Jun 2016

Health Care Facilities Compliance with NFPA 99 (Health Care Facilities Code) and NFPA 101 (Life Safety Code)

Effective May 3, 2016 Centers for Medicare and Medicaid Services (CMS) announced that health care facilities were required to meet the 2012 version of Health Care Facilities Code (NFPA 99) and Life Safety Code (NFPA 101). Up until now the 2000 editions was being used for health care compliance. Both NFPA 99 and 101 are on typical NFPA three year update schedules and both have 2015 versions published and in use.

To be familiar with NFPA 99 you need an expert understanding of many NFPA Codes and Standards. For example in just Chapter 15, Features of Fire Protection, there are references to 19 NFPA Codes. They are as follows:


Codes and Standards


Standard for Portable Fire Extinguishers


Standard for the Installation of Sprinkler Systems


Standard for the Installation of Standpipe and Hose Systems


Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems


Flammable and Combustible Liquids Code


Standard for the Installation of Oil-Burning Equipment


Standard on Fire Protection for Laboratories Using Chemicals


National Fuel Gas Code


Liquefied Petroleum Gas Code


National Electrical Code


National Fire Alarm and Signaling Code


Standard on Incinerators and Waste and Linen Handling Systems and Equipment


Standard for the Installation of Air-Conditioning and Ventilating Systems


Standard for Exhaust Systems for Air Conveying of Vapors, Gases, Mists, and Noncombustible Particulate Solids


Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations


Life Safety Code


Standard for Emergency and Standby Power Systems


Standard on Stored Electrical Energy Emergency and Standby Power Systems


Standard for Chimneys, Fireplaces, Vents, and Solid Fuel–Burning Appliances

So what are some of the main requirements of the 2012 versions of NFPA 99 and 101 that will be enforced?


  • All doors to hazardous areas must be self-closing or must close automatically.
  • Hazardous areas are to be separated from other parts of the building by smoke partitions.

Automatic Sprinkler Protection / Detection

  • Expanded sprinkler requirements to include habitable areas, closets, roofed porches, balconies and decks in new facilities.
  • All attics must have a sprinkler system if they are used for living purposes, storage or housing of fuel-fired equipment. If they are not used for these purposes, attics may have heat detection systems instead.
  • Health care facilities located in buildings that are taller than 75 feet are required to install automatic sprinkler systems within 12 years after the rule’s effective date.
  • Existing facilities must include certain fire alarm features when they choose to update their fire alarm systems.

Human Element Programs & Housekeeping

  • Health care facilities are required to have a fire watch or building evacuation if their sprinkler systems are out of service for more than 10 hours.
  • The provisions offer health care facilities greater flexibility in what they can place in corridors. Currently, they cannot include benches or other seating areas because of fire code requirements limiting potential barriers to firefighters.
  • Health care facilities will be able to include more home-like items such as fixed seating in the corridor for resting and certain decorations in patient rooms (such as pictures and other items of home decor).
  • Cooking facilities now may have an opening to the hallway corridor. This will permit residents of inpatient facilities such as nursing homes to make food for themselves or others if they choose to, and, if the patient does decide to make food, facility staff is able to provide supervision of the patient.

In addition, the 2012 edition of the NFPA’s Health Care Facilities Code gives more detailed provisions specific to different types of health care facilities. Health care providers affected by this rule must comply with all regulations within 60 days of the publication date of the final rule, which was May 4, 2016.

Risk Logic can review your facility to ensure compliance.