CMS Permits Categorical Waivers for Life Safety – S&C #13-58

Nancy Leveille and Karen Morris in Clinical & Quality

To:    State Executive Directors
        Affiliate Policy Task Force
        State Executive Directors
CMS has posted an S&C memo that permits categorical waivers to some of the requirements of the 2000 Edition of the Life Safety Code.  AHCA and the Life Safety Committee have spoken with CMS numerous times about the issues for which they are allowing these categorical waivers and we are pleased that CMS has published this memo.  The memorandum is effective immediately.  According to the Memorandum Summary:

Several Categorical LSC Waivers Permitted: The Centers for Medicare & Medicaid Services (CMS) has identified several areas of the 2000 edition of the LSC and 1999 edition of NFPA 99 that may result in unreasonable hardship on a large number of certified providers/suppliers and for which there are alternative approaches that provide an equal level of protection. This memorandum specifies the provisions that are available for waiver, including the conditions for the alternative approaches.

Providers and Suppliers Must Elect to Use the Waiver: Individual waiver applications are not required, but providers and suppliers are expected to have written documentation that they have elected to use a waiver and must notify the survey team at the entrance conference for any survey assessing LSC compliance that it has elected the use of a waiver permitted under this guidance and that it meets the applicable waiver requirements. The survey team will review the information and confirm they are meeting the circumstances for the waiver.

Please note that the entity using the waiver MUST provide the relevant information to the survey team during the entrance conference.  There is more detailed information about the waiver process within the S&C memo.  Sections that may be of particular interest to nursing centers:

2.  Openings in Exit Enclosures
3.  Emergency Generators and Standby Power Systems
4.  Doors
5.  Suites
6.  Extinguishing Requirements
8.  Clarification to Process for LSC Waivers permitted under S&C-12-21.

Please let me know if you have any questions.  Lyn
Lyn Bentley, MSW
Sr. Director of Regulatory Services
1201 L St., NW
Washington, DC  20005
Office: 202-898-6304
Mobile:  301-356-1766

NYSHFA contacts: 

Nancy Leveille
Sr. Director, Member Operational Support Services
518-462-4800 ext 20 


Karen Morris
Director, Clinical & Quality Services
518-462-4800 ext 15