CMS Outlines Plan to Sunset Various Fire and Life Safety Related 1135 Waivers

Emergency Preparedness; Regulations; COVID-19

In March of 2020, CMS implemented a number of 1135 waivers in response to the pandemic.  These blanket waivers were intended to help healthcare providers contain the spread of COVID-19 during the Public Heath Emergency. Some of these waivers specifically addressed fire and life safety requirements. 

In early April​, 2022, CMS informed healthcare providers that many of these waivers will be sunsetting.  Some have a 30-day expiration while others will end after 60 days. All the fire and life safety related waivers fall into the 60-day expiration period.  

Here is a list of the fire and life safety related blanket waivers that will be expiring on June 6, 2022, along with details around each waiver item:

Inspection, Testing and Maintenance

Healthcare providers were given the option to adjust or even pause various inspection, testing and maintenance (ITM) components for fire protection systems including automatic sprinkler systems and fire alarm systems.  If your facility has not re-engaged normal ITM tasks and frequencies, now is the time to contact your vendor(s) and schedule these services. ITM intervals can run from quarterly to every two years depending on the system component. Work with your vendor to review your most recent documentation and develop a schedule to get back on track. A reminder that CMS references the 2011 edition of NFPA 25 for sprinkler system ITM and the 2010 edition of NFPA 72 for fire alarm ITM even though more recent editions of both exist.  

Fire Drills

Healthcare providers were permitted to alter the process for conducting quarterly fire drills by providing a documented staff training program rather than facilitate traditional fire drills that could result in moving and massing residents together. The requirements of the Life Safety Code® will again apply.  Commencing in June, drills should occur quarterly on each shift, at varying times and under varied conditions.    

Temporary Walls and Partitions

Healthcare providers were permitted to install temporary barriers to provide separation and minimize contact during the pandemic. These barriers were sometimes utilized in individual rooms or used to separate entire wings or units from the remainder of the building. The waiver allowed for the use of products and finishes that would otherwise not be permitted for use as a barrier. Plywood, plastic sheathing and even plexiglass were commonly used materials. However, the Life Safety Code® only permits Class A or Class B interior wall finishes. An evaluation of all barriers installed during the pandemic should be evaluated and where they remain today, the materials should be assessed for compliance. This could result in the need to remove barriers or replace them with alternate materials. 

The use of plastic sheathing as a barrier should sunset along with the waivers. If a temporary barrier needs to remain in place, non-combustible materials such as drywall should be considered. Some organizations have adjusted their COVID units to be a dedicated wing or smoke compartment that is inherently separated by smoke barrier doors. This essentially utilizes the built-in barriers of the building to provide separation. Where these doors were previously held open, they now remain closed.  Creating temporary barriers can often impact egress. If you can use the existing compartmentation of the building, you minimize the potential for unrelated compliance issues. The use of plexiglass has been common inside facilities during the pandemic. Plexiglass is a transparent solid thermoplastic that will burn.  Under normal conditions, and without the application of the 1135 waiver, plexiglass would not be permitted as a barrier or wall finish by the Life Safety Code®. However, this does not limit the use of plexiglass as an accessory or furnishing. Appendix Section A. of the 2012 Edition of the Life Safety Code® indicates that “furnishings that, in some cases, might be secured in place for functional reasons should not be considered as interior finish.” This should allow applications such as a plexiglass barrier on a reception desk or nurse’s station to remain.  

You can find the full CMS memo on the sunsetting of the 1135 waivers at the following link: