This page provides basic information about Medicare and/or Medicaid provider compliance with Life Safety Code (LSC) requirements and includes links to applicable laws, regulations, and compliance information.

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 requirement for facilities participating in the Medicare and Medicaid programs is compliance with the 2000 edition of the LSC.  Facilities with waivers of the health occupancy provisions of the LSC or with an acceptable Plan of Correction are considered “in compliance.” 

In most cases, the State Survey Agency (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.  Most States require an initial LSC survey before admitting patients prior to becoming operational.  

To assess facilities’ compliance with the LSC and other Medicare and Medicaid fire safety requirements, the SA may enter into a subagreement or a contract with the State fire Marshal’s office or other State agency responsible for enforcing State fire code requirements. Under this agreement, 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; an

• Use only qualified fire safety inspectors in the performance of these surveys.

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 the 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. 

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 State LSC surveyor recommends waivers, but CMS ROs grant the waivers.  Therefore, LSC requests the SA receive from all providers except ICF/MRs must be forwarded to the RO for adjudication.  For ICFs/MR, the State has the authority to grant waivers of health care occupancy requirements.  There is no authority for either the State or the RO to grant waivers of Board and Care Occupancy provisions.

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Related Links Inside CMS
State Operations Manual, Chapter 2, Sections 2470-249 Guidance for Laws and Regulations for Life Safety Code Survey and Certification General Enforcement Information
Related Links Outside CMS
Hospitals - Section 1861(e)(9) of the Social Security Act Nursing Homes - Section 1819(d) of the Social Security Act Section 1919 (d) of the Social Security Act ICFs/MR - Section 1905 of the Social Security Act  Hospitals - 42 CFR 482.41(b) Nursing Homes - 42 CFR 483.70(a) ICFs/MR - 42 CFR 483.470(j) Hospices Furnishing inpatient care - 42 CFR 418.100(d) Ambulatory Surgery Centers - 42 CFR 416.44(b) Religious Nonmedical Health Care Institutions - 42 CFR 403.744 Programs of All-Inclusive Care for the Elderly - 42 CFR 460.72

Page Last Modified: 05/31/2006 2:00:00 PM
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