The Centers for Medicare & Medicaid Services (CMS) recently made an important policy decision that could have wide-reaching implications in helping hospitals deal with certain aspects of Joint Commission surveys.

CMS, which requires health care facilities to follow the 2000 edition of NFPA 101: Life Safety Code, issued a memo in March stating that it was easing the waiver process for facilities that wanted to take advantage of four pro­visions in the 2012 edition of the Life Safety Code.

One of those provisions allows for previously restricted items — including emergency crash carts and patient transportation devices — to be placed in exit corridors. This issue is of great importance to hospitals because items found in corridors are currently a top cause for Joint Commission citations.

ASHE Director of Codes and Standards Chad Beebe, AIA, SASHE, says the CMS memo is a step in the right direction. "It's nice to see recognition of the value of the latest edition of the Life Safety Code," he adds.

CMS will consider waivers to permit facilities to take advantage of the following provisions from the 2012 edition, including several aimed at giving nursing homes a more home-like atmosphere:

  • Previously restricted items can be placed in exit corridors.
  • The kitchen can be open to an exit corridor under certain circumstances.
  • Installation of direct-vent gas fireplaces and solid fuel-burning fireplaces will be allowed.
  • Combustible decorations are allowed in certain areas.

Under the CMS policy outlined in the memo — a policy that is now in effect — the agency is easing the waiver process by considering waivers without requiring facilities to show "unreasonable hardship," such as a cost so great it would put the hospital out of business.

CMS officials say waiver requests will be processed according to standard operating procedures, and each request will be evaluated separately to ensure the facility has followed all Life Safety Code requirements.

Beebe notes that hospitals must be cited first to apply for a waiver in the form of a letter to the citing agency, which should route it through the normal waiver process. The waiver request should outline the need for items in the corridor and how they help deliver patient care, Beebe says.

It is important to note that hospitals that want to take advantage of the eased waiver process cannot use corridors for routine storage. CMS has not changed its "not in use" criteria that specify that an item is not in use if it is left unattended or unmoved for more than 30 minutes.

The 2012 edition of the Life Safety Code restricts corridor items to equipment such as in-use carts, emergency equipment such as crash carts, and patient transportation devices.

For more information on the CMS memo or to get involved with ASHE advocacy work, readers should contact Chad Beebe at or 312-422-3824.

This month's column was written by Deanna Martin, senior communications specialist at ASHE.



Codes input needed

ASHE is looking for input from health facility professionals who deal with codes and standards. Has your facility faced conflicting or inappropriately interpreted codes and standards? Tell ASHE your story by using the revamped advocacy section of the ASHE website at ASHE is gathering this information as it works toward the goal of a set of unified codes that do not conflict, are created using the best science available and that provide optimal safety without overburdening hospitals. To get involved with ASHE's advocacy efforts, contact ASHE Director of Codes and Standards Chad Beebe at

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ASHE is introducing a new handbook that provides step-by-step instructions to perform health facility commissioning. The new Health Facility Commissioning Handbook accompanies the previously published Health Facility Commissioning Guidelines, which are the only set of commissioning guidelines specifically geared toward health care facilities. The new handbook shows hospitals how to get the most for their money during construction or renovation projects and how to gain performance long-term. For information on purchasing the handbook or guidelines, go to