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Life Safety Code

 
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Life Safety Code Inspections (called surveys) are required for certain health facility providers that are certified by the Center for Medicare and Medicaid Services (CMS). These surveys are conducted by Health Facilities Licensing and Certification's federally certified Life Safety Code surveyors. 
 
For more information, please contact:
 
Matthew Thomas​, RN, BSN, CFI, FIT, FF
Certified Fire Inspector
(907) 332-2483
 
-OR-

Shelley White, RN, CFI
Certified Fire Inspector
(907) 332-2483


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Current Construction & Fire Codes and Guidelines

 
Federal: The Life Safety Code (LSC) is a source for strategies to protect people based on building construction, protection, and occupancy features that minimize the effects of fire and related hazards. The publication contains various types of occupancies, covering both new and existing constructions. CMS currently uses the 2012 NFPA 101 Life Safety Code and the 2012 NFPA 99 Health Care Facilities Code (except chapters 7, 8, 12 and 13).

 
State: Physical plant statutes can be located under 7 AAC 12.900. Specifically, 7 AAC 12.900(b)(1) states approved facilities are to follow the Guidelines for Design and Construction of Hospital and Health Care Facilities, American Institute of Architects, 2001 edition.
 
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Documentation & Record Review

In accordance with the NFPA 101 Life Safety Code, Providers are to ensure all required documentation is readily and easily accessible to the Authority Having Jurisdiction (AHJ).  Each facility is expected to have a Life Safety Code Binder established and maintained for review.  Please review the file attachment below for an updated list of required documentation.
 
 
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Regulatory Guidance & References

 
The NFPA has developed a webpage for CMS providers specifically. The NFPA Codes & Standards webpage section contains useful resources for CMS requirements. The NFPA 99 (12) has a completely different systematic approach to compliance. Building systems are now required to have a risk assessment completed to determine such requirements as preventative maintenance schedule and staff education.  Review the PDF below for further risk assessment guidance from NFPA.
 
 
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Life Safety Code Waivers

The Life Safety Code (LSC) provides that the authority having jurisdiction shall determine the adequacy of protection provided for life safety from fire in accordance with the provisions of the LSC. In cases of unreasonable hardship, 42 CFR 483.70(a)(2) specifies that a waiver may be granted where it would not adversely affect resident health and safety.
 
The Secretary has delegated to Center for Medicare and Medicaid Services (CMS) the authority to grant waivers of LSC provisions for all facilities participating in Medicare and Medicaid with the exception of ICFs/MR. The State Agency (SA) may recommend approval of waivers requested by providers, but only CMS Regional Offices (RO) may grant approval of waivers. The State has the authority to grant waivers of ICFs/MR requirements. There is no authority for either the State or the RO to grant waivers of Board and Care Occupancy provisions.
 
 
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Additional Resources

 
Anchorage Building Safety Office
4700 Elmore Road
Anchorage, Alaska
(907) 343-8301 

State Fire Marshal’s Office
Plan Review Bureau
5700 E. Tudor Road
Anchorage, Alaska
(907) 269-2004
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