Problem: Prior to the 2000 edition of the Life Safety Code (LSC), previous editions of the LSC did not regulate interior finishes on walls and ceilings that were less than 1/28” in thickness. Since these interior finishes were not regulated there was obviously no documentation reflecting that the finishes met any flammability/flame spread criteria. This primarily applied to thin wall paper, paint and even the paper covering of gypsum board/sheetrock. In the 2000 edition of the LSC, the Technical Committee on Furnishings and Contents decided to regulate NEW interior finishes that were less than 1/28” in thickness and inadvertently did not exempt existing interior finishes. Even though the 2000 LSC was adopted by CMS in 2003, the error was not discovered until 2009, via cited deficiencies. There have been numerous facilities cited since 2009 for a deficiency related to no documentation on the flammability of these thin interior finishes. The cost to correct this deficiency, resulting from an error in the Code, is very expensive and had the potential to cost providers 100’s of millions of dollars.
The deficiency was brought to the attention of AHCA/NCAL’s fire safety consultant, Tom Jaeger, who immediately brought it to the attention of the National Fire Protection Association (NFPA). Mr. Jaeger submitted a request for a Tentative Interim Amendment (TIA) to the 2009 and the 2000 editions of the LSC to correct the error. A TIA is a process where the requirements in older editions of the LSC are rewritten retroactively.
NFPA issued the TIA in March of 2009 and AHCA immediately notified Centers for Medicare & Medicaid Services (CMS) that the TIA had been issued and requested CMS to notify both the CMS Regional Offices and the states. Unfortunately, CMS’s initial response was because the Federal Government adopted into Regulation the 2000 LSC with the error, the error was the “law of the land”.
After many discussions with CMS, CMS decided to issue a Survey & Certification Memorandum (S & C- 11-07-LSC) correcting the error on December 17, 2010. A copy of S & C - 11-07-LSC and the NFPA Tentative Interim Amendment (TIA 00-2) are attached to this Life Safety Update.
Solution: With the issuance of S & C Letter 11-07, the CMS Regional Offices and the states have been notified that interior finishes less than 1/28” in thickness that were installed in existing buildings prior to August 2003, the effective date of the adoption of the 2000 LSC, do not have to document the flammability or flame spread rating of these thin interior finishes.
Please note that the change in the LSC was made to Section 10.2, specifically Exception No. 2 to Section 10.2.1 and not to Chapter 19, which contains all the requirements for existing health care facilities. Chapter 19 references Section 10.2 in Chapter 19.
This change should also apply to existing assisted living facilities in those states that utilize the NFPA LSC. Assisted living providers should verify this with their state assisted living licensing agency. If you receive a deficiency citation for existing, thin interior finishes not meeting the 2000 LSC, request clarification from your state survey agency. If you do not obtain a satisfactory response we recommend you contact your state association. State associations, in turn, are encouraged to contact either Lyn Bentley or Karl Polzer with AHCA/NCAL.