per square foot to 

install sprinklers in an attic is $3.00, 

and the average estimated square 

footage per attic per facility is 1500 

square feet, for a total of $4,500 per ICF– 

IID. We estimate that all ICF–IIDs would 

spend $25,843,500 to install sprinklers 

in their attic spaces. 

Facilities that do not use their attics 

for living purposes may choose to install 

a heat detection system in the attic 

instead of sprinklers. We assume that 

639 facilities will install a heat 

detection system. We estimate the cost 

to install a heat detection system to be 

$1,000 per facility. The anticipated cost 

would be $639,000 for all affected 

facilities to install heat detection 

systems. 

Section 33.3.3.2.3 of the LSC requires 

all hazardous areas in existing facilities 

with impractical evacuation capabilities 

to be separated from other parts of the 

building by a smoke partition. This 

provision was added to the LSC in 2012 

and we anticipate there being a cost 

associated with installing the smoke 

partition. Since this is a new provision 

for 2012, only 3 states have adopted this 

requirement, accounting for 78 ICF– 

IIDs. As of December 2012, there were 

6,460 total Medicare and applicable 

Medicaid participating ICF–IIDs. We do 

not collect data regarding the evacuation 

capability of each ICF–IID. Therefore, 

for purposes of this analysis only, we 

assume that the 6,382 remaining 

facilities will need to install a smoke 

partition around all hazardous areas to 

meet this requirement. The estimated 

cost per smoke partition is $500, and we 

assume that an average ICF–IID would 

need to install 2 smoke partitions for a 

total of $1,000 per facility. The 

anticipated cost is $6,382,000. 

Section 33.3.3.4.6.2 of the LSC 

requires that, when an existing facility 

installs a new fire alarm system, or the 

existing fire alarm system is replaced, 

notification of emergency forces should 

be handled in accordance with section 

9.6.4, which states that notification of 

emergency forces should alert the 

municipal fire department and fire 


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21570 Federal Register / Vol. 79, No. 73 / Wednesday, April 16, 2014 / Proposed Rules 

brigade (if provided) of fire or other 

emergency. This provision was added to 

the LSC in 2012 and we anticipate there 

being a cost associated with upgrading 

a new or existing fire alarm system. 

Since this is a new provision for 2012, 

only 3 states have adopted this 

requirement, accounting for 78 ICF– 

IIDs. As of December 2012, there were 

6,460 total Medicare participating ICF– 

IIDs. The 6,382 remaining facilities 

would be required to add emergency 

notifications capabilities when they 

choose to update or install a new fire 

alarm system. The estimated cost per 

upgrade is $1000. For purposes of this 

analysis only, we assume that about 8.3 

percent (532) of facilities will do this in 

any given year, for an annual cost of 

$532,000 over a 12 year period. 

($1,000 per upgraded alarm system × 

532 facilities in any given year = 

532,000) 

TABLE 1—TOTAL COST FOR IMPLEMENTATION IN YEAR 1 

Requirement Provider type affected 

Cost per 

affected 

provider 

Cost for all 

providers 

High-rise sprinkler installation * .................................... Hospitals, partially sprinklered ...................................... $34,075 $5,758,717 

High-rise sprinkler installation * .................................... Hospitals, non-sprinklered ............................................ 117,028 819,197 

Self-closing or automatic closing doors on hazardous 

areas.

Ambulatory surgical centers ......................................... 1,047 1,355,865 

Sprinklers in Attics (used for living purposes, storage 

or fuel fired equipment).

Intermediate care for individuals with intellectual disabilities.4,500 25,843,500 

Heat detection systems in attics (not used for living 

purposes).

Intermediate care for individuals with intellectual disabilities.1,000 639,000 

Hazardous areas separated by smoke partitions ........ Intermediate care for individuals with intellectual disabilities.1,000 6,382,000 

Upgrade existing or install new fire alarm system with 

emergency forces notification capabilities*.

Intermediate care for individuals with intellectual disabilities.1,000 532,000 

Total ....................................................................... ....................................................................................... ........................ 41,437,279 

* Data presented for a single year of the 12 year phase-in period. 

TABLE 2—TOTAL COST OF IMPLEMENTATION FOR YEARS 2–12 

Requirement Provider type 

affected 

Cost per 

affected 

provider 

Cost for all 

providers 

High-rise sprinkler installation ...................................................................................................... Hospitals, 

partially 

sprinklered 

$34,075 $5,758,717 

High-rise sprinkler installation ...................................................................................................... Hospitals, nonsprinklered 117,028 819,197 

Upgrade existing or install new fire alarm system with emergency forces notification capabilities ............................................................................................................................................ Intermediate 

care for 

individuals 

with 

intellectual 

disabilities 

1,000 532,000 

TOTAL ANNUALLY .............................................................................................................. ........................ ........................ 7,109,914 

OVERALL TOTAL YEARS 2–12 ................................................................................... ........................ ........................ 78,209,054 

TABLE 3—TOTAL COST OF

IMPLEMENTATION FOR ALL YEARS

Year 1 of implementation ..... $41,437,279 

Years 2–12 of implementation .................................... 78,209,054 

TOTAL ........................... 119,646,333 

4. Benefits to Patients/Residents 

As a result of this rule, we believe that 

there would be a decreased risk of 

premature death. A decreased risk of 

premature death is valuable to people 

and that value is symbolized by their 

willingness to pay for such benefits. The 

Department of Transportation found in 

a recent literature review that 

willingness to pay for reductions in the 

risk of premature death equivalent to 

saving one life in expectation is 

typically over $9 million (http://

www.dot.gov/sites/dot.dev/files/docs/

VSL%20Guidance%202013.pdf). 

Although we are not quantifying the 

number of lives that would be saved 

upon implementation of this proposed 

rule due to the lack of data that could 

provide a reliable point estimate, we 

believe that there is potential for such 

a result. 

