CMS SOM App. J, Tag W451

live-in and relief staff they utilize.

Guidance §483.470(i)(3)

In the case of live-in staff, drills must occur quarterly. Typically, live-in staff can be found in

facilities that fall under Chapter 32/33 of the LSC code. Drills should be held at varying times of

the day and night for clients to practice evacuation including morning, afternoon, evening and

the middle of the night.

(j) Standard: Fire protection.

Guidance §483.470(j)

These standards are covered by the Life Safety Code (LSC) survey. The facility must meet the

appropriate chapter of the Life Safety Code, 2000 edition.

When surveying an ICF/IID for compliance with the LSC, it is first necessary to determine

whether the facility will be surveyed under Health Care (HC) or Board and Care (BC) occupancy.

• If clients receive nursing services, or if the provider elects to use Health Care, the facility

should be surveyed as a Health Care Facility under Chapter 18 or 19 of the LSC, as

appropriate.

• If clients receive personal care and protective oversight but not continuing nursing

services, the facility is to be surveyed under Board and Care and the following three

steps should be followed:

1) Determine the size (16 or less = small; 17 or more = large);

2) Determine the Evacuation Difficulty (PROMPT, SLOW, or IMPRACTICAL) using

Appendix F of the fire safety evaluation system for board and care facilities

(FSES/BC); and

3) Survey the building using one of two methods:

a. The prescriptive requirements of Chapters 32 or 33; or

b. The FSES/BC, Appendix G.

(1) General. Except as otherwise provided in this section—

(i) The facility must meet the applicable provisions of either the Health Care Occupancies

Chapters or the Residential Board and Care Occupancies Chapter of the 2000 edition of the

Life Safety Code of the National Fire Protection Association. The Director of the Office of the

Federal Register has approved the NFPA 101®2000 edition of the Life Safety Code, issued

January 14, 2000, for incorporation by reference in accordance with 5 U.S.C. 552(a) and 1 CFR

part 51. A copy of the Code is available for inspection 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:

http://www.archives.gov/federal_register/code_of_federal_regulations/ibr_locations.html.

Copies may be obtained from the National Fire Protection Association, 1 Batterymarch Park,

Quincy, MA 02269. If any changes in this edition of the Code are incorporated by reference,

CMS will publish notice in the Federal Register to announce the changes.

(ii) Chapter 19.3.6.3.2, exception number 2 of the adopted LSC does not apply to a facility.

Guidance §483.470(j)(1)(ii)

Roller latches are prohibited on corridor doors as a latching device.

(2) The State survey agency may apply a single chapter of the LSC to the entire facility or may

apply different chapters to different buildings or parts of buildings as permitted by the LSC.

(3) A facility that meets the LSC definition of a residential board and care occupancy must

have its evacuation capability evaluated in accordance with the Evacuation Difficulty Index of

the Fire Safety Evaluation System for Board and Care facilities (FSES/BC).

Guidance §483.470(j)(3)

The evacuation capability of residents is determined using Chapter 6 of NFPA 101A, 2001

edition.

4) If CMS finds that the State has a fire and safety code imposed by State law that adequately

protects a facility's clients, CMS may allow the State survey agency to apply the State's fire

and safety code instead of the LSC.

5) Beginning March 13, 2006, a facility must be in compliance with Chapter 19.2.9, Emergency

Lighting.

Guidance §483.470(j)(5)

Battery powered emergency lighting must last at least 90 minutes.

6) Beginning March 13, 2006, Chapter 19.3.6.3.2, exception number 2 does not apply to a

facility.

Guidance §483.470(j)(6)

Roller latches are prohibited on corridor doors as a latching device.

(7) Facilities that meet the LSC definition of a health care occupancy.

(i) After consideration of State survey agency recommendations, CMS may waive, for

appropriate periods, specific provisions of the Life Safety Code if the following requirements

are met:

Guidance §483.470(j)(7)(i)

Waivers may be granted only to facilities that meet the Life Safety Code definition of a Health

Care Occupancy. Waivers are not granted to facilities that met the requirements of a

Residential Board and Care Occupancy.

Waivers are recommended by the State Survey Agency and approved by the Regional Office.

(A) The waiver would not adversely affect the health and safety of the clients.

B) Rigid application of specific provisions would result in an unreasonable hardship for the

facility.

ii) Notwithstanding any provisions of the 2000 edition of the Life Safety Code to the contrary,

a facility may install alcohol-based hand rub dispensers if—

(A) Use of alcohol-based hand rub dispensers does not conflict with any State or local codes

that prohibit or otherwise restrict the placement of alcohol-based hand rub dispensers in

health care facilities;

(B) The dispensers are installed in a manner that minimizes leaks and spills that could lead to

falls;

(C) The dispensers are installed in a manner that adequately protects against inappropriate

access;

D) The dispensers are installed in accordance with chapter 18.3.2.7 or chapter 19.3.2.7 of the

2000 edition of the Life Safety Code, as amended by NFPA Temporary Interim Amendment 00–

1(101), issued by the Standards Council of the National Fire Protection Association on April 15,

2004. The Director of the Office of the Federal Register has approved NFPA Temporary

Interim Amendment 00–1(101) for incorporation by reference in accordance with 5 U.S.C.

552(a) and 1 CFR part 51. A copy of the amendment is available for inspection at the CMS

Information Resource Center, 7500 Security Boulevard, Baltimore, MD and at the Office of the

Federal Register, 800 North Capitol Street NW., Suite 700, Washington, DC. Copies may be

obtained from the National Fire Protection Association, 1 Batterymarch Park, Quincy, MA

02269; and

(E) The dispensers are maintained in accordance with dispenser manufacturer guidelines

(k) Standard: Paint.

The facility must—