Recently, the Center for Medicare & Medicaid Services (CMS) issued a Memorandum clarifying that the Fire Safety Evaluation System (FSES) can be used to evaluate the level of safety provided in a sprinklered nursing home when there are no sprinklers under overhangs and canopies that require sprinklers. Generally sprinklers are required in overhangs and canopies when they are constructed of combustible materials and they are more than 4 feet wide. Canopies that are not connected to the building, regardless of construction, do not require sprinklers. Likewise canopies and overhangs of noncombustible construction, even for sprinklered buildings, do not require sprinklers if there is no combustible storage below.
The FSES differs from a waiver in that the FSES documents whether a building provides an equivalent level of safety to the Life Safety Code, even if the building does not comply with all the prescriptive requirements of the Life Safety Code for health care facilities. In essence, a FSES is the facility’s plan of correction because it documents equivalence and no waiver is required. Generally, the equivalence is provided by the facility having fire protection features that exceed the prescriptive requirements of the Code, such as having hard wired smoke detectors in corridors and/or patient rooms or exits that exceed the minimum requirements of the Code.
A waiver, on the other hand, means that a specific feature of the building does not comply with a prescriptive requirement of the Code and alternative protection may not be provided. Because a waiver and the FSES differ, the documentation to substantiate each differs. To substantiate a waiver you must document: (1) financial hardship; and (2) the waiver will not adversely impact the safety of building occupants. To substantiate an FSES, you must document cost to correct the prescriptive requirement and equivalency. There is a difference between financial hardship and cost – that is, the FSES does NOT require documentation of financial hardship but you must document the cost associated with compliance with the prescriptive requirement and the equivalency.
The FSES cannot be used for minor deficiencies that require a minor effort and cost to achieve compliance. Unfortunately, there is no guidance given by CMS as to what constitutes minor verses major costs. AHCA agrees that the FSES should not be used for minor deficiencies. It is AHCA’s position that a minor cost is anything that costs less than $3000.00 for a small facility (60 beds or less) and $5000.00 for a large facility (more than 60 beds). The FSES was developed by CMS to find the most economic solutions to correct deficiencies and provide an equivalent level of safety to compliance with the Life Safety Code. Therefore, the FSES can also be used to determine whether a new fire protection feature can be added to the building in lieu of correcting the deficiency. For example, it may be significantly less costly to install smoke detectors, than to correct the prescriptive deficiency, if the use of the FSES documents equivalency. The cost factors would also apply in this scenario.
The FSES was developed in the 1970’s and has been successfully used ever since. FSES has been adopted by the National Fire Protection Association (NFPA) and incorporated 2 into the NFPA 101A, Guide on Alternative Approaches to Life Safety. The 2001 NFPA 101A is the reference standard to the 2000 Life Safety Code.
Please note, just like waivers, the FSES must be submitted for approval annually. Some states will do the FSES analysis, if requested. If knowledgeable and qualified, facility staff can do the FSES analysis. Facilities that must pay a third party to complete an FSES should take the annual cost of the third party into consideration when deciding to correct the deficiency or do an FSES.
This Life Safety Update was reviewed by CMS Central Office and Mr. Merrill indicated that he had no comments on this update.