Impact of CMS’ Adoption
of 2012 NFPA 101 & 99
Dave Dagenais, CHFM, CHSP, FASHE
CMS IS PROPOSING TO ADOPT NFPA 101 &
NFPA 99 WITH THE FOLLOWING
MODIFICATIONS
ADOPTION, CHANGE IN DEFINITION
Changes definition of “health care occupancy” from
applying to “4 or more patients” to “regardless of
the number of patients served”
Could apply to hospital outpatient depts.
Based on billing of hospital-based provider services
in outpatient buildings
ROLLER LATCHES
Does not allow the exception in
the LSC that permits use of
roller latches
CMS standards have permitted
use of roller latches for more
than 20 years
Roller latches have become
common in behavioral health
ALCOHOL BASED HAND RUBS
2012 LSC allows ABHRs
Accepts 2012 LSC requirements but adds
“if installed to prohibit inappropriate
access”
– Interpretive guidance is needed to
determine what this means.
SPRINKLER 4-HOUR RULE
NFPA 25 formerly required evacuation or fire watch of
facilities if a sprinkler system was out of service for
more than 4 hours in a 24-hour period.
This has been changed in NFPA 25 to 10 hours to
accommodate a “work day.”
CMS proposes going back to the 4-hour period.
CMS WILL REQUIRE OR SMOKE VENTS
Required when flammable anesthetics were used
Removed as operating room ACH increased, sprinkler
requirements were added, severity of fire risk and
extent decreased
36" SILL HEIGHT
Okay for new construction
As written will apply to existing construction
How many existing facilities will this affect?
What is the cost to fix this condition?
Is it worth it?
Staff should not break out windows during a fire
Patients should not be evacuated through windows
ADOPTION OF NFPA 99, 2012 EDITION
Directly adopts NFPA 99: Health Care Facilities Code
Except chapters:
Chapter 7
Chapter 8
Chapter 12
Chapter 13
=
=
=
=
IT and Nurse Call
Plumbing
Emergency Preparedness
Security
S&C 13-58
Issued August 30th, 2013
Covers several “categorical waivers”
MEDICAL GAS MASTER ALARMS
Allows substitution
of a centralized
computer system
for (one)
Category 1
medical gas
master alarm.
OPENINGS IN EXIT ENCLOSURES
Permits existing
openings in exit
enclosures to
mechanical
equipment
spaces if they are
protected by firerated door
assemblies.
EMERGENCY GENERATORS AND STANDBY
POWER SYSTEMS
Reduces the annual
diesel-powered
generator
exercising
requirement from
two (2) continuous
hours to one hour
and 30 minutes.
DOORS
Allows more than one
delayed-egress lock in
the egress path where
the clinical needs require
specialized security
measures or when a
patient requires
specialized protective
measures for safety.
SUITES
Allows:
1. Suite to suite egress
2. Allows one of the two
required exits to enter an
exit stair
3. Increase the sleeping room
suite size up to 10,000 sq.
ft.
EXTINGUISHING REQUIREMENTS
Allows:
1. Reduction in the testing
frequencies for sprinkler
system vane-type and
pressure switch type
waterflow alarm devices
to semiannual,
2. Electric motor-driven
pump assemblies to
monthly.
CLEAN WASTE & PATIENT RECORD
RECYCLING CONTAINERS
Allows the increase in size
of containers used
solely for recycling clean
waste or for patient
records awaiting
destruction outside of a
hazardous storage area
to be a maximum of 96gallons
S&C 12-21
Corridor Width
New “Effective”
Corridor width
5’-0”
8’-0”
 Fixed furniture
allowed
 Rolling carts,
equipment and
movement aids
allowed
Bench
c.c.
DECORATIONS
Increases the amount of wall space that may be
covered by combustible decorations
20% Not Sprinklered
30% Sprinklered
50% Sprinklered in patient room (less than 4)
FIREPLACES
Allows the installation of direct vent gas fireplaces in
smoke compartments containing patient sleeping
rooms and the installation of
solid fuel burning fireplaces in areas other than
patient sleeping areas
S&C 13-25
OR Relative Humidity
lowering the humidity requirement for operating
rooms and other anesthetizing locations from at
least 35percent to at least 20 percent.
