Medicare and Medicaid Programs; Fire Safety Requirements for Certain Health Care Facilities, 26871-26901 [2016-10043]

Agencies

• Centers for Medicare & Medicaid Services
• DEPARTMENT OF HEALTH AND HUMAN SERVICES

[Federal Register Volume 81, Number 86 (Wednesday, May 4, 2016)]
[Rules and Regulations]
[Pages 26871-26901]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2016-10043]



[[Page 26871]]

Vol. 81

Wednesday,

No. 86

May 4, 2016

Part II





Department of Health and Human Services





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Centers for Medicare & Medicaid Services





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42 CFR Parts 403, 416, 418, et al.





Medicare and Medicaid Programs; Fire Safety Requirements for Certain 
Health Care Facilities; Final Rule

Federal Register / Vol. 81 , No. 86 / Wednesday, May 4, 2016 / Rules 
and Regulations

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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

42 CFR Parts 403, 416, 418, 460, 482, 483, and 485

[CMS-3277-F]
RIN 0938-AR72


Medicare and Medicaid Programs; Fire Safety Requirements for 
Certain Health Care Facilities

AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.

ACTION: Final rule.

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SUMMARY: This final rule will amend the fire safety standards for 
Medicare and Medicaid participating hospitals, critical access 
hospitals (CAHs), long-term care facilities, intermediate care 
facilities for individuals with intellectual disabilities (ICF-IID), 
ambulatory surgery centers (ASCs), hospices which provide inpatient 
services, religious non-medical health care institutions (RNHCIs), and 
programs of all-inclusive care for the elderly (PACE) facilities. 
Further, this final rule will adopt the 2012 edition of the Life Safety 
Code (LSC) and eliminate references in our regulations to all earlier 
editions of the Life Safety Code. It will also adopt the 2012 edition 
of the Health Care Facilities Code, with some exceptions.

DATES: This regulation is effective July 5, 2016.
    The incorporation by reference of certain publications listed in 
the rule is approved by the Director of the Federal Register as of July 
5, 2016.

FOR FURTHER INFORMATION CONTACT: Kristin Shifflett, (410) 786-4133. 
Danielle Shearer, (410) 786-6617.

SUPPLEMENTARY INFORMATION: 

Acronyms

ABHR--Alcohol Based Hand Rubs
ADA--Americans with Disabilities Act
AHJ--Authority Having Jurisdiction
ASC--Ambulatory Surgical Center
ASHRAE--American Society of Heating, Refrigeration, and Air 
Conditioning Engineers
CAH--Critical Access Hospital
CDC--Centers for Disease Control and Prevention
CFR--Code of Federal Regulations
CMS--Centers for Medicare & Medicaid
DOJ--Department of Justice
EES--Essential Electrical System
FR--Federal Register
FSES--Fire Safety Evaluation System
GAO--Government Accountability Office
HHS--Department of Health and Human Services
HVAC--Heating, Ventilation, and Air Conditioning
ICF-IID--Intermediate Care Facilities for Individuals with 
Intellectual Disabilities
LSC--Life Safety Code
LTC--Long-term Care
NFPA--National Fire Protection Association
OPPS--Outpatient Prospective Payment System
PACE--Programs of All-inclusive Care for the Elderly
RFA--Regulatory Flexibility Act
RIA--Regulatory Impact Analysis
RNHCI--Religious Non-Medical Health Care Institution
TIA--Tentative Interim Amendment
UMRA--Unfunded Mandates Reform Act
WAGD--Waste Anesthetic Gas Disposal System

Definitions

    Approved, Automatic Sprinkler System; A fire protection system, 
deemed acceptable by the Authority Having Jurisdiction, consisting of 
an integrated network of piping designed in accordance with fire 
protection engineering standards and including a water supply, a water 
control valve, a water flow alarm, a drain, and automatic sprinklers 
which are fire suppression or control devices that operate 
automatically when their heat-actuated element is heated to its thermal 
rating or above, allowing water to discharge over a specified area.
    Deck: An exterior floor supported on at least two opposing sides by 
an adjacent structure and/or posts, piers, or other independent 
supports.
    Porch: An outside walking area having a floor that is elevated more 
than 8 in. (203 mm) above grade.
    Space: A portion of the health care facility designated by the 
governing body that serves a specific purpose.

    Note:  The word ``space'' takes its meaning from the context in 
which it is used as it is a definable area, such as a room, toilet 
room, storage room, assembly room, corridor, or lobby.

    Non-Supervised Automatic Sprinkler System: An automatic sprinkler 
system lacking electrical supervisory attachments and; therefore, 
unable to provide a distinctive supervisory signal to indicate a 
condition that would impair the satisfactory operation of the sprinkler 
system.
    Supervised Automatic Sprinkler System: An automatic sprinkler 
system equipped with electrical supervisory attachments, installed and 
monitored for integrity in accordance with NFPA 72, National Fire Alarm 
and Signaling Code, that provides a distinctive supervisory signal to 
indicate a condition that would impair the satisfactory operation of 
the sprinkler system.

    Note:  For a sprinkler system to be considered supervised as 
required by NFPA 101, the supervision must be electrical as 
contrasted with supervision via chaining and locking of valves in 
the open position as permitted for supervision by NFPA 13. 
Supervision in accordance with NFPA 101 involves more than valve 
monitoring as any condition that would impair satisfactory operation 
of the sprinkler system must provide a supervisory signal.

I. Background

A. Overview

    The Life Safety Code (LSC) is a compilation of fire safety 
requirements for new and existing buildings, and is updated and 
published every 3 years by the National Fire Protection Association 
(NFPA), a private, nonprofit organization dedicated to reducing loss of 
life due to fire. The LSC regulations adopted by Centers for Medicare & 
Medicaid Services (CMS) apply to hospitals, long-term care facilities 
(LTC), critical access hospitals (CAHs), ambulatory surgical centers 
(ASC), intermediate care facilities for individuals with intellectual 
disabilities (ICF-IIDs), hospice inpatient care facilities, programs 
for all inclusive care for the elderly (PACE), and religious non-
medical health care institutions (RNHCIs). The Medicare and Medicaid 
regulations have historically incorporated these requirements by 
reference, along with Secretarial waiver authority. The statutory basis 
for incorporating NFPA's LSC into the regulations we apply to Medicare 
and, as applicable, Medicaid providers and suppliers is the Secretary 
of the Department of Health and Human Services (the Secretary's) 
authority to stipulate health and safety regulations for each type of 
Medicare and (if applicable) Medicaid-participating facility, as well 
as the Secretary's general rulemaking authority, set out at sections 
1102 and 1871 of the Social Security Act (the Act).
    In our regulations, issued pursuant to the Act, we have stated that 
we believe CMS has the authority to grant waivers of some provisions of 
the LSC when necessary; for instance, to hospitals under section 
1861(e)(9) of the Act, and to LTC facilities at sections 1819(d)(2)(B) 
and 1919(d)(2)(B) of the Act. Under our current regulations, the 
Secretary may waive specific provisions of the LSC for any type of 
facility, if application of our rules would result in unreasonable 
hardship for the facility, and if the health and safety of its patients 
would not be compromised by such waiver.
    We do not consider it always necessary for a facility to be cited 
for a

[[Page 26873]]

deficiency before it can apply for or receive a waiver. This is 
particularly the case when we have evaluated specific provisions of the 
LSC, determined that a waiver would arguably apply to all similarly-
situated facilities with respect to the LSC requirement in question, 
and issued a public communication describing the specifics of such a 
categorical waiver, including any particular requirements that must be 
met in order for the waiver to apply to a facility. Waiver approval in 
these instances would be subject to a review of documentation 
maintained by the facility, verification of the applicability of the 
waiver, and confirmation that the terms and requirements of the waiver 
have been implemented by the facility. In most cases such verification 
occurs when an onsite survey of the facility is conducted. We plan to 
continue this approach, but would like to clarify that in those cases 
where we have issued a prior public communication providing for a 
categorical waiver, an advance recommendation from a state survey 
agency or accrediting organization (as applicable), is not required in 
order for a waiver to be granted. We have issued categorical waivers of 
LSC requirements when newer editions of the LSC provided equally 
effective means of ensuring life safety compared to requirements of 
earlier LSC editions. When CMS has evaluated the alternative (such as 
examining new fire safety research and technology), and concluded that 
the specific alternative would improve or maintain the safety of the 
residents or patients of the facility, CMS may defer to newer editions 
of the LSC. CMS requires that providers comply with any applicable non-
waived provisions of the version of the LSC referenced in the 
categorical waiver.
    In addition, the Secretary may accept a state's fire and safety 
code instead of the LSC if CMS determines that the protections of the 
state's fire and safety code are equivalent to, or more stringent than, 
the protections offered by the LSC. Further, the NFPA's Fire Safety 
Evaluation System (FSES), an equivalency system, provides alternatives 
to meeting various provisions of the LSC, thereby achieving the same 
level of fire protection as the LSC. These flexibilities mitigate the 
potential unnecessary burdens of applying the requirements of the LSC 
to all affected health care facilities.
    On January 10, 2003, we published a final rule in the Federal 
Register (68 FR 1374) adopting the 2000 edition of the LSC. In that 
final rule, we required that all affected providers and suppliers meet 
the provisions of the 2000 edition of the LSC, except for certain 
specific sections. One of the exceptions to the 2000 edition of the LSC 
is the code's use of roller latches on corridor doors in buildings that 
are fully protected by a sprinkler system. We believe that roller 
latches on corridor doors are a safety hazard under all circumstances, 
and prohibit their use on corridor doors in all Medicare and applicable 
Medicaid facilities. We also removed references to all previous 
editions of the LSC.
    In 2002, the Centers for Disease Control and Prevention (CDC) 
published on its Web site (https://www.cdc.gov/handhygiene/Guidelines.html) an initial set of hand hygiene guidelines for health 
care settings. The guidelines recommended the use of alcohol-based hand 
rub (ABHR) dispensers. On September 22, 2006, we published a final rule 
(71 FR 55326) to allow certain health care facilities to place ABHR 
dispensers in exit corridors under specified conditions. To accommodate 
the placement of ABHR dispensers in health care facilities, the NFPA 
retroactively amended the 2000 edition of the code. When CMS adopts an 
edition of the LSC, it adopts that edition as it existed on the day of 
publication of the proposed rule. Since the changes to the 2000 edition 
of the LSC occurred after publication of the January 2003 final rule 
that adopted the 2000 edition of the LSC, CMS was required to use the 
notice and comment rulemaking process to adopt the amendment that the 
NFPA made to the code.
    The September 2006 final rule also required that LTC facilities, at 
a minimum, install battery-powered single station smoke alarms in 
resident rooms and common areas if their buildings were not fully 
sprinklered, or if the building did not have system-based smoke 
detectors. A Government Accountability Office (GAO) report entitled 
``Nursing Home Fire Safety: Recent Fires Highlight Weaknesses in 
Federal Standards and Oversights'' GAO-04-660, July 16, 2004 (https://www.gao.gov/products/GAO-04-660) examined two LTC facility fires 
(Hartford and Nashville) in 2003, that resulted in 31 total resident 
deaths. The report examined Federal fire safety standards and 
enforcement procedures, as well as results from the fire investigations 
of these two incidents. It specifically cited requiring smoke detectors 
in these facilities as one way to strengthen the requirements. We 
agreed with the GAO findings and added this smoke alarm requirement in 
response to the GAO report.
    On August 13, 2008, we published a final rule (73 FR 47075) to 
require all LTC facilities to install automatic sprinkler systems 
throughout their buildings in accordance with the technical provisions 
of the 1999 edition of NFPA 13, Standard for the Installation of 
Sprinkler Systems, and to test, inspect, and maintain sprinkler systems 
in accordance with the technical requirements of the 1998 edition of 
NFPA 25, Standard for the Inspection, Testing and Maintenance of Water-
Based Fire Protection Systems. The August 2008 final rule required all 
LTC facilities to be equipped with sprinkler systems by August 13, 
2013. This rule was also in response to the July 2004 GAO report on 
nursing home fire safety. In addition to its findings related to smoke 
alarms, the GAO recommended that fire safety standards for 
unsprinklered LTC facilities be strengthened and stated that sprinklers 
were the single most effective fire protection feature for LTC 
facilities.
    On May 12, 2014 CMS also published a final rule, ``Part II 
Regulatory Provisions to Promote Program Efficiency, Transparency, and 
Burden Reduction'' (79 FR 27106) that allows CMS to grant very limited 
extensions of the due date for a facility that is building a 
replacement facility or undergoing major modifications to unsprinklered 
living areas.
    On October 24, 2011, we published a proposed rule (76 FR 65891), to 
reform hospital and critical access hospital conditions of 
participation. Many of the public comments received during the comment 
period strongly encouraged CMS to adopt the 2012 edition of the LSC. 
The commenters stated that the 2012 edition of the LSC would clarify 
several issues and would be beneficial to facilities.
    On April 16, 2014, we published a proposed rule (79 FR 21552), 
``Fire Safety Requirements for Certain Health Care Facilities'' that 
would amend the fire safety standards. We proposed the adoption of the 
2012 edition of the NFPA LSC and the elimination of references to 
earlier editions of the LSC.
    CMS must emphasize that the LSC is not an accessibility code, and 
compliance with the LSC does not ensure compliance with the 
requirements of the Americans with Disabilities Act (ADA). State and 
local government programs and services, including health care 
facilities, are required to comply with Title II of the ADA. Private 
entities that operate public accommodations such as nursing homes, 
hospitals, and social service center establishments are required to 
comply with Title III of the ADA. The same accessibility standards 
apply regardless of whether health care facilities are covered under 
Title II or

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Title III of the ADA.\1\ For more information about the ADA's 
requirements, see the Department of Justice's Web site at https://www.ada.gov or call 1-800-514-0301 (voice) or 1-800-514-0383 (TTY).
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    \1\ Facilities newly constructed or altered after March 15, 2012 
must comply with the 2010 Standards for Accessible Design (2010 
Standards). Facilities newly constructed or altered between 
September 15, 2010 and March 15, 2012 had the option of complying 
with either the 1991 Standards for Accessible Design (1991 
Standards) or the 2010 Standards. Facilities newly constructed 
between January 26, 1993 and September 15, 2010, or altered between 
January 26, 1992 and September 15, 2010 were required to comply with 
the 1991 Standards under Title III and either the 1991 Standards or 
the Uniform Federal Accessibility Standards under Title II.
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B. 2012 Edition of the Life Safety Code

    The 2012 edition of the LSC includes new provisions that we believe 
are vital to the health and safety of all patients and staff. Our 
intention is to ensure that patients and staff continue to experience 
the highest degree of fire safety possible. The term ``Patient(s)'' 
will be globally used throughout this document, and refers to patient, 
clients, residents and all other terms used to describe the type of 
individuals cared for in each provider type.
    The use of earlier editions of the code can become problematic due 
to advances in safety and technology, and changes made to each edition 
of the code. Newer buildings are typically built to comply with the 
newer versions of the LSC because state and local jurisdictions, as 
well as non-CMS-approved accreditation programs, often adopt and 
enforce newer versions of the code as they become available. Therefore, 
a health care facility that is constructed or renovated in 2015 would 
likely be required by its state and local authorities to comply with a 
more recent edition of the LSC, while also being required to comply 
with the 2000 edition of the LSC in order to meet the Medicare and 
applicable Medicaid regulatory requirements. Requiring compliance with 
two different editions of the LSC at the same time can create 
unnecessary conflicts, duplications, and inconsistencies that increase 
construction and compliance costs without any fire safety or patient 
care benefits. For example, the 2000 edition of the LSC limits ABHRs to 
gel form, whereas the 2012 edition of the LSC expands to allow aerosol 
and gel ABHRs. Limiting the choice of ABHRs creates barriers to 
improved hand hygiene, which has been shown to reduce the number of 
health care associated infections. We believe that adopting the 2012 
LSC would simplify and modernize the construction and renovation 
process for affected health care providers and suppliers, reduce 
compliance-related burdens, and allow for more resources to be used for 
patient care.
    The 2012 edition of the LSC contains a new chapter,--``Building 
Rehabilitation.'' This new chapter allows for the application of the 
requirements for new construction versus the requirements for existing 
construction to vary based on the type and extent of rehabilitation 
work being done to a given building. This chapter sets out different 
types of building rehabilitation work (that is, repair, renovation, 
modification, reconstruction, change of use, change of occupancy and 
addition) to which different standards apply.
    Buildings that have not received, all pre-construction governmental 
approvals before the rule's effective date, or those buildings that 
begin construction after the effective date of this regulation, will be 
required to meet the New Occupancy chapters of the 2012 edition of the 
LSC. Buildings constructed before the effective date of this regulation 
will be required to meet the Existing Occupancy chapters of the 2012 
edition of the LSC. Any changes made to buildings will be required to 
comply with Chapter 43--Building Rehabilitation, which depending on the 
changes being made, could require compliance with the new or existing 
occupancy chapters. In any instances where mandatory LSC references do 
not include existing chapters, such as Chapter 43--Building 
Rehabilitation, existing occupancies must ensure buildings and 
equipment are in compliance with provisions previously adopted by CMS 
at the time they were constructed or installed.

C. Incorporation by Reference

    In this final rule we are incorporating by reference the NFPA 
101[supreg] 2012 edition of the LSC, issued August 11, 2011, and all 
Tentative Interim Amendments issued prior to April 16, 2014; and the 
NFPA 99[supreg]2012 edition of the Health Care Facilities Code, issued 
August 11, 2011, and all Tentative Interim Amendments issued prior to 
April 16, 2014.
    (1) NFPA 101, Life Safety Code, 2012 edition, issued August 11, 
2011;
    (i) TIA 12-1 to NFPA 101, issued August 11, 2011.
    (ii) TIA 12-2 to NFPA 101, issued October 30, 2012.
    (iii) TIA 12-3 to NFPA 101, issued October 22, 2013.
    (iv) TIA 12-4 to NFPA 101, issued October 22, 2013.
    (2) NFPA 99, Standards for Health Care Facilities Code of the 
National Fire Protection Association 99, 2012 edition, issued August 
11, 2011.
    (i) TIA 12-2 to NFPA 99, issued August 11, 2011.
    (ii) TIA 12-3 to NFPA 99, issued August 9, 2012.
    (iii) TIA 12-4 to NFPA 99, issued March 7, 2013.
    (iv) TIA 12-5 to NFPA 99, issued August 1, 2013.
    (v) TIA 12-6 to NFPA 99, issued March 3, 2014.
    The materials that are incorporated by reference are reasonably 
available to interested parties and can be inspected at the CMS 
Information Resource Center, 7500 Security Boulevard, Baltimore, MD. 
Copies may be obtained from the National Fire Protection Association, 1 
Batterymarch Park, Quincy, MA 02169, www.nfpa.org, 1.617.770.3000. If 
any changes in this edition of the Code are incorporated by reference, 
CMS will publish a document in the Federal Register to announce the 
changes.
    The NFPA 101[supreg]2012 edition of the LSC (including the TIAs) 
provides minimum requirements, with due regard to function, for the 
design, operation and maintenance of buildings and structures for 
safety to life from fire. Its provisions also aid life safety in 
similar emergencies.
    The NFPA 99[supreg] 2012 edition of the Health Care Facilities Code 
(including the TIAs) provides minimum requirements for health care 
facilities for the installation, inspection, testing, maintenance, 
performance, and safe practices for facilities, material, equipment, 
and appliances, including other hazards associated with the primary 
hazards.
Health Care Occupancies
    The following are key provisions that appear in the 2012 edition of 
the LSC for Chapter 18, ``New Health Care Occupancies,'' and Chapter 
19, ``Existing Health Care Occupancies.'' We have provided the LSC 
citation and a description of the 2012 requirement at the beginning of 
each section discussed.
    The 2012 edition of the LSC classifies a ``Health Care Occupancy'' 
as a facility having 4 or more patients on an inpatient basis. We 
proposed that the LSC exception for health care occupancy facilities 
with fewer than four occupants/patients would be inapplicable to the 
Medicare and Medicaid facilities; all health care occupancies that 
provide care to one or more patients would be required to comply with 
the relevant requirements of the 2012 edition of the LSC.

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Sections 18.2.3.4(2) and 19.2.3.4(2)--Corridor Projections
    This provision requires noncontinuous projections to be no more 
than 6 inches from the corridor wall. In addition to following the 
requirements of the LSC, health care facilities must comply with the 
requirements of the ADA, including the requirements for protruding 
objects. The 2010 Standards for Accessible Design (2010 Standards) 
generally limit the protrusion of wall-mounted objects into corridors 
to no more than 4 inches from the wall when the object's leading edge 
is located more than 27 inches, but not more than 80 inches, above the 
floor. See Sections 204.1 and 307 of the 2010 Standards, available at 
https://www.ada.gov/regs2010/2010ADAStandards/Guidance2010ADAstandards.htm \2\ (``2010 Standards''). This requirement 
protects persons who are blind or have low vision from being injured by 
bumping into a protruding object that they cannot detect with a cane.
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    \2\ Regardless of which set of ADA Standards for Acessible 
Design applied at the time a facility was built or altered, the 
requirements for wall-mounted protruding objects are essentially the 
same. See Section 4.4 of the 1991 Standards, available at https://www.ada.gov/1991standards/1991standards-archive.html.
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    Although the LSC allows 6-inch projections, under the ADA, objects 
mounted above 27 inches and no more than 80 inches high can only 
protrude a maximum of 4 inches into the corridor beyond a detectable 
surface mounted less than 27 inches above the floor (except for certain 
handrails which may protrude up to 4\1/2\''). See section 307 of the 
2010 standards for requirements for handrails and post-mounted objects. 
CMS intends to provide technical assistance regarding strategies for 
how to avoid noncompliance with the ADA's protruding objects 
requirement, as well as how to modify non-compliant protruding objects.
Sections 18.7.5.7.2 and 19.7.5.7.2--Recycling
    This new provision requires that containers used solely for 
recycling clean waste be limited to a maximum capacity of 96 gallons. 
If the recycling containers are located in a protected hazardous area, 
container size will not be limited.
Sections 18.3.6.3.9.1 and 19.3.6.3.5--Roller Latches
    A roller latch is a type of door latching mechanism to keep a door 
closed. The 2012 edition of the LSC requires corridor doors to be 
provided with a means for keeping the door closed that is acceptable to 
the authority having jurisdiction. The LSC permits roller latches 
capable of keeping the door fully closed if a force of 5 pounds is 
applied at the latch edge or roller latches in fully sprinklered 
buildings. However, we proposed not to adopt these standards from the 
2012 LSC. Through fire investigations, roller latches have proven to be 
an unreliable door latching mechanism requiring extensive maintenance 
to operate properly. Many roller latches in fire situations failed to 
provide adequate protection to residents in their rooms during an 
emergency. Roller latches will be prohibited in existing and new Health 
Care Occupancies for corridor doors and doors to rooms containing 
flammable or combustible materials. These doors will be required to 
have positive latching devices instead.
Sections 18.4.2 and 19.4.2--Sprinklers in High-Rise Buildings
    This provision requires buildings over 75' (generally greater than 
7 or 8 stories) in height to have automatic sprinkler systems installed 
throughout the building. The 2012 LSC allows 12 years from when the 
authority having jurisdiction (which in this case is CMS) officially 
adopts the 2012 edition of the LSC for existing facilities to comply 
with the sprinkler system installation requirement. Therefore, those 
facilities that are not already required to do so will have 12 years 
following publication of this final rule, which adopts the 2012 LSC, to 
install sprinklers in high-rise buildings.
Sections 18.2.2.2.5.2 and 19.2.2.2.5.2--Door Locking
    Where the needs of patients require specialized protective measures 
for their safety, door-locking arrangements are permitted by this 
section. For example, locked psychiatric facilities are designed such 
that the entire facility is secure and obstructs patients and others 
from improperly entering and exiting. This provision allows interior 
doors to be locked, subject to the following requirements: (1) All 
staff must have keys; (2) smoke detection systems must be in place; (3) 
the facility must be fully sprinklered; (4) the locks are electrical 
locks that will release upon loss of power to the device; and (5) the 
locks release by independent activation of the smoke detection system 
and the water flow in the automatic sprinkler system.
Sections 18.3.2.6 and 19.3.2.6--Alcohol Based Hand Rubs (ABHRs)
    This provision explicitly allows aerosol dispensers, in addition to 
gel hand rub dispensers. The aerosol dispensers are subject to 
limitations on size, quantity, and location, just as gel dispensers are 
limited. Automatic dispensers are also now permitted in health care 
facilities, provided that the following requirements are met: (1) They 
do not release contents unless they are activated; (2) the activation 
occurs only when an object is within 4 inches of the sensing device; 
(3) any object placed in the activation zone and left in place must not 
cause more than one activation; (4) the dispenser must not dispense 
more than the amount required for hand hygiene consistent with the 
label instructions; (5) the dispenser is designed, constructed and 
operated in a way to minimize accidental or malicious dispensing; and 
(6) all dispensers are tested in accordance with the manufacturer's 
care and use instructions each time a new refill is installed. The 
provision further defines prior language regarding ``above or adjacent 
to an ignition source'' as being ``within 1 inch'' of the ignition 
source.
Sections 18.3.5 and 19.3.5--Extinguishment Requirements
    This provision is related to sprinkler system requirements and 
requires the evacuation of a building or the instituting of an approved 
fire watch when a sprinkler system is out of service for more than 10 
hours in a 24-hour period until the system has been returned to 
service. We proposed not to adopt this requirement. In its place, we 
proposed that a health care occupancy must evacuate a building or 
institute an approved fire watch when a sprinkler system is out of 
service for more than 4 hours. Based on comments received from the 
industry, we are withdrawing our proposal and adopting the requirement 
as specified by NFPA for an evacuation of a building or the instituting 
of an approved fire watch when a sprinkler system is out of service for 
more than 10 hours in a 24-hour period until the system has been 
returned to service.
Section 18.3.2.3 and 19.3.2.3--Anesthetizing Locations
    This provision requires that anesthetizing locations be protected 
in accordance with the 2012 edition of NFPA 99, Health Care Facilities 
Code. Separate from the requirements of the NFPA 99, we proposed that 
dedicated supply and exhaust systems for windowless anesthetizing 
locations must be arranged to automatically vent smoke and products of 
combustion to prevent the circulation of smoke originating from within 
and outside the operating rooms.

