Why Are Life Safety Surveyors Using a Code That’s Over a Decade Old?
Dale Lyman, CFPS
Sr. Fire Protection Consultant Telgian Engineering & Consulting| Fire Chief (Ret.)| Author-“Ambulatory Surgery Center Safety Guidebook”
It’s a common question in healthcare compliance: Why are we still using a life safety code from 2012? The short answer? Because that’s the code adopted by the Centers for Medicare & Medicaid Services (CMS), and CMS rules the game when it comes to healthcare facility compliance.
How CMS Sets the Rules
CMS is the federal agency that oversees healthcare facilities participating in Medicare and Medicaid. To ensure patient, staff, and visitor safety, CMS enforces recognized safety standards—like NFPA 101, the Life Safety Code.
However, CMS doesn’t just adopt the latest edition as soon as NFPA updates it. Instead, the U.S. Congress must formally adopt a version before it can be enforced. That’s where the delay comes in.
The Current Code: 2012 NFPA 101
The last time Congress adopted a new edition of the Life Safety Code was July 5, 2016, when they officially recognized the 2012 edition of NFPA 101. Since then, State enforcement agencies and every CMS-authorized accreditation agency—including The Joint Commission (TJC), Quad A, the Accreditation Association for Ambulatory Health Care (AAAHC), DNV Healthcare, and ACHC—has been required to survey healthcare facilities against that edition and all its referenced codes and standards.
Even though newer editions of NFPA 101 have been published, CMS still enforces the 2012 version. Until Congress adopts a newer edition, that’s the one that applies.
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What This Means for Your Facility
If your facility falls under CMS regulations, compliance with NFPA 101 (2012) isn’t optional—it’s a requirement for accreditation and Medicare/Medicaid participation. Even though there are newer Code editions, CMS/accreditation life safety surveyors will assess your facility based on the 2012 code.
Will a Newer Code Be Adopted Soon?
It’s hard to say. There’s no set timeline for when CMS will adopt a more recent edition of NFPA 101. Healthcare facilities should keep an eye on CMS updates, but in the meantime, full compliance with the 2012 edition remains the expectation.
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Fire Protection Engineer, Property Risk Control
2 周Based on the article, bringing things to state-of-art will literally require an act of Congress. Sad but stupid. Congress needs to pass a law that requires the most current edition of NFPA 101. Years ago, one of my colleagues was inspecting fire protection systems at nuclear facilities. He was required to use editions that were so old that they were hard to obtain (this was before the Internet). ??
Manager, Facilities Management, Fire Protection Systems
2 周Thanks, Dale! You are spot on about TJC surveying you to the 2012 NFPA 101 and each NFPA code referenced in it. One of the findings, I recently received was on EC.02.03.05 EP 11- Fire Pump tested under flow….NFPA 25-2011: 8.3.3; 8.3.3.4 The fire pump passed, the contractor performed the test correctly and to the NFPA 25, chapter 8, but he referenced 2023 edition of NFPA 25! As the surveyor explained, I didn’t follow the standard as set forth by CMS. I pouted for a good hour over that ??
Owner, Hardaway|Sziabowski Architects | Founder, Ambulatory Healthcare Design Lab | Elevating Outpatient Facility Design for Superior Patient Results
2 周Great clarification Dale Lyman, CFPS!
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2 周And meanwhile, administrators are in jurisdictions that enforce the International Building and Fire Codes. That is an unnecessary complication that could be eliminated by dropping 101 in favor of the ICC codes. It would also mean regular updates to adapt to new materials, etc.