CMS Issues Additional Waivers Related to Fire Protection Systems

Blog Post created by rsolomon Employee on Apr 30, 2020


The Centers for Medicare & Medicaid Services (CMS) provided an update to the extensive list of waivers that have already been issued as result of the COVID-19 public health emergency that was declared on January 31.  The April 29 release outlining COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers  amends and adds additional requirements from CMS that are being set aside under the broad powers given to the agency as part of the 1135 waiver process. In general, these waivers are retroactive back to March 1. The April 29 update from CMS lists 15 new items since April 21.  The specific issue relating to inspection, testing, and maintenance (ITM) for fire protection and life safety systems can be found on page 23.  That waiver allows adjustments to be made with regard to the frequency of scheduled and recurring ITM activities.


This recent set of waivers modifies some ITM requirements for certain types of fire protection and life safety equipment found in health care environments. During the last six weeks, hospitals and long-term care occupancies have been in a race to maintain high levels of patient and resident care while dealing with overflow capacity, limiting transmission of the virus to the dedicated health care workers who render treatment and care as well as the public, while at the same time trying to keep all of their systems and equipment running in a safe and efficient manner.  Various NFPA codes and standards such as NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems provide detailed requirements concerning the protocols necessary to verify reliability and operational status of automatic sprinkler systems and fire pumps among other key safety systems. The standard also specifies necessary frequencies related to the ITM actions associated with specific systems and system components. 


NFPA provided earlier information surrounding the management of fire protection systems and features, along with challenges dealing with ongoing construction and operation of health care facilities, including alternate care sites in two white papers that were published several weeks ago.   Those resources, Temporary Compliance Options for Code Modifications, Alternate Care Sites, and Facilities Related to Health Care and Considerations for Temporary Compliance Options in Health Care Environments During COVID-19 provided background on the CMS waiver process, laid out considerations for providing safe environments that would not be 100% code compliant, and listed a set of compliance challenges and potential solutions that could be applied.  These issues and others were discussed in a webinar sponsored by NFPA on April 15 that covered the use of resources that were stretched thin on all fronts as health care facilities were continuously challenged to deal with the large influx of COVID-19 patients.  This latest set of waivers allows health care providers to continue to focus on patient and resident care while directing ITM resources on the most critical elements of these important systems.