[[Page 26876]]

Sections 18.2.3.4 and 19.2.3.4--Corridors
    This provision allows for wheeled equipment that is in use, medical 
emergency equipment not in use, and patient lift and transportation 
equipment be permitted to be kept in the corridors for more timely 
patient care. This provision also allows facilities to place fixed 
furniture in the corridors, although the placement of furniture or 
equipment must not obstruct accessible routes required by the ADA. See 
section 403.5 of the 2010 Standards.
Sections 18.3.2.5.3 and 19.3.2.5.3--Cooking Facilities
    Cooking facilities are allowed in a smoke compartment where food is 
prepared for 30 individuals or fewer (by bed count). The cooking 
facility is permitted to be open to the corridor, provided that the 
following conditions are met:
     The area being served is limited to 30 beds or less.
     The area is separated from other portions of the facility 
by a smoke barrier.
     The range hood and stovetop meet certain standards--
    ++ A switch must be located in the area that is used to deactivate 
the cook top or range whenever the kitchen is not under staff 
supervision.
    ++ The switch also has a timer, not exceeding 120-minute capacity 
that automatically shuts off after time runs out.
     Two smoke detectors must be located no closer than 20 feet 
and not further than 25 feet from the cooktop or range.
Sections 18.7.5.1 and 19.7.5.1--Furnishings & Decorations
    This provision allows combustible decor in any health care 
occupancy as long as the d[eacute]cor is flame-retardant or treated 
with approved fire-retardant coating that is listed and labeled, and 
meet fire test standards. Additionally, decor may not exceed--(1) 20 
percent of the wall, ceiling and doors, in any room that is not 
protected by an approved automatic sprinkler system; (2) 30 percent of 
the wall, ceiling and doors, in any room (no maximum capacity) that is 
not protected by an approved, supervised automatic sprinkler system; 
and (3) 50 percent of the wall, ceiling and doors, in any room with a 
capacity of 4 people (the actual number of occupants in the room may be 
less than its capacity) that is not protected by an approved, 
supervised automatic sprinkler system.
Sections 18.5.2.3 and 19.5.2.3--Fireplaces
    This provision allows direct-vent gas fireplaces in smoke 
compartments without the 1 hour fire wall rating. Fireplaces must not 
be located inside of any patient sleeping room. Solid fuel-burning 
fireplaces are permitted and can be used only in areas other than 
patient sleeping rooms, and must be separated from sleeping rooms by 
construction of no less than a 1 hour fire resistance wall rating.
Outside Window or Door Requirements
    Separate from the requirements of the LSC, we proposed that every 
health care occupancy patient sleeping room must have an outside window 
or outside door with an allowable sill height not to exceed 36 inches 
above the floor with certain exceptions, as follows:
     Newborn nurseries and rooms intended for occupancy for 
less than 24 hours have no sill height requirements.
     Windows in atrium walls shall be considered outside 
windows for the purposes of this requirement.
     The window sill height in special nursing care areas shall 
not exceed 60 inches above the floor.
Ambulatory Health Care Occupancies
    The following are key provisions in the 2012 edition of the LSC 
from Chapter 20, ``New Ambulatory Health Care Occupancies'' and Chapter 
21, ``Existing Ambulatory Health Care Occupancies.'' We have provided 
the LSC citation and a description of the requirement at the beginning 
of each section discussed.
    The 2012 edition of the LSC defines an ``Ambulatory Health Care 
Occupancy'' as a facility capable of treating 4 or more patients 
simultaneously on an outpatient basis. CMS regulations at 42 CFR 416.44 
require that all ASCs meet the provisions applicable to Ambulatory 
Health Care Occupancy, regardless of the number of patients served. We 
believe that hospital outpatient surgical departments are comparable to 
ASCs and thus should also be required to meet the provisions applicable 
to Ambulatory Health Care Occupancy Chapters, regardless of the number 
of patients served.
Sections 20.3.2.1 and 21.3.2.1--Doors
    This provision requires all doors to hazardous areas be self-
closing or close automatically.
Sections 20.3.2.6 and 21.3.2.6--ABHRs
    This provision explicitly allows aerosol dispensers, in addition to 
gel hand rub dispensers. The aerosol dispensers are subject to 
limitations on size, quantity, and location, just as gel dispensers are 
limited. Automatic dispensers are also now permitted in ambulatory care 
facilities, provided, among other things, that--(1) they do not release 
contents unless they are activated; (2) the activation occurs only when 
an object is within 4 inches of the sensing device; (3) any object 
placed in the activation zone and left in place must not cause more 
than one activation; (4) the dispenser must not dispense more than the 
amount required for hand hygiene consistent with the label 
instructions; (5) the dispenser is designed, constructed and operated 
in a way to minimize accidental or malicious dispensing; (6) all 
dispensers are tested in accordance with the manufacturer's care and 
use instructions each time a new refill is installed. The provision 
further defines prior language regarding ``above or adjacent to an 
ignition source'' as being ``within 1 inch'' of the ignition source.
Sections 20.3.5 and 21.3.5--Extinguishment Requirements
    This provision is related to sprinkler system requirements and 
requires the evacuation of a building or the instituting of an approved 
fire watch when a sprinkler system is out of service for more than 10 
hours in a 24-hour period until the system has been returned to 
service. We proposed to replace this requirement with a separate 
requirement for evacuation or a fire watch when a sprinkler system is 
out of service for more than 4 hours. Based on comments received from 
the industry, we are withdrawing our proposal and adopting the 
requirement as specified by NFPA for an evacuation of a building or the 
instituting of an approved fire watch when a sprinkler system is out of 
service for more than 10 hours in a 24-hour period until the system has 
been returned to service.
Section 20.3.2.3 and 21.3.2.3--Anesthetizing Locations
    This provision requires that anesthetizing locations be protected 
in accordance with the 2012 edition of NFPA 99, Health Care Facilities 
Code. The 2012 edition of NFPA 99 does not require a smoke control 
ventilation system in anesthetizing locations. We proposed a 
requirement, separate from the LSC and NFPA 99, to require air supply 
and exhaust systems for windowless anesthetizing locations that is 
arranged to automatically vent smoke and products of combustion to 
prevent the circulation of smoke originating from within and outside 
the operating room.

[[Page 26877]]

Residential Board and Care Occupancies
    Both the 2000 and 2012 editions of the LSC classify ``board and 
care'' as a facility ``used for lodging or boarding of 4 or more 
patients not related to the owners or operators by blood or marriage, 
for the purpose of providing personal care services.'' We proposed that 
the LSC requirements would apply to a facility regardless of the number 
of patients served. We note that the only CMS-regulated facilities that 
would be subject to these provisions would be intermediate care 
facilities for individuals with intellectual disabilities (ICF-IIDs), 
which are regulated under 42 CFR part 483, subpart I.
    The following are key provisions that appear in the 2012 edition of 
the LSC for Chapter 32, ``New Residential Board and Care Occupancies'' 
and Chapter 33, ``Existing Residential Board and Care Occupancies.'' We 
are providing the LSC citation and a description of the requirement at 
the beginning of each section discussed.
Section 32.2.3.5.3.2--Sprinklers
    This revised provision has been expanded to require that sprinkler 
systems be installed in all habitable areas, closets, roofed porches, 
balconies and decks of new occupancies.
Sections 32.2.3.5.7 and 33.2.3.5.7--Attics
    This new provision requires attics of new and existing facilities 
to be sprinklered. For both new and existing board and care facilities, 
if the attic is used for living purposes, storage, or housing of fuel 
fired equipment, it must be protected with an automatic approved 
sprinkler system. If the attic is used for other purposes or is not 
used, then it must meet one of the following requirements: (1) Have a 
heat detection system that activates the building fire alarm system; 
(2) have automatic sprinklers; (3) be of noncombustible or limited-
combustible construction; or (4) be constructed of fire-retardant-
treated-wood.
Section 32.3.3.4.7--Smoke Alarms
    This provision will only affect newly constructed facilities. 
Approved smoke alarms are required to be installed inside every 
sleeping room, outside every sleeping area, in the immediate vicinity 
of the bedrooms, and on all levels within a resident unit.
Section 33.3.3.2.3--Hazardous Areas
    This provision is for existing facilities with impractical 
evacuation capabilities. All hazardous areas must be separated from 
other parts of the building by smoke partitions.
Waiver Authority
    We proposed to retain our existing authority to waive provisions of 
the LSC under certain circumstances, further reducing the exposure to 
additional cost and burden for facilities with unique situations. A 
waiver may be granted for a specific LSC requirement if we determine 
that--(1) the waiver would not adversely affect patient/staff health 
and safety; and (2) it would impose an unreasonable hardship on the 
facility to meet a specific LSC requirement. In cases where a provider 
or supplier has been cited for a LSC deficiency, the provider or 
supplier may request a waiver recommendation from its State Survey 
Agency or Accrediting Organization (AO) with a CMS-approved Medicare 
and applicable Medicaid accreditation program. The State Survey Agency 
or AO reviews the request and makes a recommendation to the appropriate 
CMS Regional Office. The CMS Regional Office will review the waiver 
request and the recommendation and make a final decision. CMS will not 
grant a waiver if patient health and safety is compromised.
    The LSC recognizes alternative systems, methods, or devices 
approved as equivalent by the authority having jurisdiction (AHJ) as 
being in compliance with the LSC. CMS, as the AHJ for certification, 
will determine equivalency through the waiver approval process.
State Fire Codes
    In addition to the proposed waiver option, a state may request that 
its state fire safety requirements, imposed by state law, be used in 
lieu of the 2012 edition of the LSC. The state must submit the request 
to the appropriate CMS Regional Office, and the Regional Office will 
forward the request to CMS central office for final determination.\3\
---------------------------------------------------------------------------

    \3\ CMS reminds such states that compliance with state fire 
safety requirements, like compliance with the LSC, does not ensure 
compliance with the ADA requirements.
---------------------------------------------------------------------------

Fire Safety Evaluation System (FSES)
    We retain our authority to apply the Fire Safety Evaluation System 
(FSES) option within the LSC as an alternative approach to meeting the 
requirements of the LSC. This includes the determination of how the 
FSES will be applied to each occupancy and which edition of the FSES is 
most appropriate to use.

D. 2012 Edition of the Health Care Facilities Code

    The 2012 edition of the NFPA 99, ``Health Care Facilities Code,'' 
addresses requirements for both health care occupancies and ambulatory 
care occupancies, and serves as a resource for those who are 
responsible for protecting health care facilities from fire and 
associated hazards. The purpose of this Code is to provide minimum 
requirements for the installation, inspection, testing, maintenance, 
performance, and safe practices for health care facility materials, 
equipment and appliances. This Code is a compilation of documents that 
have been developed over a 40-year period by NFPA, and is intended to 
be used by those persons involved in the design, construction, 
inspection, and operation of health care facilities, and in the design, 
manufacture, and testing of appliances and equipment used in patient 
care areas of health care facilities. It provides information on 
subjects, for example, medical gas and vacuum systems, electrical 
systems, electrical equipment, and gas equipment. The NFPA 99 applies 
specific requirements in accordance with the results of a risk-based 
assessment methodology. A risk-based approach allows for the 
application of requirements based upon the types of treatment and 
services being provided to patients or residents rather than the type 
of facility in which they are being performed. In order to ensure the 
minimum level of protection afforded by NFPA 99 is applicable to all 
patient and resident care areas within a health care facility, CMS 
proposed the adoption of the 2012 edition of NFPA 99, with the 
exception of chapters 7--Information Technology and Communications 
Systems for Health Care Facilities; 8--Plumbing; 12--Emergency 
Management; and 13--Security Management. In the following section, we 
describe the key provisions within the NFPA 99.
    The first three chapters of the NFPA 99 address the administration 
of the NFPA 99, the referenced publications and definitions.
Chapter 4--Fundamentals
    Chapter 4 provides guidance on how to apply NFPA 99 requirements to 
health care facilities based upon ``categories'' determined when using 
a risk-based methodology.
    There are four categories utilized in the risk assessment 
methodology, depending on the types of treatment and services being 
provided to patients or residents. Section 4.1.1 of NFPA 99

[[Page 26878]]

describes Category 1 as, ``Facility systems in which failure of such 
equipment or system is likely to cause major injury or death of 
patients or caregivers. . . .'' Section A.4.1.1 provides examples of 
what a major injury could include, such as amputation or a burn to the 
eye. Section 4.1.2 describes Category 2 as, ``Facility systems in which 
failure of such equipment is likely to cause minor injury to patients 
or caregivers. . . .'' Section A.4.1.2 describes a minor injury as one 
that is not serious or involving risk of life. Section 4.1.3 describes 
Category 3 as, ``Facility systems in which failure of such equipment is 
not likely to cause injury to patients or caregivers, but can cause 
patient discomfort. . . .'' Section 4.1.4 describes Category 4 as, 
``Facility systems in which failure of such equipment would have no 
impact on patient care. . . .''
    Section 4.2 requires that each facility that is a health care or 
ambulatory occupancy define its risk assessment methodology, implement 
the methodology, and document the results. CMS does not require the 
submission of risk assessment methods to CMS. However, CMS, will 
confirm that facilities are using risk assessment methodologies when 
conducting onsite surveys. We did not propose to require the use of any 
particular risk assessment procedure. However, if future situations 
indicate the need to define a particular risk assessment procedure, we 
would pursue that through a separate notice and comment rulemaking.
Chapter 5--Gas and Vacuum Systems
    The hazards addressed in Chapter 5 include the ability of oxygen 
and nitrous oxide to exacerbate fires, safety concerns from the storage 
and use of pressurized gas, and the reliance upon medical gas and 
vacuum systems for patient care. Chapter 5 does not mandate the 
installation of any systems; rather, if they are installed or are 
required to be installed, the systems will be required to comply with 
NFPA 99. Chapter 5 covers the performance, maintenance, installation, 
and testing of the following:
     Nonflammable medical gas systems with operating pressure 
below a gauge pressure of 300 psi;
     Vacuum systems in health care facilities;
     Waste anesthetic gas disposal systems (WAGD); and
     Manufactured assemblies that are intended for connection 
to the medical gas, vacuum, or WAGD systems.
Chapter 6--Electrical Systems
    The hazards addressed in Chapter 6 are related to the electrical 
power distribution systems in health care facilities, and address 
issues such as electrical shock, power continuity, fire, electrocution, 
and explosions that might be caused by faults in the electrical system.
    Chapter 6 covers the performance, maintenance, and testing of the 
electrical systems in health care facilities.
Chapter 9--Heating, Ventilation, and Air Conditioning (HVAC)
    Chapter 9 requires HVAC systems serving spaces- a portion of the 
health care facility designated by the governing body that serves a 
specific purpose or providing health care functions to be in accordance 
with the American Society of Heating, Refrigeration and Air-
Conditioning Engineers (ASHRAE) Standard 170- Ventilation of Health 
Care Facilities (2008 edition) (https://www.ashrae.org).
    Chapter 9 does not apply to existing HVAC systems, but applies to 
the construction of new health care facilities, and the altered, 
renovated, or modernized portions of existing systems or individual 
components. Chapter 9 ensures minimum levels of heating, ventilation, 
and air conditioning performance in patient and resident care areas. 
Some of the issues discussed in Chapter 9 are:
     HVAC system energy conservation.
     Commissioning.
     Piping.
     Ductwork.
     Acoustics.
     Requirements for the ventilation of medical gas storage 
and trans-filling areas.
     Waste anesthetic gases.
     Plumes from medical procedures.
     Emergency power system rooms.
     Ventilation during construction.
Chapter 10--Electrical Equipment
    Chapter 10 covers the performance, maintenance, and testing of 
electrical equipment in health care facilities. Much of this chapter 
applies to requirements for portable electrical equipment in health 
care facilities, but there are also requirements for fixed-equipment 
and information on administrative issues.
Chapter 11--Gas Equipment
    The hazards addressed in Chapter 11 relate to general fire, 
explosions, and mechanical issues associated with gas equipment, 
including compressed gas cylinders.
Chapter 14--Hyperbaric Facilities
    Chapter 14 addresses the hazards associated with hyperbaric 
facilities in health care facilities, including electrical, explosive, 
implosive, and fire hazards. Chapter 14 sets forth minimum safeguards 
for the protection of patients and personnel administering hyperbaric 
therapy and procedures. Chapter 14 contains requirements for hyperbaric 
chamber manufacturers, hyperbaric facility designers, and personnel 
operating hyperbaric facilities. It also contains requirements related 
to construction of the hyperbaric chamber itself and the equipment used 
for supporting the hyperbaric chamber, as well as administration and 
maintenance. Many requirements in this chapter are applicable only to 
new construction and new facilities.
Chapter 15--Features of Fire Protection
    Chapter 15 covers the performance, maintenance, and testing of fire 
protection equipment in health care facilities. Issues addressed in 
this chapter range from the use of flammable liquids in an operating 
room to special sprinkler protection. These fire protection 
requirements are independent of the risk-based approach, as they are 
applicable to all patient care areas in both new and existing 
facilities.
    Chapter 15 has several sections taken directly from the NFPA 101, 
including requirements for the following:
     Construction and compartmentalization of health care 
facilities.
     Laboratories.
     Utilities.
     Heating, ventilation and air conditioning systems.
     Elevators.
     Escalators.
     Conveyors.
     Rubbish Chutes.
     Incinerators.
     Laundry Chutes.
     Fire detection, alarm and communication systems.
     Automatic sprinklers and other extinguishing equipment.
     Compact storage including mobile storage and maintenance.
     Testing of water based fire protection systems.
    These sections have requirements for inspection, testing and 
maintenance which apply to all facilities, as well as specific 
requirements for existing systems and equipment that also apply to all 
facilities.

II. Provisions of the Proposed Regulations

    This section details the specific regulatory changes for each 
affected

[[Page 26879]]

provider and supplier. Due to the similar content and structure of the 
regulations for the various providers and suppliers, most of the 
information presented repeats for each provider.

1. Religious Nonmedical Health Care Institutions: Condition of 
Participation: Life Safety From Fire (Sec.  403.744)

    In Sec.  403.744, we proposed to maintain most of the current 
provisions for Religious Nonmedical Health Care Institutions (RNHCI) 
published in the Federal Register on January 10, 2003 (68 FR 1374), 
except if they conflicted with the 2012 LSC and the requirements were 
within the provisions detailed in Section I of this preamble regardless 
of the number of patients the facility served.
    In addition, we proposed to--
     Retain the requirements at Sec.  403.744(a)(1)(ii) related 
to the prohibition of roller latches in health care facilities. We also 
proposed to update the LSC chapter reference from ``19.3.6.3.2 
exception number 2'' to ``19.3.6.3.5 numbers 1 and 2 and 19.3.6.3.6 
number 2''.
     Modify the requirements specific to ABHRs, since most of 
the requirements in our regulation are now included in the 2012 edition 
of the LSC. Therefore, we proposed to remove the requirements at Sec.  
403.744(a)(4)(i), (ii), (iv) and (v).
     Retain the requirements at Sec.  403.744(a)(4)(iii) 
related to protection against inappropriate access, and redesignate it 
at Sec.  403.744(a)(4).
     Add a new requirement at Sec.  403.744(a)(5) that required 
facilities with sprinkler systems that were out of service for more 
than 4 hours in a 24-hour period to evacuate the building or portion of 
the building affected by the system outage, or establish a fire watch 
until the system is back in service, notwithstanding the lower standard 
of the LSC.
     Add a new requirement at Sec.  403.744(a)(6) to require 
window sills must not exceed 36 inches above the floor.
     Retain the requirement at Sec.  403.744(b) related to the 
Secretary's waiver authority and state imposed codes. We did not 
propose to make any changes to this section.
     Remove the requirements at Sec.  403.744(c) related to the 
phase-in period for compliance with emergency lighting. In the 2003 
final rule, we allowed facilities until March 13, 2006, to upgrade 
their emergency lighting equipment. This phase-in period has now 
expired and is no longer a necessary regulatory provision.
     Add a new Condition of Participation at Sec.  403.745 
requiring RNHCIs to comply with the 2012 edition of the NFPA 99.
     Chapters 7, 8, 12, and 13 of the NFPA 99 would not apply 
to RNHCIs.
     Allow for waivers of these provisions under the same 
conditions and procedures that we currently use for waivers of 
applicable provisions of the LSC.

