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UPDATE: Hospitals will have until November to comply with new CMS Requirements addressing 2012 Life Safety Code

Life Safety Code

UPDATE: Hospitals will have until November to comply with new CMS Requirements addressing 2012 Life Safety Code

UPDATE:  CMS published a memorandum on June 20, 2016 stating the following:

  • The Centers for Medicare & Medicaid Services (CMS) has adopted by regulation the 2012 LSC and the 2012 HCFC. The regulation effective date is July 5, 2016.
  • CMS will begin surveying for compliance with the 2012 LSC and HCFC on November 1, 2016.
  • CMS will offer an online transitional training course for existing LSC surveyors to provide an update on the new requirements. The course will be available on September 2, 2016 via the CMS Surveyor Training Website.
  • CMS will update the ASPEN program (i.e., the information system which tracks surveys) and CMS Fire Safety Forms (2786) prior to the November 1, 2016 survey start date.


UPDATE:  According to an announcement from American Society for Healthcare Engineering (ASHE), the Joint Commission stated that hospitals will have until November 7, 2016 to comply with the new Centers for Medicare & Medicaid Services requirements that include the 2012 National Fire Protection Association’s 101: Life Safety Code and NFPA99: Health Care Facilities Code.

CMS published the new Conditions of Participation in May 2016 (see the May 5, 2016 StayAlert! Notice for more information) with an effective date of July 5, 2016.

TJC has informed its customers that the new CMS survey deadline will be November 7, 2016 in order for healthcare providers and suppliers to have time to assess their facilities for compliance.

According to the ASHE report,

“In the period between July 5 and November 7, surveys will be based on the 2000 edition of the Life Safety Code…In instances where deficiencies are cited based on the 2000 edition, but would
be compliant under the 2012 edition, a facility may verify compliance with the 2012 Life Safety Code as an acceptable plan of correction…”

StayAlert! is monitoring this topic and will publish more information as it becomes available.


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