A look at CMS K-tag requirements

Some health facilities professionals may be unaware of the importance of the K-tags — scorable Centers for Medicare & Medicaid Services (CMS) requirements pertaining to adopted codes and standards — and focus instead on the regulations published by their facility’s accrediting organizations (AOs).

However, if CMS decides to conduct a validation survey shortly after the AO survey, the state agency surveyors responsible for assessing compliance with the National Fire Protection Association’s NFPA 101, Life Safety Code (LSC), and NFPA 99, Health Care Facilities Code (HCFC), will use and score compliance with CMS’ published K-tags to complete their validation survey report.

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Regardless of the AO’s published requirements, the AO is responsible for assessing compliance with those K-tags. This fact was re-emphasized when the Joint Commission recently announced its proposed 2018 changes related to the 2012 codes adoption for expanded compliance with the CMS K-tags, also stating that its surveyors are presently surveying for compliance with the K-tag requirements.

LSC and HCFC requirements

The K-tags address both LSC and HCFC requirements pertaining to the physical environment. State agency surveyors surveying on behalf of CMS, such as during validation surveys that sometimes occur after a survey by an AO, use the K-tags to determine compliance with the CMS conditions of participation and score the K-tags as compliant or noncompliant. The AOs are required to assess compliance with CMS K-tags and are doing so. Survey reports from the AOs should also indicate which K-tag requirements are noncompliant.

The AOs, such as the Joint Commission, DNV GL, Healthcare Facilities Accreditation Program and the Center for Improvement in Healthcare Quality, already may have written a K-tag requirement into their own specific mandatory requirements, such as the Joint Commission’s Elements of Performance, for example. 

Whether the K-tag requirement is stipulated or not stipulated within the AO requirements, the K-tags represent the CMS requirements and must be adhered to by organizations that wish to receive Medicare and Medicaid reimbursement from CMS. Reports from recent surveys indicate that compliance with K-tag requirements are being assessed during surveys.

The CMS K-tags related to the July 2016 CMS adoption of the 2012 LSC and HCFC are available from CMS within the document titled “Fire Safety Survey Report 2012 Code — Health Care Medicare — Medicaid.” This 50-page PDF file is labeled “Form CMS — 2786R, 2012, 10/2016” and is located online.

There are 89 LSC-based K-tags and 34 HCFC-based K-tags. The LSC-based K-tags are in Part I and are separated into seven sections with six of those seven sections being used. The HCFC-based K-tags are all within the single Part II.

Certain CMS K-tags act as wild cards to invoke entire subsections of the two adopted codes. One example is K100, which invokes all portions of LSC General Requirements Sections 18.1 and 19.1 not otherwise stipulated in the other eight 100-series K-tags. Another example is K200, which similarly invokes all portions of LSC Means of Egress Sections 18.2 and 19.2 that are not otherwise stipulated within the other 25 200-series K-tags. K300 similarly invokes LSC Protection Sections 18.3 and 19.3. LSC K-tag sections 4, 5 and 7 have similar wild card K-tags. Section 6 was reserved by CMS and is not presently used for hospitals.

Within Part II, there are also wild cards. Examples are K-tag K900 that specifically invokes “any NFPA 99 requirements (excluding Chapters 7, 8 12 and 13) that are not addressed by the provided K-tags, but are deficient.” (Those NFPA 99-2012 chapters were not adopted by CMS.) 

K-tag K901 invokes NFPA 99-2012 Fundamentals Chapter 4. K902 invokes all portions of NFPA 99-2012 Gas and Vacuum Systems Chapter 5 not otherwise stipulated. K911 invokes all portions of NFPA 99-2012 Electrical Systems Chapter 6 not otherwise stipulated. K919 similarly invokes NFPA 99-2012 Electrical Equipment Chapter 10. K922 invokes NFPA 99-2012 Gas Equipment Chapter 11. K931 invokes NFPA 99-2012 Hyperbaric Facilities Chapter 14. And, finally, K932 invokes NFPA 99-2012 Features of Fire Protection Chapter 15.

