CMS Clarifies Responsibilities of ESRD Facilities to Comply with Life Safety Code

On July 12, 2013, the Center for Clinical Standards and Quality / Survey & Certification Group within the Centers for Medicare & Medicaid Services (CMS) released a memorandum clarifying the responsibilities of ESRD facilities to comply with the National Fire Protection Association Life Safety Code (LFC) 101. The memorandum points out the following:

  • Effective July 16, 2012, compliance by certified ESRD facilities with the applicable requirements of the 2000 edition of the National Fire Protection Association (NFPA) Life Safety Code 101 is limited to those ESRD facilities that are located adjacent to high hazardous occupancies and those facilities that do not exit to the outside at grade level from the patient treatment area.
  • ESRD facilities are still required to comply with state and local fire codes and other safety standards required by 42 CFR Part 494 Conditions for Coverage (CfC) for ESRD facilities.
  • Providers may submit an attestation to claim an exemption to the NFPA LSC requirements if they are not located adjacent to high hazard occupancies and they do provide exits at grade level from the patient treatment area level.

The memorandum also includes the necessary steps for ESRD providers to attest to exemption (if applicable) from the LSC requirements as well as a "Model Attestation Statement" that can be customized and used for submission.