CMS Adopts 2012 NFPA Life Safety Code: What you need to know

The changes are official. Let's make sure you  know all ten of the major changes for your healthcare facility.



Remember the blog post, Top 5 Possible Changes in the 2012 NFPA Life Safety Code, we wrote? On July 4, 2016, the Centers for Medicare & Medicaid Services (CMS) will officially adopt the 2012 Life Safety Code, making those changes reality.
Let’s revisit.
Back in January we told you:
#1 Annual fire rated door inspections and tests and documentation are required ( &
#2 A change in the stairwell identification signs involving illumination, tactile lettering, dimension and location. This effectively renders the existing stairwell identification signs noncompliant (
#3 Certain wheeled equipment is allowed to be left unattended in the 8-foot wide corridor, provided a minimum of 5-feet of clear width remains (
#4 Changes in NFPA 72, National Fire Alarm and Signaling Code, 2010 edition referenced by the 2012 LSC require additional information for fire alarm testing reports (
#5 Changes with a NFPA standard referenced by the 2012 LSC eliminated the fire-retardant visqueen plastic barriers used during construction (18/
Now, let’s talk about the next five major changes.


#6 High-Rise Hospitals (

Existing high-rise hospitals must be fully protected with sprinklers within 12 years of adopting the new 2012 Life Safety Code. A high-rise hospital is defined as a minimum of 75ft high or seven stories.
What’s new?
Existing high-rise hospitals were not required to be fully sprinklered unless renovation or new construction was implemented.
What does that mean for you?
There are estimated to be more than 175 high-rise hospitals that are not fully protected with automatic sprinklers. Capital funding will have to be allocated and plans made to ensure all high-rise hospitals become fully sprinklered within 12 years of CMS adopting the 2012 LSC.


#7 Door Locks for Safety Needs (

New definitions will clarify where locks are permitted in egress doors.
What’s new?
The code allows for three special locking arrangements: clinical needs, delayed egress, and access control.
What does that mean for you?
This now requires staff having the ability to readily unlock doors, a smoke detection system throughout the space, a fully sprinklered building, electric, fail-safe locks to release upon loss of power, and a lock release by activation of smoke detection and/or sprinkler systems.


#8 Portable Fire Extinguishers

2012 Edition references the 2010 Edition of the NFPA 10.
What’s new?
Portable fire extinguishers (FE) need to be securely installed with a manufacturer bracket or hanger, a listed bracket, in a cabinet, or wall recess. The installed FE needs to have a strap-type bracket where physical damage is possible and operating instructions need to be visible. A Non-rechargeable FE needs to be removed after 12 years from date of manufacture. Halogenated FEs are limited to where equipment protection is necessary. FEs need to receive maintenance and recharging by certified staff or vendor (except monthly inspections) and they can be electronically monitored.
What does that mean for you?
The largest impact of change in fire extinguishers to the average facility is the electronic monitoring that is now permitted. Manufacturers of these specialized monitoring cabinets have sensors to ensure nothing is parked in front of the cabinet, special listed mounted brackets to determine the weight and presence of the extinguisher, and pressure sensors integrated with the extinguisher to monitor pressure ranges. These specialized monitoring cabinets communicate back to a central monitoring area, and have proven to be very useful in high-theft areas.


#9 Alcohol Based Hand-Rub Dispensers (

New 2012 LSC Requirement.
What’s new?
There are a number of changes to this, however, the most impactful is that you are no longer permitted to have more than 10gal in total quantity of fluid in a single smoke compartment.
What does that mean for you?
You’ll need to be very mindful of how often and at what quantity you install ABHR dispensers in your facilities. Regularly check total ABHR capacity in individual smoke compartments to ensure it does not exceed the new, 10 gallon total.


 #10 Sprinkler Testing

2012 Edition references the 2011 Edition of the NFPA 25,
What’s new?
Several significant changes include: deficiencies must be repaired by qualified individuals, location of shut-off valves needs to be identified, there should be an informational sign at system control risers for anti-freeze loop, dry system, pre-action system, and the auxiliary system control value, and performance-based programs are now permitted.
What does that mean for you?
There are many different ways to accomplish this list of new requirements. For example, when identifying the location of all shut-off valves in your sprinkler system you can plot them on your CAD drawings, mark the suspended ceiling grids where the valves are located, list them on charts which are posted in conspicuous areas of the facilities department, or do all three.

This can be a complex issue, so if you have any questions, send me an email and I'd be happy to help.


Bill Ledger AIA, ACHA, LEED AP
Associate, Registered Architect