Navigating the Latest FSES Information From CMS

Life Safety; Emergency Preparedness

​​​If you have never heard of the Fire Safety Evaluation System (FSES), then your facility is likely not impacted and do not need an alternate means to achieve Life Safety Code® compliance. However, for a small group of providers across the county, the FSES has been a critical tool used to address select deficiencies that would otherwise be incredibly costly and operationally disruptive if forced to remediate via normal means.

If you have been utilizing an FSES, you likely felt great relief when CMS issued a final rule on July 29th that permitted the use of alternate mandatory values. This action allowed many organizations that had passed the FSES under the 2001 edition of NFPA101A, then failed the FSES under the 2013 edition of NFPA 101A, to pass once again. 

On October 26th, CMS published a revised S&C Memo ​(17-15-LSC) that outlined details around the FSES final rule. While the memo provides helpful clarity and guidance, it includes one statement that could be confusing:

“Time limited waivers previously allowed for existing NF/SNF that had an FSES on record prior to July 5, 2016, are rescinded with the adoption of the FSES mandatory values in NFPA 101A, 2001 edition.” 

The term “rescinded” could be interpreted to signal that providers with a time limited waiver (TLW) related to a failing FSES must immediately conduct and submit an updated FSES. However, in a recent correspondence with AHCA, CMS clarified this is not the case. Rather, providers can continue to work under their existing TLW until their next federal survey. At that time, they will again be cited for the underlying deficiency and will be expected to submit an updated passing FSES as part of their Plan of Correction (POC). 

Recognizing the process of conducting a FSES assessment and preparing the FSES documentation can take some time, it may be prudent to commence that process prior to your next survey. This will ensure you can submit the updated FSES as part of your Plan of Correction within the required timeframe.