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RTN1311_B8_CMS Categorical Waivers


EC: Clarifications and Expectations: What the CMS Life Safety Code Waivers Mean for You: Getting your questions answered[®] [REF: CMS, EOC, SFT] EC News November 2013, Vol 16, #11, Pg 1 JCe1311_B8

Two months ago in the 9/11/13 issue of Joint Commission Online, TJC reported on the seven topical areas (i.e., • Openings in exit enclosures • Emergency generators and standby power systems • Doors • Suites • Extinguishing requirements • Clean waste and patient record recycling containers • Medical gas alarms) in which CMS had granted Categorical Waivers. The waivers themselves were announced in CMS Survey and Certification Letter 13-58-LSC on 8/30/13. This article accomplishes two things:

1 – It reports that four more topics (i.e., • Wheeled equipment in the egress corridor • One alternative kitchen cooking arrangement open to the egress corridor per smoke compartment • Direct vent gas fireplaces and solid fuel-burning fireplaces • Combustible decorations) have been added to the original seven and

2 – Through a Q&A format, it provides a more in-depth explanation of categorical waivers, the 11 categories and more specifics about the actual waivers available in each.

Tip: EOC and Safety leaders should review this article for a quick overview of what is addressed in each category of waiver and determine if any seem appropriate for your facility. If so, consult S&C 13-58-LSC for more details. Pay particular attention to the waiver available in the Doors category for psychiatric patients.
See also: See this article’s “Comments” for additional background information and RTN1309_B5_CMS Waivers @ LSC/NFPA

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One response to “RTN1311_B8_CMS Categorical Waivers”

  1. Re: Categorical Waivers
    • JCo: – CMS grants waivers to several areas of the Life Safety Code®[®] [REF: CMS, E&M, JCSC, SFT, LDR] Joint Commission Online, September 11, 2013, Pg 1 #JCo1309_B5

    Concern about potentially unreasonable hardship on organizations attempting to comply with selected Life Safety Code requirements has resulted in CMS granting waivers in the following areas:

    •Medical gas master alarms
    •Openings in exit enclosures
    •Emergency generators and standby power systems
    •Doors
    •Suites
    •Extinguishing requirements
    •Clean waste and patient record recycling containers

    TJC says, “Health care organizations can immediately take advantage of the waivers without seeking formal approval from CMS. However, organizations are expected to have written documentation that they have elected to use a waiver. This can be done by noting it in the “Additional Comments” field of the statement of conditions (SOC) in the basic building information (BBI) for those categorical waivers associated with the Life Safety Code. For the requirements in the Environment of Care (EC) chapter, organizations should document the decision in the EC committee minutes (or an equivalent place).” CMS S&C 13-58-LSC) explains the waiver process details including the conditions for alternative approaches.
    Tip: As per TJC, “Organizations should also notify the surveyor at the beginning of a survey that they have chosen the waiver. It is not acceptable for an organization to first notify surveyors of waiver election after an LSC citation has been issued”.

    – See more at: http://www.fieldsinc.com/category/cat-rtn_1309/page/2#JCo1309_B5

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