The RFA requires agencies to analyze 

options for regulatory relief of small 

entities, if a rule has a significant impact 

on a substantial number of small 

entities. For purposes of the RFA, small 

entities include small businesses, 

nonprofit organizations, and 

government agencies. Individuals and 

states are not included in the definition 

of a small entity. For purposes of the 

RFA, most of the providers and 

suppliers that would be affected by this 

rule (hospitals, ASCs, and ICF–IIDs) are 

considered to be small entities, either by 

virtue of their nonprofit or government 

status or by having yearly revenues 

below industry threshold established by 

the Small Business Administration (for 

details, see the Small Business 

Administration’s Web site at http://

www.sba.gov/content/small-businesssize-standards. 


emcdonald on DSK67QTVN1PROD with PROPOSALS2
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We estimate that implementation of 

the high-rise sprinkler requirements of 

this rule will cost all affected hospitals 

approximately $6.6 million total in any 

1 year. That’s a total of $408,903 per 

individual facility that is partially 

sprinklered or $34,075 per year over the 

12 year phase-in period and/$1.4 

million per individual facility that is 

non-sprinklered or $117,028 per year 

over the 12 year phase-in period. We 

estimate the implementation of this rule 

will cost affected ASCs approximately 

$1.4 million in the first year of 

implementation, or $1,047 per ASC. We 

estimate that implementation of this 

rule will cost affected ICF–IIDs 

approximately $32.9 million in the first 

year of implementation, or $6,500 per 

affected ICF–IID. The Department of 

Health and Human Services uses as its 

measure of significant economic impact 

on a substantial number of small entities 

a change in revenues of more than 3 to 

5 percent. Therefore, the Secretary 

proposes to certify that this rule will not 

have a significant impact on a 

substantial number of small entities, 

since the impact will be less than 3 

percent of the revenue. 

In addition, section 1102(b) of the Act 

requires us to prepare a regulatory 

impact analysis if a rule may have a 

significant impact on the operations of 

a substantial number of small rural 

hospitals. This analysis must conform to 

the provisions of section 603 of the 

RFA. For purposes of section 1102(b) of 

the Act, we define a small rural hospital 

as a hospital that is located outside of 

a metropolitan statistical area and has 

fewer than 100 beds. We believe that 

this rule will not have a significant 

impact on the operations of a substantial 

number of small rural hospitals. 

Section 202 of the Unfunded 

Mandates Reform Act of 1995 (UMRA) 

also requires that agencies assess 

anticipated costs and benefits before 

issuing any rule whose mandates 

require spending in any 1 year of $100 

million in 1995 dollars, updated 

annually for inflation. In 2013, that 

threshold is approximately $141 

million. This rule will not have an 

impact on the expenditures of state, 

local, or tribal governments in the 

aggregate, or on the private sector of 

$141 million. 

Executive Order 13132 establishes 

certain requirements that an agency 

must meet when it promulgates a 

proposed rule (and subsequent final 

rule) that imposes substantial direct 

requirement costs on state and local 

governments, preempts state law, or 

otherwise has Federalism implications. 

This rule has no Federalism 

implications. 

List of Subjects 

42 CFR Part 403 

Health insurance, Hospitals, 

Intergovernmental relations, 

Incorporation by reference, Medicare, 

Reporting and recordkeeping 

requirements. 

42 CFR Part 416 

Health facilities, Kidney diseases, 

Incorporation by reference, Medicare, 

Reporting and recordkeeping 

requirements. 

42 CFR Part 418 

Health facilities, Hospice care, 

Medicare, Reporting and recordkeeping 

requirements. 

42 CFR Part 460 

Aged, Health, Incorporation by 

reference, Medicare, Medicaid, 

Reporting and record keeping 

requirements. 

42 CFR Part 482 

Grant programs-health, Hospitals, 

Incorporation by reference, Medicaid, 

Medicare, Reporting and recordkeeping 

requirements. 

42 CFR Part 483 

Grant programs-health, Health 

facilities, Health professions, Health 

records, Incorporation by reference, 

Medicaid, Medicare, Nursing homes, 

Nutrition, Reporting and recordkeeping 

requirements, Safety. 

42 CFR Part 485 

Grant programs—health, Health 

facilities, Incorporation by reference, 

Medicaid, Medicare, Reporting and 

record keeping requirements. 

For the reasons set forth in the 

preamble, the Centers for Medicare & 

Medicaid Services proposes to amend 

42 CFR chapter IV as set forth below: 

PART 403—SPECIAL PROGRAMS AND 

PROJECTS 

■ 1. The authority citation for part 403 

continues to read as follows: 

Authority: Secs. 1102 and 1871 of the 

Social Security Act (42 U.S.C. 1302 and 

1395hh). 

■ 2. Amend § 403.744 by— 

■ A. Revising paragraph (a)(1)(i). 

■ B. Amending paragraph (a)(1)(ii) by 

removing the reference to ‘‘Chapter 

19.3.6.3.2, exception number 2’’ and 

adding in its place ‘‘Chapter 19.3.6.3.5 

numbers 1 and 2 and Chapter 19.3.6.3.6 

number 2’’. 

■ C. Revising paragraph (a)(4). 

■ D. Adding paragraphs (a)(5) and (6). 

■ E. Removing paragraph (c). 

The revisions and additions read as 

follows: 

§ 403.744 Condition of participation: Life 

safety from fire. 

(a)(1) * * * 

(i) Except as otherwise provided in 

this section, the RNHCI must meet the 

applicable provisions of the 2012 

edition of the Life Safety Code of the 

National Fire Protection Association, 

regardless of the number of individuals 

served. The Director of the Office of the 

Federal Register has approved the NFPA 

101® 2012 edition of the Life Safety 

Code, issued August 11, 2011, for 

incorporation by reference in 

accordance with 5 U.S.C. 552(a) and 1 

CFR part 51. A copy of the Code is 

available for inspection at the CMS 

Information Resource Center, 7500 

Security Boulevard, Baltimore, MD or at 

the National Archives and Records 

Administration (NARA). For 

information on the availability of this 

material at NARA, call 202–741–6030, 

or go to: http://www.archives.gov/

federal_register/code_of_federal_

regulations/ibr_locations.html. Copies 

may be obtained from the National Fire 

Protection Association, 1 Batterymarch 

Park, Quincy, MA 02269. If any changes 

in this edition of the Code are 

incorporated by reference, CMS will 

publish notice in the Federal Register to 

announce the changes. 