HOW TO REQUEST A CATEGORICAL WAIVER
Document your desire and that you comply with the
waiver provisions in your policy and procedures
manual.
Verbally announce that you are requesting the waivers at
each entrance interview of a survey
Check with your State Agency and verify the waivers will
be accepted for licensing
Indicate Life Safety waiver requests in your BBI
Indicate Environment of Care waiver requests in your
management plan
ITEMS DELETED-OVERVIEW
Laboratory requirements
Manufacturers’ requirements on electrical equipment
Annexes B, D, & E are deleted. They are technology
not used any longer.
All of the Occupancy Chapters
NEW ITEMS-OVERVIEW
Standard becomes a Code
Fundamentals Chapter on Risk
Information Technology and Communication Systems
Plumbing
Heating
Emergency Management (new requirements)
Security
Fire Protection unique to Health Care Facilities
HOW THE CODE WORKS
Determine the worst case procedure.
Select the Risk Category.
Select the systems or procedures in the Code that are
prescribed by that level of risk Category
ADMINISTRATION
(CHAPTER 1)
To provide minimum requirements for the:
Performance
Maintenance, Testing and Inspection
Safe practices based on risk
ADMINISTRATION
(CHAPTER 1)
Applies to all health care facilities (other than home
health)
Applies to NEW construction and equipment only
 altered or renovated or modernized
Some testing and maintenance requirements apply to
existing
Emergency Management and Security apply to
existing
REFERENCED PUBLICATIONS
(CHAPTER 2)
All Referenced publication material has been updated
to most current version
DEFINITIONS
(CHAPTER 3)
3.3.9 Anesthetizing location – General anesthesia
3.3.17 Battery powered lighting units – NFPA 70
3.3.63 General anesthesia and levels of sedation
Deep sedation
General anesthesia
Minimal sedation
Moderate sedation
3.3.109 Medical support gas
FUNDAMENTALS
(CHAPTER 4)
Category 1 - Facility systems in which failure of such
equipment or system is likely to cause major injury
or death of patients or caregivers shall be designed
to meet system Category 1 requirements as
defined in this code.
FUNDAMENTALS
(CHAPTER 4)
Category 2 - Facility systems in which failure of such
equipment is likely to cause minor injury to
patients or caregivers shall be designed to meet
system Category 2 requirements as defined in this
code.
FUNDAMENTALS
(CHAPTER 4)
Category 3 - Facility systems in which failure of such
equipment is not likely to cause injury to the
patients or caregivers, but can cause patient
discomfort shall be designed to meet system
Category 3 requirements as defined in this code.
FUNDAMENTALS
(CHAPTER 4)
Category 4 -Facility systems in which failure of such
equipment would have no impact on patient care
shall be designed to meet system Category 4
requirements as defined in this code.
FUNDAMENTALS
(CHAPTER 4)
4.2* Risk Assessment. Categories shall be
determined by following and documenting a
defined risk assessment procedure.
A.4.2 Risk assessment should follow procedures such
as those outlined in ISO 31010, NFPA 551, SEMI
S10-0307 or other formal process. The results of
the assessment procedure should be documented
and records retained.
GAS AND VACUUM SYSTEMS
(CHAPTER 5)
Adding testing and inspection requirements on
existing non-stationary medical booms
Testing per manufacturers
recommendations, every 18
months or based on risk
assessment.
GAS AND VACUUM SYSTEMS
(CHAPTER 5)
5.1.4.8 Zone Valves. All station outlets/inlets shall be
supplied through a zone valve as follows:
The zone valve shall be placed such that a wall
intervenes between the valve and outlets/inlets that
it controls.