2. Ambulatory Surgery Centers: Condition for Coverage: Environment 
(Sec.  416.44)

    In Sec.  416.44, we proposed that all ASCs meet the provisions 
applicable to Ambulatory Health Care Centers in the 2012 edition of the 
LSC, except as detailed in section I of this preamble, regardless of 
the number of patients the facility serves. We also proposed to retain 
the provision at Sec.  416.44(b)(2) and (b)(3) related to the 
Secretary's waiver authority and state imposed codes. We did not 
propose to make any changes to these provisions.
    In addition, we proposed to--
     Remove the requirements at Sec.  416.44(b)(4) related to 
the phase-in period for compliance with emergency lighting. This phase-
in period has now expired and this phase-in provision is no longer a 
necessary regulatory provision.
     Modify the requirements specific to ABHRs since most of 
the requirements are now included in the 2012 edition of the LSC. 
Specifically, we proposed to remove the requirements at Sec.  
416.44(b)(5)(i), (ii), (iv), (A) through (G), and (v).
     Retain the requirements at Sec.  416.44(b)(5)(iii) related 
to protection against inappropriate access and redesignate it at Sec.  
416.44(b)(4).
     Add a new requirement at Sec.  416.44(b)(5) to require a 
facility with a sprinkler system that is out of service for more than 4 
hours in a 24-hour period to evacuate the building or portion of the 
building affected by the system outage, or establish a fire watch until 
the system is back in service, notwithstanding the lower standard of 
the 2012 LSC.
     Add a new requirement at Sec.  416.44(b)(6) to require 
facilities with windowless anesthetizing locations to have an air 
supply and exhaust system that automatically vents smoke and products 
of combustion, prevents recirculation of smoke originating within the 
operating room, and prevents the circulation of smoke entering the 
system intake.
     Add a new paragraph at Sec.  416.44(c) requiring ASCs to 
comply with the 2012 edition of the NFPA 99.
     Chapters 7, 8, 12, and 13 of the NFPA 99 would not apply 
to ASCs.
     Allow for waivers of these provisions under the same 
conditions and procedures that we currently use for waivers of 
applicable provisions of the LSC.

3. Hospice Care: Condition of Participation: Hospices That Provides 
Inpatient Care Directly (Sec.  418.110)

    In Sec.  418.110, we proposed that all inpatient hospice facilities 
meet the provisions applicable to health care occupancies in the 2012 
edition of the LSC, with the exceptions discussed in section I of this 
preamble, regardless of the number of patients they serve. We note that 
this is not a change in requirements, but merely a clarification that, 
for LSC purposes, an inpatient hospice facility is considered a health 
care occupancy. The LSC does not apply to hospice care that is provided 
in a patient's home.
    In addition, we proposed to--
     Retain the requirements at Sec.  418.110(d)(1)(ii) related 
to the prohibition of roller latches in health care facilities. We 
proposed to update the LSC chapter reference from ``19.3.6.3.2 
exception number 2'' to ``19.3.6.3.5 numbers 1 and 2 and 19.3.6.3.6 
number 2.''
     Retain the provision at Sec.  418.110(d)(2) and (3) 
related to the Secretary's waiver authority and state imposed codes. We 
did not propose any changes to these provisions.
     Modify the requirements specific to ABHRs because most of 
the requirements are now included in the 2012 edition of the LSC. We 
proposed to remove the requirements at Sec.  418.110(d)(4)(i), (ii) and 
(iv). We proposed to retain the requirements at Sec.  
418.110(d)(4)(iii) related to protection against inappropriate access 
and redesignate this requirement at Sec.  418.110(d)(4).
     Add a new requirement at Sec.  418.110(d)(5) to require a 
facility with a sprinkler system that is out of service for more than 4 
hours in a 24-hour period to evacuate the building or portion of the 
building affected by the system outage, or establish a fire watch until 
the system is back in service, notwithstanding the lower standard of 
the 2012 LSC.
     Add a new requirement at Sec.  418.110(d)(6) to require 
that window sills must not exceed 36 inches.
     Add a new paragraph at Sec.  418.110(e) requiring hospices 
to comply with the 2012 edition of the NFPA 99.
     Chapters 7, 8, 12, and 13 of the NFPA 99 not would apply 
to hospices.

[[Page 26880]]

     Allow for waivers of these provisions under the same 
conditions and procedures that we currently use for waivers of 
applicable provisions of the LSC.

4. Programs of All-Inclusive Care for the Elderly (PACE): Condition of 
Participation: Physical Environment (Sec.  460.72)

    In Sec.  460.72, we proposed to retain most of the provisions of 
the existing final regulation for Programs of All-Inclusive Care for 
the Elderly (PACE) published in the Federal Register on January 10, 
2003 (68 FR 1374), regardless of the number of patients the PACE 
facility serves. PACE providers will continue to be required to meet 
LSC specifications for the type of facilities in which the programs are 
located (that is, hospitals and office buildings).
    In addition, we proposed to--
     Retain the requirements at Sec.  460.72(b)(1)(ii) related 
to the prohibition of roller latches in health care facilities. We 
proposed to update the LSC chapter reference from ``19.3.6.3.2 
exception number 2'' to ``19.3.6.3.5 numbers 1 and 2 and 19.3.6.3.6 
number 2.''
     Retain the provision at Sec.  460.72(b)(2)(i) and (ii) 
related to the Secretary's waiver authority and state imposed codes. We 
did not propose to make any changes to these provisions.
     Remove the requirement at Sec.  460.72(b)(3) related to 
the phase-in period for compliance with emergency lighting. This phase-
in period has now expired and is no longer a necessary regulatory 
provision.
     Remove the requirements at Sec.  460.72(b)(4) related to 
the phase-in period for the prohibition of roller latches in health 
care facilities. This phase-in period has now ended and is no longer a 
necessary regulatory provision.
     Modify the requirements specific to ABHRs because most of 
the requirements are now located in the 2012 edition of the LSC. We 
proposed to remove the requirements at Sec.  460.72(b)(5)(i), (ii), 
(iv) and (v). We proposed to retain the requirements at Sec.  
460.72(b)(5)(iii) related to protection against inappropriate access, 
and redesignate it to Sec.  460.72(b)(3). We proposed to add a new 
requirement at Sec.  460.72(b)(4) to require a facility with a 
sprinkler system that is out of service for more than 4 hours in a 24-
hour period to evacuate the building or portion of the building 
affected by the system outage, or establish a fire watch until the 
system is back in service, notwithstanding the lower standard of the 
2012 LSC.
     Add a new paragraph at Sec.  460.72(d) to require PACE 
centers to comply with the 2012 edition of the NFPA 99.
     Chapters 7, 8, 12, and 13 of the NFPA 99 would not apply 
to PACEs.
     Allow for waivers of these provisions under the same 
conditions and procedures that we currently use for waivers of 
applicable provisions of the LSC.

5. Hospitals: Condition of Participation: Physical Environment (Sec.  
482.41)

    In Sec.  482.41, we proposed that the hospitals meet the health 
care occupancy provisions of the 2012 edition of the LSC, regardless of 
the number of patients the hospital serves. There can be multiple 
occupancy classifications within a single hospital. Therefore, multiple 
chapters of the code may be applied to a single hospital in accordance 
with the Multiple Occupancies provisions in 18.1.3 and 19.1.3. We also 
proposed that hospital outpatient surgical departments are comparable 
to ASCs and thus should be required to meet the provisions applicable 
to Ambulatory Health Care Occupancy chapters, regardless of the number 
of patients served.
    In addition, we proposed to--
     Retain most of the provisions from the existing final 
regulation for hospitals published in the Federal Register on January 
10, 2003 (68 FR 1374).
     Retain the requirements at Sec.  482.41(b)(1)(ii) related 
to the prohibition of roller latches in health care facilities. We 
proposed to update the LSC chapter reference from ``19.3.6.3.2 
exception number 2'' to ``19.3.6.3.5 numbers 1 and 2 and 19.3.6.3.6 
number 2.''
     Retain the provision at Sec.  482.41(b)(2) and (3) related 
to the Secretary's waiver authority and state imposed codes. We did not 
propose to make any changes to these provisions.
     Remove the requirements at Sec.  482.41(b)(4) related to 
the phase-in period for compliance with emergency lighting. This phase-
in period has now ended, and is no longer a necessary regulatory 
provision.
     Remove the requirements at Sec.  482.41(b)(5) related to 
the phase-in period of the prohibition on roller latches in health care 
facilities. This phase-in period has now expired and is no longer a 
necessary regulatory provision.
     Retain the requirements at Sec.  482.41(b)(6) through 
(b)(8), and redesignate them at Sec.  482.41(b)(4) through (b)(6), 
without changes.
     Modify the requirements specific to ABHRs since most of 
the requirements are now located in the 2012 edition of the LSC. We 
proposed to remove the requirements at Sec.  482.41(b)(9)(i), (ii), 
(iv) and (v). We proposed to retain the requirement at Sec.  
482.41(b)(9)(iii) related to protection against inappropriate access 
and redesignate it at Sec.  482.41(b)(7).
     Add a new requirement at Sec.  482.41(b)(8) to require a 
facility with a sprinkler system that is out of service for more than 4 
hours in a 24-hour period to evacuate the building or portion of the 
building affected by the system outage, or establish a fire watch until 
the system is back in service, notwithstanding the lower standard of 
the 2012 LSC.
     Add a new requirement at Sec.  482.41(b)(9) that to 
require facilities with windowless anesthetizing locations to have an 
air supply and exhaust system that automatically vents smoke and 
products of combustion, prevents recirculation of smoke originating 
within the surgical suite, and prevents the circulation of smoke 
entering the system intake.
     Add a new requirement at Sec.  482.41(b)(10) to require a 
minimum 36 inch window sill, with certain exceptions for newborn 
nurseries, rooms intended for occupancy for less than 24 hours, and 
special nursing care areas.
     Add a new paragraph at Sec.  482.41(c) requiring hospitals 
to comply with the 2012 edition of the NFPA 99.
     Chapters 7, 8, 12, and 13 of the NFPA 99 would not apply 
to hospitals.
     Allow for waivers of these provisions under the same 
conditions and procedures that we currently use for waivers of 
applicable provisions of the LSC.

6. Long-Term Care Facilities: Condition of Participation: Physical 
Environment (Sec.  483.70)

    In Sec.  483.70, we proposed to retain most of the provisions of 
the existing final regulation for LTC facilities published in the 
Federal Register on January 10, 2003 (68 FR 1374) regardless of the 
number of residents the facility serves.
    In addition, we proposed to--
     Retain the requirements at Sec.  483.70(a)(1)(ii) related 
to the prohibition of roller latches in health care facilities. We 
proposed to update the LSC chapter reference from ``19.3.6.3.2 
exception number 2'' to ``19.3.6.3.5 numbers 1 and 2 and 19.3.6.3.6 
number 2.''
     Retain the provision at Sec.  483.70(a)(2) and (3) related 
to the Secretary's waiver authority and state imposed codes. We did not 
propose to make any changes to these provisions.

[[Page 26881]]

     Remove the requirements at Sec.  483.70(a)(4) related to 
the phase-in period for compliance with emergency lighting. This phase-
in period has now expired and is no longer a necessary regulatory 
provision.
     Remove the requirements at Sec.  483.70(a)(5) related to 
the phase-in period for the prohibition of roller latches in health 
care facilities. This phase-in period has now ended and is no longer a 
necessary regulatory provision.
     Modify the requirements specific to ABHRs since most of 
the requirements are now included in the 2012 edition of the LSC. 
Specifically, we proposed to remove the requirements at Sec.  
483.70(a)(6)(i), (ii), (iv) and (v). We proposed to retain the 
requirement at Sec.  483.70(a)(6)(iii) related to protection against 
inappropriate access, and redesignate it at Sec.  483.70(a)(4).
     Retain the requirements at Sec.  483.70(a)(7)(i), (ii), 
(iii), (A) and (B) related to installation, inspection, testing and 
maintenance of battery operated single station smoke alarms, without 
changes. We proposed to redesignate these requirements at Sec.  
483.70(a)(5) (i), (ii), (iii) (A) and (B).
     Retain the requirements at Sec.  483.70(a)(8)(i) and (ii) 
related to the installation of supervised automatic sprinklers and the 
testing, inspection and maintenance of the sprinkler system. We 
proposed to redesignate these requirements as Sec.  483.70(a)(6)(i) and 
(ii), without changes.
     Add a new requirement at Sec.  483.70(a)(7) to require a 
minimum 36 inch window sill.
     Add a new paragraph at Sec.  483.70(b) to require LTC 
facilities to comply with the 2012 edition of the NFPA 99.
     Chapters 7, 8, 12, and 13 of the NFPA 99 would not apply 
to LTC facilities.
     Allow for waivers of these provisions under the same 
conditions and procedures that we currently use for waivers of 
applicable provisions of the LSC.

7. Intermediate Care Facilities for Individuals With Intellectual 
Disabilities: Condition of Participation: Physical Environment (Sec.  
483.470)

    In Sec.  483.470, we proposed to retain most of the provisions of 
the existing regulation for ICFs/IID. In accordance with the regulatory 
requirements at Sec.  483.470 (j)(2), ICFs/IID will continue to be 
permitted to meet either the Residential Board and Care Occupancies 
chapter or the Health Care Occupancy chapter of the LSC, as 
appropriate, in accordance with the determination of the State survey 
agency, regardless of the number of patients the facility serves.
    In addition, we proposed to--
     Not adopt the provisions at Chapters 32.3.2.11.2 and 
33.3.2.11.2, related to ``lockups.'' Lock-ups, as described in the LSC, 
are not appropriate under any circumstances for board and care 
facilities.
     Retain the requirements at Sec.  483.470(j)(1)(ii) related 
to the prohibition of roller latches in health care facilities. We 
proposed to update the LSC chapter reference from ``19.3.6.3.2 
exception number 2'' to ``19.3.6.3.5 numbers 1 and 2 and 19.3.6.3.6 
number 2.''
     Retain the requirements at Sec.  483.470(j)(2), (3), and 
(4).
     Remove the requirements at Sec.  483.470(j)(5) related to 
the phase-in period for compliance with emergency lighting. This phase-
in period has expired and is no longer a necessary regulatory 
provision.
     Remove Sec.  483.470(j)(6) related to the phase-in period 
for the prohibition of roller latches in health care facilities. This 
phase-in period has now ended and is no longer a necessary regulatory 
provision.
     Retain the provision at Sec.  483.470(j)(7)(A) and (B) 
related to the Secretary's waiver authority and state imposed codes. We 
proposed to redesignate these provisions at Sec.  483.470(j)(5)(A) and 
(B) without change.
     Modify the requirements specific to ABHRs since most of 
the requirements are now included in the 2012 edition of the LSC. 
Specifically, we proposed to remove the requirements at Sec.  
483.470(j)(7)(ii)(A), (B), (D) and (E). We proposed to retain the 
requirements at Sec.  483.470(j)(7)(ii)(C) related to protection 
against inappropriate access, and redesignate it at Sec.  
483.470(j)(5)(ii).
     Add a new requirement at Sec.  483.470(j)(5)(iii) to 
require a facility with a sprinkler system that is out of service for 
more than 4 hours in a 24-hour period to evacuate the building or 
portion of the building affected by the system outage, or establish a 
fire watch until the system is back in service, notwithstanding the 
lower standard of the 2012 LSC.
     Add a new paragraph at Sec.  483.470(j)(5)(iv) to require 
ICF-IIDs to comply with the 2012 edition of the NFPA 99.
     Chapters 7, 8, 12, and 13 of the NFPA 99 would not apply 
to ICF-IIDs.
     Allow for waivers of these provisions under the same 
conditions and procedures that we currently use for waivers of 
applicable provisions of the LSC.

8. Critical Access Hospitals: Condition of Participation: Physical 
Plant and Environment (Sec.  485.623)

    In Sec.  485.623, we proposed to retain most of the provisions of 
the existing final regulation for Critical Access Hospitals (CAHs) 
published in the Federal Register on January 10, 2003 (68 FR 1374), 
regardless of the number of patients the facility serves.
    In addition, we proposed to--
     Retain the requirements at Sec.  485.623(d)(1)(ii) related 
to the prohibition of roller latches in health care facilities. We 
proposed to update the LSC chapter reference from ``19.3.6.3.2 
exception number 2'' to ``19.3.6.3.5 numbers 1 and 2 and 19.3.6.3.6 
number 2.''
     Retain the requirements at Sec.  485.623(d)(2) through 
(d)(4), without any changes.
     Remove the requirement at Sec.  485.623(d)(5) related to 
the phase-in period for compliance with emergency lighting. This phase-
in period has now expired and is no longer a necessary regulatory 
provision.
     Remove the requirement at Sec.  485.623(d)(6) related to 
the phase-in period of the prohibition on roller latches in health care 
facilities. This phase-in period has also expired and is no longer a 
necessary regulatory provision.
     Modify the requirements specific to ABHRs since most of 
the requirements are now incorporated in the 2012 edition of the LSC. 
Specifically, we proposed to remove the requirements at Sec.  
485.623(d)(7)(i), (ii), (iv) and (v). We proposed to retain the 
requirement at Sec.  485.623(d)(7)(iii) related to protection against 
inappropriate access and redesignate it at Sec.  485.623(d)(5).
     Add a new requirement at Sec.  485.623(d)(6) to require a 
facility with a sprinkler system that is out of service for more than 4 
hours in a 24-hour period to evacuate the building or portion of the 
building affected by the system outage, or establish a fire watch until 
the system is back in service, notwithstanding the lower standard of 
the 2012 LSC.
     Add a new requirement at Sec.  485.623(d)(7) to require 
facilities with windowless anesthetizing locations to have an air 
supply and exhaust system that automatically vents smoke and products 
of combustion, prevents recirculation of smoke originating within the 
surgical suite, and prevents the circulation of smoke entering the 
system intake.
     Add a new requirement at Sec.  485.623(d)(8) to require a 
minimum 36 inch window sill, with the exception of

[[Page 26882]]

newborn nurseries, rooms intended for occupancy for less than 24 hours, 
and special nursing care areas. Windows in atrium walls are considered 
outside windows for the purposes of this provision.
     Add a new paragraph at Sec.  485.623(e) requiring CAHs to 
comply with the 2012 edition of the NFPA 99.
     Chapters 7, 8, 12, and 13 of the NFPA 99 would not apply 
to CAHs.
     Allow for waivers of these provisions under the same 
conditions and procedures that we currently use for waivers of 
applicable provisions of the LSC.

III. Analysis of and Responses to Public Comments

    We received over 362 public comments concerning the LSC proposed 
rule, ``Fire Safety Requirements for Certain Health Care Facilities'' 
(79 FR 21552), which this rule is finalizing. The majority of the 
comments were from medical societies, hospital associations, hospitals, 
medical centers, LTC facilities, and advocate groups for different 
provider types. The remaining comments were from individual physicians, 
nurses, facility engineers, and private citizens. A summary of the 
major issues and our responses follow:

LSC--Health Care Occupancies

    We note that only the following CMS-regulated facilities would be 
subject to these comments, unless otherwise specified: Hospitals, CAHs, 
LTC facilities, hospices, RNHCIs, and PACE facilities.
    Comment: One commenter recommended adding language to the LTC 
requirements at Sec.  483.70, similar to other provider sections, about 
establishing a firewatch or evacuating a building when a sprinkler 
system is out of service for more than 4 hours in a 24 hour period. The 
commenter stated that adding this requirement to the LTC regulations 
would provide protection for the residents of nursing homes when the 
sprinkler system is out of service.
    Response: We thank the commenter for their comment. We agree that 
requiring additional safety measures when a sprinkler system is out of 
service for a significant amount of time is important in the LTC 
facility environment. We originally intended to include this regulatory 
requirement in the proposed rule; however, it was inadvertently left 
out of regulations text. We would like to clarify that we have removed 
the 4 hour requirement and are now following the LSC requirement of 
implementing a fire watch or building evacuation if the sprinkler 
system is out for more than 10 hours in a 24-hour period. We have made 
the appropriate correction in this final rule, and have included the 
appropriate language in the regulation text at Sec.  483.70(a)(8).
    Comment: One commenter stated that the proposed rule does not 
address whether a hospital that is not fully sprinklered and provides 
swing beds needs to meet the more stringent requirements from S & C-13-
55-LSC that applies to hospitals.
    Response: The survey and certification memorandum that the 
commenter references is related to the requirements for the 
installation and maintenance of automatic sprinkler systems in LTC 
facilities. Swing beds are not considered to be LTC facilities. Rather, 
swing beds are part of a hospital or CAH and must meet the LSC 
provisions applicable to those facility-types. Therefore, swing beds 
are only required to meet certain specified regulations for LTC 
facilities, not including the LTC facility sprinkler system 
requirements.
    Comment: CMS solicited public comment to determine if a phase-in 
period of 12 years is enough time for facilities to install fully 
compliant sprinkler systems in high-rise buildings, and asked whether 
other provider types are, or may be, located in a high-rise building. 
We received very few responses to this solicitation. The majority of 
the commenters who responded stated that 12 years was enough time to 
fully sprinkler a high-rise healthcare facility, and some commenters 
stated that 12 years was more than enough time. We did not receive any 
comments stating that this was not enough time to install sprinkler 
systems in high-rise buildings. Commenters also stated that ambulatory 
care and residential board and care occupancies may also be located 
within high-rise hospital buildings.
    Response: We agree with commenters that 12 years is an appropriate 
phase-in period, and we are finalizing this proposal with a phase-in 
period of 12 years from the publication date of this rule. We thank the 
commenters for the input on other occupancy types that could be located 
in high-rise buildings. Since these occupancy types are located in 
hospital buildings, we have already accounted for them in our total 
number of high-rise hospital buildings.
    Comment: One commenter asked whether an alternative care setting 
used to provide services to PACE participants would be required to meet 
the ABHR requirements and the sprinkler system outage requirement.
    Response: All PACE center facilities are required to meet the 
requirements found at 42 CFR 460.72, ``Physical Environment''. This 
includes meeting all the requirements for the specific occupancy type 
they fall under within the LSC. This requirement also applies to the 
type of setting in which a center is located, which would include 
alternative care settings.
    Comment: Some commenters have expressed concern regarding cooking 
facilities that are open to the corridor. One commenter did not support 
cooking facilities being open to the corridor and believes that it 
could increase the number of fires in these facilities due to misuse. 
Other commenters supported having cooking facilities that are open to 
the corridor and believed it would promote person-centered care and 
make for a more home-like atmosphere. A few commenters suggested 
changes to this requirement, including--
     Requiring that an operational exhaust hood for the cooking 
facility should not contribute to nor create an egress corridor return 
air plenum (an air pressure differential between different parts of a 
building);
     Requiring that the activate/deactivate switch be hidden 
from view;
     Requiring that staff must be present when a range hood or 
stovetop is in use; and
     Requiring that cooking facilities be screened off when not 
in use to prevent resident access.
    Response: We appreciate the suggestions concerning cooking 
facilities in LTC facilities; however we feel that the LSC includes 
many requirements to make sure that cooking facilities are safe. All 
facilities are ultimately responsible for assuring the safety of all 
residents at all times, and they may choose to implement additional 
safety precautions, such as those described above, to further assure 
safety. Since other fire safety standards prohibit the use of a 
corridor as a plenum in the facility ventilation system, the 
introduction of a cooking exhaust fan would need to be accounted for in 
the design and not create a corridor plenum situation.
    Comment: One commenter suggested that, in addition to installing 
sprinklers in existing high-rise health care occupancies, we should 
also require existing non high-rise health care occupancies to install 
sprinkler systems throughout their buildings.
    Response: While we encourage all facilities to install sprinklers, 
there is not enough evidence for CMS to support requiring all 
facilities to be retrofitted for sprinklers. In the event that the NFPA 
should incorporate a requirement for universal sprinklers into a future 
edition of the LSC, we would strongly consider adopting such a change.