* * * * * 

(4) The RNHCI may place alcoholbased hand rub dispensers in its facility 

if the dispensers are installed in a 

manner that adequately protects against 

inappropriate access. 

(5) When a sprinkler system is out of 

service for more than 4 hours in a 24- 

hour period, the RHNCI must— 

(i) Evacuate the building or portion of 

the building affected by the system 

outage until the system is back in 

service, or 

(ii) Establish a fire watch until the 

system is back in service. 

(6) Every sleeping room must have an 

outside window or outside door, and 

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. 

* * * * * 

■ 3. Add § 403.745 to read as follow: 

§ 403.745 Condition of participation: 

Building Safety. 

(a) Standard: building safety. Except 

as otherwise provided in this section, 

the RNHCI must meet the applicable 

provisions of the 2012 edition of the 

Health Care Facilities Code of the 

National Fire Protection Association, 


emcdonald on DSK67QTVN1PROD with PROPOSALS2
21572 Federal Register / Vol. 79, No. 73 / Wednesday, April 16, 2014 / Proposed Rules 

regardless of the number of patients 

served. The Director of the Office of the 

Federal Register has approved the NFPA 

99® 2012 edition of the Health Care 

Facilities Code, issued August 11, 2011, 

for incorporation by reference in 

accordance with 5 U.S.C. 552(a) and 1 

CFR part 51. A copy of the Code is 

available for inspection at the CMS 

Information Resource Center, 7500 

Security Boulevard, Baltimore, MD or at 

the National Archives and Records 

Administration (NARA). For 

information on the availability of this 

material at NARA, call 202–741–6030, 

or go to: http://www.archives.gov/

federal_register/code_of_federal_

regulations/ibr_locations.html. Copies 

may be obtained from the National Fire 

Protection Association, 1 Batterymarch 

Park, Quincy, MA 02269. If any changes 

in this edition of the Code are 

incorporated by reference, CMS will 

publish notice in the Federal Register to 

announce the changes. 

(b) Standard: exceptions. Chapters 7, 

8, 12, and 13 of the adopted Health Care 

Facilities Code do not apply to an 

RNHCI. 

(c) Waiver. If application of the Health 

Care Facilities Code required under 

paragraph (a) of this section would 

result in unreasonable hardship upon 

the RNHCI, CMS may waive specific 

provisions of the Health Care Facilities 

Code, but only if the waiver does not 

adversely affect the health and safety of 

individuals. 

PART 416—AMBULATORY SURGICAL 

SERVICES 

■ 4. The authority citation for part 416 

continues to read as follows: 

Authority: Secs. 1102 and 1871 of the 

Social Security Act (42 U.S.C. 1302 and 

1395hh). 

■ 5. Amend § 416.44 by— 

■ A. Revising paragraph (b)(1). 

■ B. Removing paragraph (b)(4). 

■ C. Redesignating paragraph (b)(5) as 

paragraph (b)(4). 

■ D. Revising newly redesignated 

paragraph (b)(4). 

■ E. Adding new paragraphs (b)(5) and 

(6) 

■ F. Redesignating paragraphs (c) and 

(d) as (d) and (e). 

■ G. Adding new paragraph (c). 

The revisions and additions read as 

follows: 

§ 416.44 Condition for coverage— 

Environment. 

* * * * * 

(b) * * * 

(1) Except as otherwise provided in 

this section, the ASC must meet the 

provisions applicable to Ambulatory 

Health Care Centers of the 2012 edition 

of the Life Safety Code of the National 

Fire Protection Association, regardless 

of the number of patients served. The 

Director of the Office of the Federal 

Register has approved the NFPA 101®

2012 edition of the Life Safety Code, 

issued August 11, 2011, for 

incorporation by reference in 

accordance with 5 U.S.C. 552(a) and 1 

CFR part 51. A copy of the Code is 

available for inspection at the CMS 

Information Resource Center, 7500 

Security Boulevard, Baltimore, MD and 

at the National Archives and Records 

Administration (NARA). For 

information on the availability of this 

material at NARA, call 202–741–6030, 

or go to: http://www.archives.gov/

federal_register/code_of_federal_

regulations/ibr_locations.html. Copies 

may be obtained from the National Fire 

Protection Association, 1 Batterymarch 

Park, Quincy, MA 02269. If any changes 

in this edition of the Code are 

incorporated by reference, CMS will 

publish notice in the Federal Register to 

announce the changes. 

* * * 

(4) An ASC may place alcohol-based 

hand rub dispensers in its facility if the 

dispensers are installed in a manner that 

adequately protects against 

inappropriate access. 

(5) When a sprinkler system is out of 

service for more than 4 hours in a 24- 

hour period, the ASC must— 

(i) Evacuate the building or portion of 

the building affected by the system 

outage until the system is back in 

service, or 

(ii) Establish a fire watch until the 

system is back in service. 

(6) In windowless anesthetizing 

locations, the ASC must have a supply 

and exhaust system that— 

(i) Automatically vents smoke and 

products of combustion, 

(ii) Prevents recirculation of smoke 

originating within the surgical suite, 

and 

(iii) Prevents the circulation of smoke 

entering the system intake. 

(c) Standard: building safety. Except 

as otherwise provided in this section, 

the ASC must meet the applicable 

provisions of the 2012 edition of the 

Health Care Facilities Code of the 

National Fire Protection Association, 

regardless of the number of patients 

served. The Director of the Office of the 

Federal Register has approved the NFPA 

99® 2012 edition of the Health Care 

Facilities Code, issued August 11, 2011, 

for incorporation by reference in 

accordance with 5 U.S.C. 552(a) and 1 

CFR part 51. A copy of the Code is 

available for inspection at the CMS 

Information Resource Center, 7500 

Security Boulevard, Baltimore, MD or at 

the National Archives and Records 

Administration (NARA). For 

information on the availability of this 

material at NARA, call 202–741–6030, 

or go to: http://www.archives.gov/

federal_register/code_of_federal_

regulations/ibr_locations.html. Copies 

may be obtained from the National Fire 

Protection Association, 1 Batterymarch 

Park, Quincy, MA 02269. If any changes 

in this edition of the Code are 

incorporated by reference, CMS will 

publish notice in the Federal Register to 

announce the changes. 

