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CMS Issues Some Physical Environment 1135 Blanket Waivers for ITM Deviations as well as Some Other New Life Safety Code Deviations

| Dave Stymiest

CMS issued some new physical environment blanket waivers on April 29, 2020 permitting certain CMS-mandated inspection, testing, and maintenance (ITM) activities to be adjusted during the federal emergency declaration. The previous broadly-distributed April 29th version included the ITM blanket waivers on page 23, but additional changes since then included some other CMS physical environment blanket waivers on May 11, 2020 relating to Alcohol-Based Hand-Rub (ABHR) dispenser locations, Fire Drills,  and Temporary Construction. The new May 11th version includes the ITM waivers starting on page 25, and the newest other Life Safety Code blanket waivers starting on page 26. As further changes occur, it is likely that the starting page numbers will change again.

Readers can also go to the CMS web page and search for the physical environment ITM section title Specific Physical Environment Waiver Information.

Firstly, the following listed requirements are considered critical ITM activities by CMS and are NOT included within the CMS ITM blanket waiver. These tasks must still be completed and documented in accordance with their Life Safety Code (LSC) and Health Care Facilities Code (HCFC) requirements as mandated by CMS.


  • Sprinkler system monthly electric motor-driven and weekly diesel engine-driven fire pump testing.
  • Portable fire extinguisher monthly inspections.
  • Elevators with firefighters’ emergency operations monthly testing.
  • Emergency generator 30 continuous minute monthly testing and associated transfer switch monthly testing.
  • Means of egress daily inspections in areas that have undergone construction, repair, alterations or additions to ensure its ability to be used instantly in case of emergency.

With the exception of the above list, CMS is temporarily modifying other provisions to the extent necessary to permit facilities to adjust other scheduled ITM frequencies and activities. Health care facilities are still responsible for documenting such decisions and activities per CMS requirements.

We recommend that readers download the latest CMS blanket waivers PDF and read the full portion of the blanket waivers PDF that applies.

The recently-added Specific Life Safety Code (LSC) for Multiple Providers – Waiver Information (New since 4/30 Release) can also be found by searching for that title.

The latest added CMS physical environment blanket waivers address:

  • Alcohol-based Hand-Rub (ABHR) Dispensers: We are waiving the prescriptive requirements for the placement of alcohol based hand rub (ABHR) dispensers for use by staff and others due to the need for the increased use of ABHR in infection control. However, ABHRs contain ethyl alcohol, which is considered a flammable liquid, and there are restrictions on the storage and location of the containers. This includes restricting access by certain patient/resident population to prevent accidental ingestion. Due to the increased fire risk for bulk containers (over five gallons) those will still need to be stored in a protected hazardous materials area. Refer to: 2012 LSC, sections 18/ In addition, facilities should continue to protect ABHR dispensers against inappropriate use as required by 42 CFR §482.41(b)(7) for hospitals ….”
  • Fire Drills: Due to the inadvisability of quarterly fire drills that move and mass staff together, we will instead permit a documented orientation training program related to the current fire plan, which considers current facility conditions. The training will instruct employees, including existing, new or temporary employees, on their current duties, life safety procedures and the fire protection devices in their assigned area. Refer to: 2012 LSC, sections 18/”
  • Temporary Construction: CMS is waiving requirements that would otherwise not permit temporary walls and barriers between patients. Refer to: 2012 LSC, sections 18/”