Ask an Expert
Discuss My Needs
Menu
Discuss My Needs
Ask an Expert
Keyes Life Safety

Our Life Safety educational resource hub is full of healthcare knowledge to help you be better informed of the changing world around you. 

Rather than sit back and act on decisions made by others, we are leading the charge as it relates to identifying best practices for Life Safety Code® and compliance. We have real people that give our clients real information that can be put into practice.

Interested in reading our experts' take on Life Safety? Then subscribe to our free blog below! We discuss readers' questions, share interesting observations from the field, and more.

CMS Revises Communication on 1135 Waivers

by Brad Keyes, CHSP, on May 12, 2020 1:00:20 AM

As reported on this website last week, CMS issued a formal communication on April 29, 2020, that granted 1135 blanket waivers on Physical Environment items for Inspection, Testing & Maintenance (ITM). CMS is temporarily modifying its Conditions of Participation (CoP) requirements to the extent necessary to permit healthcare facilities to adjust scheduled inspection, testing, and maintenance frequencies and activities for the facility and medical equipment.

In the April 29, 2020 communication, CMS stated the following NFPA 101-2012 Life Safety Code (LSC) and NFPA 99-2012 Health Care Facilities Code (HCFC) ITM are considered critical and are not included in this waiver:

  • Sprinkler system monthly electric motor-driven and weekly diesel engine-driven fire pump testing.
  • Portable fire extinguisher monthly inspection.
  • Elevators with firefighters’ emergency operations monthly testing.
  • Emergency generator 30 continuous minutes of monthly testing and associated transfer switch monthly testing.
  • Means of egress daily inspection in areas that have undergone construction, repair, alterations, or additions to ensure its ability to be used instantly in case of emergency.

In a revised communication on the 1135 waivers issued May 8, 2020, CMS is modifying (and clarifying) the following requirements:

  • Alcohol-based Hand Rub (ABHR) Dispensers: CMS is waiving the prescriptive requirements for the placement of ABHR dispensers for use by staff and others due to the need for the increased use of ABHR in infection control. However, ABHRs contain ethyl alcohol which is considered a flammable liquid, and there are restrictions on the storage and location of containers that must be adhered to.
  • Fire Drills: Due to the inadvisability of quarterly fire drills that move and mass staff together, CMS will instead permit a documented orientation training program related to the current fire plan, which considers current facility conditions. The training will instruct employees, including existing, new or temporary employees, on their current duties, life safety procedures, and fire protection devices in their assigned area.
  • Temporary Construction: CMS is waiving requirements that would otherwise not permit temporary walls and barriers between patients.

To review the actual revised CMS communication, click on the following link and examine pages 24 - 26: 

https://www.cms.gov/files/document/summary-covid-19-emergency-declaration-waivers.pdf

Topics:WaiversAccreditation/CertificationAccreditationCOVID-19CMS

Real people. Real solutions.

We help you be better informed of the changing world around you.  Our life safety blog answers your real world questions! 

More...

More...

Subscribe to Updates

We care and want to help.

We want to help coach, guide, and navigate you through all things Life Safety.
DISCUSS MY NEEDS