CMS SOM App. A, Tag A-0720

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.

Interpretive Guidelines §482.41(c)(1), (2):

Medicare-participating hospitals must comply with the 2012 edition of the NFPA 99 - Health

Care Facilities Code (HCFC) and Tentative Interim Amendments 12-2 through 12-6 for all

inpatient and outpatient care locations. This includes locations such as emergency departments,

surgical departments, intensive care units, observation units, etc. Chapters 7, 8, 12 and 13 of the

HCFC were not adopted by CMS and therefore do not apply to hospitals. In addition, the

hospital must be in compliance with the referenced publications in the HCFC.

Hospitals may request a waiver of specific HCFC provisions that would result in unreasonable

hardship if applied and would not adversely affect the health and safety of patients. HCFC

waivers may be recommended by the State survey agency or AO, but only the CMS RO may

grant those waivers for Medicare or Medicaid-participating hospitals.

Survey Procedures §482.41(c)(1), (2):

There is a separate survey form (Form CMS-2786) used by the SA LSC surveyors to evaluate

compliance with the HCFC.

As part of its survey Plan of Correction, a hospital may request a waiver of specific HCFC

provisions that would result in unreasonable hardship on a facility and that would have no

adverse effect on the health and safety of patients. The State survey agency (SAs) or CMS

approved Accreditation Organizations (AO) may recommend approval of waivers requested by

providers, but only CMS locations may grant approval of waivers. Therefore, all LSC and HCFC

waiver requests recommended for approval by SAs and AO, must be forwarded to the CMS

location for adjudication. There is no authority for either the State or the CMS location to grant

waivers of Board and Care Occupancy provisions.