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[Federal Register Volume 79, Number 73 (Wednesday, April 16, 2014)]
[Proposed Rules]
[Pages 21551-21576]
From the Federal Register Online via the Government Printing Office [www.gpo.gov]
[FR Doc No: 2014-08602]

[[Page 21551]]

Vol. 79

Wednesday,

No. 73

April 16, 2014

Part III

Department of Health and Human Services

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Centers for Medicare & Medicaid Services

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

Medicare and Medicaid Programs; Fire Safety Requirements for Certain 
Health Care Facilities; Proposed Rule

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

[[Page 21552]]

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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.

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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 non-medical 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) Medicaid-participating 
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

[[Page 21553]]

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 system-based 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-CMS-approved 
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 Medicaid-participating 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 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. 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 cross-referenced 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 home-like 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 
home-like setting in health care facilities. Cooking facilities are 
allowed in a smoke compartment where food is prepared for 30 
individuals or fewer (by

[[Page 21556]]

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 d[eacute]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 Sec.  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 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. . . .''

[[Page 21557]]

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 cross-referenced 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

[[Page 21558]]

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 cross-referenced 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

[[Page 21559]]

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 vacuum-
producing 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 factory-assembled 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.

[[Page 21560]]

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 line-powered 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.

[[Page 21561]]

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.

[[Page 21562]]

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 fixed-equipment 
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,

[[Page 21563]]

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;

[[Page 21564]]

     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 (Sec.  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 Sec.  
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 
Sec.  403.744(a)(4)(i), (ii), (iv) and (v). We propose to retain the 
requirements at Sec.  403.744(a)(4)(iii) related to protection against 
inappropriate access, and would redesignate it at Sec.  403.744(a)(4).
    We propose to add a new requirement at Sec.  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 Sec.  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 Sec.  
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 Sec.  
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 Sec.  
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 
(Sec.  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 Sec.  
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 Sec.  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 Sec.  
416.44(b)(5)(i), (ii), (iv), (A) through (G), and (v). We also propose 
to retain the requirements at Sec.  416.44(b)(5)(iii) related to 
protection against inappropriate access, and would redesignate it at 
Sec.  416.44(b)(4).
    We propose to add a new requirement at Sec.  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 Sec.  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 Sec.  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 (Sec.  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 Sec.  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 Sec.  
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 
Sec.  418.110(d)(4)(i), (ii) and (iv). We also propose to retain the

[[Page 21565]]

requirements at Sec.  418.110(d)(4)(iii) related to protection against 
inappropriate access, and would redesignate this requirement at Sec.  
418.110(d)(4).
    We propose to add a new requirement at Sec.  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 Sec.  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 Sec.  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 (Sec.  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 Sec.  
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 Sec.  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 Sec.  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 Sec.  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 Sec.  
460.72(b)(5)(i), (ii), (iv) and (v). In addition, we propose to retain 
the requirements at Sec.  460.72(b)(5)(iii) related to protection 
against inappropriate access, and would redesignate it at Sec.  
460.72(b)(3).
    We propose to add a new requirement at Sec.  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 Sec.  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 (Sec.  
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 Sec.  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 Sec.  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 Sec.  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 Sec.  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 Sec.  482.41(b)(7) through 
(b)(8), and would redesignate them at Sec.  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 Sec.  
482.41(b)(9)(i), (ii), (iv) and (v). We propose to retain the 
requirement at Sec.  482.41(b)(9)(iii) related to protection against 
inappropriate access, and would redesignate it at Sec.  482.41(b)(7).
    We are proposing to add a new requirement at Sec.  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 Sec.  
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

[[Page 21566]]

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 Sec.  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 Sec.  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 (Sec.  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 
Sec.  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 Sec.  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 Sec.  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 Sec.  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 Sec.  
483.70(a)(6)(i), (ii), (iv) and (v). We propose to retain the 
requirement at Sec.  483.70(a)(6)(iii) related to protection against 
inappropriate access, and would redesignate it at Sec.  483.70(a)(4).
    We propose to retain the requirements at Sec.  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 
Sec.  483.70(a)(5) (i), (ii), (iii) (A) and (B).
    In addition, we propose to retain the requirements at Sec.  
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 Sec.  
483.70(a)(6)(i) and (ii), without changes.
    We also propose to add a new requirement at Sec.  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 Sec.  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 (Sec.  
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 Sec.  
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 Sec.  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 Sec.  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 Sec.  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 Sec.  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 Sec.  
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 Sec.  483.470(j)(7)(ii)(A),

