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Compliance News: CMS to Survey 2012 Codes Starting November 1, 2016

| David Stymiest

SSR’s May 2016 Compliance News article entitled CMS Adopts the 2012 Codes  provided breaking news along with numerous hyperlinks to assist organizations in assessing the impact of CMS’ adoption of the 2012 codes.

In its June 20, 2016 Survey & Certification Letter S&C 16-29-LSC, CMS advised that CMS will begin surveying to the 2012 Life Safety Code® and 2012 Health Care Facilities Code on November 1, 2016.

Hospitals may want to review final rule, as well as the new codes and referenced standards, soon to determine the impact of the changed Conditions of Participation on their facilities.  All hospital facilities that were in place prior to the adoption of the 2012 codes will be expected to meet the NFPA 101-2012 and NFPA 99-2012 existing requirements.

In the period between July 5 (when the 2012 codes take effect according to the previous CMS notification) and November 1, surveys will be based on NFPA 101-2000.  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 according to CMS.

In the S&C Letter 16-29-LSC, CMS also clarified its previous communications regarding when EXISTING vs. NEW requirements apply with the statement: “Buildings constructed before July 5, 2016 can meet Existing Occupancy requirements. In addition, buildings that receive design approval or building permits for construction before July 5, 2016 can meet Existing Occupancy requirements. All other building construction must meet New Occupancy requirements.”

After fully reviewing the CMS final rule, both the full version (including the background) and the abbreviated version (including only the updated CMS Conditions of Participation), we recommend that Compliance News readers review the full version to gain a complete understanding of the impact of the 2012 codes adoption.  The background discussions include the originally published Proposed Rule, CMS’ summary of public comments, and CMS’ response to the public comments.  In some cases, we believe that an understanding of this background information is essential to a full interpretation of the final rule.

As we stated last month, staff training is warranted where newer requirements will result in changes to existing processes.  Both ASHE and NFPA have been offering webinars and publications dealing with many of the changes. Many of the remaining 2016 conferences will also address some of the changes.

Questions related to this article may be directed to the author, David Stymiest, PE, CHFM, CHSP, FASHE, at