[[Page 26883]]

    Comment: Some commenters stated that medical equipment should not 
be permanently fixed in the corridors. This could present a safety 
issue during a fire or evacuation and also makes the corridor smaller 
in size.
    Response: We follow the LSC requirement for medical equipment in 
the corridors, which allows any equipment that is in use, including 
medical emergency equipment and patient lift and transportation 
equipment to be permitted to be kept in the corridors for more timely 
patient care. Facilities may place fixed furniture in the corridors, 
although the placement of furniture or equipment must not obstruct 
accessible routes required by the ADA. The potential risks of this 
change are low because the LSC has shifted to a ``defend in place'' 
approach that does not rely upon evacuation as the primary means of 
fire safety.
    Comment: One commenter suggested that CMS only permit decorations 
in rooms that have sprinklers in them. Furthermore, the commenter 
stated that, with such sprinkler protection, there would not be a need 
to mandate a maximum percentage of space that could be covered by 
decorations.
    Response: The NFPA, through its committee of experts and consensus 
process, determined that decorations may not exceed--(1) 20 percent of 
the wall, ceiling and doors, in any room that is not protected by an 
approved automatic sprinkler system; (2) 30 percent of the wall, 
ceiling and doors, in any room that is not protected by an approved, 
supervised automatic sprinkler system; and (3) 50 percent of the wall, 
ceiling and doors, in any room with a capacity of 4 people (the actual 
number of occupants in the room may be less than its capacity) that is 
not protected by an approved, supervised automatic sprinkler system. We 
believe that it is appropriate to adopt these consensus standards. We 
also note that the health care occupancy type that is most likely to 
have a significant amount of room d[eacute]cor is a LTC facility, given 
that patients reside in such facilities for longer periods of time, and 
that all LTC facilities are required to have sprinklers installed 
throughout their buildings.
    Comment: One commenter recommended that two smoke detectors be 
located no closer than 20 feet and not further than 25 feet from a 
fireplace.
    Response: There are currently no requirements for smoke detectors 
within a certain distance of a fireplace. If a facility wants to add 
additional smoke detectors closer to fireplaces they are free to do so. 
An electrically supervised (connected to the facility fire alarm panel) 
carbon monoxide detector is required in the room containing the 
fireplace to increase the level of safety for the residents or patients 
in the facility. We believe that the current requirements for 
sprinklers and smoke detectors are sufficient to assure resident 
safety, particularly because fireplaces are only in open areas and not 
permitted in resident rooms. The health care occupancy type that is 
most likely to have a fireplace is a LTC facility, because there are 
more options for the location of fireplaces in LTC facilities, making 
the facilities feel more home-like. All LTC facilities should be fully 
sprinklered, with smoke detectors in designated areas of the 
facilities, such as corridors and resident sleeping areas.

LSC--ASC

    We note that the only CMS-regulated facilities that would be 
subject to these comments would be ambulatory surgical centers, which 
are regulated under 42 CFR part 416.
    Comment: One commenter believes that we should allow grandfathering 
for ASCs that meet previous editions of the LSC. The commenter states 
that trying to modify an existing facility to meet provisions in the 
2012 edition of the LSC would have significant cost implications for 
existing ASCs, and may cause ASCs to close.
    Response: For existing ASCs, most provisions in the 2012 edition of 
the LSC are similar to past editions. Furthermore, existing facilities 
in compliance with previous editions of the LSC are not required to 
upgrade to a later edition of the LSC for certain provisions, unless 
there is a building renovation, which could require compliance with new 
occupancy chapters. In addition, an ASC may also request a waiver for a 
specific provision of the LSC, further reducing the exposure to 
additional costs and burden for ASCs with unique situations that can 
justify the application of waivers and will not endanger the health and 
safety of patients. A waiver may be granted for a specific LSC 
requirement if we determine: (1) The waiver would not adversely affect 
patient and staff health and safety; and (2) it would impose an 
unreasonable hardship on the facility to meet a specific LSC 
requirement.
    Comment: One commenter suggested an increase to Medicare 
reimbursements to freestanding ASCs, stating that the current 
reimbursement model is not sufficient.
    Response: We thank the commenter for this comment; however, 
reimbursement rates are beyond the scope of this rule. We recommend 
submitting such comments separately to CMS or commenting on the next 
Outpatient Prospective Payment System/Ambulatory Surgical Centers 
(OPPS/ASC) proposed rule.

LSC--Board & Care

    We note that the only CMS-regulated facilities that would be 
subject to these comments would be intermediate care facilities for 
individuals with intellectual disabilities (ICF-IIDs), which are 
regulated under 42 CFR part 483, subpart I.
    Comment: One commenter expressed concern about a process that 
permits board and care occupancies to assess their own evacuation 
capacity. The commenter notes that facilities have strong incentive to 
overestimate their evacuation capability in order to avoid more 
stringent requirements. The commenter believes that this provision 
would undermine CMS' efforts to improve safety.
    Response: CMS looks at the assessment of evacuation capabilities as 
part of the survey process to verify the accuracy of the self-
evaluation. CMS requires surveyors to independently determine the 
evacuation difficulty score at each survey and use the determined 
evacuation difficulty score to perform the survey.
    Comment: CMS solicited comments regarding whether or not CMS should 
require existing facilities to install smoke alarms in accordance with 
section 9.6.2.10, which would require the addition of smoke alarms 
inside sleeping rooms, outside every sleeping area, in the immediate 
vicinity of the bedrooms, and on all levels within the resident units. 
The commenters who responded to this solicitation unanimously agreed 
that CMS should not require existing residential board and care 
facilities to install smoke alarms inside sleeping rooms, outside every 
sleeping area, in the immediate vicinity of the bedrooms, and on all 
levels within the resident units. All of the commenters believed that 
it would be an undue burden, and suggested that, in order for them to 
meet this requirement, a payment rate adjustment would be in order.
    Response: We agree that a regulation to require smoke alarms is not 
necessary at this time, as there is not enough evidence for us to make 
it a requirement to upgrade existing facilities. We strongly encourage 
existing residential board and care facilities to install smoke alarms 
inside sleeping rooms, outside every sleeping area, in the immediate 
vicinity of the bedrooms, and on all levels within the resident units 
to provide an additional level of safety. With regards to any payment 
rate adjustment, we remind commenters that

[[Page 26884]]

payment rates are not within the scope of this rule, but recommend 
submitting comments on such issues separately to CMS.
    Comment: The LSC requires newly constructed residential board and 
care occupancies to install sprinklers in habitable areas, closets, 
roofed porches, balconies and decks. In the proposed rule, CMS 
recommended that existing facilities also install sprinklers in the 
same areas. Commenters stated that CMS should continue to recommend, 
but not require, sprinklers for existing residential board and care. 
The commenters also stated that if CMS were to require the installation 
of sprinklers in those areas that they would need to have at least a 5 
year phase-in period, and that a payment rate adjustment would be in 
order for affected facilities.
    Response: We thank the commenters for their comments regarding this 
topic. We would like to clarify that sprinklers are only required for 
new residential board and care construction and existing facilities 
rated as impractical evacuation capability. The facility itself 
determines their evacuation capability, and must ensure that the 
appropriate safety protections are in place to protect the patients and 
staff within the building, if they are determined to have an 
impractical evacuation capabilities. CMS regulations require the use of 
NFPA 101A, Guide on Alternative Approaches to Life Safety, 2010 
Edition, Chapter 6, Evacuation Capability Determination for Board and 
Care Occupancies to determine the evacuation difficulty index. CMS 
continues to recommend that existing facilities install sprinklers in 
habitable areas, closets, roofed porches, balconies and decks as an 
additional safety precaution. Decks being an exterior floor supported 
on at least two opposing sides by an adjacent structure and/or posts, 
piers, or other independent supports and, porches being an outside 
walking area having a floor that is elevated more than 8 in. (203 mm) 
above grade. With regards to any payment rate adjustment, we remind 
commenters that payment rates are not within the scope of this rule, 
but recommend submitting such comments separately to CMS.
    Comment: A few commenters expressed concern with having to install 
sprinklers in attics used for living purposes, storage, or housing of 
fuel-fired equipment. Commenters also expressed concern with having to 
install either a heat detection system that activates the building fire 
alarm, or having automatic sprinklers, or constructing attics of 
noncombustible or limited-combustible construction or constructing 
attics of fire-retardant-treated-wood if the attic is used for other 
purposes. The commenters stated that compliance with this provision 
would be expensive and possibly warrant a payment rate adjustment. The 
commenters requested a minimum 5-year phase-in period to install new 
protection systems in attics.
    Response: A 5-year phase-in period is, we believe, significantly 
more time than is actually needed to meet this requirement. According 
to the information gathered by CMS from the installation of sprinklers 
in LTC facilities requirement, which was required to be in compliance 
by August 13, 2013, most LTC facilities were able to install sprinklers 
throughout their entire buildings in 5 years. Attics have much less 
square footage than an entire building. We believe that 3 years from 
the effective date of this rule would be an ample amount of time to 
come into compliance with this requirement, therefore, we are 
finalizing a 3-year phase-in period. With regards to any payment rate 
adjustment, we remind commenters that payment rates are not within the 
scope of this rule, but recommend submitting such comments separately 
to CMS.
    Comment: One commenter requested additional explanation regarding 
our proposed exclusion of the lock-up provisions contained within the 
board and care occupancy chapters of the LSC. The commenter proposed an 
alternative to this exclusion, which would allow lock-ups while 
requiring a specific staffing ratio requirement.
    Response: Lock-ups are incidental use areas where occupants are 
restrained and such occupants are mostly incapable of self-preservation 
because of security measures not under the occupants' control. Lock-ups 
are prohibited in Medicare and Medicaid participating ICF-IID 
facilities. The health and safety regulations for ICF-IIDs at 42 CFR 
483.450 effectively prohibit the use of lock-up spaces as described in 
the LSC; therefore, there should be no lock-up space in the building.

LSC--General

    Comment: Some commenters questioned whether Tentative Interim 
Amendments (TIAs) that have been written with regards to the NFPA 101 
and NFPA 99 apply, since some of them were published after CMS 
published the proposed rule.
    Response: Because the TIAs are considered a component of the LSC, 
the following TIAs issued prior to the publication of the proposed rule 
on April 16, 2014, will apply to all facilities. We have also included 
language in the final regulations text to this effect. The following 
TIAs will apply:
    (i) TIA 12-1 to NFPA 101, issued August 11, 2011.
    (ii) TIA 12-2 to NFPA 101, issued October 30, 2012.
    (iii) TIA 12-3 to NFPA 101, issued October 22, 2013.
    (iv) TIA 12-4 to NFPA 101, issued October 22, 2013.
    (v) TIA 12-2 to NFPA 99, issued August 11, 2011.
    (vi) TIA 12-3 to NFPA 99, issued August 9, 2012.
    (vii) TIA 12-4 to NFPA 99, issued March 7, 2013.
    (viii) TIA 12-5 to NFPA 99, issued August 1, 2013.
    (ix) TIA 12-6 to NFPA 99, issued March 3, 2014.
    Comment: Some commenters agree with the continued prohibition of 
roller latches in facilities, as they are a safety concern. However, 
some commenters stated that some doors are not required to latch (that 
is, toilet rooms, bathrooms) and that roller latches should be allowed 
on those particular doors with no penalty. A few commenters also 
discussed the importance of roller latches in psychiatric units. Those 
commenters stated that roller latches have limited uses on psychiatric 
units to address patients barricading themselves in their rooms or 
using hanging points (on the levers) for potential suicides.
    Response: CMS would like to clarify that roller latches are 
prohibited on all corridor doors. However, doors to toilet rooms, 
bathrooms, shower rooms, sink closets, and similar auxiliary spaces 
that do not contain flammable or combustible materials would be allowed 
to have roller latches. We do not believe that permitting the use of 
roller latches in auxiliary spaces presents a danger to patients or 
staff. Therefore, we have revised the proposed regulatory requirement 
throughout this rule to clarify this distinction. We note that this 
requirement is different than the 2012 LSC requirement for door 
latching.
    Comment: A few commenters expressed concern with Chapter 43, 
``Renovation'', of the NFPA 101. The commenters suggested that the date 
of submission of construction plans to the State for plan review should 
be the ``trigger'' to apply chapter 43. They also stated that 
facilities have no control over when plans are actually reviewed; for 
example, a building may be designed under the current 2000 NFPA 101 
code, but may not be approved until after the final publication of this 
rule, which means they would have to meet the

[[Page 26885]]

2012 NFPA 101 code. Commenters also asked CMS to define ``constructed'' 
in reference to determining whether a building is consider new or 
existing.
    Response: Buildings that have not yet received all pre-construction 
governmental approvals required by the jurisdictions in which the 
building is to be built before the rule's effective date, or those 
buildings that begin construction after the effective date of this 
regulation, would be required to meet the New Occupancy chapters of the 
2012 edition of the LSC. While we share the commenter's concern 
regarding plans that may be under review for a lengthy period of time, 
we do not believe that it is in the best interest of patient and staff 
safety to permit constructing of a building that does not meet the 
codes that are effective as of the day that construction begins.
    Comment: One commenter suggested that hospitals and ASCs should be 
required to test their emergency generators when they are disconnected 
from the normal utility.
    Response: Facilities are required to test their load emergency 
power systems on a monthly basis, per the requirements of section 
8.4.1, 2010 edition of NFPA 110, Standard for Emergency and Standby 
Power Systems.
    Comment: Some commenters suggested that CMS should provide training 
for surveyors and providers regarding the new codes, updated guidance, 
and forms. One commenter suggested that CMS not only provide training 
for State fire authorities, but also for architects, engineers, and 
building officials.
    Response: CMS agrees that training is very important, and does 
provide training for state surveyors who work with CMS to enforce these 
regulations. However, we do not provide training for any provider/
supplier type for any health and safety rules, including those related 
to the LSC. We encourage providers/suppliers, architects, engineers or 
building officials to contact the NFPA and their relevant industry 
associations to identify their specific training needs and appropriate 
offerings that may address those needs with regards to the LSC.
    Comment: Many commenters support the adoption of the 2012 NFPA 101 
LSC. However, the majority of those commenters also stated that CMS 
should adopt the 2012 NFPA 101 in its entirety, without any changes to 
the provisions.
    Response: Through our surveys, comments, and experience, we have 
determined that for the health and safety of patients and staff we 
could not adopt the LSC in its entirety. We believe that the provisions 
that we have not adopted are not appropriate for Medicare and Medicaid 
providers and suppliers. For example, we continue to prohibit roller 
latches on corridor doors because, in our view, they present a safety 
hazard. Also, we are not adopting the provision regarding lock-ups 
because lock-ups are prohibited in the ICF-IIDs regulations, separate 
from the LSC. This practice is permitted under the National Technology 
Transfer and Advancement Act (https://www.gpo.gov/fdsys/pkg/PLAW-104publ113/pdf/PLAW-104publ113.pdf), which does not mandate that we use 
an entire code without exceptions if we determine it is impractical or 
unnecessary to do so.
    Comment: Several commenters requested CMS to revise the rule to 
allow health care facilities to choose other codes that are nationally 
recognized, such as the International Building Code and International 
Fire Code. The commenters asserted that referencing only the NFPA's LSC 
creates conflict for many jurisdictions that enforce other equivalent 
or more stringent fire and life safety requirements. The commenters 
further stated that, by not referencing other applicable codes, CMS 
favors one code to the detriment of other codes.
    Response: We continue to specifically cite the LSC because under 
sections 1819(d)(2)(B) and 1919(d)(2)(B) of the Act, nursing homes must 
meet the provisions of ``such edition (as specified by the Secretary in 
regulation) of the LSC of the National Fire Protection Association . . 
. . '' To avoid confusion, and to be consistent for all provider types, 
we require the LSC for all facilities. This is especially applicable 
for facilities with mixed occupancies. For example, a health care 
facility's west wing could be a nursing home while the rest of the 
facility is a hospital. It would be impractical as well as burdensome 
for the facility to follow the LSC for the nursing home and another 
health and safety code for the hospital. The regulation reflects this 
by requiring a single code for all health care facilities. The NFPA and 
the IBC organizations try to align their respective requirements as 
much as possible and the 2012 LSC is a reflection of that effort. We 
also note that jurisdictions are permitted to enforce more stringent 
requirements on top of those required by the Federal LSC requirements.
    Comment: Some commenters requested CMS to adopt updated versions of 
the LSC more quickly in the future. One commenter requested that CMS 
should adopt any updated version of the LSC within 90 days of the LSC 
publication.
    Response: We cannot adopt the LSC within 90 days of the LSC 
publication because we are required to give notice to the public that 
we are proposing to revise a regulation. Once we notify the public of 
the proposal, the public must have the opportunity to comment on the 
revisions, and we must respond to the comments before the update 
becomes final and legally enforceable. We do review each edition of the 
NFPA 101 and NFPA 99 every 3 years to see if there are any significant 
provisions that we need to adopt and will continue to do so. We have 
reviewed the 2015 edition of the LSC and do not feel that there are any 
significant provisions that need to be addressed at this time.
    Comment: Many commenters have suggested that CMS develop a process 
to be able to permit a facility to apply for a waiver prior to being 
cited for a deficiency. The commenters stated that it is currently 
standard practice for CMS to decline to review any requests for waivers 
filed before there has been a deficiency cited during a survey.
    Response: We agree and have implemented a process to approve 
categorical waivers. We do not consider it always necessary for a 
facility to be cited for a deficiency before it can apply for or 
receive a waiver. This is particularly the case when we have evaluated 
specific provisions of the LSC, determined that a waiver would apply to 
all similarly-situated facilities with respect to the LSC requirement 
in question, and issued a public communication describing the specifics 
of such a categorical waiver, including any particular requirements 
that must be met in order for the waiver to apply to a facility. 
Facilities may still submit requests for non-categorical waivers, which 
is currently done after a citation of a deficiency is found on a fire 
safety survey. The waiver request includes the reason why the waiver of 
a specific life safety requirement cannot be complied with, and is 
submitted as part of the facility Plan of Correction of Deficiencies 
found on the survey to the State Agency or Regional Office for review 
and approval/disapproval by the CMS Regional Office. For example, CMS 
released the following Survey & Cert (S&C) Memos on categorical 
waivers, and the application process:

 April 19, 2013--S&C: 13-25: Relative Humidity (RH): Waiver of 
LSC Anesthetizing Location Requirements; Discussion of Ambulatory 
Surgical Center (ASC) Operating Room Requirements https://www.cms.gov/
Medicare/Provider-Enrollment-and-

[[Page 26886]]

Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-
Letter-13-25.pdf.
 August 30, 2013--S&C: 13-58: 2000 Edition National Fire 
Protection Association (NFPA) 101[supreg] LSC Waivers https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-13-58.pdf.
 September 26, 2014--S&C: 14-46 Categorical Waiver for Power 
Strips Use in Patient Care Areas https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-14-46.pdf.

    Comment: One commenter expressed concern with the proposal that 
facilities maintain antifreeze in their sprinkler systems in certain 
proportions. The commenter recommended that CMS withdraw this 
requirement, or reconsider its inclusion, until products become 
available which do not require more than 50 percent antifreeze (in 
compliance with the proposed rule), but which would still keep the 
sprinkler systems from freezing.
    Response: Where traditional antifreeze solutions for existing 
systems remain an option, consideration should be given to alternatives 
to using antifreeze. Antifreeze is not required to prevent the freezing 
of systems. Owners should investigate alternative methods to prevent 
the freezing of wet pipe systems in environments or locations that may 
be subject to freezing.
    Comment: A few commenters suggested that CMS allow facilities the 
opportunity to apply for a waiver rather than install sprinklers if 
they can show that staff and patients can be quickly evacuated or that 
they offer the same level of protection without the sprinklers.
    Response: Sprinklers are considered to be a basic level of 
protection for new and certain rehabilitated buildings, and we do not 
believe that it would be in the best interest of building occupants to 
waive these sprinkler requirements. Furthermore, we only require 
universal retrofitting to add sprinklers in high-rise health care 
occupancies, LTC facilities, in the attics of board and care 
facilities. Impractical evacuation capability facilities are all 
required to be protected throughout by an approved automatic sprinkler 
system. There is strong evidence that sprinklers in these particular 
environments are an essential fire safety feature; therefore we do not 
believe it is in the best interest of patients and staff to waive these 
requirements under any circumstances. https://www.facilitiesnet.com/firesafety/article/Fire-Safety-Facilities-Management-Fire-Safety-Feature-1620.
    Comment: Some commenters expressed concern with the use of the term 
``inappropriate access'' in regards to the placement of ABHRs. The 
commenters requested clarification of what is meant by the regulatory 
requirement that dispensers are installed in a manner that adequately 
protects against inappropriate access.
    Response: As stated in the ABHR final rule published in September 
22, 2006 (71 FR 55326), there are certain patients or resident 
populations, such as residents of dementia wards, who may misuse ABHR 
solutions, which are both toxic and flammable. As a toxic substance, 
ABHR solutions are very dangerous if they are ingested, placed in the 
eyes, or otherwise misused. As a flammable substance, ABHR solutions 
could be used to start fires that endanger lives and destroy property. 
Due to disability or disease, some patients are more likely to harm 
themselves or others by inappropriately using ABHR solutions. In order 
to avoid any and all dangerous situations, a facility will have to take 
all appropriate precautions to secure the ABHR dispensers from 
inappropriate access. This may mean that facilities choose to not 
install ABHR dispensers in corridors in or near dementia or psychiatric 
units. It may also mean that facilities choose to install ABHR 
dispensers only in areas that can be easily and frequently monitored, 
such as in view of a nursing station or a continuously monitored 
security camera. These are just a few of the many options that 
facilities may choose to utilize in securing ABHR dispensers against 
inappropriate access.
    Comment: A few commenters expressed concern with the requirement in 
Chapter 8 of the 2012 edition of NFPA 101, which stipulates that all 
penetrations of a fire-rated wall or floor must be protected by an 
``Approved Fire Stop System or Device,'' instead of simply offering 
protection equivalent to the surfaces penetrated, as was required in 
the 2000 edition of NFPA 101. The commenters stated that this 
requirement would result in higher costs for new facilities required to 
use proprietary devices or systems. If CMS requires an existing 
facility to meet this new standard due to application for a new 
provider agreement, the cost implications could be even greater as 
existing wires and other penetrating elements would need to be removed 
then reinstalled as necessary in order to comply. The commenters 
requested that existing facilities be exempted from this requirement.
    Response: The 2012 edition of NFPA 101, Section 8.3.5 states ``The 
provisions of 8.3.5 shall not apply to approved existing materials and 
methods of construction used to protect existing through-penetrations 
and existing membrane penetrations in fire walls, fire barrier walls, 
or fire resistance-rated horizontal assemblies, unless otherwise 
required by Chapters 11 through 43.'' Section 8.3.5.1 requires firestop 
systems and devices; therefore, this requirement would not be 
applicable to existing installations.
    Comment: Many commenters expressed concerns with our proposed 
regulation regarding fire watches. We proposed to require a fire watch 
if a sprinkler system is out for more than 4 hours. Commenters 
explained that most system maintenance extends over an 8-hour period of 
time during a normal workday, and that, during the outage additional 
staff with expertise in sprinkler system operation are present to 
address sprinkler system problems. Additionally, during a sprinkler 
system outage, the fire alarms are still functioning to detect a fire. 
Therefore, commenters recommend only requiring the fire watch if the 
system will be out of service for 10 hours or more.
    Response: We agree that most sprinkler system outages occur during 
a regular work day with sufficient staff levels to provide appropriate 
monitoring and assure patient safety from fire. Therefore, we are 
withdrawing the proposal that all system shutdowns of more than 4 hours 
would require a fire watch. We believe a fire watch would consist of 
dedicated staff with no other duties constantly circulating throughout 
the facility or the portion of the facility affected by the sprinkler 
system impairment looking for a fire, fire hazards or hazardous 
conditions that may affect the fire safety of the facility. Facilities 
may wish to maintain documentation of the rounds of a fire watch, but 
this is not required.
    Comment: The 2000 edition of the NFPA 99 required separate 
ventilation systems for windowless anesthetizing locations in all newly 
constructed health care occupancies. Although the NFPA removed the 
ventilation system requirement from the 2012 edition of the NFPA 99, 
CMS proposed to retain the ventilation requirement for all hospitals 
and ASCs. Approximately one third of commenters who submitted comments 
on this rule commented on this proposal. With the exception of two 
commenters who supported the proposal, the vast majority of

