Life Safety Code (LSC) Surveys

2472 – Life Safety Code (LSC) Surveys (Rev. 1, 05-21-04) 2472A - Authority to Grant Waivers for LSC Surveys (Rev. 91, Issued: 09-27-13, Effective: 09-27-13, Implementation: 09-27-13) The LSC provides that the authority having jurisdiction shall determine the adequacy of protection provided for life safety from fire in accordance with the provisions of the LSC. In cases of unreasonable hardship, 42 CFR 483.70(a)(2) specifies that a waiver may be granted where it would not adversely affect resident health and safety. The Secretary has delegated to CMS the authority to grant waivers of LSC provisions for all facilities participating in Medicare and Medicaid with the exception of ICFs/IID. The State LSC surveyor recommends waivers, but CMS ROs grant the waivers. Therefore, LSC requests the SA receive from all providers except ICF/IIDs must be forwarded to the RO for adjudication. For ICFs/IID, the State has the authority to grant waivers of health care occupancy requirements. There is no authority for either the State or the RO to grant waivers of Board and Care Occupancy provisions. 2472B - Subagreements With State Fire Authorities (Rev. 91, Issued: 09-27-13, Effective: 09-27-13, Implementation: 09-27-13) To assess facilities’ compliance with the LSC and other Medicare and Medicaid fire safety requirements, the SA may enter into a subagreement or a contract with the State fire Marshal’s office or other State agency responsible for enforcing State fire code requirements. Under this agreement, the designated State fire authority generally agrees to: • Survey all non-accredited hospitals, hospices, ASCs, SNFs, NFs, CAHs, RNHCIs, PACE Facilities and ICFs/IID in accordance with schedules you furnished; • Survey accredited hospitals selected for validation surveys or surveyed as a result of a substantial allegation of an unsafe conditions; • Complete the appropriate Fire Safety Survey Report (Form CMS-2786); • Prepare statements of deficiencies and review PoCs (Form CMS-2567); • Make recommendations to you regarding facilities’ compliance with program fire safety requirements; and • Use only qualified fire safety inspectors in the performance of these surveys. 2472C - Coordinating LSC Survey (Rev. 1, 05-21-04) In most cases, the SA schedules the LSC survey to coincide with the health survey; however, the timing of the LSC is left to the discretion of the SAs. The SA determines whether the LSC survey is to occur before, after, or simultaneously with the health survey. If the health survey and the LSC survey are conducted at different times, data entry into OSCAR must be deferred until both surveys are completed, and the data of the latest segment of the total survey (the health portion or the LSC portion) is used for OSCAR purposes. In order to complete data submissions in a timely manner, input of the life safety code survey data of long term care facilities should take place not later than 60 days after the conclusion of the long term care survey. Most States require an initial LSC survey before admitting patients prior to becoming operational. Regardless of the timing of the LSC survey, the SA should schedule it so that all certification actions are completed timely. 2472D - ASC Surveys (Rev. 1, 05-21-04) The SA uses Form CMS-2786U to survey ASCs. The SA lists any LSC deficiencies found during an ASC survey on Form CMS-2567 and requests a PoC as with any LSC survey of a health care facility. 2472E - Involvement of SA Surveyors in LSC Surveys (Rev. 91, Issued: 09-27-13, Effective: 09-27-13, Implementation: 09-27-13) A full-scale LSC survey need not be performed every year if building characteristics have not changed. As long as the fire authority surveys every third year and the institution remains in compliance, the SA surveyors can complete a Fire Safety Survey Report - Short Form (CMS-2786S) as part of the recertification survey in the intervening years. (See §2476.) In surveys of ICFs/IID, fire authorities decide, in accordance with guidelines in Appendix I, which chapters of the LSC pertain in each instance and survey accordingly. However, the fire authority is not professionally trained to observe resident behavior and relies on information furnished by staff members to rate the level of mobility and self-preservation of residents. Consequently, when the SA surveys an ICF/IID, it takes a copy of the Worksheet for Rating Residents (F-1, Side 2, Form CMS-2786M) for each resident that the fire authority completed, and takes a blank copy of the same worksheet. Complete Items I through VI of the Worksheet to corroborate the information used by the fire authority. The SA reconciles any discrepancies with the fire authority before certifying the facility. Fire authorities are also advised in Appendix I to alert the SA to situations involving institutions not in compliance which present immediate jeopardy to residents so that the SA can initiate timely termination development without waiting for the written documentation of the LSC survey.