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Achieving a state of readiness: The importance of life safety code compliance

Life safety codes exist to ensure health care institutions are able to provide the highest quality of care.

Joe Cassata, AIA, CannonDesign
04/05/2017

Life safety codes exist to ensure health care institutions are able to provide the highest quality of care.Ask any Centers for Medicare & Medicaid Services (CMS) code-compliance firm and they will tell you the importance of life safety code compliance cannot be stressed enough. The proof is in the number of citations they bestow: Life safety citations have been among the top cited issues for the past several years, with the two most common citations relating to sprinkler system maintenance and electrical wiring and equipment.

More often than not, the high rate of these deficiencies is directly linked to a misunderstanding of NFPA 101: Life Safety Code—a code that was updated in July 2016 when CMS released its final rule. This update adopts the NFPA’s 2012 edition of the Life Safety Code as well as provisions of the NFPA’s 2012 edition of NFPA 99: Health Care Facilities Code. Although the update is filled with extremely important information, it can be a little daunting to sift through.

When it comes to life safety, regular code updates are necessary due to continual advancements in technology and safety protocols, as well as new scenarios that present themselves as health care delivery changes. Implementing the latest and greatest life safety measures is straightforward and standard in new construction, but things get a little more complicated in older facilities.

Hospitals are built for permanence, meaning they’re built to stick around for a long time without significant depreciation; they typically have a lifespan of 100 years. Over the course of their lifespan, many of these older hospitals go through renovations, but they’re often phased and can span decades. The sporadic nature of these renovations can result in buildings that adhere to various versions of the NFPA Life Safety Code and lack consistent documentation or life safety drawings.

In the Northeast, a 100-year-old health care institution recently faced this problem with facilities ranging from the 1890s through the early 1970s.

Life safety codes exist to ensure health care institutions are able to provide the highest quality of care.During an unannounced CMS validation survey, inspectors encountered a number of violations, not the least of which was not having updated life safety drawings and documentation. The subsequent CMS inspection report contained a number of condition-level deficiencies, which could lead to a terminated Medicare contract if not fixed within 90 days.

Life safety inspections aren’t doom and gloom. Life safety codes exist to ensure health care institutions are able to provide the highest quality of care, which is a very good thing for patients and institutions. The key to looking at inspections in a positive light is understanding the codes and having the certainty that your facilities are compliant.  


Joe Cassata leads CannonDesign’s facility optimization solutions team in its efforts to help organizations understand and leverage their facility assets to be more efficient, effective, and sustainable. He has more than 20 years of experience as a project manager and partners with clients on developing insightful facility-condition assessments, maintenance planning, asset management, space-use studies, and other services. This article originally appeared on the CannonDesign Blog. CannonDesign is a CFE Media content partner.

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