ELECTRICAL SYSTEMS
(CHAPTER 6)
“Wet Location”
changes to “Wet
Procedure
Location”
throughout the
entire document
ELECTRICAL SYSTEMS
(CHAPTER 6)
Requires that
overcurrent
protection devices
only be accessible
to authorized
personnel and not
permitted in public
access spaces
ELECTRICAL SYSTEMS
(CHAPTER 6)
Increases minimum number of receptacles
General Care – From 4 to 8
Critical Care – From 6 to 14
Operating Rooms – New requirement of 36
ELECTRICAL SYSTEMS
(CHAPTER 6)
Permits fuel transfer
pumps, receptacles,
ventilation fans,
louvers and cooling
systems related to
generators to be added
to the life safety or
critical branch (deleted
from equipment
branch)
ELECTRICAL SYSTEMS
(CHAPTER 6)
Monthly Generator Testing - 10 second transfer not
required
(Annual Confirmation)
ELECTRICAL SYSTEMS
(CHAPTER 6)
New section which permits
switches in lighting
circuits connected to Life
Safety and critical branch
as long as they don’t
serve as illumination of
egress as required by
NFPA 101
ELECTRICAL SYSTEMS
(CHAPTER 6)
New section on campus electrical systems being
added
Attempts to
clear up
conflicts
 with NEC
ELECTRICAL SYSTEMS
(CHAPTER 6)
Requires all operating rooms to be wet procedure
locations (unless risk assessment is done)
ELECTRICAL SYSTEMS
(CHAPTER 6)
Permits isolated power or ground fault protection
within operating rooms
ELECTRICAL SYSTEMS
(CHAPTER 6)
Eliminates emergency system heading and
equipment system heading and utilizes branches
Life Safety
Critical
Equipment
ELECTRICAL SYSTEMS
(CHAPTER 6)
Added text to permit a 0.1 second delay for selective
coordination
IT AND COMMUNICATION
(CHAPTER 7)
New chapter covers
IT rooms
Fire protection
Nurse call
Emergency call
Staff emergency assistance
PLUMBING
(CHAPTER 8)
TIA will cover plumbing requirements
Essentially will refer to other
model codes or standards
TIA
8.1.4.1 Nonmedical Compressed Air
8.3.1 Potable Water. Potable water systems shall comply with applicable plumbing
codes.
8.3.2 Nonpotable Water. Nonpotable water systems shall comply with applicable
plumbing codes.
8.3.3 Water Heating. Maximum hot water temperatures shall comply with applicable
plumbing codes.
8.3.4 Water Conditioning. Water shall be treated or heated to control pathogens in
the water.
8.3.5 Nonmedical Compressed Air.
8.3.7 Grease Interceptors.
8.3.10 Grey Waste Water.
8.3.11 Clear Waste Water.
HEATING, VENTILATION AND AIR CONDITIONING
(CHAPTER 9)
New TIA will cover oxygen transfilling room
requirements
Waste Anesthesia Gas Disposal (WAGD)
TIA
9.3.3 Commissioning
9.3.7 Medical Gas Storage or Transfilling.
9.3.7.5.2 Natural Ventilation
9.3.7.5.3 Mechanical Ventilation.
9.3.8 Waste Gas.
9.3.9 Medical Plume Evacuation
ELECTRICAL EQUIPMENT
(CHAPTER 10)
Chapter reorganized
Testing requirements have been updated
Leakage requirements have been updated
MULTIPLE OUTLET CONNECTIONS
(POWER TAPS)
10.2.3.6
• Allows power taps that meet the following
o Permanently attached
o Some of load not over 75%
o Cord meets NFPA 70
o Electrical integrity is regularly verified and
documented
o When new equipment is attached, integrity must
be verified again.
GAS EQUIPMENT
(CHAPTER 11)
11.3.2.5 Temperature limitations to storage of
cylinders must comply with 5.1.3.3.1.7
(temperatures not to exceed 54o C or 130o F.
11.4.3.1.1 Specifies the requirements for carts and
hand trucks that transport cylinders (must be self
supporting and have appropriate chains.)