(1) Chapters 7, 8, 12, and 13 of the 

adopted Health Care Facilities Code do 

not apply to an ASC. 

(2) If application of the Health Care 

Facilities Code required under 

paragraph (c) of this section would 

result in unreasonable hardship upon 

the ASC, CMS may waive specific 

provisions of the Health Care Facilities 

Code, but only if the waiver does not 

adversely affect the health and safety of 

patients. 

* * * * * 

PART 418—HOSPICE CARE 

■ 6. The authority citation for part 418 

continues to read as follows: 

Authority: Secs. 1102 and 1871 of the 

Social Security Act (42 U.S.C. 1302 and 

1395hh). 

§ 418.108 [Amended] 

■ 7. Amend § 418.108 by— 

■ A. Amending paragraph (a)(2) by 

removing the reference ‘‘§ 418.110(b) 

and (e)’’ and by adding in its place the 

reference ‘‘§ 418.110(b) and (f)’’. 

■ B. Amending paragraph (b)(1)(ii) by 

removing the reference ‘‘§ 418.110(e)’’ 

and by adding in its place the reference 

‘‘§ 418.110(f)’’. 

■ 8. Amend § 418.110 by— 

■ A. Revising paragraph (d)(1)(i). 

■ B. Amending paragraph (d)(1)(ii) by 

removing the reference to ‘‘Chapter 

19.3.6.3.2, exception number 2’’ and 

adding in its place ‘‘Chapter 19.3.6.3.5 

numbers 1 and 2 and Chapter 19.3.6.3.6 

number 2’’. 

■ C. Revising paragraph (d)(4). 

■ D. Adding paragraphs (d)(5) and (6). 

■ E. Redesignating paragraphs (e) 

through (o) as (f) through (p). 

■ F. Adding new paragraph (e). 

The revisions and additions read as 

follows: 

§ 418.110 Condition of participation: 

Hospices that provide inpatient care 

directly. 

* * * * * 

(d)(1) * * * 

(i) Except as otherwise provided in 

this section, the hospice must meet the 


emcdonald on DSK67QTVN1PROD with PROPOSALS2
Federal Register / Vol. 79, No. 73 / Wednesday, April 16, 2014 / Proposed Rules 21573 

provisions applicable to health care 

occupancies of the 2012 edition of the 

Life Safety Code of the National Fire 

Protection Association, regardless of the 

number of patients served. The Director 

of the Office of the Federal Register has 

approved the NFPA 101® 2012 edition 

of the Life Safety Code, issued August 

11, 2011, for incorporation by reference 

in accordance with 5 U.S.C. 552(a) and 

1 CFR part 51. A copy of the code is 

available for inspection at the CMS 

Information Resource Center, 7500 

Security Boulevard, Baltimore, MD or at 

the National Archives and Records 

Administration (NARA). For 

information on the availability of this 

material at NARA, call 202–741–6030, 

or go to: http://www.archives.gov/

federalregister/

codeoffederalregulations/

ibrlocations.html. Copies may be 

obtained from the National Fire 

Protection Association, 1 Batterymarch 

Park, Quincy, MA 02269. If any changes 

in the edition of the Code are 

incorporated by reference, CMS will 

publish a notice in the Federal Register 

to announce the changes. 

* * * * * 

(4) A hospice may place alcohol-based 

hand rub dispensers in its facility if the 

dispensers are installed in a manner that 

adequately protects against access by 

vulnerable populations. 

(5) When a sprinkler system is out of 

service for more than 4 hours in a 24- 

hour period, the hospice must— 

(i) Evacuate the building or portion of 

the building affected by the system 

outage until the system is back in 

service, or 

(ii) Establish a fire watch until the 

system is back in service. 

(6) Every sleeping room must have an 

outside window or outside door, and 

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. 

(e) Standard: Building Safety. Except 

as otherwise provided in this section, 

the hospice must meet the applicable 

provisions of the 2012 edition of the 

Health Care Facilities Code of the 

National Fire Protection Association, 

regardless of the number of patients 

served. The Director of the Office of the 

Federal Register has approved the NFPA 

99® 2012 edition of the Health Care 

Facilities Code, issued August 11, 2011, 

for incorporation by reference in 

accordance with 5 U.S.C. 552(a) and 1 

CFR part 51. A copy of the Code is 

available for inspection at the CMS 

Information Resource Center, 7500 

Security Boulevard, Baltimore, MD or at 

the National Archives and Records 

Administration (NARA). For 

information on the availability of this 

material at NARA, call 202–741–6030, 

or go to: http://www.archives.gov/

federal_register/code_of_federal_

regulations/ibr_locations.html. Copies 

may be obtained from the National Fire 

Protection Association, 1 Batterymarch 

Park, Quincy, MA 02269. If any changes 

in this edition of the Code are 

incorporated by reference, CMS will 

publish notice in the Federal Register to 

announce the changes. 

(1) Chapters 7, 8, 12, and 13 of the 

adopted Health Care Facilities Code do 

not apply to a hospice. 

(2) If application of the Health Care 

Facilities Code required under 

paragraph (e) of this section would 

result in unreasonable hardship upon 

the hospice, CMS may waive specific 

provisions of the Health Care Facilities 

Code, but only if the waiver does not 

adversely affect the health and safety of 

patients. 

* * * * * 

PART 460—PROGRAMS OF ALL 

INCLUSIVE CARE FOR THE ELDERLY 

(PACE) 

■ 9. The authority citation for part 460 

continues to read as follows: 

Authority: Secs. 1102, 1871, 1894(f), and 

1934(f) of the Social Security Act (42 U.S.C. 