[[Page 21567]]

(B), (D) and (E). We propose to retain the requirements at Sec.  
483.470(j)(7)(ii)(C) related to protection against inappropriate 
access, and would redesignate it at Sec.  483.470(j)(5)(ii).
    We propose to add a new requirement at Sec.  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 Sec.  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 (Sec.  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 Sec.  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 Sec.  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 Sec.  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 Sec.  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 Sec.  485.623(d)(7)(i), (ii), (iv) and (v). We propose 
to retain the requirement at Sec.  485.623(d)(7)(iii) related to 
protection against inappropriate access, and would redesignate it at 
Sec.  485.623(d)(5).
    We are proposing to add a new requirement at Sec.  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 Sec.  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 Sec.  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 Sec.  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

[[Page 21568]]

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 high-
rise 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 non-sprinklered 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 non-sprinklered 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.
---------------------------------------------------------------------------

    \1\ The 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.
---------------------------------------------------------------------------

    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 high-rise 
hospitals by their current sprinkler status, we used the methodology 
described above to estimate the distribution of fully sprinklered, 
partially sprinklered, and non-sprinklered 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 high-rise 
facilities in states that did not submit data). We estimate that 682 of 
those high-rise facilities are fully

[[Page 21569]]

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.
---------------------------------------------------------------------------

    \2\ The 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.
    \3\ The following states provided data regarding the average 
square footage for non-sprinklered high-rise facilities containing 
health care facilities- California, Hawaii, and Iowa.
---------------------------------------------------------------------------

    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 x $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 x $11 per square foot).
    We estimated that there are 7 non-sprinklered 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 x 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 x $11 per square foot).
    We estimate the total cost associated with the installation of 
sprinklers in partially sprinklered and non-sprinklered facilities to 
be $78,934,966 ($69,104,607 for all partially sprinklered facilities + 
$9,830,359 for all non-sprinklered 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

[[Page 21570]]

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 x 532 facilities in any given year = 
532,000)

                                Table 1--Total Cost for Implementation in Year 1
----------------------------------------------------------------------------------------------------------------
                                                                                     Cost per
                  Requirement                        Provider type affected          affected      Cost for all
                                                                                     provider        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      Ambulatory surgical centers.....           1,047       1,355,865
 hazardous areas.
Sprinklers in Attics (used for living           Intermediate care for                      4,500      25,843,500
 purposes, storage or fuel fired equipment).     individuals with intellectual
                                                 disabilities.
Heat detection systems in attics (not used for  Intermediate care for                      1,000         639,000
 living purposes).                               individuals with intellectual
                                                 disabilities.
Hazardous areas separated by smoke partitions.  Intermediate care for                      1,000       6,382,000
                                                 individuals with intellectual
                                                 disabilities.
Upgrade existing or install new fire alarm      Intermediate care for                      1,000         532,000
 system with emergency forces notification       individuals with intellectual
 capabilities*.                                  disabilities.
                                               -----------------------------------------------------------------
    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
----------------------------------------------------------------------------------------------------------------
                                                                                     Cost per
                           Requirement                             Provider type     affected      Cost for all
                                                                     affected        provider        providers
----------------------------------------------------------------------------------------------------------------
High-rise sprinkler installation................................      Hospitals,         $34,075      $5,758,717
                                                                       partially
                                                                     sprinklered
High-rise sprinkler installation................................  Hospitals, non-        117,028         819,197
                                                                     sprinklered
Upgrade existing or install new fire alarm system with emergency    Intermediate           1,000         532,000
 forces notification capabilities...............................        care for
                                                                     individuals
                                                                            with
                                                                    intellectual
                                                                    disabilities
                                                                 -----------------------------------------------
    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-business-size-standards.

[[Page 21571]]

    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

0
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).

0
2. Amend Sec.  403.744 by--
0
A. Revising paragraph (a)(1)(i).
0
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''.
0
C. Revising paragraph (a)(4).
0
D. Adding paragraphs (a)(5) and (6).
0
E. Removing paragraph (c).
    The revisions and additions read as follows:

Sec.  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[supreg] 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 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 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.
* * * * *
0
3. Add Sec.  403.745 to read as follow:

Sec.  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,

[[Page 21572]]

regardless of the number of patients served. The Director of the Office 
of the Federal Register has approved the NFPA 99[supreg] 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

0
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).

