CMS SOM App. M, Tag L827

(1) Except as otherwise provided in this section--

(i) The hospice must meet the applicable provisions and must proceed in

accordance with the Life Safety Code (NFPA 101 and Tentative Interim

Amendments TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4.)

(ii) Notwithstanding paragraph (d)(1)(i)) of this section, corridor doors and

doors to rooms containing flammable or combustible materials must be

provided with positive latching hardware. Roller latches are prohibited

on such doors.

(1) In consideration of a recommendation by the State survey agency or

Accrediting Organization or at the discretion of the Secretary, may waive, for

periods deemed appropriate, specific provisions of the Life Safety Code which

would result in unreasonable hardship upon a hospice facility, but only if the

waiver will not adversely affect the health and safety of the patients.

(1) The provisions of the adopted edition of the Life Safety Code do not apply in a

State if CMS finds that a fire and safety code imposed by State law adequately

protects patients in hospices.

(1) A hospice may place alcohol-based hand rub dispensers in its facility if the

dispensers are installed in a manner that adequately protects against access by

vulnerable populations.

(1) When a sprinkler system is shut down for more than 10 hours, the hospice

must:

(i) Evacuate the building or portion of the building affected by the system

outage until the system is back in service, or

(ii) Establish a fire watch until the system is back in service.

(1) Buildings must have an outside window or outside door in every sleeping room,

and for any building constructed after July 5, 2016 the sill height must not

exceed 36 inches above the floor. Windows in atrium walls are considered

outside windows for the purposes of this requirement.