1302 and 1395, 1395eee(f), and 1396u–4(f)). 

■ 10. Amend § 460.72 by— 

■ A. Revising paragraph (b)(1)(i). 

■ B. Amending paragraph (b)(1)(ii) by 

removing the reference to ‘‘Chapter 

19.3.6.3.2, exception number 2’’ and 

adding in its place ‘‘Chapter 19.3.6.3.5 

numbers 1 and 2 and Chapter 19.3.6.3.6 

number 2’’. 

■ C. Removing paragraphs (b)(3) and (4). 

■ D. Redesignating paragraph (b)(5) as 

paragraph (b)(3). 

■ E. Revising newly redesignated 

paragraph (b)(3). 

■ F. Adding new paragraph (b)(4) and 

paragraph (d). 

The revisions and addition read as 

follows: 

§ 460.72 Physical environment. 

* * * * * 

(b) * * * 

(1) * * * 

(i) Except as otherwise provided in 

this section, a PACE center must meet 

the applicable provisions of the 2012 

edition of the Life Safety Code (LSC) of 

the National Fire Protection Association 

that apply to the type of setting in 

which the center is located, regardless 

of the number of PACE enrollees served. 

The Director of the Office of the Federal 

Register has approved the NFPA 101®

2012 edition of the Life Safety Code, 

issued August 11, 2011, for 

incorporation by reference in 

accordance with 5 U.S.C. 552(a) and 1 

CFR part 51. A copy of the Code is 

available for inspection at the CMS 

Information Resource Center, 7500 

Security Boulevard, Baltimore, MD or at 

the National Archives and Records 

Administration (NARA). For 

information on the availability of this 

material at NARA, call 202–741–6030, 

or go to: http://www.archives.gov/

federal_register/code_of_federal_

regulations/ibr_locations.html. Copies 

may be obtained from the National Fire 

Protection Association, 1 Batterymarch 

Park, Quincy, MA 02269. If any changes 

in this edition of the Code are 

incorporated by reference, CMS will 

publish notice in the Federal Register to 

announce the changes. 

* * * * * 

(3) A PACE center may install 

alcohol-based hand rub dispensers in its 

facility if the dispensers are installed in 

a manner that adequately protects 

against inappropriate access. 

(4) When a sprinkler system is out of 

service for more than 4 hours in a 24- 

hour period, the PACE center must— 

(i) Evacuate the building or portion of 

the building affected by the system 

outage until the system is back in 

service, or 

(ii) Establish a fire watch until the 

system is back in service. 

* * * * * 

(d) Standard: Building Safety. Except 

as otherwise provided in this section, a 

PACE center must meet the applicable 

provisions of the 2012 edition of the 

Health Care Facilities Code of the 

National Fire Protection Association, 

regardless of the number of patients 

served. The Director of the Office of the 

Federal Register has approved the NFPA 

99® 2012 edition of the Health Care 

Facilities Code, issued August 11, 2011, 

for incorporation by reference in 

accordance with 5 U.S.C. 552(a) and 1 

CFR part 51. A copy of the Code is 

available for inspection at the CMS 

Information Resource Center, 7500 

Security Boulevard, Baltimore, MD or at 

the National Archives and Records 

Administration (NARA). For 

information on the availability of this 

material at NARA, call 202–741–6030, 

or go to: http://www.archives.gov/

federal_register/code_of_federal_

regulations/ibr_locations.html. Copies 

may be obtained from the National Fire 

Protection Association, 1 Batterymarch 

Park, Quincy, MA 02269. If any changes 

in this edition of the Code are 

incorporated by reference, CMS will 


emcdonald on DSK67QTVN1PROD with PROPOSALS2
21574 Federal Register / Vol. 79, No. 73 / Wednesday, April 16, 2014 / Proposed Rules 

publish notice in the Federal Register to 

announce the changes. 

(1) Chapters 7, 8, 12, and 13 of the 

adopted Health Care Facilities Code do 

not apply to a PACE center. 

(2) If application of the Health Care 

Facilities Code required under 

paragraph (d) of this section would 

result in unreasonable hardship upon 

the PACE center, CMS may waive 

specific provisions of the Health Care 

Facilities Code, but only if the waiver 

does not adversely affect the health and 

safety of patients. 

* * * * * 

PART 482—CONDITIONS OF 

PARTICIPATION FOR HOSPITALS 

■ 11. The authority citation for part 482 

continues to read as follows: 

Authority: Secs. 1102, 1871, and 1881 of 

the Social Security Act (42 U.S.C. 1302, 

1395hh, and 1395rr), unless otherwise noted. 

■ 12. Amend § 482.41 by— 

■ A. Revising paragraph (b)(1)(i). 

■ B. Amending paragraph (b)(1)(ii) by 

removing the reference to ‘‘Chapter 

19.3.6.3.2, exception number 2’’ and 

adding in its place ‘‘Chapter 19.3.6.3.5 

numbers 1 and 2 and Chapter 19.3.6.3.6 

number 2’’. 

■ C. Removing paragraphs (b)(4) and (5). 

■ D. Redesignating paragraphs (b)(6) 

through (9) as paragraphs (b)(4) through 

(7), respectively. 

■ E. Revising newly redesignated 

paragraph (b)(7). 

■ F. Adding new paragraphs (b)(8), (9), 

and (10). 

■ G. Redesignating paragraph (c) as 

paragraph (d). 

■ H. Adding new paragraph (c). 

The revisions and additions read as 

follows: 

§ 482.41 Condition of participation: 

Physical environment. 