[[Page 26887]]

commenters who commented on this issue strongly disagreed with this 
proposal. The commenters stated that installing and maintaining 
separate ventilation systems in windowless anesthetizing locations in 
existing buildings would be a significant expense, with estimates of 
$30,000 per system per anesthetizing location. The commenters stated 
that installing and maintaining separate ventilation systems as part of 
constructing a new building is also a significant expense, with 
estimates ranging from $75,000 to $100,000 per anesthetizing location. 
The commenters stated that installing and maintaining ventilation 
systems in windowless anesthetizing locations, and thus incurring this 
large expense, is unnecessary for the following reasons:
     Of the millions of surgical procedures performed each 
year, 0.00092 percent per year results in surgical fires;
     Surgical fires are largely preventable, and training on 
prevention of and prompt response to fires is much more likely to be 
effective for patient safety than installing and maintaining 
ventilation systems;
     While anesthetics used to be flammable, they are not 
flammable anymore, which significantly reduces the risk of fires in 
anesthetizing locations;
     Most anesthetizing locations have quick response 
sprinklers present to extinguish any fire that may occur, eliminating 
the need for a smoke ventilation system. Healthcare occupancies 
required to install sprinklers to fulfill new construction or 
renovation requirements would need to install quick response sprinklers 
through smoke compartments containing patient rooms. If an 
anesthetizing location is located in the same compartment as the 
patient sleeping rooms, then the anesthetizing location would require 
quick response sprinklers;
     The types of fires that occur in anesthetizing locations 
produce such a small amount of smoke that the smoke would not 
compromise the ability of staff to implement emergency interventions to 
extinguish a fire;
     Staff in anesthetizing locations have training in updated 
techniques to quickly extinguish any fire that may occur;
     Some facilities have smoke purge systems that are just as 
capable of smoke control as the proposed ventilation system; and
     The proposed smoke ventilation system may, under certain 
circumstances, create an increased risk for surgical infections in the 
affected anesthetizing locations.
    Response: In light of the concerns raised by commenters, we agree 
that requiring the installation of smoke ventilation systems would not 
be an effective use of hospital and ASC resources. We agree that a 
focus on preventing and quickly extinguishing surgical fires will 
likely have a more significant positive impact on patient safety, and 
encourage hospitals, CAHs, and ASCs to continue this important work. We 
also agree that the presence of quick response sprinkler heads, 
alternative smoke purge systems, which can continue to be used, and the 
use of non-flammable anesthetics all contribute to a very minimal risk 
of smoke requiring ventilation in the first place. Therefore, we have 
removed this requirement from the regulations text for hospitals, CAHs, 
and ASCs.
    Comment: The LSC applies a specific occupancy type to a facility 
that has 4 or more patients. Many commenters disagreed with our 
proposal to require all facilities to meet the occupancy requirements 
regardless of the number of patients because it would require small 
facilities to meet more stringent requirements. Commenters stated that 
there is no evidence to support the need for additional safety measures 
in these facilities.
    Response: We agree with the commenters that meeting a more 
stringent occupancy classification is not necessary for very small 
health care occupancies with less than 4 patients at any given time, 
and therefore, are withdrawing our proposal. This will not affect any 
facilities as we are keeping the requirement as it was in the 2000 
edition of the LSC and are not making any changes. ASCs continue to be 
required to meet the occupancy requirements for ambulatory care 
occupancies ``regardless of the number of patients served.'' While this 
requirement is different from the definition of ambulatory care 
occupancy in the LSC, it is consistent with the previous rule adopting 
the 2000 edition of the NFPA 101 (68 FR 1374), which applied the 
ambulatory care occupancy chapter to all ASCs, regardless of the number 
of patients served.
    Comment: Many commenters expressed concern with the window sill 
height requirement. The 2000 edition of the LSC required that newly 
constructed health care occupancies cannot have a sill height exceeding 
36 inches above the floor (with certain exceptions). The NFPA removed 
this requirement from the 2012 edition of the LSC. However, CMS 
proposed to retain this requirement and apply it to all facilities, 
whether they were new or existing construction. The vast majority of 
the commenters expressed concern with retrofitting existing facilities 
to meet this proposed requirement, and the financial burden they would 
incur. Commenters also disagreed with the justification for the 
proposal.
    Response: We agree with commenters that requiring existing 
facilities to change their existing window structures to meet this 
requirement would be an undue burden. We have revised the regulation to 
assure that any facilities built after the effective date of this final 
rule will have to meet the 36 inch window sill height requirement, in 
accordance with the 2000 edition of the LSC. Existing facilities that 
were not required to meet this specification at the time of 
construction would not be required to change window sill heights at 
this time. The Secretary does not have statutory authority to require a 
minimum window sill requirement, however we believe that while window 
sill height is not directly associated with fire safety, but it is 
important to quality of life and beneficial to the healing process.
    Comment: Many commenters expressed concern with the corridor 
projections requirement. The LSC allows for 6'' corridor projections, 
but the 2010 ADA Standards for Accessible Design (2010 Standards) only 
allow 4'' corridor projections. The commenters suggested only requiring 
4'' corridor projections in new construction and newly renovated 
construction. The commenters also noted that ABHR dispensers, TV/
computer monitors, and computer kiosks often project more than 4'' and 
would have to be moved. A few commenters stated that projections of 4'' 
or more should be allowed if alternative means are used such as 
vertical guards. Some commenters also asked why the LSC and CMS allows 
fixed furniture in corridors of LTC facilities up to 2 feet, but will 
not allow projections of more than 4''. One commenter suggested not 
adopting section 7.2.2.4.4.5 regarding the installation of handrails. 
This section requires handrails be mounted to provide a clearance of 
not less than 2\1/4\ inches from the wall. The commenter states that 
this is not ADA compliant or IBC compliant, there is no maximum 
distance from the wall, that this wider gap increases the risk of 
entrapment if a person's hand slips while going down the stairs, and 
that this should also apply to existing construction. One commenter 
also questioned whether or not the ADA 4'' projections apply to areas 
that are not patient treatment areas, like mechanical or chemical 
rooms.

[[Page 26888]]

    Response: As noted, CMS recognizes that the LSC is not an 
accessibility code and stresses that compliance with this code is not a 
substitute for compliance with the ADA. The 2010 ADA standards address 
many concerns raised by commenters, including the clear floor width of 
walking surfaces in corridors and handrail clearance. See Section 403.5 
and 505.5 of the 2010 ADA standards at https://www.ada.gov/regs2010/2010ADAStandards/2010ADAStandards.htm. In addition to following the 
requirements of the LSC, health care facilities are also required to 
follow all requirements of the ADA. Where there are conflicts between 
the LSC and the ADA, the more stringent standard takes precedence. 
Therefore, facilities must comply with the ADA's requirements for 
protruding objects, which establishes more stringent protrusion limits 
so that a person using a cane may avoid bodily harm. See section 307.2 
of the 2010 ADA standards, available at https://www.ada.gov/regs2010/2010ADAStandards/2010ADAStandards.htm (establishing a 4'' limit for 
wall-mounted protruding objects and a 4\1/2\'' limit for handrails). 
Title II of the ADA applies to health care programs and services of 
state and local governments; and Title III of the ADA applies to 
private entities providing health care services. When structural 
changes are made to existing facilities to provide program access 
required by Title II, the 2010 ADA standards are the applicable 
accessibility standard. Newly constructed or altered Title II and Title 
III facilities must also comply with the 2010 ADA standards. Existing 
Title III facilities are required to remove barriers to accessibility 
when barrier removal is readily achievable, and the 2010 ADA standards 
are the applicable accessibility standard. Changes to the 2010 ADA 
standards are beyond the scope of this rule. Any questions regarding 
the requirements of the ADA should be directed to DOJ. Technical 
assistance regarding ADA compliance can be obtained at https://www.ada.gov or 1-800-514-0301 (voice) and 1-800-514-0383 (TTY).
    Comment: One commenter suggested that there be a requirement for 
each provider or supplier to conduct an annual inspection and 
maintenance of fire door assemblies. Another commenter explicitly 
disagreed with this recommendation, stating that the final rule should 
clarify that annual inspection of doors in an egress path is not 
required in healthcare, ambulatory care, and business occupancies. 
Specifically, the commenter stated that hospitals are already 
performing visual inspection of these door assemblies and already 
assure latching and smooth operation at all times. The commenter 
asserted that conducting an additional annual inspection would be 
unnecessarily burdensome.
    Response: As proposed, we will maintain the required annual 
inspection and maintenance of door assemblies. This rule will thus 
require documentation that the facility actually inspected and 
performed maintenance necessary on this important fire protection 
feature. This inspection could be combined with any other maintenance 
effort that the facility may be performing.
    Comment: One commenter questioned whether the requirement that a 
recycling bin must be 96 gallons or less would apply to recycling bins 
that are stored outside.
    Response: This requirement only applies to any recycling bins 
located within a building.
    Comment: One commenter stated that 1 year is an adequate timeframe 
to allow facilities to make necessary changes to add smoke partitions 
around hazardous areas, and that this requirement will not require many 
facilities to make changes because building codes have required 
separation of hazardous areas for a long period of time.
    Response: Since most building codes already require the separation 
of hazardous areas, and facilities are probably already meeting this 
requirement, we agree that a 1 year phase-in period from the effective 
date of this final rule is appropriate to enable affected facilities to 
comply with the requirement for hazardous areas separation. Affected 
facilities will have 1 year from the effective date of this final rule 
to add smoke partitions around hazardous areas that are not already 
protected by this feature.
    Comment: We proposed to adopt the 2012 edition of the NFPA 101, 
which references the 2010 edition of NFPA 101A, Guide on Alternative 
Approaches to Life Safety. One commenter recommended that we adopt the 
2013 edition of the NFPA 101A instead. The commenter believes that 
there are some very significant differences between the 2010 and 2013 
editions of NFPA 101A, including:

 Section 4.3.2 ``Selection of Zones to be Evaluated''
 Section 4.6.9.3 ``Mechanically Assisted Systems''
 Section 4.7.10 ``Step 10--Determine Equivalency Conclusion''
 Worksheet 4.7.11 ``Conclusions''

    Response: In order to be consistent with the 2012 edition of the 
LSC, we are not separately adopting the 2013 edition of the NFPA 101A. 
We will continue to follow the 2010 edition of the NFPA 101A. If we 
adopt a newer version of the LSC in the future that also adopts the 
2013 edition of the NFPA 101A, we will review that document at that 
time.
    Comment: One commenter suggested that CMS and, by extension, those 
accreditation organizations that perform deeming surveys, should not 
cite LSC deficiencies that are self-identified by the provider or 
supplier. The commenter believes that a survey policy which encourages 
non-citation of self-identified LSC deficiencies will provide an 
incentive to hospital facility managers to self-identify their LSC 
deficiencies, record them on a list, and manage the resolution of the 
deficiencies.
    Response: We applaud facilities that self-identify LSC 
deficiencies; however, CMS is most concerned with the safety of 
patients and staff. Therefore, if the facility is able to self-identify 
deficiencies, they should be in the process of fixing those 
deficiencies and able to develop a suitable plan of correction for any 
deficiencies that are cited by surveyors.
    Comment: A commenter is concerned that the 2012 edition of the LSC 
eases the requirements for smoke barriers in existing facilities with 
less than 30 beds. The commenter suggested that CMS should require any 
facilities with less than 30 beds that were originally built with or 
added a smoke barrier dividing the floor into at least two smoke 
compartments to keep that smoke barrier, even though the 2012 edition 
would allow the facility to remove the smoke barrier.
    Response: We appreciate the suggestion. We do not anticipate 
facilities actively taking steps to remove existing smoke barriers in 
light of this change in the LSC. Should facilities undertake 
construction at a future date, they would still be required to meet the 
2012 edition of the LSC. We believe that the 2012 edition of the LSC 
assures the appropriate level of safety for all residents/patients.

NFPA 99--Health Care Facilities Code

    Comment: Many commenters support the adoption of the 2012 NFPA 99 
Health Care Facilities code. However, many commenters expressed 
confusion as to why the NFPA 99 is not being adopted in full, and some 
chapters are being excluded.
    Response: As stated in the proposed rule, we will not be adopting 
Chapters 7, 8 and 13 because we have no authority to regulate these 
specific topics in health care facilities.

[[Page 26889]]

Additionally, the content of Chapter 12, Emergency management, is 
already being addressed in a separate rule for emergency preparedness. 
Although, we have not adopted these chapters, providers may use these 
chapters for their individual facility needs.
    Comment: Some commenters encouraged the adoption of the 2012 
edition of the NFPA 99 Health Care Facilities code because it allows 
for the use of relocatable power taps, which provide additional 
electrical receptacles. The 1999 edition of the NFPA 99 does not allow 
the use of relocatable power taps.
    Response: We appreciate the support of the commenters, and agree 
that relocatable power taps can be appropriately used in health care 
environments. Therefore, we are finalizing this change as proposed.
    Comment: A few commenters expressed concerns with multiple issues 
found in the 2012 edition of the NFPA 99 that they believe would 
require a facility to upgrade to be in compliance with the following: 
Ductwork, HVAC system designs, electrical and medical gas system 
requirements, ground fault protection requirements, piped medical gas 
systems, and receptacle requirements. The commenters suggested that 
these sections be applied only to new facilities and facilities being 
remodeled.
    Response: We appreciate the opportunity to clarify the requirements 
of NFPA 99. The 2012 edition of the NFPA 99 does not divide its 
chapters and requirements into new and existing. We note that in the 
2012 edition of NFPA 99 Section 1.3.2 states ``Construction and 
equipment requirements shall be applied only to new construction and 
new equipment, except as modified in individual chapters.'' The 
sections described in the comments do not have any modified 
requirements; therefore, in accordance with the requirements of NFPA 
99, these requirements only apply to new construction and new 
equipment.

General or Other Comments

    Comment: One commenter suggested that we add a list of acronyms at 
the beginning of the rule.
    Response: We have added a list of acronyms to the beginning of the 
document. We have also spelled out each acronym the first time it is 
used in the rule.

IV. Provisions of the Final Regulations

    We are adopting the provisions of this rule as proposed, except for 
the following changes and clarifications:

RNHCI--

    We are clarifying that our adoption of the 2012 edition of the NFPA 
101 and NFPA 99, includes the following TIAs issued prior to April 16, 
2014:
    (i) TIA 12-1 to NFPA 101, issued August 11, 2011.
    (ii) TIA 12-2 to NFPA 101, issued October 30, 2012.
    (iii) TIA 12-3 to NFPA 101, issued October 22, 2013.
    (iv) TIA 12-4 to NFPA 101, issued October 22, 2013.
    (v) TIA 12-2 to NFPA 99, issued August 11, 2011.
    (vi) TIA 12-3 to NFPA 99, issued August 9, 2012.
    (vi) TIA 12-4 to NFPA 99, issued March 7, 2013.
    (viii) TIA 12-5 to NFPA 99, issued August 1, 2013
    (ix) TIA 12-6 to NFPA 99, issued March 3, 2014.
     We are clarifying that the prohibition on roller latches 
applies only to doors to corridors and to rooms containing flammable or 
combustible materials.
     We are revising the requirements for the shutdown of a 
sprinkler system for an extended period of time.
     We are revising the window sill requirement for new 
construction only to indicate that such sills must not be higher than 
36 inches above the floor.

ASCs--

    We are clarifying that our adoption of the 2012 edition of the NFPA 
101 and NFPA 99, includes the following TIAs issued prior to April 16, 
2014, regardless of the number of patients served:
    (i) TIA 12-1 to NFPA 101, issued August 11, 2011.
    (ii) TIA 12-2 to NFPA 101, issued October 30, 2012.
    (iii) TIA 12-3 to NFPA 101, issued October 22, 2013.
    (iv) TIA 12-4 to NFPA 101, issued October 22, 2013.
    (v) TIA 12-2 to NFPA 99, issued August 11, 2011.
    (vi) TIA 12-3 to NFPA 99, issued August 9, 2012.
    (vii) TIA 12-4 to NFPA 99, issued March 7, 2013.
    (viii) TIA 12-5 to NFPA 99, issued August 1, 2013.
    (ix) TIA 12-6 to NFPA 99, issued March 3, 2014.
     We are removing the requirements for the installation of a 
dedicated air supply and exhaust system in windowless anesthetizing 
locations.
     We are revising the requirements for door locking 
mechanisms on hazardous areas.
     We are revising the requirements for the shutdown of a 
sprinkler system for an extended period of time.
     We are revising the window sill requirements for new 
construction only to indicate that such sills must not be higher than 
36 inches above the floor.

Hospice--

    We are clarifying that our adoption of the 2012 edition of the NFPA 
101 and NFPA 99, includes the following TIAs issued prior to April 16, 
2014:
    (i) TIA 12-1 to NFPA 101, issued August 11, 2011.
    (ii) TIA 12-2 to NFPA 101, issued October 30, 2012.
    (iii) TIA 12-3 to NFPA 101, issued October 22, 2013.
    (iv) TIA 12-4 to NFPA 101, issued October 22, 2013.
    (v) TIA 12-2 to NFPA 99, issued August 11, 2011.
    (vi) TIA 12-3 to NFPA 99, issued August 9, 2012.
    (vii) TIA 12-4 to NFPA 99, issued March 7, 2013.
    (viii) TIA 12-5 to NFPA 99, issued August 1, 2013.
    (ix) TIA 12-6 to NFPA 99, issued March 3, 2014.
     We are clarifying that the prohibition on roller latches 
applies only to doors to corridors and to rooms containing flammable or 
combustible materials.
     We are revising the requirements for the shutdown of a 
sprinkler system for an extended period of time.
     We are revising the window sill requirement for new 
construction only to indicate that such sills must not be higher than 
36 inches above the floor.

PACE--

    We are clarifying that our adoption of the 2012 edition of the NFPA 
101 and NFPA 99, includes the following TIAs issued prior to April 16, 
2014:
    (i) TIA 12-1 to NFPA 101, issued August 11, 2011.
    (ii) TIA 12-2 to NFPA 101, issued October 30, 2012.
    (iii) TIA 12-3 to NFPA 101, issued October 22, 2013.
    (iv) TIA 12-4 to NFPA 101, issued October 22, 2013.
    (v) TIA 12-2 to NFPA 99, issued August 11, 2011.
    (vi) TIA 12-3 to NFPA 99, issued August 9, 2012.
    (vii) TIA 12-4 to NFPA 99, issued March 7, 2013.
    (viii) TIA 12-5 to NFPA 99, issued August 1, 2013.
    (ix) TIA 12-6 to NFPA 99, issued March 3, 2014.
     We are clarifying that the prohibition on roller latches 
applies

[[Page 26890]]

only to doors to corridors and to rooms containing flammable or 
combustible materials.
     We are revising the requirements for the shutdown of a 
sprinkler system for an extended period of time.

Hospitals--

    We are clarifying that our adoption of the 2012 edition of the NFPA 
101 and NFPA 99, includes the following TIAs issued prior to April 16, 
2014:
    (i) TIA 12-1 to NFPA 101, issued August 11, 2011.
    (ii) TIA 12-2 to NFPA 101, issued October 30, 2012.
    (iii) TIA 12-3 to NFPA 101, issued October 22, 2013.
    (iv) TIA 12-4 to NFPA 101, issued October 22, 2013.
    (v) TIA 12-2 to NFPA 99, issued August 11, 2011.
    (vi) TIA 12-3 to NFPA 99, issued August 9, 2012.
    (vii) TIA 12-4 to NFPA 99, issued March 7, 2013.
    (viii) TIA 12-5 to NFPA 99, issued August 1, 2013.
    (ix) TIA 12-6 to NFPA 99, issued March 3, 2014.
     We are clarifying that the prohibition on roller latches 
applies only to doors to corridors and to rooms containing flammable or 
combustible materials.
     We are clarifying that all outpatient surgical departments 
must meet applicable provisions in Ambulatory Health Care occupancy 
chapter, regardless of the number of patients served.
     We are revising the requirements for the shutdown of a 
sprinkler system for an extended period of time.
     We are removing the requirement for installation of a 
dedicated air supply and exhaust system in windowless anesthetizing 
locations.
     We are revising the window sill requirement for new 
construction only to indicate that such sills must not be higher than 
36 inches above the floor.

LTC--

    We are clarifying that our adoption of the 2012 edition of the NFPA 
101 and NFPA 99, includes the following TIAs issued prior to April 16, 
2014:
    (i) TIA 12-1 to NFPA 101, issued August 11, 2011.
    (ii) TIA 12-2 to NFPA 101, issued October 30, 2012.
    (iii) TIA 12-3 to NFPA 101, issued October 22, 2013.
    (iv) TIA 12-4 to NFPA 101, issued October 22, 2013.
    (v) TIA 12-2 to NFPA 99, issued August 11, 2011.
    (vi) TIA 12-3 to NFPA 99, issued August 9, 2012.
    (vii) TIA 12-4 to NFPA 99, issued March 7, 2013.
    (viii) TIA 12-5 to NFPA 99, issued August 1, 2013.
    (ix) TIA 12-6 to NFPA 99, issued March 3, 2014.
     We are clarifying that the prohibition on roller latches 
applies only to doors leading into corridors and leading into rooms 
containing flammable or combustible materials.
     We are revising the requirements for the shutdown of a 
sprinkler system for an extended period of time.

ICF-IIDs--

    We are clarifying that our adoption of the 2012 edition of the NFPA 
101 and NFPA 99, includes the following TIAs issued prior to April 16, 
2014:
    (i) TIA 12-1 to NFPA 101, issued August 11, 2011.
    (ii) TIA 12-2 to NFPA 101, issued October 30, 2012.
    (iii) TIA 12-3 to NFPA 101, issued October 22, 2013.
    (iv) TIA 12-4 to NFPA 101, issued October 22, 2013.
    (v) TIA 12-2 to NFPA 99, issued August 11, 2011.
    (vi) TIA 12-3 to NFPA 99, issued August 9, 2012.
    (vii) TIA 12-4 to NFPA 99, issued March 7, 2013.
    (viii) TIA 12-5 to NFPA 99, issued August 1, 2013.
    (ix) TIA 12-6 to NFPA 99, issued March 3, 2014.
     We are clarifying that the prohibition on roller latches 
applies only to doors to corridors and to rooms containing flammable or 
combustible materials.
     We are revising the exclusion of provisions related to 
``Lockups.''
     We are revising the requirements for the shutdown of a 
sprinkler system for an extended period of time.
     We are revising the window sill requirement for new 
construction only to indicate that such sills must not be higher than 
36 inches above the floor.

