Life Safety Code & Health Care Facilities Code (HCFC)

Survey protocols and Interpretive Guidelines are established to provide guidance to personnel conducting surveys. They serve to clarify and/or explain the intent of the regulations and all surveyors are required to use them in assessing compliance with Federal requirements. The purpose of the protocols and guidelines is to direct the surveyor's attention to certain avenues for investigation in preparation for the survey, in conducting the survey, and in evaluation of the survey findings.

The Life Safety Code (LSC) & Health Care Facilities Code (HCFC) survey is conducted in accordance with the appropriate protocols and substantive requirements in the statute and regulations to determine whether a citation of non-compliance is appropriate. Deficiencies are based on a violation of the statute or regulations, which, in turn, is to be based on observations of the provider's performance or practices.

The survey procedures in Appendix I are used for all LSC/HCFC surveys (initial and recertification) of facilities subject to Survey and Certification inspections for Medicare/Medicaid certification. This includes, but is not limited to, Skilled Nursing Facilities (SNFs), Nursing Facilities (NFs) whether freestanding, distinct parts, or dually certified, Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICFs/IID), Ambulatory Surgical Centers (ASC), inpatient Hospice facilities, Program for All inclusive Care for the Elderly (PACE) facilities, Critical Access Hospitals (CAH), Psychiatric and General Hospitals, End-Stage Renal Disease (ESRD) facilities, and Religious Nonmedical Health Care Institutions (RNHCI)including validation surveys of accredited facilities. These procedures also apply to complaint investigations.

The Interpretive Guidelines include three parts:

• The first part contains the survey tag number.
• The second part contains the wording of the regulation.
• The third part contains guidance to surveyors, including additional survey procedures and probes.