* * * * * 

(b) * * * 

(1) * * * 

(i) Except as otherwise provided in 

this section, the hospital must meet the 

applicable provisions of the 2012 

edition of the Life Safety Code of the 

National Fire Protection Association, 

regardless of the number of patients 

served. The Director of the Office of the 

Federal Register has approved the NFPA 

101® 2012 edition of the Life Safety 

Code, issued August 11, 2011, for 

incorporation by reference in 

accordance with 5 U.S.C. 552(a) and 1 

CFR part 51. A copy of the Code is 

available for inspection at the CMS 

Information Resource Center, 7500 

Security Boulevard, Baltimore, MD or at 

the National Archives and Records 

Administration (NARA). For 

information on the availability of this 

material at NARA, call 202–741–6030, 

or go to: http://www.archives.gov/

federal_register/code_of_federal_

regulations/ibr_locations.html. Copies 

may be obtained from the National Fire 

Protection Association, 1 Batterymarch 

Park, Quincy, MA 02269. If any changes 

in this edition of the Code are 

incorporated by reference, CMS will 

publish notice in the Federal Register to 

announce the changes. 

* * * * * 

(7) A hospital may install alcoholbased hand rub dispensers in its facility 

if the dispensers are installed in a 

manner that adequately protects against 

inappropriate access; 

(8) When a sprinkler system is out of 

service for more than 4 hours in a 24- 

hour period, the hospital must— 

(i) Evacuate the building or portion of 

the building affected by the system 

outage until the system is back in 

service, or 

(ii) Establish a fire watch until the 

system is back in service. 

(9) In windowless anesthetizing 

locations, the hospital must have a 

supply and exhaust system that— 

(i) Automatically vents smoke and 

products of combustion. 

(ii) Prevents recirculation of smoke 

originating within the surgical suite. 

(iii) Prevents the circulation of smoke 

entering the system intake. 

(10) Except for, newborn nurseries 

and rooms intended for occupancy for 

less than 24 hours, every sleeping room 

must have an outside window or 

outside door, and the sill height must 

not exceed 36 inches above the floor. 

Special nursing care areas shall not 

exceed 60 inches. Windows in atrium 

walls are considered outside windows 

for the purposes of this requirement. 

(c) Standard: building safety. Except 

as otherwise provided in this section, 

the hospital must meet the applicable 

provisions of the 2012 edition of the 

Health Care Facilities Code of the 

National Fire Protection Association, 

regardless of the number of patients 

served. The Director of the Office of the 

Federal Register has approved the NFPA 

99® 2012 edition of the Health Care 

Facilities Code, issued August 11, 2011, 

for incorporation by reference in 

accordance with 5 U.S.C. 552(a) and 1 

CFR part 51. A copy of the Code is 

available for inspection at the CMS 

Information Resource Center, 7500 

Security Boulevard, Baltimore, MD or at 

the National Archives and Records 

Administration (NARA). For 

information on the availability of this 

material at NARA, call 202–741–6030, 

or go to: http://www.archives.gov/

federal_register/code_of_federal_

regulations/ibr_locations.html. Copies 

may be obtained from the National Fire 

Protection Association, 1 Batterymarch 

Park, Quincy, MA 02269. If any changes 

in this edition of the Code are 

incorporated by reference, CMS will 

publish notice in the Federal Register to 

announce the changes. 

(1) Chapters 7, 8, 12, and 13 of the 

adopted Health Care Facilities Code do 

not apply to a hospital. 

(2) If application of the Health Care 

Facilities Code required under 

paragraph (c) of this section would 

result in unreasonable hardship upon 

the hospital, CMS may waive specific 

provisions of the Health Care Facilities 

Code, but only if the waiver does not 

adversely affect the health and safety of 

patients. 

* * * * * 

PART 483—REQUIREMENTS FOR 

STATES AND LONG TERM CARE 

FACILITIES 

■ 13. The authority citation for part 483 

continues to read as follows: 

Authority: Secs. 1102, 1128l and 1871 of 

the Social Security Act (42 U.S.C. 1302 and 

1395hh). 

§ 483.15 [Amended] 

■ 14. In § 483.15, amend paragraph 

(h)(4) by removing the reference 

‘‘§ 483.70(d)(2)(iv)’’ and by adding in its 

place the reference ‘‘§ 483.70(e)(2)(iv)’’. 

■ 15. Amend § 483.70 by— 

■ A. Revising paragraph (a)(1)(i). 

■ B. Amending paragraph (a)(1)(ii) by 

removing the reference to ‘‘Chapter 

19.3.6.3.2, exception number 2’’ and 

adding in its place ‘‘Chapter 19.3.6.3.5 

numbers 1 and 2 and Chapter 19.3.6.3.6 

number 2’’. 

■ C. Removing paragraphs (a)(4) and (5). 

■ D. Redesignating paragraphs (a)(6) 

through (8) as paragraphs (a)(4) through 

(6), respectively. 

■ E. Revising newly redesignated 

paragraphs (a)(4). 

■ F. Adding new paragraph (a)(7). 

■ G. Redesignating paragraphs (b) 

through (h) as paragraphs (c) through (i). 

■ H. Adding new paragraph (b). 

The revisions read as follows: 

§ 483.70 Physical environment. 

* * * * * 

(a)(1) * * * 

(i) Except as otherwise provided in 

this section, the long term care facility 

must meet the applicable provisions of 

the 2012 edition of the Life Safety Code 

of the National Fire Protection 

Association, regardless of the number of 

residents served. The Director of the 

Office of the Federal Register has 


emcdonald on DSK67QTVN1PROD with PROPOSALS2
Federal Register / Vol. 79, No. 73 / Wednesday, April 16, 2014 / Proposed Rules 21575 

approved the NFPA 101® 2012 edition 

of the Life Safety Code, issued August 

11, 2011, for incorporation by reference 

in accordance with 5 U.S.C. 552(a) and 

1 CFR part 51. A copy of the Code is 

available for inspection at the CMS 

Information Resource Center, 7500 

Security Boulevard, Baltimore, MD or at 

the National Archives and Records 

Administration (NARA). For 

information on the availability of this 

material at NARA, call 202–741–6030, 

or go to: http://www.archives.gov/

federal_register/code_of_federal_

regulations/ibr_locations.html. Copies 

may be obtained from the National Fire 

Protection Association, 1 Batterymarch 

Park, Quincy, MA 02269. If any changes 

in this edition of the Code are 

incorporated by reference, CMS will 

publish notice in the Federal Register to 

announce the changes. 

