Life Safety Code & Health Care Facilities Code Requirements

This page provides basic information about Medicare and/or Medicaid provider and supplier compliance with the 2012 edition of the National Fire Protection Association (NFPA) Life Safety Code (LSC) and Health Care Facilities Code (HCFC). Please see LSC/HCFC 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 HCFC is a set of requirements intended to provide minimum requirements for the installation, inspection, testing, maintenance, performance and safe practices for facilities, material, equipment and appliances. The LSC and HCFC, which is revised periodically, is a publication of the NFPA, which was founded in 1896 to promote the science and improve the methods of fire protection.

The LSC & HCFC survey is conducted in accordance with the appropriate protocols and substantive requirements in the statute and regulations to determine whether a citation of non-compliance is appropriate. Deficiencies are based on a violation of the statute or regulations, which, in turn, is to be based on observations of the provider's performance or practices.

The survey procedures in Appendix I are used for all facilities subject to LSC/HCFC surveys (initial and recertification) for Medicare/Medicaid certification, and complaint investigations. 

This includes, but is not limited to, Skilled Nursing Facilities (SNF), Nursing Facilities (NF) (whether freestanding, distinct parts, or dually certified), Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID), Ambulatory Surgical Centers (ASC), inpatient Hospice facilities, Program for All-inclusive Care for the Elderly (PACE) facilities, Hospitals, Critical Access Hospitals (CAH), Rural Emergency Hospitals (REH), Psychiatric Hospitals, End-Stage Renal Disease (ESRD) facilities, and Religious Nonmedical Health Care Institutions (RNHCI), including validation surveys of accredited facilities. 

CMS partners with State Agencies (SA) and approved Accreditation Organizations (AO) to assess facilities for compliance with the LSC requirements. SAs may enter into sub-agreements or contracts with the State Fire Marshal offices or other State agencies responsible for enforcing State fire code requirements. Under these agreements, consistent with SA requirements, the designated State fire authority generally agrees to:

• Survey SNFs/NFs, ICFs/IIDs, ASCs, inpatient Hospice facilities, PACE, Hospitals, CAHs, REHs, Psychiatric Hospitals, ESRDs, and RNHCIs in accordance with SA-furnished schedules;
• Survey accredited facilities selected for validation surveys or surveyed as a result of a substantial allegation of an unsafe condition;
• Complete the appropriate Fire Safety Survey Reports (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 life safety from fire and building safety requirements; and
• Use only qualified LSC/HCFC inspectors who have received required CMS training prior to the performance of these surveys.

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

Facilities that meet the LSC and HCFC requirements or provide an acceptable Plan of Correction are considered "in compliance."

LSC and HCFC Waivers - The LSC and HCFC permit the authority having jurisdiction to determine the adequacy of protection provided for life safety from fire and building safety. In addition, in consideration of a recommendation by the SA or AO or at the discretion of the Secretary. CMS may waive for periods deemed appropriate specific provisions of the LSC and HCFC which would result in unreasonable hardship upon a facility, but only if the waiver will not adversely affect the health and safety of the patients or residents. 

The Secretary has delegated to CMS the authority to grant waivers of LSC and HCFC. The SAs or CMS-approved AO may recommend approval of waivers requested by providers, but only CMS Locations may grant approval of waivers. Therefore, all LSC and HCFC waiver requests recommended for approval by SAs and AOs, must be forwarded to the CMS Location for adjudication. There is no authority for either the State or the CMS Locations to grant waivers of Board and Care Occupancy provisions.

Exemption for State Law - The LSC nor HCFC 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. (See Section 1863 of the Act.)

The State submits a request that State codes be utilized in lieu of the LSC and HCFC to a CMS Location. The CMS Location will forward the request to CMS Headquarters (HQ) for a determination along with a copy of the enabling legislation so that the HQ can determine whether the applicable State law adequately protects patients in all State healthcare facilities. Upon notification by HQ, the CMS Location advises the State authority whether the State code is acceptable in lieu of the LSC and HCFC.