CAHs--

    We are clarifying that our adoption of the 2012 edition of the NFPA 
101 and NFPA 99, includes the following TIAs issued prior to April 16, 
2014:
    (i) TIA 12-1 to NFPA 101, issued August 11, 2011.
    (ii) TIA 12-2 to NFPA 101, issued October 30, 2012.
    (iii) TIA 12-3 to NFPA 101, issued October 22, 2013.
    (iv) TIA 12-4 to NFPA 101, issued October 22, 2013.
    (v) TIA 12-1 to NFPA 99, issued August 11, 2011.
    (vi) TIA 12-2 to NFPA 99, issued August 11, 2011.
    (vii) TIA 12-3 to NFPA 99, issued August 9, 2012.
    (viii) TIA 12-4 to NFPA 99, issued March 7, 2013.
    (ix) TIA 12-5 to NFPA 99, issued August 1, 2013.
    (x) TIA 12-6 to NFPA 99, issued March 3, 2014.
     We are clarifying that the prohibition on roller latches 
applies only to doors to corridors and to rooms containing flammable or 
combustible materials.
     We are revising the requirements for the shutdown of a 
sprinkler system for an extended period of time.
     We are removing the requirement for installation of a 
dedicated air supply and exhaust system in windowless anesthetizing 
locations.
     We are revising the window sill requirement for new 
construction only to indicate that such sills must not be higher than 
36 inches above the floor.

V. Collection of Information Requirements

    This final rule does not impose any new reporting, recordkeeping or 
third-party disclosure requirements. However, this final rule does 
reference the NFPA 99 that has several non-reported recordkeeping 
requirements for medical gas and vacuum systems, and electrical 
equipment. We believe that documenting maintenance and testing is a 
usual and customary business practice in accordance with the 
implementing regulations of the Paperwork Reduction Act of 1995 (PRA) 
at 5 CFR 1320.3(b)(2), and it would not impose any additional 
information collection burden beyond that associated with the normal 
course of business. Consequently, it need not be reviewed by the Office 
of Management and Budget under the authority of the Paperwork Reduction 
Act of 1995.

VI. Regulatory Impact Analysis

    In accordance with the provisions of Executive Order 12866, this 
regulation was reviewed by the Office of Management and Budget.

A. Overall Impact

    We have examined the impacts of this rule as required by Executive 
Order 12866 on Regulatory Planning and Review (September 30, 1993), 
Executive Order 13563 on Improving Regulation and Regulatory Review 
(January 18, 2011), the Regulatory Flexibility Act (RFA) (September 19, 
1980, Pub. L. 96-354), section 1102(b) of the Social Security Act, 
section 202 of the Unfunded Mandates Reform Act of 1995 (March 22, 
1995; Pub. L. 104-4), Executive Order 13132 on Federalism

[[Page 26891]]

(August 4, 1999) and the Congressional Review Act (5 U.S.C. 804(2).
    Executive Orders 12866 and 13563 direct agencies to assess all 
costs and benefits of available regulatory alternatives and, if 
regulation is necessary, to select regulatory approaches that maximize 
net benefits (including potential economic, environmental, public 
health and safety effects, distributive impacts, and equity). Executive 
Order 13563 emphasizes the importance of quantifying both costs and 
benefits, of reducing costs, of harmonizing rules, and of promoting 
flexibility. A regulatory impact analysis (RIA) must be prepared for 
major rules with economically significant effects ($100 million or more 
in any 1 year). The overall economic impact for this rule is estimated 
to be $18 million in the first year of implementation, $12 million, 
annually, for years 2 and 3 of implementation, and $6 million, 
annually, for years 4-12 of implementation. We estimate that this 
rulemaking is not ``economically significant'' as measured by the $100 
million threshold, and hence not a major rule under the Congressional 
Review Act. Accordingly, we have prepared a Regulatory Impact Analysis 
(RIA) that, to the best of our ability, presents the costs and benefits 
of rulemaking.

B. Statement of Need

    The 2012 edition of the LSC includes new provisions that we believe 
are vital to the health and safety of all patients and staff. Our 
intention is to ensure that patients and staff continue to experience 
the highest degree of fire safety possible. The use of earlier editions 
of the code can become problematic due to advances in safety and 
technology and changes made to each edition of the code. Newer 
buildings are typically built to comply with the newer versions of the 
LSC because state and local jurisdictions, as well as non-CMS-approved 
accreditation programs, often adopt and enforce newer versions of the 
code as they become available. We believe that adopting the 2012 LSC 
would simplify and modernize the construction and renovation process 
for affected health care providers and suppliers, reduce compliance-
related burdens, and allow for more resources to be used for patient 
care. Many health care facilities complete unnecessary work and incur 
unnecessary expense without any gain in fire safety by continuing to 
comply with the 2000 edition of the LSC.
    The 2012 edition of the NFPA 99, ``Health Care Facilities Code,'' 
addresses requirements for both health care occupancies and ambulatory 
care occupancies, and serves as a resource for those who are 
responsible for protecting health care facilities from fire and 
associated hazards. The purpose of this Code is to provide minimum 
requirements for the installation, inspection, testing, maintenance, 
performance, and safe practices for health care facility materials, 
equipment and appliances. This Code is a compilation of documents that 
have been developed over a 40-year period by NFPA, and is intended to 
be used by those persons involved in the design, construction, 
inspection, and operation of health care facilities, and in the design, 
manufacture, and testing of appliances and equipment used in patient 
care areas of health care facilities. Many requirements of the LSC 
already cross reference the NFPA 99, and it addresses additional 
building safety topics that are related to important fire safety issues 
specific to health care facilities.
    We believe that it is in the best interest of CMS to adopt the more 
recent 2012 edition of the NFPA 101 and the 2012 edition of the NFPA 
99, in order to be up to date with all of the latest upgrades to health 
care facilities and safety requirements.

C. Summary of Impacts

       Table 1--Total Annual Cost of Implementation for All Years
------------------------------------------------------------------------
                                                                Millions
------------------------------------------------------------------------
Year 1 of implementation.....................................        $18
Years 2-3 of implementation..................................         24
Years 4-12 of implementation.................................         53
                                                              ----------
  Total Years 1-12 of implementation.........................         95
------------------------------------------------------------------------
Note: This cost may be less depending on the number of States that have
  already adopted the 2012 edition of the LSC.


                             Table 2--Total Annual Cost for Implementation in Year 1
----------------------------------------------------------------------------------------------------------------
                                                                                     Cost per
                  Requirement                        Provider type affected          affected      Cost for all
                                                                                     provider        providers
----------------------------------------------------------------------------------------------------------------
High-rise sprinkler installation..............  Hospitals, partially sprinklered         $34,075      $4,429,783
High-rise sprinkler installation..............  Hospitals, non-sprinklered......         117,028       1,053,253
Self-closing or automatic closing doors on      ASCs............................           1,047       1,763,148
 hazardous areas.
Sprinklers in attics (used for living           ICF-IIDs........................           4,500       5,980,500
 purposes, storage or fuel fired equipment).
Heat detection systems in attics (not used for  ICF-IIDs........................           1,000         212,333
 living purposes).
Hazardous areas separated by smoke partitions.  ICF-IIDs........................           1,000       4,624,000
Upgrade existing or install new fire alarm      ICF-IIDs........................           1,000         384,000
 system.
                                                                                 -------------------------------
    Total.....................................  ................................  ..............      18,447,017
----------------------------------------------------------------------------------------------------------------


                           Table 3--Total Annual Cost of Implementation for Years 2-3
----------------------------------------------------------------------------------------------------------------
                                                                                     Cost per
                  Requirement                        Provider type affected          affected      Cost for all
                                                                                     provider        providers
----------------------------------------------------------------------------------------------------------------
High-rise sprinkler installation..............  Hospitals, partially sprinklered         $34,075      $4,429,783
High-rise sprinkler installation..............  Hospitals, non-sprinklered......         117,028       1,053,253
Upgrade existing or install new fire alarm      ICF-IIDs........................           1,000         384,000
 system.
Sprinklers in attics (used for living           ICF-IIDs........................           4,500       5,980,500
 purposes, storage or fuel fired equipment).

[[Page 26892]]

 
Heat detection systems in attics (not used for  ICF-IIDs........................           1,000         212,333
 living purposes).
                                                                                 -------------------------------
    Total Annually............................  ................................  ..............      12,059,869
                                                                                 -------------------------------
        Overall Total Years 2-3...............  ................................  ..............      24,119,738
----------------------------------------------------------------------------------------------------------------


                              Table 4--Total Cost of Implementation for Years 4-12
----------------------------------------------------------------------------------------------------------------
                                                                                     Cost per
                  Requirement                        Provider type affected          affected      Cost for all
                                                                                     provider        providers
----------------------------------------------------------------------------------------------------------------
High-rise sprinkler installation..............  Hospitals, partially sprinklered         $34,075      $4,429,783
High-rise sprinkler installation..............  Hospitals, non-sprinklered......         117,028       1,053,253
Upgrade existing or install new fire alarm      ICF-IIDs........................           1,000         384,000
 system.
                                                                                 -------------------------------
    Total Annually............................  ................................  ..............       5,867,036
                                                                                 -------------------------------
        Overall Total Years 4-12..............  ................................  ..............      52,803,324
----------------------------------------------------------------------------------------------------------------

D. Detailed Economic Analysis

1. Burden Assessment
Sprinklers in High-Rise Buildings
    Section 19.4.2 of the LSC requires that all existing high-rise 
buildings containing health care occupancies be protected throughout by 
an approved, supervised automatic sprinkler system. We feel that this 
requirement will only affect hospitals and any other provider type 
located in the same building as a hospital (for example, an ASC that is 
located in a hospital building). This provision was added to the LSC in 
2012 and we anticipate that there would be a cost associated with 
installing the sprinklers. Since this is a new provision for the 2012 
edition of the LSC, 14 states have adopted this requirement, accounting 
for an estimated 142 high-rise facilities.
    To develop the most accurate estimate possible for this provision, 
we requested data from all 50 states regarding the sprinkler status of 
high-rise buildings containing health care occupancies, and the average 
square footage needing to be sprinklered. Of the 50 states, we received 
some data from 30 states.\4\ We calculated the average number of high-
rise hospitals for all of the states that responded. Overall, 15.64 
percent of hospitals were located in high-rise buildings. We also used 
the data submitted to determine the average number of fully, partially 
and non-sprinklered high-rise buildings in each state for which we have 
data. First, we calculated the percentages of fully, partially, and 
non-sprinklered hospitals for each state. We then averaged the 
percentage of fully, partially and non-sprinklered buildings across all 
states for which there was data, with a result of 84.66 percent of 
hospitals in high-rise buildings being fully sprinklered, 14.6 percent 
being partially sprinklered and 0.74 percent being non-sprinklered.
---------------------------------------------------------------------------

    \4\ The following states submitted data regarding the sprinkler 
status of high-rise buildings containing health care facilities--
Arizona, Arkansas, California, Colorado, Delaware, Hawaii, Idaho, 
Iowa, Kansas, Louisiana, Maine, Maryland, Massachusetts, Minnesota, 
Missouri, Montana, Nebraska, Nevada, New Hampshire, New Mexico, 
North Dakota, Oklahoma, Pennsylvania, Rhode Island, South Dakota, 
Texas, Utah, Virginia, Washington, and Wyoming.
---------------------------------------------------------------------------

    Next, we applied these percentages to the states that did not 
respond to our data request or that provided a limited amount of data. 
For example, Alabama has a total of 125 hospitals. Based on the data 
from states that submitted information, we know that, on average, 15.64 
percent of hospitals have high-rise buildings, for an estimated 20 
high-rise hospitals in Alabama. We used this same methodology to 
estimate the average number of high-rise hospitals in all of the states 
that did not respond to our data request or that provided only a 
limited amount of data, for a total of 179 high-rise hospitals. Of the 
179 estimated high-rise hospitals in states that did not respond, we 
estimate there are 151 fully sprinklered, 26 partially sprinklered, and 
2 non-sprinklered. We note that these numbers do not directly match 
because there was limited actual data available for the state of 
Massachusetts. The number of high-rise hospitals in Massachusetts is 
included in the count of states for which we have reported data. 
However, because we did not receive a breakdown of those high-rise 
hospitals by their current sprinkler status, we used the methodology 
described to estimate the distribution of fully sprinklered, partially 
sprinklered, and non-sprinklered high-rise hospitals in that state.
    We combined this information with the information from the states 
that submitted data to develop an estimate of 515 high-rise facilities 
with health care occupancies throughout all 37 states and the District 
of Columbia that have not adopted the 2012 NFPA 101 (336 high-rise 
facilities in states that submitted data + 179 estimated high-rise 
facilities in states that did not submit data). We estimate that 376 of 
those high-rise facilities are fully sprinklered, 130 are partially 
sprinklered, and 9 are not sprinklered.
    We also requested that the 50 states and the District of Columbia 
submit information regarding the area (measured in square feet) per 
partially sprinklered and non-sprinklered facility that does not 
currently have sprinklers. Only 8 states supplied data regarding the 
area to be sprinklered in partially sprinklered facilities.\5\ In 
addition, 3 states supplied data regarding the area to be sprinklered 
in non-sprinklered facilities.\6\ We did not specify size and

[[Page 26893]]

age data. Of the states that responded with square footage data, we 
estimate that an average partially sprinklered facility would need to 
install sprinklers to protect 37,173 square feet, and an average non-
sprinklered facility would need to install sprinklers to protect 
127,667 square feet. Regardless of the square footage, any facility in 
a high-rise building 75' or over is required to be sprinklered. We 
applied all of the data submitted and averages calculated to figure out 
the total average area that will need to be sprinklered in all 
partially sprinklered facilities and non-sprinklered facilities, and 
the cost associated with that installation. Based on the information 
provided by the public in comments received on the hospital conditions 
of participation (76 FR 65891), the cost per square foot to install 
sprinklers is approximately $11. We estimated that there are 130 
partially sprinklered facilities that would install sprinklers to cover 
an average of 37,173 square feet per facility, for a total of 4,832,490 
square feet. At an estimated cost of $11 per square foot to install 
sprinklers, we estimate a total cost of $53,157,390 for all partially 
sprinklered facilities (4,832,490 square feet x $11 per square foot). 
We estimate that an average partially sprinklered facility would spend 
$408,903 to complete the sprinkler installation (37,173 square feet per 
facility x $11 per square foot).
---------------------------------------------------------------------------

    \5\ The following states provided data regarding the average 
square footage for partially sprinklered high-rise facilities 
containing health care facilities--California, Hawaii, Iowa, Kansas, 
Nebraska, Pennsylvania, Virginia, and Washington.
    \6\ The following states provided data regarding the average 
square footage for non-sprinklered high-rise facilities containing 
health care facilities--California, Hawaii, and Iowa.
---------------------------------------------------------------------------

    We estimated that there are 9 non-sprinklered facilities 
nationwide, and that an average non-sprinklered facility would install 
sprinklers for, 127,667 square feet, for a total of 1,149,003 square 
feet (9 facilities x 127,667 square feet per facility). At an estimated 
cost of $11 per square foot to install sprinklers, we estimate that it 
would cost $12,639,033 for all non-sprinklered facilities to install 
sprinklers in their facilities. We estimate that an average non-
sprinklered facility would spend $1,404,337 per facility (127,667 
square feet x $11 per square foot).
    Therefore, we estimate the total cost associated with the 
installation of sprinklers in partially sprinklered and non-sprinklered 
facilities to be $65,796,423 ($53,157,390 for all partially sprinklered 
facilities + $12,639,033 for all non-sprinklered facilities). This cost 
would be distributed over a phase-in period of 12 years, per the phase-
in period established within the LSC, or an average yearly cost of $5.5 
million.
Sprinklers Out of Service for More Than 10 Hours
    We have removed the requirement for a fire watch or building 
evacuation if the sprinkler system is out of service for more than 4 
hours, and have adopted the LSC requirements of a fire watch or 
building evacuation if the sprinkler system is out for more than 10 
hours in a 24-hour period. Based on comments received from 
stakeholders, associations and the public, sprinkler systems are 
generally only out of service for 8 hours in a 24-hour period. 
Therefore, we do not anticipate additional costs associated with this 
requirement. If there is an event where the sprinkler system would be 
out of service for more than 10 hours in a 24-hour period, we feel that 
it would be considered a standard business practice to implement a fire 
watch or building evacuation, as the previous requirement was more 
stringent and required a fire watch or building evacuation after the 
sprinkler system is out of service for more than 4 hours.
Doors to Hazardous Areas
    Sections 20.3.2.1 and 21.3.2.1 of the LSC requires all doors to 
hazardous areas to be self-closing or automatic-closing. This 
requirement is only located in sections 20.3.2.1 and 21.3.2.1, which 
applies to Ambulatory health care. This provision was added to the LSC 
in 2003, and we anticipate that there would be a cost associated with 
installing the self-closing or automatic closing doors. Since 2003, 35 
states have adopted this requirement, accounting for an estimated 3,684 
ASCs. As of December 2013, there were 5,368 total Medicare and 
applicable Medicaid participating ASCs. The 1,684 remaining facilities 
would be required to upgrade their door closing mechanisms to meet this 
requirement. The estimated cost per door is $349, and we would assume 
the average facility has 3 hazardous areas that would require a 
replacement door closing mechanism for a total cost of $1,047 per 
facility. The anticipated cost is $1,763,148.
Sprinklers or Heat Detection Systems in Attics
    Sections 32.2.3.5.7 and 33.2.3.5.7 of the LSC requires attics of 
new and existing residential board and care occupancies, which, for our 
purposes, are ICF-IIDs to be sprinklered if the attic space is used for 
living purposes, including storage and fuel fired equipment. Facilities 
that do not use their attics for living purposes may choose to install 
a heat detection system in place of the sprinklers. This provision was 
added to the LSC in 2012. Since this is a new provision for the 2012 
edition of the LSC, only 14 states have adopted this requirement, 
accounting for an estimated 1,750 ICF-IIDs. We are not including those 
1,750 facilities in our analysis. For purposes of this analysis only, 
we assume that about 10 percent (637) of facilities will install a heat 
detection system because they do not use the attic for living purposes. 
As of December 2013, there were 6,374 total Medicare participating ICF-
IIDs. After excluding those facilities located in states that have 
already adopted this requirement and those that would install a heat 
detection system instead of sprinklers, the 3,987 remaining facilities 
would be required to install sprinklers in their attics to meet this 
requirement. Installing sprinklers into an unfinished attic is less 
complicated than installing sprinklers in a finished hospital, 
therefore the cost per square foot would be less to install in attics 
than hospitals. The estimated cost per square foot to install 
sprinklers in an attic is $3.00, and the average estimated square 
footage per attic per facility is 1500 square feet, for a total of 
$4,500 per ICF-IID. We estimate that all ICF-IIDs would spend 
$17,941,500 to install sprinklers in their attic spaces. After 
soliciting public comment, we have decided to finalize a 3 year phase-
in period, which would make the cost $5,980,500 per year over 3 years.
    Facilities that do not use their attics for living purposes may 
choose to install a heat detection system in the attic instead of 
sprinklers. As stated, for the purposes of this analysis only, we 
assume that about 10 percent (637) of facilities will install a heat 
detection system because they do not use the attic for living purposes. 
We estimate the cost to install a heat detection system to be $1,000 
per facility. The anticipated cost would be $637,000 for all affected 
facilities to install heat detection systems. After soliciting public 
comment, we have decided to finalize a 3 year phase-in period, which 
would make the cost $212,333 per year over 3 years.
Hazardous Area Separation
    Section 33.3.3.2.3 of the LSC requires all hazardous areas in 
existing residential board and care occupancies (which, under our 
regulations, are ICF-IIDs) with impractical evacuation capabilities to 
be separated from other parts of the building by a smoke partition. 
This provision was added to the LSC in 2012 and we anticipate there 
being a cost associated with installing the smoke partition. Since this 
is a new provision for 2012, only 14 states have adopted this 
requirement, accounting for 1,750 ICF-IIDs. As of December 2013, there 
were 6,374 total Medicare and applicable Medicaid participating

[[Page 26894]]

ICF-IIDs. We do not collect data regarding the evacuation capability of 
each ICF-IID. Therefore, for purposes of this analysis only, we assume 
that the 4,624 remaining facilities will need to install a smoke 
partition around all hazardous areas to meet this requirement. The 
estimated cost per smoke partition is $500, and we assume that an 
average ICF-IID would need to install 2 smoke partitions for a total of 
$1,000 per facility. The anticipated cost is $4,624,000.
Fire Alarm System Upgrade
    Section 33.3.3.4.6.2 of the LSC requires that, when an existing 
residential board and care occupancy (that is, ICF-IIDs) installs a new 
fire alarm system, or the existing fire alarm system is replaced, 
notification of emergency forces should be handled in accordance with 
section 9.6.4. Section 9.6.4states that notification of emergency 
forces should alert the municipal fire department and fire brigade (if 
provided) of fire or other emergency. This provision was added to the 
LSC in 2012, and we anticipate there being a cost associated with 
upgrading a new or existing fire alarm system. Since this is a new 
provision for 2012, only 14 states have adopted this requirement, 
accounting for 1,750 ICF-IIDs. As of December 2013, there were 6,374 
total Medicare participating ICF-IIDs. The 4,624 remaining facilities 
would be required to add emergency notifications capabilities when they 
choose to update or install a new fire alarm system. The estimated cost 
per upgrade is $1,000. For purposes of this analysis only, we assume 
that about 8.3 percent (384) of facilities will do this in any given 
year, for an annual cost of $384,000 over a 12-year period.

($1,000 per upgraded alarm system x 384 facilities in any given year = 
$384,000)
2. Benefits to Patients/Residents
    As a result of this rule, we believe that there would be a 
decreased risk of premature death. A decreased risk of premature death 
is valuable to people and that value is symbolized by their willingness 
to pay for such benefits. The Department of Transportation found in a 
recent literature review that willingness to pay for reductions in the 
risk of premature death equivalent to saving one life in expectation is 
typically over $9 million (https://www.dot.gov/sites/dot.dev/files/docs/VSL%20Guidance%202013.pdf). Although we are not quantifying the number 
of lives that would be saved upon implementation of this rule due to 
the lack of data that could provide a reliable point estimate, we 
believe that there is potential for such a result. In order to ``break 
even'' on the cost of this rule--in other words, in order for the total 
costs of implementing this rule to equal the total benefits of doing 
so--this rule would need to save 1.3 lives per year for 12 years at a 7 
percent discount rate and a value of $9 million per life saved would 
cause the rule to break even. It would take about 1.1 lives per year 
for 12 years at a 3 percent discount rate. Given our review of the 
current literature on fire safety in health care facilities, we are 
confident that implementing the 2012 LSC will save at least that number 
of lives.