* * * * * 

(4) A long-term care facility may 

install alcohol-based hand rub 

dispensers in its facility if the 

dispensers are installed in a manner that 

adequately protects against 

inappropriate access. 

* * * * * 

(7) Every sleeping room must have an 

outside window or outside door, and 

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. 

(b) Standard: building safety. Except 

as otherwise provided in this section, 

the long term care facility must meet the 

applicable provisions of the 2012 

edition of the Health Care Facilities 

Code of the National Fire Protection 

Association, regardless of the number of 

residents served. The Director of the 

Office of the Federal Register has 

approved the NFPA 99® 2012 edition of 

the Health Care Facilities Code, issued 

August 11, 2011, for incorporation by 

reference in accordance with 5 U.S.C. 

552(a) and 1 CFR part 51. A copy of the 

Code is available for inspection at the 

CMS Information Resource Center, 7500 

Security Boulevard, Baltimore, MD or at 

the National Archives and Records 

Administration (NARA). For 

information on the availability of this 

material at NARA, call 202–741–6030, 

or go to: http://www.archives.gov/

federal_register/code_of_federal_

regulations/ibr_locations.html. Copies 

may be obtained from the National Fire 

Protection Association, 1 Batterymarch 

Park, Quincy, MA 02269. If any changes 

in this edition of the code are 

incorporated by reference, CMS will 

publish notice in the Federal Register to 

announce the changes. 

(1) Chapters 7, 8, 12, and 13 of the 

adopted Health Care Facilities Code do 

not apply to a long term care facility. 

(2) If application of the Health Care 

Facilities Code required under 

paragraph (b) of this section would 

result in unreasonable hardship upon 

the long term care facility, CMS may 

waive specific provisions of the Health 

Care Facilities Code, but only if the 

waiver does not adversely affect the 

health and safety of residents. 

* * * * * 

■ 16. Amend § 483.470 by— 

■ A. Revising paragraph (j)(1)(i). 

■ B. Amending paragraph (j)(1)(ii) by 

removing the reference to ‘‘Chapter 

19.3.6.3.2, exception number 2’’ and 

adding in its place ‘‘Chapter 19.3.6.3.5 

numbers 1 and 2 and Chapter 19.3.6.3.6 

number 2’’. 

■ C. Adding a new paragraph (j)(1)(iii). 

■ D. Removing paragraphs (j)(5) and (6). 

■ E. Redesignating paragraph (j)(7) as 

paragraph (j)(5). 

■ F. Revising newly redesignated 

paragraph (j)(5). 

The revisions and additions read as 

follows: 

§ 483.470 Condition of participation: 

Physical environment. 

* * * * * 

(j) * * * 

(1) * * * 

(i) Except as otherwise provided in 

this section, the facility must meet the 

applicable provisions of either the 

Health Care Occupancies Chapters or 

the Residential Board and Care 

Occupancies Chapter of the 2012 

edition of the Life Safety Code of the 

National Fire Protection Association, 

regardless of the number of clients 

served. The Director of the Office of the 

Federal Register has approved the NFPA 

101® 2012 edition of the Life Safety 

Code, issued August 11, 2011, for 

incorporation by reference in 

accordance with 5 U.S.C. 552(a) and 1 

CFR part 51. A copy of the Code is 

available for inspection at the CMS 

Information Resource Center, 7500 

Security Boulevard, Baltimore, MD or at 

the National Archives and Records 

Administration (NARA). For 

information on the availability of this 

material at NARA, call 202–741–6030, 

or go to: http://www.archives.gov/

federal_register/code_of_federal_

regulations/ibr_locations.html. Copies 

may be obtained from the National Fire 

Protection Association, 1 Batterymarch 

Park, Quincy, MA 02269. If any changes 

in this edition of the Code are 

incorporated by reference, CMS will 

publish notice in the Federal Register to 

announce the changes. 

* * * * * 

(iii) Chapters 32.3.2.11.2 and 

33.3.2.11.2 of the adopted 2012 LSC do 

not apply to a facility. 

* * * * * 

(5) Facilities that meet the LSC 

definition of a health care occupancy. 

(i) After consideration of State survey 

agency recommendations, CMS may 

waive, for appropriate periods, specific 

provisions of the Life Safety Code if the 

following requirements are met: 

(A) The waiver would not adversely 

affect the health and safety of the 

clients. 

(B) Rigid application of specific 

provisions would result in an 

unreasonable hardship for the facility. 

(ii) A facility may install alcoholbased hand rub dispensers if the 

dispensers are installed in a manner that 

adequately protects against 

inappropriate access. 

(iii) When a sprinkler system is out of 

service for more than 4 hours in a 24- 

hour period, the facility must— 

(A) Evacuate the building or portion 

of the building affected by the system 

outage until the system is back in 

service, or 

(B) Establish a fire watch until the 

system is back in service. 

(iv) Except as otherwise provided in 

this section, ICF–IIDs must meet the 

applicable provisions of the 2012 

edition of the Health Care Facilities 

Code of the National Fire Protection 

Association, regardless of the number of 

clients served. The Director of the Office 

of the Federal Register has approved the 

NFPA 99® 2012 edition of the Health 

Care Facilities Code, issued August 11, 

2011, for incorporation by reference in 

accordance with 5 U.S.C. 552(a) and 1 

CFR part 51. A copy of the Code is 

available for inspection at the CMS 

Information Resource Center, 7500 

Security Boulevard, Baltimore, MD or at 

the National Archives and Records 

Administration (NARA). For 

information on the availability of this 

material at NARA, call 202–741–6030, 

or go to: http://www.archives.gov/

federal_register/code_of_federal_

regulations/ibr_locations.html. Copies 

may be obtained from the National Fire 

Protection Association, 1 Batterymarch 

Park, Quincy, MA 02269. If any changes 

in this edition of the Code are 

incorporated by reference, CMS will 

publish notice in the Federal Register to 

announce the changes. 

