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Compliance News: What About the Other Standards?

| David Stymiest

The healthcare facilities community is expecting CMS adoption of NFPA 101-2012 (Life Safety Code®) and NFPA 99-2012 (Health care Facilities Code) later this year or sometime early next year.  While we have been awaiting adoption, may organizations have already made it a point to become familiar with some of the major changes within those two codes since the NFPA 101-2000 and NFPA 99-1999 editions.

An area that has not been given as much attention, and certainly deserves it, is the list of numerous referenced standards that will also be 10 to 15 years newer.  Those standards have changed as well, and many of them have changed substantially since the 2000 Life Safety Code® was approved by the NFPA Standards Council.

The Life Safety Code® edition that is invoked by any AHJ is important because that edition controls not only its own directly-stated requirements but also, through mandatory references to many other NFPA standards that were in effect when it was issued, many other aspects of both construction and operations.

Most hospitals are very familiar with the construction/renovation aspects of newer codes and standards (for example NFPA 70, the National Electrical Code™, NFPA 90A governing air conditioning and ventilating system installation, and NFPA 13 governing sprinkler system installation, among many others.) These consensus-based national standards are often invoked by state and local building codes whenever renovation and new construction projects are undertaken.  Another example is when AHJs invoke a newer edition of the Facilities Guidelines Institute (FGI) Guidelines for Design and Construction of Hospitals and Outpatient Facilities.

Below are just some examples from the list of over 50 newer NFPA standards that can have requirements invoked for CMS CoP compliance upon CMS’ adoption of the 2012 Life Safety Code® and 2012 Health Care Facilities Code.  These newer standards have changed, and those changes will definitely affect hospital facilities department inspection, testing and maintenance (ITM) processes.

NFPA Standard Major Topic UnderNFPA 101-2000 UnderNFPA 101-2012
NFPA 99 Health Care Facilities 1999 2012
NFPA 55 Compressed Gases 1998 2010
NFPA 10 Fire Extinguishers 1998 2010
NFPA 25 Water-Based Fire Protection 1998 2011
NFPA 20 Fire Pumps 2000 2010
NFPA 30 Flammable & Combustible Liquids Not published 2012
NFPA 17A Wet Chemical Extinguishing Systems 1998 2009
NFPA 96 Kitchen Hoods 1998 2011
NFPA 45 Laboratory Fire Protection 1996 2011
NFPA 72 Fire Alarm 1999 2010
NFPA 110 Emergency Power Supply Systems 1999 2010
NFPA 80 Fire Doors and Other Opening Protectives 1999 2010
NFPA 105 Smoke door Assemblies and Other Opening Protectives 1999 2010
NFPA 241 Safeguarding Construction, Alteration, and Demolition Operations 1999 2009

Sometimes regulatory changes occur that affect all hospitals independently of consensus-based codes and standards.  A recent major example is the CMS December 2013 Alternate Equipment Management changes (and subsequent related TJC July 2014 Alternate Equipment Maintenance changes) that raised the bar on compliance related to utility system equipment inventories as well as inspection, testing, and maintenance (ITM) activities.

We recommend that health care facilities managers plan for the needed additional training over the next 6-12 months.  It will be important and it should be timely.

Questions on the above may be directed to the author at