LeadingAge Working to Extend Flexibility Relating to Fire Safety Evaluation System

Posted on August 18, 2021 by Jonathan Lips

The LeadingAge Minnesota staff team is working to identify care center members who rely upon the Fire Safety Evaluation System (FSES) as an alternative means to demonstrate compliance with fire safety requirements of NFPA 101®: Life Safety Code® (LSC).

This issue affects only a few nursing facilities in Minnesota, but we want to make sure we connect with those impacted.

There are some nursing facilities around the country with older physical plants where it may not be possible to achieve literal compliance with certain aspects of the LSC due to construction type or other issues. The FSES is a system developed several years ago for facilities to achieve and document an equivalent level of safety in a manner acceptable to regulators. In response to a life safety survey citation, a facility may engage a consultant to conduct an FSES evaluation and submit that report as part of its plan of correction.

When CMS adopted the 2012 edition of the LSC in 2016, however, some facilities that used the FSES to show compliance could no longer achieve a passing score on a short list of selected items, such as fire extinguishing systems, because of a change in scoring methodology. The level of safety in these buildings had not changed, but the updated scoring methodology left facilities in a different place in terms of compliance. In response, CMS authorized its regional offices to issue waivers through 2021, and in 2019 issued a proposed rule to address the problem. However, CMS has not finalized the rule, and the opportunity for waivers will expire at the end of 2021.

The scoring methodology change did not create a compliance problem for all facilities that use the FSES process. Some that were impacted by the scoring change may have resolved their issues through some building modification. But we want to be proactive in identifying potentially affected facilities to understand any issues our members are facing and join with the LeadingAge National team in working with CMS as needed before year's end.

If your facility utilizes the FSES in some way relating to the Life Safety Code® compliance, please get in touch with Jonathan Lips.  We have reached some facilities already but want to ensure we don't miss any organizations within our membership that may be affected.