User-friendliness

CMS has added user-friendliness to some LSC-based K-tags. Where a requirement pertaining to new health care occupancies (LSC Chapter 18) is different from a companion requirement pertaining to existing health care occupancies (LSC Chapter 19), CMS has placed both requirements within the same K-tag. This eases understanding of the changes in requirements and likely will facilitate better understanding during surveys as well. 

Facilities professionals should consider the following short example from K232, titled “Aisle, Corridor or Ramp Width”:

2012 EXISTING 

The width of aisles or corridors (clear or unobstructed) serving as exit access shall be at least 4 feet and maintained to provide the convenient removal of nonambulatory patients on stretchers, except as modified by 19.2.3.4, exceptions 1-5. 

19.2.3.4, 19.2.3.5

and:

2012 NEW

The width of aisles or corridors (clear and unobstructed) serving as exit access in hospitals and nursing homes shall be at least 8 feet. In limited care facility and psychiatric hospitals, width of aisles or corridors shall be at least 6 feet, except as modified by the 18.2.3.4 or 18.2.3.5 exceptions. 

18.2.3.4, 18.2.3.5

In other cases where the LSC requirement is the same for both new health care occupancies (LSC Chapter 18) and existing health care occupancies (LSC Chapter 19), the K-tag also clearly indicates that situation as well. Consider the following short example from K291, titled “Emergency Lighting”:

Emergency lighting of at least 1 1/2-hour duration is provided automatically in accordance with 7.9. 

18.2.9.1, 19.2.9.1

In some cases, there are multiple requirements from both the LSC and HCFC as well as other referenced or invoked codes or standards. In the example below from K322 titled “Laboratories”, CMS has aggregated multiple requirements (from LSC multiple chapters, HCHF multiple chapters, NFPA 45 and NFPA 54) into a single K-tag:

Laboratories employing quantities of flammable, combustible, or hazardous materials that are considered a severe hazard are protected by 1-hour fire resistance-rated separation, automatic sprinkler system, and are in accordance with 8.7 and with NFPA 99. 

Laboratories not considered a severe hazard are protected as hazardous areas (see K321). 

Laboratories using chemicals are in accordance with NFPA 45. 

Gas appliances are of appropriate design and installed in accordance with NFPA 54. Shutoff valves are marked to identify material they control. Devices requiring medical grade oxygen from the piped distribution system meet the requirements under 11.4.2.2 (NFPA 99). 

18.3.2.2, 19.3.2.2, 8.7, 8.7.4.1 (LSC)

9.3.1.2, 11.4.3.2, 15.4 (NFPA 99)

Other cited requirements

When CMS adopted the 2012 LSC and HCFC, the impacts went beyond specific requirements written into those codes. 

Both codes also reference and invoke requirements from many other NFPA standards, among them the National Fire Alarm and Signaling Code NFPA 72-2010, and updated standards such as Fire Extinguishers (NFPA 10-2010), Sprinklers (NFPA 25-2011), Fire Pumps (NFPA 20-2010), Laboratory Fire Protection (NFPA 45-2011), Emergency Power Supply Systems (NFPA 110-2010), National Fuel Gas Code (NFPA 54-2011) and many other more recent NFPA codes and standards.

In addition to the more general K-tags stated previously, some LSC K-tags also specifically invoke other referenced NFPA standards. 

For example, K224 on Horizontal Sliding Doors references NFPA 80-2010; K322 on Laboratories references NFPA 45-2011 and NFPA 54-2012; K324 on Cooking Facilities references NFPA 96-2011; K325 on Alcohol Based Hand Rub Dispensers references NFPA 30-2012; several K-tags reference NFPA 13-2010, NFPA 25-2011, NFPA 70-2011 and NFPA 72 -2010; and so on.