0
5. Amend Sec.  416.44 by--
0
A. Revising paragraph (b)(1).
0
B. Removing paragraph (b)(4).
0
C. Redesignating paragraph (b)(5) as paragraph (b)(4).
0
D. Revising newly redesignated paragraph (b)(4).
0
E. Adding new paragraphs (b)(5) and (6)
0
F. Redesignating paragraphs (c) and (d) as (d) and (e).
0
G. Adding new paragraph (c).
    The revisions and additions read as follows:

Sec.  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[supreg] 
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[supreg] 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

0
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).

Sec.  418.108  [Amended]

0
7. Amend Sec.  418.108 by--
0
A. Amending paragraph (a)(2) by removing the reference ``Sec.  
418.110(b) and (e)'' and by adding in its place the reference ``Sec.  
418.110(b) and (f)''.
0
B. Amending paragraph (b)(1)(ii) by removing the reference ``Sec.  
418.110(e)'' and by adding in its place the reference ``Sec.  
418.110(f)''.
0
8. Amend Sec.  418.110 by--
0
A. Revising paragraph (d)(1)(i).
0
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''.
0
C. Revising paragraph (d)(4).
0
D. Adding paragraphs (d)(5) and (6).
0
E. Redesignating paragraphs (e) through (o) as (f) through (p).
0
F. Adding new paragraph (e).
    The revisions and additions read as follows:

Sec.  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

[[Page 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[supreg] 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[supreg] 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)

0
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)).

0
10. Amend Sec.  460.72 by--
0
A. Revising paragraph (b)(1)(i).
0
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''.
0
C. Removing paragraphs (b)(3) and (4).
0
D. Redesignating paragraph (b)(5) as paragraph (b)(3).
0
E. Revising newly redesignated paragraph (b)(3).
0
F. Adding new paragraph (b)(4) and paragraph (d).
    The revisions and addition read as follows:

Sec.  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[supreg] 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[supreg] 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

[[Page 21574]]

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

0
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.

0
12. Amend Sec.  482.41 by--
0
A. Revising paragraph (b)(1)(i).
0
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''.
0
C. Removing paragraphs (b)(4) and (5).
0
D. Redesignating paragraphs (b)(6) through (9) as paragraphs (b)(4) 
through (7), respectively.
0
E. Revising newly redesignated paragraph (b)(7).
0
F. Adding new paragraphs (b)(8), (9), and (10).
0
G. Redesignating paragraph (c) as paragraph (d).
0
H. Adding new paragraph (c).
    The revisions and additions read as follows:

Sec.  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[supreg] 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 alcohol-based 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[supreg] 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

0
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).

Sec.  483.15  [Amended]

0
14. In Sec.  483.15, amend paragraph (h)(4) by removing the reference 
``Sec.  483.70(d)(2)(iv)'' and by adding in its place the reference 
``Sec.  483.70(e)(2)(iv)''.
0
15. Amend Sec.  483.70 by--
0
A. Revising paragraph (a)(1)(i).
0
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''.
0
C. Removing paragraphs (a)(4) and (5).
0
D. Redesignating paragraphs (a)(6) through (8) as paragraphs (a)(4) 
through (6), respectively.
0
E. Revising newly redesignated paragraphs (a)(4).
0
F. Adding new paragraph (a)(7).
0
G. Redesignating paragraphs (b) through (h) as paragraphs (c) through 
(i).
0
H. Adding new paragraph (b).
    The revisions read as follows:

Sec.  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

[[Page 21575]]

approved the NFPA 101[supreg] 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[supreg] 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.
* * * * *
0
16. Amend Sec.  483.470 by--
0
A. Revising paragraph (j)(1)(i).
0
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''.
0
C. Adding a new paragraph (j)(1)(iii).
0
D. Removing paragraphs (j)(5) and (6).
0
E. Redesignating paragraph (j)(7) as paragraph (j)(5).
0
F. Revising newly redesignated paragraph (j)(5).
    The revisions and additions read as follows:

Sec.  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[supreg] 
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 alcohol-based 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[supreg] 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

[[Page 21576]]

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

0
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)).

0
18. Amend Sec.  485.623 by--
0
A. Revising paragraph (d)(1)(i).
0
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''.
0
C. Removing paragraphs (d)(5) and (6).
0
D. Redesignating paragraph (d)(7) as paragraph (d)(5).
0
E. Revising newly redesignated paragraph (d)(5).
0
F. Adding paragraphs (d)(6), (7), and (8) and (e)
    The revisions and additions read as follows:

Sec.  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[supreg] 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[supreg] 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
```