Life Safety Code
October 06, 2008

Requesting an Equivalency for The Life Safety Chapter

A section in Overview of the Life Safety Chapter states:

Managing Compliance with the NFPA Life Safety Code

The Joint Commission recognizes that there will be times when the provisions of the Life Safety Code cannot be met because of construction, accidental damage, or other unpredictable situations.  In these situations, the organization either resolves the deficiency immediately or manages it through one of the options described below

  • A management process that documents the deficiency and actions to resolve the situation within 45 days.
  • A Life Safety Code Equivalency approved by The Joint Commission. Equivalencies are used when an organization uncovers an existing Life Safety Code deficiency that cannot be corrected without major construction.  In these cases, the hospital may ask The Joint Commission to approve an equivalency, which is accomplished by submitting documentation that demonstrates that alternative building features exist that comply with the intent of the Life Safety Code. The Joint Commission must approve equivalencies even when other regulatory bodies have approved an equivalency or granted a waiver.
  • A Plan for Improvement (PFI) located in the Statement of Conditions™. The Joint Commission reviews the PFI as part of the on-site survey, and the organization uses it in the Periodic Performance Review process. If the hospital uses the SOC to document a PFI, has initiated interim life safety measures (See LS.01.02.01) and is meeting the time frames listed in the PFI, The Joint Commission will not consider the deficiency as a Requirement for Improvement in the accreditation process. All corrections must be completed within six months of the projected completion date.

Requesting an Equivalency

Background
When deficiencies exist to the elements of performance (EPs) within each standard listed in the Life Safety Chapter as they pertain to NFPA 101-2000, the Life Safety Code®, requesting an equivalency may be an option for compliance in lieu of completing repairs or making alterations.

Traditional Procedure

  1. Identify each deficiency.
    A.  Reference both The Joint Commission standard and Element of Performance and the applicable NFPA 101®-2000; Life Safety Code® (LSC) paragraph.
    B.  State the intent of the LSC.
  2. Propose an alternate solution.
    A.  Explain proposal in writing.
    B.  Provide detailed drawings showing existing conditions and proposed
         solution (maximum size of unfolded drawings - 11 in x 17 in).
    C.  Indicate the total cost and describe the source, availability, and
          commitment of funds for the proposed alternate solution.
    D.  Provide a timetable of events from present through completion.
  3. Have one of the following certify, in writing, that to the best of their knowledge, your proposed alternate solution meets either the intent of the LSC identified in 1A above or will provide an equivalent level of life safety:

    A.  Fire protection engineer
    B.  Registered architect
    C.  Local authority having jurisdiction (over enforcement of fire safety).
    D.  Submit to the address given below.

Fire Safety Evaluation System (FSES)

  1. Survey facility to determine all Life Safety Code® (LSC) deficiencies. Reference document is NFPA 101-2000, Life Safety Code.
  2. Provide a current Statement of Conditions (SOC), Part 2 - Basic Building Information (BBI) for each building where an equivalency is requested.
  3. Perform the FSES equivalency evaluation. Reference document is NFPA 101A-2001, Alternate Approaches to Life Safety. For each FSES Fire/Smoke Zone:

    A.  Complete FSES Worksheets 4.7.1 through 4.7.9. Evaluate zone as it
          presently exists. Drawings, SOC, and LSC deficiencies must support
          point values selected.
    B.  List all LSC deficiencies (include LSC reference numbers) identified
          Within the zone during step number 1 above. 
    C.  Provide a floor plan. Unfolded attachments must not be larger than 11 in 
          x 17 in. Indicate zone boundaries. Identify or illustrate (provide a legend) 
         each of the following features of life safety that exists and where credit is
         taken on FSES Worksheet 4.7.6: direct exits, exit stairs, horizontal exits,
         2-hr fire rated separations, or smoke barriers/partitions.

  4. Complete FSES Worksheet 4.7.10 for each building containing one or more zones being evaluated.
  5. Determine if an equivalent condition exists:
    A.  Review FSES Worksheet 4.7.9 for each zone being evaluated. Any FSES
          Worksheet 4.7.9 containing no response indicates that an equivalent
          level condition does not exist in that zone.
    B.  Review FSES Worksheet 4.7.10 for each building containing zones being
          evaluated. Any FSES Worksheet 4.7.10 containing a Not Met response
          indicates that an equivalent condition does not exist in any zone within 
          that building.
    • Those zones having all Yes responses to FSES Worksheet 4.7.9 and either Met or Not App. responses to FSES Worksheet 4.7.10 indicate that an equivalent condition presently exists.
  6. Submit a SOC, Part 4 - Plan for Improvement (PFI) for each zone where an equivalent condition does not presently exist. An acceptable PFI must contain:
    A.  Proposed Actions - fully explain proposal in writing.
    B.  An indication of the total cost and a description of the source, availability,
         and commitment of funds.
    C.  A timetable of events from present through completion.
    D.  FSES Worksheet 4.7.7A. The column labeled “Condition After PFI” must 
          validate the numeric values that will result when the PFI is completed. Open .pdf version.
         Any numeric increase in “Condition After PFI” from “Condition Before PFI”
         must be supported by the proposed actions.
    E.  A list of all LSC deficiencies that will remain after the PFI is completed.
  7. All above steps must be accomplished using the most current information available. Do not submit an FSES equivalency request where survey or evaluation information is more than one year old. Drawings and BBI must be current and accurate but are not subject to the one year restriction.
  8. Submit to the address given below.

Mail all submissions to:
The Joint Commission
Environment of Care
Standards Interpretation Group
One Renaissance Boulevard
Oakbrook Terrace, Illinois 60181

Note: Equivalency requests will be returned if the above procedure is not followed or the information submitted is incomplete.

Open .pdf version of this worksheet.