E. Alternatives Considered

    As a regulatory alternative, we could have chosen not to update our 
fire safety provisions. We believe that this is not an acceptable 
alternative because many health care facilities complete unnecessary 
work and incur unnecessary expense without any gain in fire safety by 
continuing to comply with the 2000 edition of the LSC. Many states have 
adopted subsequent editions of the LSC. This has caused confusion for, 
and imposed additional burdens on, health care facilities, that must 
request waivers or modify designs to meet the requirements of both the 
state- and federally-adopted editions of the LSC. Updating the LSC 
would not only relieve the regulatory burden on health care providers, 
but also assist in ensuring the health and safety of patients and 
staff.
    We considered an alternative phase-in period for the requirement to 
install sprinklers in high rise health care occupancies. The LSC allows 
for a 12-year phase-in period, which would begin on the day a final 
rule is published. We considered shortening this period in order to 
accelerate compliance. However, based on our recent experience with 
requiring LTC facilities to install sprinklers within 5 years, and the 
difficulties that several facilities have faced in meeting this 
deadline, we have learned that a shorter phase-in period is not always 
feasible for facilities. We also considered a longer phase-in period, 
but believe that extending beyond 12 years set out in the LSC may not 
sufficiently convey the importance of this requirement to improving 
patient and staff safety in these buildings.
    We considered not including separate requirements for window sill 
heights. Although the NFPA has removed these requirements from the LSC, 
because the total concept approach of all health care facilities should 
be designed, constructed, maintained and operated to minimize the 
possibility of a fire emergency requiring the evacuation of occupants 
can be achieved without reliance on such window sill requirements, we 
felt that this was an important issues that still needed to be required 
for the safety of patients, visitors, and staff. Window sill height 
requirements were eliminated from the 2012 edition of the LSC. We 
believe that this requirement is essential to allow easier access for 
emergency personnel in the event of a fire or other emergency situation 
and it is important to quality of life and the healing process. This 
will, however, only be required in new facilities.
    We considered not including the adoption of the NFPA 99 Health care 
Facilities code. However, many requirements of the LSC already cross-
reference the NFPA 99, therefore we decided to adopt the NFPA 99 
because it addresses additional building safety topics that are related 
to important fire safety issues specific to health care facilities. The 
requirements of NFPA 99, like those in NFPA 101, will be legally 
enforceable to the extent specified in this rule.
    We also considered adoption of chapters 7, 8, 12, and 13 of the 
NFPA 99, related to information technology, plumbing, emergency 
management, and security management. We believe that information 
technology, plumbing and security management are not within the scope 
of the conditions of participation and conditions for coverage. In 
addition, emergency management topics are addressed in our December 27, 
2013 proposed rule, ``Medicare and Medicaid Programs: Emergency 
Preparedness Requirements for Medicare and Medicaid Participating 
Providers and Suppliers'' (78 FR 79081).

F. Accounting Statement

    As required by OMB Circular A-4 (available at https://www.whitehouse.gov/omb/circulars_a004_a-4), we have prepared an 
accounting statement in Table X showing the classification of the 
transfers and costs associated with the provisions of this rule for CY 
2015.

[[Page 26895]]



             Table 5--Accounting Statement: Classification of Estimated Costs Between 2016 and 2027
----------------------------------------------------------------------------------------------------------------
                                                                                  Units
              Category                    Estimates     --------------------------------------------------------
                                                            Year dollar     Discount rate (%)    Period covered
----------------------------------------------------------------------------------------------------------------
Costs *
Annualized Monetized ($million/year)                8.6               2015                  7          2016-2027
                                                    8.2               2015                  3          2016-2027
----------------------------------------------------------------------------------------------------------------
* Costs are associated with the provisions of the life safety code.

G. Regulatory Flexibility Act (RFA)

    The RFA requires agencies to analyze options for regulatory relief 
of small entities, if a rule has a significant impact on a substantial 
number of small entities. For purposes of the RFA, small entities 
include small businesses, nonprofit organizations, and government 
agencies. Individuals and states are not included in the definition of 
a small entity. For purposes of the RFA, most of the providers and 
suppliers that would be affected by this rule (hospitals, ASCs, and 
ICF-IIDs) are considered to be small entities, either by virtue of 
their nonprofit or government status or by having yearly revenues below 
industry threshold established by the Small Business Administration 
(for details, see the Small Business Administration's Web site at 
https://www.sba.gov/content/small-business-size-standards).
     We estimate that the following affected facilities are 
expected to spend less than $3,500 in any given year on a per average 
facility basis; all LTC facilities, all hospices with inpatient care 
facilities, all PACE facilities, all RNHCIs, all existing ASCs, all 
existing CAHs, and all existing fully sprinklered hospitals.
     We estimate that the average affected ICF-IID will spend 
$5,400-$8,900 in the first year, which requires the most significant 
investment and, by year four, that amount drops to $3,400 per year.
     We estimate that the average affected partially 
sprinklered high-rise hospital and the average affected non-sprinklered 
high-rise hospitals will spend $36,475-$119,428 each year during the 12 
year phase-in period to install sprinklers. After the installation of 
sprinklers, we estimate that the annual cost decreases to $2,400 per 
year.
     We estimate that newly constructed hospitals will spend 
$2,400, newly constructed CAHs will spend $2,400 and newly constructed 
ASCs will spend $2,400, respectively, in any given year.
    The Department of Health and Human Services uses as its measure of 
significant economic impact on a substantial number of small entities a 
change in revenues of more than 3 to 5 percent. Therefore, the 
Secretary proposes to certify that this rule will not have a 
significant impact on a substantial number of small entities, since the 
impact will be less than 3 percent of the revenue. The preceding 
economic analysis, together with the remainder of this preamble, 
constitutes that analysis.
    In addition, section 1102(b) of the Act requires us to prepare a 
regulatory impact analysis if a rule may have a significant impact on 
the operations of a substantial number of small rural hospitals. This 
analysis must conform to the provisions of section 604 of the RFA. For 
purposes of section 1102(b) of the Act, we define a small rural 
hospital as a hospital that is located outside of a metropolitan 
statistical area and has fewer than 100 beds. We believe that this rule 
will not have a significant impact on the operations of a substantial 
number of small rural hospitals.

H. Unfunded Mandates Reform Act (UMRA)

    Section 202 of the Unfunded Mandates Reform Act of 1995 (UMRA) also 
requires that agencies assess anticipated costs and benefits before 
issuing any rule whose mandates require spending in any 1 year of $100 
million in 1995 dollars, updated annually for inflation. In 2015, that 
threshold is approximately $144 million. This rule will not have an 
impact on the expenditures of state, local, or tribal governments in 
the aggregate, or on the private sector of $144 million in any one 
year.

I. Federalism

    Executive Order 13132 establishes certain requirements that an 
agency must meet when it promulgates a proposed rule (and subsequent 
final rule) that imposes substantial direct requirement costs on state 
and local governments, preempts state law, or otherwise has Federalism 
implications. This rule has no Federalism implications.

J. Congressional Review Act

    This regulation is subject to the Congressional Review Act 
provisions of the Small Business Regulatory Enforcement Fairness Act of 
1996 (5 U.S.C. 801 et seq.) and has been transmitted to the Congress 
and the Comptroller General for review.
    In accordance with the provisions of Executive Order 12866, this 
rule was reviewed by the Office of Management and Budget.

List of Subjects

42 CFR Part 403

    Health insurance, Hospitals, Intergovernmental relations, 
Incorporation by reference, Medicare, Reporting and recordkeeping 
requirements.

42 CFR Part 416

    Health facilities, Kidney diseases, Incorporation by reference, 
Medicare, Reporting and recordkeeping requirements.

42 CFR Part 418

    Health facilities, Hospice care, Incorporation by reference, 
Medicare, Reporting and recordkeeping requirements.

42 CFR Part 460

    Aged, Health, Incorporation by reference, Medicare, Medicaid, 
Reporting and recordkeeping requirements.

42 CFR Part 482

    Grant programs--health, Hospitals, Incorporation by reference, 
Medicaid, Medicare, Reporting and recordkeeping requirements.

42 CFR Part 483

    Grant programs--health, Health facilities, Health professions, 
Health records, Incorporation by reference, Medicaid, Medicare, Nursing 
homes, Nutrition, Reporting and recordkeeping requirements, Safety.

42 CFR Part 485

    Grant programs--health, Health facilities, Incorporation by 
reference,

[[Page 26896]]

Medicaid, Medicare, Reporting and recordkeeping requirements.
    For the reasons set forth in the preamble, the Centers for Medicare 
& Medicaid Services amends 42 CFR chapter IV as set forth below:

PART 403--SPECIAL PROGRAMS AND PROJECTS

0
1. The authority citation for part 403 continues to read as follows:

    Authority:  42 U.S.C. 1395b-3 and Secs. 1102 and 1871 of the 
Social Security Act (42 U.S.C. 1302 and 1395hh).


0
2. Amend Sec.  403.744 by--
0
a. Revising paragraphs (a)(1)(i) and (ii).
0
b. Revising paragraph (a)(4).
0
c. Adding paragraphs (a)(5) and (6).
0
d. Revising paragraphs (b)(1) and (c).
    The revisions and additions read as follows:


Sec.  403.744  Condition of participation: Life safety from fire.

    (a)
    (1) * * *
    (i) The RNHCI must meet the applicable provisions and must proceed 
in accordance with the Life Safety Code (NFPA 101 and Tentative Interim 
Amendments TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4).
    (ii) Notwithstanding paragraph (a)(1)(i) of this section, corridor 
doors and doors to rooms containing flammable or combustible materials 
must be provided with positive latching hardware. Roller latches are 
prohibited on such doors.
* * * * *
    (4) The RNHCI may place alcohol-based hand rub dispensers in its 
facility if the dispensers are installed in a manner that adequately 
protects against inappropriate access.
    (5) When a sprinkler system is shut down for more than 10 hours the 
RHNCI must:
    (i) Evacuate the building or portion of the building affected by 
the system outage until the system is back in service, or
    (ii) Establish a fire watch until the system is back in service.
    (6) Building must have an outside window or outside door in every 
sleeping room, and for any building constructed after July 5, 2016 the 
sill height must not exceed 36 inches above the floor. Windows in 
atrium walls are considered outside windows for the purposes of this 
requirement.
    (b) * * *
    (1) In consideration of a recommendation by the State survey agency 
or Accrediting Organization, or at the discretion of the Secretary, may 
waive, for periods deemed appropriate, specific provisions of the Life 
Safety Code, which would result in unreasonable hardship upon a RNHCI 
facility, but only if the waiver will not adversely affect the health 
and safety of the patients.
* * * * *
    (c) The standards incorporated by reference in this section are 
approved for incorporation by reference by the Director of the Office 
of the Federal Register in accordance with 5 U.S.C. 552(a) and 1 CFR 
part 51. You may inspect a copy at the CMS Information Resource Center, 
7500 Security Boulevard, Baltimore, MD or at the National Archives and 
Records Administration (NARA). For information on the availability of 
this material at NARA, call 202-741-6030, or go to: https://www.archives.gov/federal_register/code_of_federal_regulations/ibr_locations.html. If any changes in this edition of the Code are 
incorporated by reference, CMS will publish a document in the Federal 
Register to announce the changes.
    (1) National Fire Protection Association, 1 Batterymarch Park, 
Quincy, MA 02169, www.nfpa.org, 1.617.770.3000.
    (i) NFPA 101, Life Safety Code, 2012 edition, issued August 11, 
2011;
    (ii) TIA 12-1 to NFPA 101, issued August 11, 2011.
    (iii) TIA 12-2 to NFPA 101, issued October 30, 2012.
    (iv) TIA 12-3 to NFPA 101, issued October 22, 2013.
    (v) TIA 12-4 to NFPA 101, issued October 22, 2013.
    (2) [Reserved]

0
3. Add Sec.  403.745 to read as follows:


Sec.  403.745  Condition of participation: Building Safety.

    (a) Standard: Building Safety. Except as otherwise provided in this 
section the RNHCI must meet the applicable provisions and must proceed 
in accordance with the Health Care Facilities Code (NFPA 99 and 
Tentative Interim Amendments TIA 12-2, TIA 12-3, TIA 12-4, TIA 12-5 and 
TIA 12-6).
    (b) Standard: Exceptions. Chapters 7, 8, 12, and 13 of the adopted 
Health Care Facilities Code do not apply to a RNHCI.
    (c) Waiver. If application of the Health Care Facilities Code 
required under paragraph (a) of this section would result in 
unreasonable hardship for the RNHCI, CMS may waive specific provisions 
of the Health Care Facilities Code, but only if the waiver does not 
adversely affect the health and safety of individuals.
    (d) Incorporation by reference. The standards incorporated by 
reference in this section are approved for incorporation by reference 
by the Director of the Office of the Federal Register in accordance 
with 5 U.S.C. 552(a) and 1 CFR part 51. You may inspect a copy at the 
CMS Information Resource Center, 7500 Security Boulevard, Baltimore, MD 
or at the National Archives and Records Administration (NARA). For 
information on the availability of this material at NARA, call 202-741-
6030, or go to: https://www.archives.gov/federal_register/code_of_federal_regulations/ibr_locations.html. If any changes in this 
edition of the Code are incorporated by reference, CMS will publish a 
document in the Federal Register to announce the changes.
    (1) National Fire Protection Association, 1 Batterymarch Park, 
Quincy, MA 02169, www.nfpa.org, 1.617.770.3000.
    (i) NFPA 99, Standards for Health Care Facilities Code of the 
National Fire Protection Association 99, 2012 edition, issued August 
11, 2011.
    (ii) TIA 12-2 to NFPA 99, issued August 11, 2011.
    (iii) TIA 12-3 to NFPA 99, issued August 9, 2012.
    (iv) TIA 12-4 to NFPA 99, issued March 7, 2013.
    (v) TIA 12-5 to NFPA 99, issued August 1, 2013.
    (vi) TIA 12-6 to NFPA 99, issued March 3, 2014.
    (2) [Reserved]

PART 416--AMBULATORY SURGICAL SERVICES

0
4. The authority citation for part 416 continues to read as follows:

    Authority:  Secs. 1102 and 1871 of the Social Security Act (42 
U.S.C. 1302 and 1395hh).


0
5. Amend Sec.  416.44 by--
0
a. Revising paragraphs (b)(1) and (2).
0
b. Removing paragraph (b)(4).
0
c. Redesignating paragraph (b)(5) as paragraph (b)(4).
0
d. Revising newly redesignated paragraph (b)(4).
0
e. Adding new paragraphs (b)(5), and (6).
0
f. Redesignating paragraphs (c) and (d) as paragraphs (d) and (e).
0
g. Adding new paragraphs (c) and (f).
    The revisions and additions read as follows:


Sec.  416.44  Condition for coverage--Environment.

* * * * *
    (b) * * *
    (1) Except as otherwise provided in this section, the ASC must meet 
the provisions applicable to Ambulatory

[[Page 26897]]

Health Care Occupancies and must proceed in accordance with the Life 
Safety Code (NFPA 101 and Tentative Interim Amendments TIA 12-1, TIA 
12-2, TIA 12-3, and TIA 12-4).
    (2) In consideration of a recommendation by the State survey agency 
or Accrediting Organization or at the discretion of the Secretary, may 
waive, for periods deemed appropriate, specific provisions of the Life 
Safety Code, which would result in unreasonable hardship upon an ASC, 
but only if the waiver will not adversely affect the health and safety 
of the patients.
    * * *
    (4) An ASC may place alcohol-based hand rub dispensers in its 
facility if the dispensers are installed in a manner that adequately 
protects against inappropriate access.
    (5) When a sprinkler system is shut down for more than 10 hours, 
the ASC must:
    (i) Evacuate the building or portion of the building affected by 
the system outage until the system is back in service, or
    (ii) Establish a fire watch until the system is back in service.
    (6) Beginning July 5, 2017, an ASC must be in compliance with 
Chapter 21.3.2.1, Doors to hazardous areas.
    (c) Standard: Building Safety. Except as otherwise provided in this 
section, the ASC must meet the applicable provisions and must proceed 
in accordance with the 2012 edition of the Health Care Facilities Code 
(NFPA 99, and Tentative Interim Amendments TIA 12-2, TIA 12-3, TIA 12-
4, TIA 12-5 and TIA 12-6).
    (1) Chapters 7, 8, 12, and 13 of the adopted Health Care Facilities 
Code do not apply to an ASC.
    (2) If application of the Health Care Facilities Code required 
under paragraph (c) of this section would result in unreasonable 
hardship for the ASC, CMS may waive specific provisions of the Health 
Care Facilities Code, but only if the waiver does not adversely affect 
the health and safety of patients.
* * * * *
    (f) The standards incorporated by reference in this section are 
approved for incorporation by reference by the Director of the Office 
of the Federal Register in accordance with 5 U.S.C. 552(a) and 1 CFR 
part 51. You may inspect a copy at the CMS Information Resource Center, 
7500 Security Boulevard, Baltimore, MD or at the National Archives and 
Records Administration (NARA). For information on the availability of 
this material at NARA, call 202-741-6030, or go to: https://www.archives.gov/federal_register/code_of_federal_regulations/ibr_locations.html. If any changes in this edition of the Code are 
incorporated by reference, CMS will publish a document in the Federal 
Register to announce the changes.
    (1) National Fire Protection Association, 1 Batterymarch Park, 
Quincy, MA 02169, www.nfpa.org, 1.617.770.3000.
    (i) NFPA 99, Standards for Health Care Facilities Code of the 
National Fire Protection Association 99, 2012 edition, issued August 
11, 2011.
    (ii) TIA 12-2 to NFPA 99, issued August 11, 2011.
    (iii) TIA 12-3 to NFPA 99, issued August 9, 2012.
    (iv) TIA 12-4 to NFPA 99, issued March 7, 2013.
    (v) TIA 12-5 to NFPA 99, issued August 1, 2013.
    (vi) TIA 12-6 to NFPA 99, issued March 3, 2014.
    (vii) NFPA 101, Life Safety Code, 2012 edition, issued August 11, 
2011;
    (viii) TIA 12-1 to NFPA 101, issued August 11, 2011.
    (ix) TIA 12-2 to NFPA 101, issued October 30, 2012.
    (x) TIA 12-3 to NFPA 101, issued October 22, 2013.
    (xi) TIA 12-4 to NFPA 101, issued October 22, 2013.
    (2) [Reserved]

PART 418--HOSPICE CARE

0
6. The authority citation for part 418 continues to read as follows:

    Authority:  Secs. 1102 and 1871 of the Social Security Act (42 
U.S.C. 1302 and 1395hh).


Sec.  418.108  [Amended]

0
7. Amend Sec.  418.108 by--
0
a. Amending paragraph (a)(2) by removing the reference ``Sec.  
418.110(b) and (e)'' and by adding in its place the reference ``Sec.  
418.110(b) and (f)''.
0
b. Amending paragraph (b)(1)(ii) by removing the reference ``Sec.  
418.110(e)'' and by adding in its place the reference ``Sec.  
418.110(f)''.

0
8. Amend Sec.  418.110 by--
0
a. Revising paragraphs (d)(1)(i) and (ii).
0
b. Revising paragraphs (d)(2) and (4).
0
c. Adding paragraphs (d)(5) and (6).
0
d. Redesignating paragraphs (e) through (o) as (f) through (p).
0
e. Adding new paragraph (e).
0
f. Amending newly redesignated paragraph (g)(4) introductory text by 
removing the reference ``paragraph (f)(2)(iv) and (f)(2)(v) of this 
section'' and adding in its place the reference ``paragraphs (g)(2)(iv) 
and (g)(2)(v) of this section''.
0
g. Amending newly redesignated paragraph (n)(9) by removing the 
reference ``paragraph (n) of this section'' and adding in its place the 
reference ``paragraph (o) of this section''.
0
h. Amending newly redesignated paragraph (n)(13) by removing the 
reference ``Sec.  418.110(m)(11)'' and adding in its place the 
reference ``paragraph (n)(11) of this section''.
0
i. Adding paragraph (q).
    The revisions and additions read as follows:


Sec.  418.110  Condition of participation: Hospices that provide 
inpatient care directly.

* * * * *
    (d) * * *
    (1) * * *
    (i) The hospice must meet the applicable provisions and must 
proceed in accordance with the Life Safety Code (NFPA 101 and Tentative 
Interim Amendments TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4.)
    (ii) Notwithstanding paragraph (d)(1)(i) of this section, corridor 
doors and doors to rooms containing flammable or combustible materials 
must be provided with positive latching hardware. Roller latches are 
prohibited on such doors.
    (2) In consideration of a recommendation by the State survey agency 
or Accrediting Organization or at the discretion of the Secretary, may 
waive, for periods deemed appropriate, specific provisions of the Life 
Safety Code, which would result in unreasonable hardship upon a hospice 
facility, but only if the waiver will not adversely affect the health 
and safety of the patients.
* * * * *
    (4) A hospice may place alcohol-based hand rub dispensers in its 
facility if the dispensers are installed in a manner that adequately 
protects against access by vulnerable populations.
    (5) When a sprinkler system is shut down for more than 10 hours, 
the hospice must:
    (i) Evacuate the building or portion of the building affected by 
the system outage until the system is back in service, or
    (ii) Establish a fire watch until the system is back in service.
    (6) Buildings must have an outside window or outside door in every 
sleeping room, and for any building constructed after July 5, 2016 the 
sill height must not exceed 36 inches above the floor. Windows in 
atrium walls are considered outside windows for the purposes of this 
requirement.

[[Page 26898]]

    (e) Standard: Building Safety. Except as otherwise provided in this 
section, the hospice must meet the applicable provisions and must 
proceed in accordance with the Health Care Facilities Code (NFPA 99 and 
Tentative Interim Amendments TIA 12-2, TIA 12-3, TIA 12-4, TIA 12-5 and 
TIA 12-6).
    (1) Chapters 7, 8, 12, and 13 of the adopted Health Care Facilities 
Code do not apply to a hospice.
    (2) If application of the Health Care Facilities Code required 
under paragraph (e) of this section would result in unreasonable 
hardship for the hospice, CMS may waive specific provisions of the 
Health Care Facilities Code, but only if the waiver does not adversely 
affect the health and safety of patients.
* * * * *
    (q) The standards incorporated by reference in this section are 
approved for incorporation by reference by the Director of the Office 
of the Federal Register in accordance with 5 U.S.C. 552(a) and 1 CFR 
part 51. You may inspect a copy at the CMS Information Resource Center, 
7500 Security Boulevard, Baltimore, MD or at the National Archives and 
Records Administration (NARA). For information on the availability of 
this material at NARA, call 202-741-6030, or go to: https://www.archives.gov/federal_register/code_of_federal_regulations/ibr_locations.html. If any changes in this edition of the Code are 
incorporated by reference, CMS will publish a document in the Federal 
Register to announce the changes.
    (1) National Fire Protection Association, 1 Batterymarch Park, 
Quincy, MA 02169, www.nfpa.org, 1.617.770.3000.
    (i) NFPA 99, Standards for Health Care Facilities Code of the 
National Fire Protection Association 99, 2012 edition, issued August 
11, 2011.
    (ii) TIA 12-2 to NFPA 99, issued August 11, 2011.
    (iii) TIA 12-3 to NFPA 99, issued August 9, 2012.
    (iv) TIA 12-4 to NFPA 99, issued March 7, 2013.
    (v) TIA 12-5 to NFPA 99, issued August 1, 2013.
    (vi) TIA 12-6 to NFPA 99, issued March 3, 2014.
    (vii) NFPA 101, Life Safety Code, 2012 edition, issued August 11, 
2011;
    (viii) TIA 12-1 to NFPA 101, issued August 11, 2011.
    (ix) TIA 12-2 to NFPA 101, issued October 30, 2012.
    (x) TIA 12-3 to NFPA 101, issued October 22, 2013.
    (xi) TIA 12-4 to NFPA 101, issued October 22, 2013.
    (2) [Reserved]

PART 460--PROGRAMS OF ALL INCLUSIVE CARE FOR THE ELDERLY (PACE)

0
9. The authority citation for part 460 continues to read as follows:

    Authority:  Secs. 1102, 1871, 1894(f), and 1934(f) of the Social 
Security Act (42 U.S.C. 1302 and 1395, 1395eee(f), and 1396u-4(f)).


0
10. Amend Sec.  460.72 by--
0
a. Revising paragraphs (b)(1)(i) and (ii).
0
b. Revising paragraph (b)(2)(ii)
0
c. Removing paragraphs (b)(3) and (4).
0
d. Redesignating paragraph (b)(5) as paragraph (b)(3).
0
e. Revising newly redesignated paragraph (b)(3).
0
f. Adding new paragraphs (b)(4), (d), and (e).
    The revisions and addition read as follows:


Sec.  460.72  Physical environment.

