ED Accreditation Update: CMS, JCAHO now using same Life Safety Code

Facilities will see easing of some restrictions

Emergency departments (EDs) received some welcome news in January when the Centers for Medicare & Medicaid Services (CMS) adopted the same edition of the Life Safety Code referenced in the Joint Commission standards. The change affects EDs accredited by the Joint Commission that receive Medicare reimbursement from CMS.

The change comes as a big relief to those hospitals that had to comply with both CMS and Joint Commission codes, says Dean Samet, associate director of the Standards Interpretation Group of the Joint Commission.

The Joint Commission and CMS base fire safety requirements on the National Fire Protection Association’s (NPFA) Life Safety Code, which reflects technology and philosophy of fire protection as well as lessons learned from actual fires. The Life Safety Code is updated every three years, and until now, CMS had relied upon the 1985 version of the code. The Joint Commission adopted the 2000 revision in November; previously, it had referenced the 1997 version. Organizations surveyed by both agencies had to comply with the more stringent 1985 version.

Organizations now will be able to take advantage of code exceptions that have been introduced into the newer editions of the Life Safety Code, according to Samet.

The biggest change hospitals will see is in the many exceptions that are permitted for buildings that are fully equipped with sprinklers, he says. For example:

  • Smoke dampers will not be needed in heating and cooling ducts penetrating required smoke barrier walls.
  • Vision panels in the same corridor walls and doors can be constructed of plain glass of unlimited size.
  • Certain areas previously considered hazardous (for example, employee locker rooms and kitchens) are no longer considered hazardous.


For more information on the Life Safety Codes, contact:

  • Dean Samet, Associate Director, Standards Interpretation Group, Joint Commission for Accreditation of Healthcare Organizations, One Renaissance Blvd., Oakbrook Terrace, IL 60818. Email: dsamet@JointCommission.org. Phone: (630) 792-5759. Fax: (630) 792-5005.
  • A copy of the National Fire Protection Association’s (NFPA’s) 2000 Life Safety Code may be purchased at the NFPA web site, www.nfpa.org/catalog. Click on Life Safety Code, and follow the links to the purchase page. Cost is $109.95, or $98.96 for NFPA members.