Compliance with the Centers for Medicare & Medicaid Services’ Life Safety Code regulations is continuously a challenge for skilled nursing facilities around the nation.  These complex rules and regulations are designed to provide residents, staff and visitors with a safe environment of care.

A key element of life safety compliance is good documentation practices to help illustrate conformity with the applicable editions of the National Fire Protections Association’s codes and standard as well as referenced publications. Currently, CMS is enforcing the 2012 edition of NFPA 101 (The Life Safety Code) and the 2012 edition of NFPA 99 (Health Care Facilities Code). Chapter 2 of the Life Safety Code (LSC) provides a complete listing of all referenced codes, standards and publications that are also enforced by CMS in heathcare facilities.

The development of comprehensive “compliance binders” to help organize all of the required records and documents associated with the LSC in a skilled nursing facility is great way to help ensure survey success. 

While not rocket science, compliance binders should be neatly organized and tabbed to illustrate each individual life safety program element that requires documentation. Based on my experience with the LSC survey process in SNFs in several states, it is a common practice for surveyors to require this type of “paper” documentation rather than view the same information in a data base on a computer screen.

In no specific order, here are some of the tabbed sections that should be included in a comprehensive life safety compliance binder:

  • Inspection, Testing and Maintenance Records
  • Fire alarm system
  • Fire sprinkler system
  • Fire Extinguishes
  • Kitchen hood fire suppression system
  • Kitchen hood cleaning
  • Emergency generator system
  • Smoke / fire dampers
  • Emergency lights
  • Exit signs
  • Electrical outlets
  • Piped medical gas
  • Alcohol-based hand rub dispensers (ABHR)
  • Fire Drills- one per shift per quarter (date, time and shift)
  • Smoking policy and procedure
  • Fire Watch policy and procedure
  • Annual Fire Door Assembly Inspection (FDAI) records
  • NFPA 99 Risk Assessment policy and procedure

While the frequency (daily, weekly, monthly, quarterly, semi-annual, annual, etc.) and the specific nature of inspection, testing and maintenance (ITM) regimens for the life safety elements itemized above varies, each tabbed section should include all required documentation in accordance with the frequency and scope enforced by CMS. 

Additionally, providers should work closely with service contractors and vendors to ensure that those companies are providing ITM services and associated documentation records in compliance with all of the requirements.

Here is a detailed checklist citing the majority of Life Safety Code elements in SNFs.

Stan Szpytek is the president of consulting firm Fire and Life Safety, Inc. He is the Life Safety/Disaster Planning Consultant for the Arizona Health Care Association and California Association of Health Facilities (CAHF). Visit or e-mail Szpytek at [email protected].