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Intensity of Life and Safety Codes for an ASC CMS Certification

Updated: Jul 29, 2023

In the healthcare industry, ensuring patients' safety and well-being is paramount. This includes compliance with the National Fire Protection Association (NFPA) 101 Life Safety Code (LSC) and NFPA 99 Health Care Facilities Code (HCFC). These codes are designed to provide a reasonable degree of safety from fire, smoke, and panic, as well as minimum requirements for the installation, inspection, testing, and maintenance of facilities, equipment, and appliances.

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Understanding the NFPA Codes

The National Fire Protection Association (NFPA) was founded in 1896 to promote science and improve fire protection methods. They publish the NFPA 101 Life Safety Code (LSC) and NFPA 99 Health Care Facilities Code (HCFC), which are revised periodically to ensure up-to-date safety standards.

The LSC focuses on construction, protection, and operational features that provide safety from fire, smoke, and panic. On the other hand, the HCFC sets requirements for facilities, materials, equipment, and appliances to ensure performance, safe practices, and patient safety.

Medicare and Medicaid Provider Compliance

Facilities participating in the Medicare and Medicaid programs must comply with the 2012 edition of the NFPA LSC and HCFC. The Centers for Medicare and Medicaid Services (CMS) partner with State Agencies (SA) to assess facilities for compliance with these requirements.

State Agencies may enter into agreements with the State Fire Marshal offices or other State agencies responsible for enforcing fire code requirements. These agreements outline the responsibilities of the designated State fire authority, which generally include surveying non-accredited hospitals, hospices, Ambulatory Surgical Centers (ASCs), Skilled Nursing Facilities (SNFs), and other healthcare facilities.

Compliance Surveys and Reporting

State Agencies are responsible for conducting compliance surveys in accordance with schedules provided by CMS. These surveys may coincide with health surveys or occur before, after, or simultaneously. The State Agencies use qualified fire safety inspectors who have received CMS training to perform these surveys.

During the surveys, the State Agencies complete the Fire Safety Survey Report (Form CMS-2786) and identify any deficiencies in compliance with the LSC and HCFC. They also review the Plans of Correction (Form CMS-2567) submitted by the facilities and make recommendations to the State Agencies regarding compliance.

In Compliance and Unreasonable Hardship

Facilities that conform to the LSC and HCFC or have an acceptable Plan of Correction are considered "in compliance" with the requirements. However, in cases of unreasonable hardship, CMS regulation allows for the granting of waivers that do not adversely affect resident health and safety.

The authority having jurisdiction, as specified in the LSC and HCFC, can determine the adequacy of life safety protection provided. While State Agencies or CMS approved Accreditation Organizations (AO) may recommend approval of waivers, only CMS Regional Offices (RO) can grant them. It is important to note that waivers cannot be granted for Board and Care Occupancy provisions.

Exemption for State Law

If CMS determines that a State has an effective fire and safety code imposed by State law that adequately protects patients in healthcare facilities, the LSC and HCFC may not be applicable. In such cases, the State can submit a request to utilize their own codes in lieu of the NFPA codes.

The request, along with the enabling legislation, is forwarded to the CMS central office for determination. Once the CMS central office determines the adequacy of the State code, the State authority is notified of the acceptance or rejection of their request.

The Role of NFPA in Compliance

The NFPA codes published by the National Fire Protection Association serve as the basis for determining compliance with fire safety requirements in healthcare facilities. CMS utilizes these codes to assess facilities participating in Medicare and Medicaid programs.

By adhering to the NFPA codes, healthcare facilities demonstrate their commitment to patient safety and fire protection. Compliance with these codes not only ensures the well-being of patients but also contributes to the overall quality of care provided.


Compliance with the NFPA Life Safety Code (LSC) and Health Care Facilities Code (HCFC) is a critical aspect of maintaining a safe environment in healthcare facilities. Medicare and Medicaid participating facilities must adhere to these codes to ensure the safety and well-being of their patients.

State Agencies, in partnership with CMS, conduct compliance surveys to assess facilities' adherence to the LSC and HCFC requirements. Facilities that are in compliance or have an acceptable Plan of Correction are considered to be meeting the necessary standards.

By following the guidelines set forth by the NFPA and CMS, healthcare facilities can prioritize patient safety and provide a secure environment for both patients and staff. Compliance with the LSC and HCFC not only promotes safety but also contributes to the overall quality of care delivered.

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