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Life Safety Code

Waves With Medical Caduceus Logo Silhouette In Red
Life Safety Code Inspections (called surveys) are required for certain health facility providers that are certified by the Center for Medicare and Medicaid Services (CMS). These surveys are conducted by Health Facilities Licensing and Certification's federally certified Life Safety Code surveyors. 
For more information, please contact:
Matthew Thomas​, RN, BSN, CFI, FIT, FF
Life Safety Code Surveyor

Shelley White, RN, CFI
Life Safety Code Surveyor

Life Safety Code Waivers

The Life Safety Code (LSC) provides that the authority having jurisdiction shall determine the adequacy of protection provided for life safety from fire in accordance with the provisions of the LSC. In cases of unreasonable hardship, 42 CFR 483.70(a)(2) specifies that a waiver may be granted where it would not adversely affect resident health and safety.
The Secretary has delegated to Center for Medicare and Medicaid Services (CMS) the authority to grant waivers of LSC provisions for all facilities participating in Medicare and Medicaid with the exception of ICFs/MR. The State Agency (SA) may recommend approval of waivers requested by providers, but only CMS Regional Offices (RO) may grant approval of waivers. The State has the authority to grant waivers of ICFs/MR requirements. There is no authority for either the State or the RO to grant waivers of Board and Care Occupancy provisions.

Categorical Waivers

Providers and suppliers are expected to have written documentation that they have elected to use the waiver. A provider or supplier must notify the LSC survey team at the entrance conference that it has elected the use the waiver permitted under this guidance and that it meets the applicable waiver requirements. The survey team will review the information and confirm the facility meets the conditions for the waiver.

Documentation & Record Review

In accordance with the NFPA 101 Life Safety Code, Providers are to ensure all required documentation is readily and easily accessible to the Authority Having Jurisdiction (AHJ).  Each facility is expected to have a Life Safety Code Binder established and maintained for review.  Please review the file attachment below for an updated list of required documentation.