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Life Safety Code Requirements

This page provides basic information about Medicare and/or Medicaid provider compliance with National Fire Protection Association (NFPA) 101 Life Safety Code (LSC) requirements and includes links to applicable laws, regulations, and compliance information. Please see LSC Laws, Regulations, and Compliance Information link below in the Downloads section.

The LSC is a set of fire protection requirements designed to provide a reasonable degree of safety from fire. It covers construction, protection, and operational features designed to provide safety from fire, smoke, and panic. The LSC, which is revised periodically, is a publication of NFPA, which was founded in 1896 to promote the science and improve the methods of fire protection.

The basic life safety from fire requirement for facilities participating in the Medicare and Medicaid programs is compliance with the 2000 edition of the NFPA LSC. CMS partners with State Agencies (SA) to assess facilities for compliance with the LSC requirements. SAs may enter into subagreements or contracts with the State Fire Marshal offices or other State agencies responsible for enforcing State fire code requirements. Under these agreements, the designated State fire authority generally agrees to:

  • Survey all non-accredited hospitals, hospices, ASCs, SNFs, NFs, CAHs, RNHCIs, PACE Facilities and ICFs/MR in accordance with schedules the SA furnishes;
  • Survey accredited hospitals selected for validation surveys or surveyed as a result of a substantial allegation of an unsafe conditions;
  • Complete the appropriate Fire Safety Survey Report (Form CMS-2786);
  • Prepare statements of deficiencies and review Plans of Correction (Form CMS-2567);
  • Make recommendations to the SA regarding facilities' compliance with program fire safety requirements; and
  • Use only qualified fire safety inspectors in the performance of these surveys.

In most cases, the SA schedules the LSC survey to coincide with the health survey; however, the timing of the LSC is left to the discretion of the SAs. The SA determines whether the LSC survey is to occur before, after, or simultaneously with the health survey. States may also require their own initial survey before permitting facilities to become operational and admit patients.

Facilities conforming to the LSC or with an acceptable Plan of Correction are considered "in compliance."

Unreasonable Hardship/Waivers - The LSC provides that the authority having jurisdiction shall determine the adequacy of protection provided for life safety from fire in accordance with the provisions of the LSC. In cases of unreasonable hardship, 42 CFR 483.70(a)(2) specifies that a waiver may be granted where it would not adversely affect resident health and safety.

The Secretary has delegated to CMS the authority to grant waivers of LSC provisions for all facilities participating in Medicare and Medicaid with the exception of ICFs/MR. The SAs may recommend approval of waivers requested by providers, but only CMS Regional Offices (RO) may grant approval of waivers. Therefore, all LSC waiver requests recommended for approval by SAs, except ICF/MRs, must be forwarded to the RO for adjudication. The State has the authority to grant waivers of ICFs/MR requirements. There is no authority for either the State or the RO to grant waivers of Board and Care Occupancy provisions.

Exemption for State Law - The LSC is not applicable where CMS finds that a State has in effect a fire and safety code imposed by State law that adequately protects patients in health care facilities, except for small ICFs/MR surveyed under the Residential Board and Care Chapters (Chapters 32 and 33). (See Section 1863 of the Act.)

The State submits a request that State codes be utilized in lieu of the LSC to the CMS/RO. That office will forward the request to the CMS central office (CO) for a determination along with a copy of the enabling legislation so that the CO can determine whether the applicable State law adequately protects patients in healthcare facilities. Upon notification by CO, the RO advises the State authority that submitted the request whether the State code is acceptable in lieu of the LSC. State codes cannot be submitted for ICFs/MR since CMS has no authority to accept them in lieu of the LSC.

National Fire Protection Association (NFPA) - The NFPA publishes the Codes and Standards CMS uses in determining compliance with the fire safety requirements of our regulations. The Healthcare Interpretations Task Force (HITF) as a group of technical experts provide interpretive guidance to help answer questions concerning the Life Safety Code to various health care organizations including CMS.