CMS SOM App. H, Tag V417

(1) Except as provided in paragraph (d)(2) of this

section, dialysis facilities that do not provide one or more exits to the outside at grade level

from the patient treatment area level, must comply with provisions of the 2012 edition of

the Life Safety Code of the National Fire Protection Association (NFPA 101 and tentative

interim amendments TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4) applicable to

Ambulatory Health Care Occupancies [which is incorporated by reference in paragraph (f)

of this section], regardless of the number of patients served.

Interpretive Guidance § 494.60(d)(1)

ESRD facilities that do not provide one or more exits to the outside at grade level from the

patient treatment area must comply with the requirements contained in the 2012 edition of the

Life Safety Code (NFPA 101) and the Tentative Interim Amendments TIA 12-1, TIA 12-2, TIA

12-3 and TIA 12-4 applicable to the Ambulatory Health Care Occupancies, regardless of the

number of patients served.

Dialysis facilities that provide one or more exits to the outside at grade level would be exempt

from meeting the requirements in the 2012 edition of the Life Safety Code (NFPA 101) and the

applicable tentative interim amendments. Exempt facilities must continue to comply with state

and local fire codes.

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“Exit to the outside at grade level from the patient treatment area level” is to mean that ESRD

facilities are on the ground or grade level of a building where patients do not have to traverse up

or down stairways to evacuate to the outside. Accessibility ramps in the exit area that provide an

ease of access between the patient treatment level and the outside ground level are not

considered stairways.

A dialysis facility required to comply with the LSC must operate in accordance with the code

chapters (Chapters 20 or 21) applicable to ambulatory health care occupancies. However, a

dialysis facility may be located in a mixed occupancy building. If a dialysis facility is located in

a building with other tenants and occupancies, it must be separated by a one-hour fire-resistance-rated wall in accordance with the LSC. For purposes of this regulation, when a

portion of the dialysis facility is used intermittently by another entity (e.g., an exam room is used

for the nephrologist’s office practice) it is not intended that the portion used intermittently would

be separated from the dialysis facility by a one-hour fire wall.

If the dialysis facility is located within a hospital, but not separated from the hospital by two-hour fire wall construction, the dialysis facility must meet the hospital LSC requirements. If a

hospital-based chronic outpatient facility provides acute services for hospitalized patients in the

same space and within the hospital walls, the outpatient dialysis facility must meet the more-stringent hospital chapters of the LSC.

Survey instructions found in State Operations Manual (SOM), Appendix I, are used as

applicable, along with the Fire Safety Survey Report Form, 2786U to survey for fire safety. The

fire safety standard will be surveyed by a fire specialist from the State Agency or a CMS-approved Accrediting Organization, if accredited; generally, the LSC inspections will be done

separately from the rest of the ESRD facility survey.