(A) Chapter 7,8,12 and 13 of the 

adopted Health Care Facilities Code 

does not apply to an ICF–IID. 

(B) If application of the Health Care 

Facilities Code required under 

paragraph (iv) of this section would 

result in unreasonable hardship upon 


emcdonald on DSK67QTVN1PROD with PROPOSALS2
21576 Federal Register / Vol. 79, No. 73 / Wednesday, April 16, 2014 / Proposed Rules 

the ICF–IID, CMS may waive specific 

provisions of the Health Care Facilities 

Code, but only if the waiver does not 

adversely affect the health and safety of 

clients. 

* * * * * 

PART 485—CONDITIONS OF 

PARTICIPATION: SPECIALIZED 

PROVIDERS 

■ 17. The authority citation for part 485 

continues to read as follows: 

Authority: Secs. 1102 and 1871 of the 

Social Security Act (42 U.S.C. 1302 and 

1395(hh)). 

■ 18. Amend § 485.623 by— 

■ A. Revising paragraph (d)(1)(i). 

■ B. Amending paragraph (d)(1)(ii) by 

removing the reference to ‘‘Chapter 

19.3.6.3.2, exception number 2’’ and 

adding in its place ‘‘Chapter 19.3.6.3.5 

numbers 1 and 2 and Chapter 19.3.6.3.6 

number 2’’. 

■ C. Removing paragraphs (d)(5) and (6). 

■ D. Redesignating paragraph (d)(7) as 

paragraph (d)(5). 

■ E. Revising newly redesignated 

paragraph (d)(5). 

■ F. Adding paragraphs (d)(6), (7), and 

(8) and (e) 

The revisions and additions read as 

follows: 

§ 485.623 Condition of participation: 

Physical plant and environment. 

* * * * * 

(d) * * * 

(1) * * * 

(i) Except as otherwise provided in 

this section, the CAH must meet the 

applicable provisions of the 2012 

edition of the Life Safety Code of the 

National Fire Protection Association, 

regardless of the number of patients 

served. The Director of the Office of the 

Federal Register has approved the NFPA 

101® 2012 edition of the Life Safety 

Code, issued August 11, 2011, for 

incorporation by reference in 

accordance with 5 U.S.C. 552(a) and 1 

CFR part 51. A copy of the Code is 

available for inspection at the CMS 

Information Resource Center, 7500 

Security Boulevard, Baltimore, MD or at 

the National Archives and records 

Administration (NARA). For 

information on the availability of this 

material at NARA, call 202–741–6030, 

or go to: http://www.archives.gov/

federal_register/code_of_federal_

regulations/ibr_locations.html. Copies 

may be obtained from the National Fire 

Protection Association, 1 Batterymarch 

Park, Quincy, MA 02269. If any changes 

in this edition of the Code are 

incorporated by reference, CMS will 

publish notice in the Federal Register to 

announce the changes. 

* * * * * 

(5) A CAH may install alcohol-based 

hand rub dispensers in its facility if the 

dispensers are installed in a manner that 

adequately protects against 

inappropriate access. 

(6) When a sprinkler system is out of 

service for more than 4 hours in a 24- 

hour period, the CAH must— 

(i) Evacuate the building or portion of 

the building affected by the system 

outage until the system is back in 

service, or 

(ii) Establish a fire watch until the 

system is back in service. 

(7) In windowless anesthetizing 

locations, the CAH must have a supply 

and exhaust system that— 

(i) Automatically vents smoke and 

products of combustion, 

(ii) Prevents recirculation of smoke 

originating within the surgical suite, 

and 

(iii) Prevents the circulation of smoke 

entering the system intake. 

(8) Except for, newborn nurseries and 

rooms intended for occupancy for less 

than 24 hours, every sleeping room 

must have an outside window or 

outside door, and the sill height must 

not exceed 36 inches above the floor. 

Special nursing care areas shall not 

exceed 60 inches. Windows in atrium 

walls are considered outside windows 

for the purposes of this requirement. 

(e) Standard: building safety. Except 

as otherwise provided in this section, 

the CAH must meet the applicable 

provisions of the 2012 edition of the 

Health Care Facilities Code of the 

National Fire Protection Association, 

regardless of the number of patients 

served. The Director of the Office of the 

Federal Register has approved the NFPA 

99® 2012 edition of the Health Care 

Facilities Code, issued August 11, 2011, 

for incorporation by reference in 

accordance with 5 U.S.C. 552(a) and 1 

CFR part 51. A copy of the Code is 

available for inspection at the CMS 

Information Resource Center, 7500 

Security Boulevard, Baltimore, MD or at 

the National Archives and Records 

Administration (NARA). For 

information on the availability of this 

material at NARA, call 202–741–6030, 

or go to: http://www.archives.gov/

federal_register/code_of_federal_

regulations/ibr_locations.html. Copies 

may be obtained from the National Fire 

Protection Association, 1 Batterymarch 

Park, Quincy, MA 02269. If any changes 

in this edition of the Code are 

incorporated by reference, CMS will 

publish notice in the Federal Register to 

announce the changes. 

(1) Chapters 7, 8, 12, and 13 of the 

adopted Health Care Facilities Code do 

not apply to a CAH. 

(2) If application of the Health Care 

Facilities Code required under 

paragraph (e) of this section would 

result in unreasonable hardship upon 

the CAH, CMS may waive specific 

provisions of the Health Care Facilities 

Code, but only if the waiver does not 

adversely affect the health and safety of 

patients. 

* * * * * 

Dated: August 22, 2013. 

Marilyn Tavenner, 

Administrator, Centers for Medicare & 

Medicaid Services. 

Approved: March 7, 2014. 

Kathleen Sebelius, 

Secretary, Department of Health and Human 

Services. 

[FR Doc. 2014–08602 Filed 4–14–14; 11:15 am] 

BILLING CODE 4120–01–P 


emcdonald on DSK67QTVN1PROD with PROPOSALS2