EMERGENCY MANAGEMENT
(CHAPTER 12)
Completely rewritten and expanded for 2012
Two categories of risk
In-patient facility is expected to be operable
In-patient and out-patient areas that augment the
critical mission but not receive in-patients
Requires a Hazard Vulnerability Analysis (HVA)
Natural Hazards
Human-caused Events
Technological Events
EMERGENCY MANAGEMENT
(CHAPTER 12)
Requires plans to manage resources and assets
Requires Exercises
Requires Evaluation of Exercises
Special Care was taken to avoid conflicts with the
Joint Commission and CMS
SECURITY MANAGEMENT
(CHAPTER 13)
Planning for protection of the Staff and Facility beyond
disasters
Requires a Security Vulnerability Assessment (SVA)
Requires a responsible person
Education requirements of security staff
 Customer Service
 Emergency Procedures
 Use of Force
 De-escalation
 Use of Restraints
SECURITY MANAGEMENT
(CHAPTER 13)
Requires procedures for
Hostage
Bomb Threat
Workplace Violence
Disorderly Conduct
Restraining Orders
SECURITY MANAGEMENT
(CHAPTER 13)
Identifies known security sensitive areas
Emergency Departments
Pediatric and Infant Care units
Medication Storage
Clinical Labs
Forensic Patient Treatment Areas
Dementia or Behavior Health Units
Communications, data infrastructure and medical
records
SECURITY MANAGEMENT
(CHAPTER 13)
Other subjects covered
Media control
Crowd control
Security equipment – follow NFPA 731
Employee practices
Security operations
HYPERBARIC FACILITIES
(CHAPTER 14)
Piping requirements have been updated
New requirements for location of shutoff valve
Updated requirements for reserve to central supply
system
New requirements for hyperbaric medical air system
FEATURES OF FIRE PROTECTION
(CHAPTER 15)
Chapter applies to new and existing
Pulls most of text from NFPA 101
Fire alarm and detection
Protection of gas cylinder storage
HVAC detection requirements
Defend in place requirements
Closets sprinkler exception (less than 6 sq. ft.)
Orientation and training requirements
DEFINITIONS
(CHAPTER 3)
Normally occupied
building service
equipment support
area
People not present on a
regular basis
MEANS OF EGRESS
(CHAPTER 7)
7.2.1.5.1
• Door leaves shall open readily
from the egress side.
7.2.1.5.2
• The requirements of 7.2.1.5.1
shall not apply when door is
exposed to elevator
temperature in compliance
with listing.
MEANS OF EGRESS
(CHAPTER 7)
7.2.1.5.10.6
Two release operation is permitted on existing doors
when an occupant load does not exceed three
providing it does not require simultaneous
operation.
EXISTING HEALTHCARE OCCUPANCY
(CHAPTER 19)
19.2.2.2.5.1
• Door locking is permitted for clinical or security
needs provided staff can readily unlock doors.
o Provisions must exist for rapid removal
• Remote control locks
• Keys carried by staff
• Other reliable means
o Only one lock per door
o More than one permitted with AHJ
DELAYED EGRESS LOCKS
(CHAPTER 19)
• More than one delayed egress lock is permitted in
the egress path
DELAYED EGRESS LOCKS
(CHAPTER 19)
19.2.3.4
• Permits items in corridor such as wheeled
equipment, carts in use, medical emergency
equipment, patient lift and transport equipment
and fixed furniture as long as it does not reduce
the corridor width to less than 5 feet.
SUITES
(CHAPTER 19)
19.2.5.7.2.3
• Permits sleeping suites to be 7500 sq. ft. where
protected with sprinklers.
• Can go to 10,000 sq. ft.
o Direct visual supervision
o Supervised sprinkler system
o Automatic smoke detection
SUITES
(CHAPTER 19)
Permits suites to egress through adjoining suite and
more than one intervening room.
ALCOHOL BASED HAND RUB
(CHAPTER 19)
19.3.2.6
• Exempts one dispenser per room from the 10gallon per smoke compartment requirement.
DECORATIONS
(CHAPTER 19)
19.7.5.6
Increases the amount of wall space that may be
covered by combustible decorations
• 20% Not Sprinklered
• 30% Sprinklered
• 50% Sprinklered in patient room (less than 4)
SPRINKLERS
(CHAPTER 19)
19.3.5.10
Sprinklers not required in clothes closets in patient
sleeping rooms where the area does not exceed 6
sq. ft.
CONTAINERS FOR RECYCLING, CLEAN WASTE
OR PATIENT RECORDS (CHAPTER 19)
19.3.5.10
May be between 32 – 96 gallons if
they meet FM standard 6921.
Thank You
Questions?
Dave Dagenais, CHFM, CHSP, FASHE