Life Safety Code (LSC)

The Life Safety Code (LSC) is a set of standards governed and published by the National Fire Protection Association (NFPA). The LSC, also known as the NFPA-101, establishes the minimum requirements for new and existing buildings to protect occupants from fire, smoke and toxic fumes. CMS adopted the 2000 edition of the LSC to assist health care facilities with compliance issues commonly encountered during LSC surveys.

This page provides current information related to provider compliance with LSC requirements and includes links to applicable laws, regulations and compliance information.

Federal and State Requirements

State Operations Manual (SOM)- Appendix I - Survey Procedures and Interpretive Guidelines for LSC Surveys.
S and C Policy Letters - A list of CMS Survey and Certification (S&C) Policy Letters related LSC and a summary as well as links to the actual S&C letters.
Life Safety Code Survey Regulations - A list of applicable laws, regulations and compliance information and links.
Kentucky LSC Long Term Care (LTC) Facility Guide - Guidance for certified LTC facilities for navigating through the NFPA 101.

Interpretations

Health Care Interpretations Task Force (HITF) - A group of technical experts provide interpretive guidance to various health care organizations including CMS to answer questions concerning the LSC.
Kentucky Formal Interpretation 99-09 - A formal interpretation issued by KY Division of Building Code Enforcement related to sprinkler protection.

Compliance Issues

K-Tag Reference Sheet - A complete listing of LSC deficiencies that may be cited during a LSC survey.
LSC Scope and Severity (S/S) Grid - For any K-Tag issued during a LSC survey a letter score relating to the scope and severity of the deficiency is assigned. This decision matrix adopted by CMS includes definitions of scope and severity levels.
Top 15 LSC Deficiencies and Tips to Avoid Them

Certified Facility LSC Incident Reporting

OIG-DHC Certified Facility LSC Incident Reporting Form (PDF)

CMS Guidance

Fire Reporting Procedure - CMS Region IV Atlanta, GA (May 26, 2009)
S&C-04-23 - Procedures in the Event of a Fire in a Medicare or Medicaid Certified Health Care Facility
42 CFR 483.70a - Requirements for Nursing Homes
42 CFR 482.41b - Requirements for Hospitals
S and C-04-09 - Guidelines to Support Management of Complaints and Incidents

	See Also...
	CMS LSC Requirements KEYES Life Safety Compliance - FAQ NFPA Codes and Standards Free access to read only NFPA Codes U.S. Consumer Product Safety Commission Kentucky State Fire Marshal

	Health Care Facility Variance Information
	Health Care Facility Variance Request Form 902 KAR - Chapter 20 Health Services and Facilities provides facility specifications. (Note: Once hyperlink has been opened, you must scroll down to find Chapter 20 information) 906 KAR - Chapter 1 Office of the Inspector General

	Miscellaneous Information
	CMS Fire Safety Survey Reports - A listing of LSC survey report forms and links to electronic copies. Architect Program Review Fee Worksheet (PDF) CO Detector Program - Application CO Detector Alarm Response - Model Plan

Last Updated 6/6/2013

Privacy | Security | Disclaimer | Accessibility Statement