Applying NFPA 99 to health care facilities

The impact of applying NFPA 99: Health Care Facilities Code to hospitals and health care facilities, fire and life safety systems varies depending on the level of care provided.


This article is peer-reviewed.Learning Objectives:

  • Identify major changes to the 2015 edition of NFPA 99: Health Care Facilities Code that impact fire protection engineers.
  • Determine the impact of NFPA 99 on hospitals and health care facilities.
  • Learn about NFPA 99’s adoption by the Centers for Medicare & Medicaid Services (CMS) and how it affects fire and life safety requirements.

NFPA 99: Health Care Facilities Code identifies criteria applicable to heath care facilities including hospitals and nursing homes. The impact of applying NFPA 99 to health care facilities varies depending on the level of care provided. NFPA 99-2015 is the latest edition, but there are few changes from the 2012 edition focused on fire protection other than editorial revisions. NFPA 99-2012 is more widely used due to its adoption by the Centers for Medicare & Medicaid Services (CMS). Editions prior to the 2012 edition of NFPA 99 were limited in their application since they were not individually adopted by CMS. However, limited portions of NFPA 99-1999 were referenced by applicable CMS criteria. Changes to NFPA 99 from earlier editions to both the 2012 and 2015 editions will be discussed as they apply to fire protection and life safety, with changes specific to the 2015 edition identified in each section.

Figure 1: This flowchart illustrates a simple qualitative risk assessment approach based on yes/no answers to the level of patient and caregiver impact. All graphics courtesy: JENSEN HUGHESNFPA 99 has taken on a new level of importance in the past year due to the CMS issuance of CMS-3277-F, Medicare and Medicaid Programs; Fire Safety Requirements for Certain Health Care Facilities. The rule revised 42 CFR Parts 403, 416, 418, 460, 482, 483, and 485, which address program requirements for hospitals, long-term care facilities, ambulatory surgical centers, and others. The final rule became effective July 5, 2016, with enforcement beginning Nov. 1, 2016. As part of this rule, CMS adopted the 2012 editions of NFPA 99 and NFPA 101: Life Safety Code along with all associated tentative interim amendments (TIAs) issued prior to April 16, 2014. CMS reviews the fire and life safety provisions of the final rule through Form 2786, with K-Tags (deficiency number identifiers) starting with 900 being those applicable to NFPA 99 requirements.

NFPA 99 consists of 15 chapters, from general building requirements to criteria that affect the various building systems including fire protection systems. CMS does not require compliance with chapters 7 (information technology systems), 8 (plumbing systems), 12 (emergency management), and 13 (security management), as these chapters were not adopted in the final rule. CMS has enacted an emergency-preparedness rule (CMS-3178-F) in lieu of adopting Chapter 12, whereby compliance with the emergency-preparedness rule is required by Nov. 16, 2017. Where local jurisdictions do not require compliance with NFPA 99, the excluded chapters noted provide pertinent information in regards to designing and maintaining the building systems and could be used as a reference.

The risk assessment in NFPA 99

One of the changes to NFPA 99-2012 and later editions is the move to a risk-based approach for determining applicable requirements rather than the former prescriptive approach based on facility type. NFPA 99 now requires a risk assessment to determine the applicable risk category for each building system. The risk category is then applied to chapters 5 through 11 of NFPA 99 as appropriate for the system. The main focus is seen in Chapter 5 (gas and vacuum systems) and Chapter 6 (electrical systems). Although this requirement has caused concern, the process can be simple since the failure of the system is assumed without human intervention. Each building system is to be categorized into one of the following four categories:

  • Category 1—Systems in which failure is likely to cause major injury or death. Systems are required to be available at all times to support patient needs. Examples might include life-support ventilation equipment, emergency power for operating rooms, and medical-gas systems in intensive care units. Category 1 systems are likely to be found in intensive care units, operating rooms, delivery rooms, and areas dealing with general anesthesia.
  • Category 2—Systems in which failure is likely to cause minor injury. Systems are expected to provide a high level of reliability; however, limited failures can be tolerated without significant impact on patients. Examples might include cooling systems in the southern U.S., resident emergency-call systems, heating systems in the northern U.S., and lighting or potable water in patient-care areas. Category 2 systems are likely to be found in general-care rooms, such as inpatient bedrooms and dialysis rooms.
  • Category 3—Systems in which failure is unlikely to cause injury. Failure of the system does not have an immediate impact on patients or their safety. Examples might include cooling systems in the northern U.S., lighting and potable-water systems outside of patient-care areas and plumbing/sanitary systems. Category 3 systems are likely to be found in basic-care rooms, such as treatment or exam rooms.
  • Category 4—Systems in which failure has no impact on patient care. Examples might include lawn sprinklers, television service, and the public-address system. Category 4 systems are likely to be found in support rooms, such as waiting rooms and lounges.

The risk assessment is required to be performed by following and documenting a defined process, as described in NFPA 551: Guide for the Evaluation of Fire Risk Assessments  or ISO/IEC 31010: Risk Management – Risk Assessment Techniques. The process can be as simple as depicted in Figure 1. The process identified in Figure 1 is a qualitative approach based on yes or no answers for each building system’s impact. It does not address the probability of failure similarly to that used in NFPA 551 nor require in-depth knowledge of the systems and possible failures. It is important that those performing the assessment are knowledgeable in the procedures, equipment, and systems being evaluated. Appropriate personnel could include building engineers, caregivers, and administrators. Documentation of the risk assessment should include the risk assessment process used, all participants of the assessment, and all systems with assigned risk categories. CMS does not require the risk assessment to be submitted, but it is required to be kept onsite and available at the time of the survey. K-Tag 901 is used to cite a missing risk assessment. NFPA 99-2015 notes that the risk assessment does not have to be performed for any system assigned a Category 1 classification. Category 1 systems have the most stringent requirements; therefore, documentation is only required for those systems in lower-risk categories to show that those systems are appropriately assigned.

Existing facilities

Existing facilities will not see major changes with the application of NFPA 99-2015 with the exception of inspection, testing, and maintenance (ITM) requirements. In general, existing building systems are permitted to remain, even if they are not in strict compliance with the code, unless the authority having jurisdiction (AHJ) determines that their continued use constitutes a distinct hazard to life. This allowance of existing systems provides a basis that existing facilities do not have to upgrade their medical-gas/vacuum, electrical, and HVAC systems, along with other utility infrastructure, to meet the requirements of the new edition. The wording of this requirement leaves the AHJ with latitude to potentially require updates to building systems, such that facilities should review the status of their systems conservatively to ensure that no surprises occur during inspections. When systems are replaced, the systems may need to meet the requirements for new systems as noted in the applicable code(s). At the beginning of several chapters, including chapters 5 and 6, the code specifies which criteria are applicable to existing facilities. It is important that each facility identify which requirements are applicable, especially those relating to ITM, to ensure compliance with the code. Where a building has a mixture of new and old systems due to alterations and renovations, the determination of applicable requirements becomes more complex, and it is important that the basis for the determination is well-documented.

NFPA 99 requirements

Chapter 15 of NFPA 99 contains the fire protection requirements applicable to new and existing facilities. Most of the fire protection and life safety requirements are not specifically included in this chapter, but references are made to other NFPA codes including:

  • Facilities that contain laboratories using chemicals
  • The storage and handling of flammable and combustible liquids or gases
  • Elevators and emergency or standby power systems.

NFPA 99 also relies on NFPA 101, or the fire code enforced by the local AHJ, for building construction and compartmentation, fire alarm and smoke-detection systems, and fire suppression systems. This language was revised from NFPA 99-2012 to state “applicable code” in lieu of listing the various building and fire code possibilities.

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