Mary Madison, RN, RAC-CT, CDP
Clinical Consultant – Briggs Healthcare
CMS posted QSO-20-40-LSC on Friday, September 25, 2020.
CMS regulation allows for the waiver of specific provisions of the 2012 NFPA 99 where the application would result in unreasonable hardship upon a provider or supplier, but only if the waiver does not adversely affect the health and safety of patients or residents.
The 2012 NFPA 99 does not include provisions for the use of CMT, which may be more efficient and economical to install. This may result in unreasonable hardship upon providers and suppliers. The 2018 NFPA 99 established requirements for the installation, inspection, testing, maintenance, performance, and safe practices for CMT that provide protection from related hazards.
The inability to install CMT may cause unreasonable hardship and a minimum level of protection is achieved based on compliance with provisions in the 2018 NFPA 99, CMS is providing a categorical waiver to allow for the use of CMT in new and existing facilities in accordance with the 2018 NFPA 99, sections 5.1.10, 5.2.10, and 5.3.10.
The NFPA 99 requires the installation of CMT to be made by American Society of Safety Engineers (ASSE) 6010, Professional Qualifications Standard for Medical Gas Systems Installers, qualified installers who are experienced in performing such installations. In addition, inspection and testing must be performed on all new piped medical gas and vacuum systems, additions, renovations, temporary installations, or repaired systems to ensure, by a documented process and procedure, that all applicable provisions of the NFPA 99 have been adhered to and system integrity has been achieved or maintained.
The 3-page memorandum includes information on the categorical waiver process, including:
Providers and suppliers that want to utilize a categorical waiver must formally elect and document their decision. At the survey entrance conference, a provider/supplier that has elected to use a categorical waiver must provide the survey team with their documented decision and verification of compliance with all applicable provisions. It is not acceptable for a facility to notify surveyors of the election to use a categorical waiver after the survey team has issued a citation. The survey team will review the documentation decision to use the categorical waiver and confirm the facility is compliant with all applicable provisions. This will confirm a minimum level of protection is afforded to protect the health and safety of patients and residents, as required by regulation.
If a provider/supplier conforms to the requirements identified for the categorical waiver, it will not be required to request waiver approval from a CMS Location nor will it need to be cited for an associated deficiency in order to implement this categorical waiver.
If the survey team determines that the provisions required for the categorical waiver are not being met, a deficiency must be cited under the applicable NFPA 99 waiver regulatory standard:
- ASC: §416.44(c)(2
- CAH: §485.623(e)(2)
- ESRD: §494.60(e)(3)
- RNHCI: §403.745(c)
- Inpatient Hospice: §418.110(e)(2)
- PACE: §460.72(d)(2)
- Hospital: §482.41(c)(2)
- LTC: §483.70(b)(2)
- ICF-IID: §483.470(j)(5)(v)(B)
Be sure to share this memorandum with Administration and review the entire memo.