* * * * *
    (b) * * *
    (1) * * *
    (i) A PACE center must meet the applicable provisions and must 
proceed in accordance with the Life Safety Code (NFPA 101 and Tentative 
Interim Amendments TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4.)
    (ii) Notwithstanding paragraph (b)(1)(i) of this section, corridor 
doors and doors to rooms containing flammable or combustible materials 
must be provided with positive latching hardware. Roller latches are 
prohibited on such doors.
    (2) * * *
    (ii) In consideration of a recommendation by the State survey 
agency or Accrediting Organization or at the discretion of the 
Secretary, may waive, for periods deemed appropriate, specific 
provisions of the Life Safety Code, which would result in unreasonable 
hardship upon a PACE facility, but only if the waiver will not 
adversely affect the health and safety of the patients.
    (3) A PACE center may install alcohol-based hand rub dispensers in 
its facility if the dispensers are installed in a manner that 
adequately protects against inappropriate access.
    (4) When a sprinkler system is shut down for more than 10 hours in 
a 24-hour period, the PACE must:
    (i) Evacuate the building or portion of the building affected by 
the system outage until the system is back in service, or
    (ii) Establish a fire watch until the system is back in service.
* * * * *
    (d) Standard: Building Safety. Except as otherwise provided in this 
section, a PACE center must meet the applicable provisions and must 
proceed in accordance with the Health Care Facilities Code (NFPA 99 and 
Tentative Interim Amendments TIA 12-2, TIA 12-3, TIA 12-4, TIA 12-5 and 
TIA 12-6).
    (1) Chapters 7, 8, 12, and 13 of the adopted Health Care Facilities 
Code do not apply to a PACE center.
    (2) If application of the Health Care Facilities Code required 
under paragraph (d) of this section would result in unreasonable 
hardship for the PACE center, CMS may waive specific provisions of the 
Health Care Facilities Code, but only if the waiver does not adversely 
affect the health and safety of patients.
    (e) The standards incorporated by reference in this section are 
approved for incorporation by reference by the Director of the Office 
of the Federal Register in accordance with 5 U.S.C. 552(a) and 1 CFR 
part 51. You may inspect a copy at the CMS Information Resource Center, 
7500 Security Boulevard, Baltimore, MD or at the National Archives and 
Records Administration (NARA). For information on the availability of 
this material at NARA, call 202-741-6030, or go to: https://www.archives.gov/federal_register/code_of_federal_regulations/ibr_locations.html. If any changes in this edition of the Code are 
incorporated by reference, CMS will publish a document in the Federal 
Register to announce the changes.
    (1) National Fire Protection Association, 1 Batterymarch Park, 
Quincy, MA 02169, www.nfpa.org, 1.617.770.3000.
    (i) NFPA 99, Standards for Health Care Facilities Code of the 
National Fire Protection Association 99, 2012 edition, issued August 
11, 2011.
    (ii) TIA 12-2 to NFPA 99, issued August 11, 2011.
    (iii) TIA 12-3 to NFPA 99, issued August 9, 2012.
    (iv) TIA 12-4 to NFPA 99, issued March 7, 2013.
    (v) TIA 12-5 to NFPA 99, issued August 1, 2013.
    (vi) TIA 12-6 to NFPA 99, issued March 3, 2014.
    (vii) NFPA 101, Life Safety Code, 2012 edition, issued August 11, 
2011;
    (viii) TIA 12-1 to NFPA 101, issued August 11, 2011.
    (ix) TIA 12-2 to NFPA 101, issued October 30, 2012.
    (x) TIA 12-3 to NFPA 101, issued October 22, 2013.
    (xi) TIA 12-4 to NFPA 101, issued October 22, 2013.
    (2) [Reserved]

[[Page 26899]]

PART 482--CONDITIONS OF PARTICIPATION FOR HOSPITALS

0
11. The authority citation for part 482 continues to read as follows:

    Authority:  Secs. 1102, 1871, and 1881 of the Social Security 
Act (42 U.S.C. 1302, 1395hh, and 1395rr), unless otherwise noted.


0
12. Amend Sec.  482.41 by--
0
a. Revising paragraphs (b)(1)(i) and ii).
0
b. Revising paragraph (b)(2).
0
c. Removing paragraphs (b)(4) and (b)(5).
0
d. Redesignating paragraphs (b)(6) through (9) as paragraphs (b)(4) 
through (7), respectively.
0
e. Revising newly redesignated paragraph (b)(7).
0
f. Adding new paragraphs (b)(8), and (9).
0
g. Redesignating paragraph (c) as paragraph (d).
0
h. Adding new paragraphs (c) and (e).
    The revisions and additions read as follows:


Sec.  482.41  Condition of participation: Physical environment.

* * * * *
    (b) * * *
    (1) * * *
    (i) The hospital must meet the applicable provisions and must 
proceed in accordance with the Life Safety Code (NFPA 101 and Tentative 
Interim Amendments TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4.)
    (ii) Notwithstanding paragraph (b)(1)(i) of this section, corridor 
doors and doors to rooms containing flammable or combustible materials 
must be provided with positive latching hardware. Roller latches are 
prohibited on such doors.
    (2) In consideration of a recommendation by the State survey agency 
or Accrediting Organization or at the discretion of the Secretary, may 
waive, for periods deemed appropriate, specific provisions of the Life 
Safety Code, which would result in unreasonable hardship upon a 
hospital, but only if the waiver will not adversely affect the health 
and safety of the patients.
* * * * *
    (7) A hospital may install alcohol-based hand rub dispensers in its 
facility if the dispensers are installed in a manner that adequately 
protects against inappropriate access;
    (8) When a sprinkler system is shut down for more than 10 hours, 
the hospital must:
    (i) Evacuate the building or portion of the building affected by 
the system outage until the system is back in service, or
    (ii) Establish a fire watch until the system is back in service.
    (9) Buildings must have an outside window or outside door in every 
sleeping room, and for any building constructed after July 5, 2016 the 
sill height must not exceed 36 inches above the floor. Windows in 
atrium walls are considered outside windows for the purposes of this 
requirement.
    (i) The sill height requirement does not apply to newborn nurseries 
and rooms intended for occupancy for less than 24 hours.
    (ii) The sill height in special nursing care areas of new 
occupancies must not exceed 60 inches.
    (c) Standard: Building safety. Except as otherwise provided in this 
section, the hospital must meet the applicable provisions and must 
proceed in accordance with the Health Care Facilities Code (NFPA 99 and 
Tentative Interim Amendments TIA 12-2, TIA 12-3, TIA 12-4, TIA 12-5 and 
TIA 12-6).
    (1) Chapters 7, 8, 12, and 13 of the adopted Health Care Facilities 
Code do not apply to a hospital.
    (2) If application of the Health Care Facilities Code required 
under paragraph (c) of this section would result in unreasonable 
hardship for the hospital, CMS may waive specific provisions of the 
Health Care Facilities Code, but only if the waiver does not adversely 
affect the health and safety of patients.
* * * * *
    (e) The standards incorporated by reference in this section are 
approved for incorporation by reference by the Director of the Office 
of the Federal Register in accordance with 5 U.S.C. 552(a) and 1 CFR 
part 51. You may inspect a copy at the CMS Information Resource Center, 
7500 Security Boulevard, Baltimore, MD or at the National Archives and 
Records Administration (NARA). For information on the availability of 
this material at NARA, call 202-741-6030, or go to: https://www.archives.gov/federal_register/code_of_federal_regulations/ibr_locations.html. If any changes in this edition of the Code are 
incorporated by reference, CMS will publish a document in the Federal 
Register to announce the changes.
    (1) National Fire Protection Association, 1 Batterymarch Park, 
Quincy, MA 02169, www.nfpa.org, 1.617.770.3000.
    (i) NFPA 99, Standards for Health Care Facilities Code of the 
National Fire Protection Association 99, 2012 edition, issued August 
11, 2011.
    (ii) TIA 12-2 to NFPA 99, issued August 11, 2011.
    (iii) TIA 12-3 to NFPA 99, issued August 9, 2012.
    (iv) TIA 12-4 to NFPA 99, issued March 7, 2013.
    (v) TIA 12-5 to NFPA 99, issued August 1, 2013.
    (vi) TIA 12-6 to NFPA 99, issued March 3, 2014.
    (vii) NFPA 101, Life Safety Code, 2012 edition, issued August 11, 
2011;
    (viii) TIA 12-1 to NFPA 101, issued August 11, 2011.
    (ix) TIA 12-2 to NFPA 101, issued October 30, 2012.
    (x) TIA 12-3 to NFPA 101, issued October 22, 2013.
    (xi) TIA 12-4 to NFPA 101, issued October 22, 2013.
    (2) [Reserved]

PART 483--REQUIREMENTS FOR STATES AND LONG TERM CARE FACILITIES

0
13. The authority citation for part 483 continues to read as follows:

    Authority:  Secs. 1102, 1128I, 1819, 1871 and 1919 of the Social 
Security Act (42 U.S.C. 1302, 1320a-7, 1395i, 1395hh and 1396r).


Sec.  483.15  [Amended]

0
14. In Sec.  483.15, amend paragraph (h)(4) by removing the reference 
``Sec.  483.70(d)(2)(iv) of this part'' and by adding in its place the 
reference ``Sec.  483.70(e)(2)(iv)''.

0
15. Amend Sec.  483.70 by--
0
a. Revising paragraphs (a)(1)(i) and ii).
0
b. Revising paragraph (a)(2).
0
c. Removing paragraphs (a)(4) and (5).
0
d. Redesignating paragraphs (a)(6) through (8) as paragraphs (a)(4) 
through (6), respectively.
0
e. Revising newly redesignated paragraph (a)(4).
0
f. Adding new paragraphs (a)(7) and (8).
0
g. Redesignating paragraphs (b) through (h) as paragraphs (c) through 
(i).
0
h. Adding new paragraphs (b) and (j).
    The revisions read as follows:


Sec.  483.70  Physical environment.

* * * * *
    (a) * * *
    (1) * * *
    (i) The LTC facility must meet the applicable provisions and must 
proceed in accordance with the Life Safety Code (NFPA 101 and Tentative 
Interim Amendments TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4.)
    (ii) Notwithstanding paragraph (a)(1)(i) of this section, corridor 
doors and doors to rooms containing flammable or combustible materials 
must be provided with positive latching hardware. Roller latches are 
prohibited on such doors.

[[Page 26900]]

    (2) In consideration of a recommendation by the State survey agency 
or Accrediting Organization or at the discretion of the Secretary, may 
waive, for periods deemed appropriate, specific provisions of the Life 
Safety Code, which would result in unreasonable hardship upon a long-
term care facility, but only if the waiver will not adversely affect 
the health and safety of the patients.
* * * * *
    (4) A long-term care facility may install alcohol-based hand rub 
dispensers in its facility if the dispensers are installed in a manner 
that adequately protects against inappropriate access.
* * * * *
    (7) Buildings must have an outside window or outside door in every 
sleeping room, and for any building constructed after July 5, 2016 the 
sill height must not exceed 36 inches above the floor. Windows in 
atrium walls are considered outside windows for the purposes of this 
requirement.
    (8) When a sprinkler system is shut down for more than 10 hours, 
the ASC must:
    (i) Evacuate the building or portion of the building affected by 
the system outage until the system is back in service, or
    (ii) Establish a fire watch until the system is back in service.
    (b) Standard: Building safety. Except as otherwise provided in this 
section, the LTC facility must meet the applicable provisions and must 
proceed in accordance with the Health Care Facilities Code (NFPA 99 and 
Tentative Interim Amendments TIA 12-2, TIA 12-3, TIA 12-4, TIA 12-5 and 
TIA 12-6).
    (1) Chapters 7, 8, 12, and 13 of the adopted Health Care Facilities 
Code do not apply to a LTC facility.
    (2) If application of the Health Care Facilities Code required 
under paragraph (b) of this section would result in unreasonable 
hardship for the LTC facility, CMS may waive specific provisions of the 
Health Care Facilities Code, but only if the waiver does not adversely 
affect the health and safety of residents.
* * * * *
    (j) The standards incorporated by reference in this section are 
approved for incorporation by reference by the Director of the Office 
of the Federal Register in accordance with 5 U.S.C. 552(a) and 1 CFR 
part 51. You may inspect a copy at the CMS Information Resource Center, 
7500 Security Boulevard, Baltimore, MD or at the National Archives and 
Records Administration (NARA). For information on the availability of 
this material at NARA, call 202-741-6030, or go to: https://www.archives.gov/federal_register/code_of_federal_regulations/ibr_locations.html. If any changes in this edition of the Code are 
incorporated by reference, CMS will publish a document in the Federal 
Register to announce the changes.
    (1) National Fire Protection Association, 1 Batterymarch Park, 
Quincy, MA 02169, www.nfpa.org, 1.617.770.3000.
    (i) NFPA 99, Standards for Health Care Facilities Code of the 
National Fire Protection Association 99, 2012 edition, issued August 
11, 2011.
    (ii) TIA 12-2 to NFPA 99, issued August 11, 2011.
    (iii) TIA 12-3 to NFPA 99, issued August 9, 2012.
    (iv) TIA 12-4 to NFPA 99, issued March 7, 2013.
    (v) TIA 12-5 to NFPA 99, issued August 1, 2013.
    (vi) TIA 12-6 to NFPA 99, issued March 3, 2014.
    (vii) NFPA 101, Life Safety Code, 2012 edition, issued August 11, 
2011;
    (viii) TIA 12-1 to NFPA 101, issued August 11, 2011.
    (ix) TIA 12-2 to NFPA 101, issued October 30, 2012.
    (x) TIA 12-3 to NFPA 101, issued October 22, 2013.
    (xi) TIA 12-4 to NFPA 101, issued October 22, 2013.
    (2) [Reserved]
0
16. Amend Sec.  483.470 by--
0
a. Revising paragraphs (j)(1)(i) and (ii).
0
b. Adding paragraphs (j)(1)(iii) and (iv).
0
c. Removing paragraphs (j)(5) and (6).
0
d. Redesignating paragraph (j)(7) as paragraph (j)(5).
0
e. Revising newly redesignated paragraph (j)(5).
0
f. Adding paragraph (m).
    The revisions and additions read as follows:


Sec.  483.470  Condition of participation: Physical environment.

* * * * *
    (j) * * *
    (1) * * *
    (i) The facility must meet the applicable provisions of either the 
Health Care Occupancies Chapters or the Residential Board and Care 
Occupancies Chapter and must proceed in accordance with the Life Safety 
Code (NFPA 101 and Tentative Interim Amendments TIA 12-1, TIA 12-2, TIA 
12-3, and TIA 12-4.)
    (ii) Notwithstanding paragraph (j)(1)(i) of this section, corridor 
doors and doors to rooms containing flammable or combustible materials 
must be provided with positive latching hardware. Roller latches are 
prohibited on such doors.
    (iii) Chapters 32.3.2.11.2 and 33.3.2.11.2 of the adopted 2012 Life 
Safety Code do not apply to a facility.
    (iv) Beginning July 5, 2019, an ICF-IID must be in compliance with 
Chapter 33.2.3.5.7.1, Sprinklers in attics, or Chapter 33.2.3.5.7.2, 
Heat detection systems in attics of the Life Safety Code.
* * * * *
    (5) Facilities that meet the Life Safety Code definition of a 
health care occupancy. (i) In consideration of a recommendation by the 
State survey agency or Accrediting Organization or at the discretion of 
the Secretary, may waive, for periods deemed appropriate, specific 
provisions of the Life Safety Code, which would result in unreasonable 
hardship upon a residential board and care facility, but only if the 
waiver will not adversely affect the health and safety of the patients.
    (ii) A facility may install alcohol-based hand rub dispensers if 
the dispensers are installed in a manner that adequately protects 
against inappropriate access.
    (iii) When a sprinkler system is shut down for more than 10 hours, 
the ICF-IID must:
    (A) Evacuate the building or portion of the building affected by 
the system outage until the system is back in service, or
    (B) Establish a fire watch until the system is back in service.
    (iv) Beginning July 5, 2019, an ICF-IID must be in compliance with 
Chapter 33.2.3.5.7.1, sprinklers in attics, or Chapter 33.2.3.5.7.2, 
heat detection systems in attics of the Life Safety Code.
    (v) Except as otherwise provided in this section, ICF-IIDs must 
meet the applicable provisions and must proceed in accordance with the 
Health Care Facilities Code (NFPA 99 and Tentative Interim Amendments 
TIA 12-2, TIA 12-3, TIA 12-4, TIA 12-5 and TIA 12-6).
    (A) Chapter 7,8,12 and 13 of the adopted Health Care Facilities 
Code does not apply to an ICF-IID.
    (B) If application of the Health Care Facilities Code required 
under paragraph
    (j)(5)(iv) of this section would result in unreasonable hardship 
for the ICF-IID, CMS may waive specific provisions of the Health Care 
Facilities Code, but only if the waiver does not adversely affect the 
health and safety of clients.
* * * * *
    (m) The standards incorporated by reference in this section are 
approved for incorporation by reference by the Director of the Office 
of the Federal

[[Page 26901]]

Register in accordance with 5 U.S.C. 552(a) and 1 CFR part 51. You may 
inspect a copy at the CMS Information Resource Center, 7500 Security 
Boulevard, Baltimore, MD or at the National Archives and Records 
Administration (NARA). For information on the availability of this 
material at NARA, call 202-741-6030, or go to: https://www.archives.gov/federal_register/code_of_federal_regulations/ibr_locations.html. If any 
changes in this edition of the Code are incorporated by reference, CMS 
will publish a document in the Federal Register to announce the 
changes.
    (1) National Fire Protection Association, 1 Batterymarch Park, 
Quincy, MA 02169, www.nfpa.org, 1.617.770.3000.
    (i) NFPA 99, Standards for Health Care Facilities Code of the 
National Fire Protection Association 99, 2012 edition, issued August 
11, 2011.
    (ii) TIA 12-2 to NFPA 99, issued August 11, 2011.
    (iii) TIA 12-3 to NFPA 99, issued August 9, 2012.
    (iv) TIA 12-4 to NFPA 99, issued March 7, 2013.
    (v) TIA 12-5 to NFPA 99, issued August 1, 2013.
    (vi) TIA 12-6 to NFPA 99, issued March 3, 2014.
    (vii) NFPA 101, Life Safety Code, 2012 edition, issued August 11, 
2011;
    (viii) TIA 12-1 to NFPA 101, issued August 11, 2011.
    (ix) TIA 12-2 to NFPA 101, issued October 30, 2012.
    (x) TIA 12-3 to NFPA 101, issued October 22, 2013.
    (xi) TIA 12-4 to NFPA 101, issued October 22, 2013.
    (2) [Reserved]

PART 485--CONDITIONS OF PARTICIPATION: SPECIALIZED PROVIDERS

0
17. The authority citation for part 485 continues to read as follows:

    Authority:  Secs. 1102 and 1871 of the Social Security Act (42 
U.S.C. 1302 and 1395(hh)).

0
18. Amend Sec.  485.623 by--
0
a. Revising paragraphs (d)(1)(i) and (ii).
0
b. Revising paragraph (d)(2).
0
c. Removing paragraphs (d)(5) and (6).
0
d. Redesignating paragraph (d)(7) as paragraph (d)(5).
0
e. Revising newly redesignated paragraph (d)(5).
0
f. Adding paragraphs (d)(6), (7), (e), and (f).
    The revisions and additions read as follows:


Sec.  485.623  Condition of participation: Physical plant and 
environment.

* * * * *
    (d) * * *
    (1) * * *
    (i) The CAH must meet the applicable provisions and must proceed in 
accordance with the Life Safety Code (NFPA 101 and Tentative Interim 
Amendments TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4.)
    (ii) Notwithstanding paragraph (d)(1)(i) of this section, corridor 
doors and doors to rooms containing flammable or combustible materials 
must be provided with positive latching hardware. Roller latches are 
prohibited on such doors.
    (2) In consideration of a recommendation by the State survey agency 
or Accrediting Organization or at the discretion of the Secretary, may 
waive, for periods deemed appropriate, specific provisions of the Life 
Safety Code, which would result in unreasonable hardship upon a CAH, 
but only if the waiver will not adversely affect the health and safety 
of the patients.
* * * * *
    (5) A CAH may install alcohol-based hand rub dispensers in its 
facility if the dispensers are installed in a manner that adequately 
protects against inappropriate access.
    (6) When a sprinkler system is shut down for more than 10 hours, 
the CAH must:
    (i) Evacuate the building or portion of the building affected by 
the system outage until the system is back in service, or
    (ii) Establish a fire watch until the system is back in service.
    (7) Buildings must have an outside window or outside door in every 
sleeping room, and for any building constructed after July 5, 2016 the 
sill height must not exceed 36 inches above the floor. Windows in 
atrium walls are considered outside windows for the purposes of this 
requirement.
    (i) The sill height requirement does not apply to newborn nurseries 
and rooms intended for occupancy for less than 24 hours.
    (ii) Special nursing care areas of new occupancies shall not exceed 
60 inches.
    (e) Standard: Building safety. Except as otherwise provided in this 
section, the CAH must meet the applicable provisions and must proceed 
in accordance with the Health Care Facilities Code (NFPA 99 and 
Tentative Interim Amendments TIA 12-2, TIA 12-3, TIA 12-4, TIA 12-5 and 
TIA 12-6).
    (1) Chapters 7, 8, 12, and 13 of the adopted Health Care Facilities 
Code do not apply to a CAH.
    (2) If application of the Health Care Facilities Code required 
under paragraph (e) of this section would result in unreasonable 
hardship for the CAH, CMS may waive specific provisions of the Health 
Care Facilities Code, but only if the waiver does not adversely affect 
the health and safety of patients.
    (f) The standards incorporated by reference in this section are 
approved for incorporation by reference by the Director of the Office 
of the Federal Register in accordance with 5 U.S.C. 552(a) and 1 CFR 
part 51. You may inspect a copy at the CMS Information Resource Center, 
7500 Security Boulevard, Baltimore, MD or at the National Archives and 
Records Administration (NARA). For information on the availability of 
this material at NARA, call 202-741-6030, or go to: https://www.archives.gov/federal_register/code_of_federal_regulations/ibr_locations.html. If any changes in this edition of the Code are 
incorporated by reference, CMS will publish a document in the Federal 
Register to announce the changes.
    (1) National Fire Protection Association, 1 Batterymarch Park, 
Quincy, MA 02169, www.nfpa.org, 1.617.770.3000.
    (i) NFPA 99, Standards for Health Care Facilities Code of the 
National Fire Protection Association 99, 2012 edition, issued August 
11, 2011.
    (ii) TIA 12-2 to NFPA 99, issued August 11, 2011.
    (iii) TIA 12-3 to NFPA 99, issued August 9, 2012.
    (iv) TIA 12-4 to NFPA 99, issued March 7, 2013.
    (v) TIA 12-5 to NFPA 99, issued August 1, 2013.
    (vi) TIA 12-6 to NFPA 99, issued March 3, 2014.
    (vii) NFPA 101, Life Safety Code, 2012 edition, issued August 11, 
2011;
    (viii) TIA 12-1 to NFPA 101, issued August 11, 2011.
    (ix) TIA 12-2 to NFPA 101, issued October 30, 2012.
    (x) TIA 12-3 to NFPA 101, issued October 22, 2013.
    (xi) TIA 12-4 to NFPA 101, issued October 22, 2013.
    (2) [Reserved]

    Dated: March 11, 2016.
Andrew M. Slavitt,
Acting Administrator, Centers for Medicare & Medicaid Services.
    Dated: March 30, 2016.
Sylvia M. Burwell,
Secretary, Department of Health and Human Services.
[FR Doc. 2016-10043 Filed 5-3-16; 8:45 am]
 BILLING CODE 4120-01-P