Additionally, the Combustible Decorations K-tag K753 references both NFPA 701-2010 and NFPA 289-2009. K771 on Engineered Smoke Control Systems references NFPA 92-2012 for testing. Within the Construction, Repair, and Improvement Operations K-tag K791, CMS invokes NFPA 241-2009. The Elevators K-tag K531 invokes American Society of Mechanical Engineers (ASME)/American National Standards Institute (ANSI) A17.1 and ASME/ANSI A17.3 along with applicable LSC requirements. 

And within the HCFC K-tags, there are similar references invoking requirements from other newer NFPA standards. Thus, K918 references NFPA 70-2011, NFPA 110-2010 and NFPA 111-2010; K920 references NFPA 70-2011; and so on.

High-interest topics 

As with most health care facility compliance matters, the details are very important. In many cases, the adopted codes and the referenced codes and standards contain the details required for compliance. Because the K-tag wild cards require compliance with the NFPA codes and standards, it is necessary to know those details. 

The K-tags often contain abbreviated statements of requirements, and limiting an organization’s compliance activities to the specific K-tag language to the exclusion of additional details stipulated within the NFPA codes and standards is not recommended. 

The list of examples in the following paragraphs contains just a few of the topics that already have been identified as ones of special emphasis:

• K-tag K111 is titled “Building Rehabilitation” and invokes LSC Building Rehabilitation Chapter 43 along with the pertinent portions of Chapter 18 (new health care) and Chapter 19 (existing health care). K111 governs all Repairs, Renovations, Modifications, Reconstruction, Change of Use or Change of Occupancy, and Additions to existing buildings covered by the CMS K-tags. Those with authority to mandate or design changes within existing buildings should be familiar with LSC Chapter 43 (including more than five pages of detailed requirements) and its impact on all work within existing buildings.  
• K-tag K933 is titled “Features of Fire Protection — Fire Loss Prevention in Operating Rooms” and references NFPA 99-2012, Paragraph 15.13. It contains some, but not all, of the detail of that code subsection, indicating the likelihood of detailed survey focus on those requirements. The two full pages of code language should be reviewed and shared with all stakeholders.
• K-tag K222, titled “Egress Doors”, stipulates the only five special locking arrangements where egress doors may be equipped with a latch or a lock that requires the use of a tool or key from the egress side.
• K-tag K325, titled “Alcohol Based Hand Rub Dispenser (ABHR)”, includes 10 specific sets of criteria that apply to these devices. The criteria include the new requirement for ABHR protection against inappropriate access. The references include LSC references along with six references to different CFR (Code of Federal Regulations) parts.
• K-tag K323 on “Anesthetizing Locations” covers gas and vacuum systems, the essential electrical system, and heating, cooling and ventilation requirements along with the impacts of the instructions for use. K323 also invokes ANSI/American Society for Healthcare Engineering/ American Society of Heating, Refrigerating and Air-Conditioning Engineers Standard 170, Ventilation of Health Care Facilities, along with several references from LSC and HCFC. 
• K-tag K345 is titled “Fire Alarm System — Testing and Maintenance.” It invokes NFPA 70, NFPA 72, NFPA 25 and portions of the LSC. 

Necessary part of compliance

The K-tags are a necessary part of overall physical environment code compliance, but by no means the only part. 

Other portions are publications by the applicable AO as well as the adopted 2012 codes, NFPA codes and standards that are referenced by those adopted codes, and future publications by applicable authorities having jurisdiction.

Facilities professionals seeking to become better versed in the K-tags should obtain the most recent applicable CMS document. 

Although CMS had not published its Interpretive Guidelines for the K-tags as of this writing, the field anticipates that they will become an important part of the health facilities professional’s understanding of CMS’ interpretations.

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David L. Stymiest, P.E., CHFM, CHSP, FASHE, is a senior consultant at Smith Seckman Reid, Nashville, Tenn. He can be reached at DStymiest@SSR-inc.com.