Dateline @ TJC

Certification, accreditation and communications experts within The Joint Commission share experiences, case studies and news that add insight and value to the accreditation and certification journey.

Top Four Life Safety Code Requirements Debunked


By George Mills, MBA, FASHE, CEM, CHFM, CHSP, Director of Engineering

A few issues in the physical environment have been prone to public discussion recently, related to the Life Safety Code. It’s important to clarify them before it affects your bottom line or, more importantly, your patients.

Emergency Department Occupancy Classification

The clarification with the greatest financial impact concerns emergency department (ED) occupancy classification, especially for free standing EDs. Generally, free-standing EDs have been identified as ambulatory occupancies. However, earlier this year, an external communication identified EDs as health care occupancies, based on patient care in EDs that appeared to exceed the 24-hour stay that defines ambulatory. The Joint Commission uses the National Fire Protection Association’s (NFPA) 101-2012 edition to define occupancy, and EDs can be identified as either ambulatory or health care occupancies, depending on the patient’s length of stay and ability for self-preservation.

Per NFPA 101-2012, 18/ and 18/, a health care occupancy provides sleeping accommodations for persons who are mostly incapable of self-preservation, or provides housing on a 24-hour basis for occupants.

Per NFPA 101-2012,, an ambulatory health care occupancy applies for services or treatment that is provided simultaneously to four or more patients and that provides, on an outpatient basis, one or more of the following:

  1. treatment for patients that renders the patients incapable of taking action for self-preservation under emergency conditions without the assistance of others;
  2. anesthesia that renders the patients incapable of taking action for self-preservation under emergency conditions without the assistance of others;
  3. emergency or urgent care for patients who, due to the nature of their injury or illness, are incapable of taking action for self-preservation under emergency conditions without the assistance of others.

EDs are considered to be, at minimum, ambulatory health care occupancies unless they exceed the 24-hour stay provision of health care.  If they exceed the provision, they are considered health care occupancies.

Urgent care centers and free-standing emergency centers, if rendering four or more patients incapable of taking action for self-preservation but do not exceed 24-hour stay, are also ambulatory health care occupancies.

Urgent care centers that do not have the capacity to render four or more patients incapable of self-care simultaneously may meet the criteria for business occupancies. Business differs from ambulatory by allowing up to 3 people rendered incapable of self-preservation. Within the ambulatory classification, four or more are rendered incapable of self-care, and healthcare accounts for four or more plus over-night sleeping.

Annual Fire & Smoke Door Inspections

The Centers for Medicare & Medicaid Services (CMS) and The Joint Commission agree that door inspections are important to the ongoing reliability of an organization’s fire protection program. 

Annual inspection and testing is required for fire doors and smoke door barrier assemblies per NFPA 80-2010, Standard for Fire Doors and Other Opening Protectives, and NFPA 105-2010, Standard for Smoke Door Assemblies and Other Opening Protectives, as well as NFPA 101-2012 section

Note: This annual inspection and testing must be completed by July 5, 2017, which is one year after CMS’ regulatory adoption of NFPA 101-2012. Although health care and ambulatory chapters of NFPA 101-2012 do not specifically cite, properly configured and reliably operable doors are essential to fire protection and building egress. Please keep this in mind.

Doors to be included in the annual door inspection, based on, include:

  • door leaves equipped with panic hardware or fire exit hardware in accordance with
  • door assemblies in exit enclosures
  • electrically controlled egress doors
  • door assemblies with special locking arrangements subject to

The Joint Commission does not require the following doors to be included in the annual door inspection:

  • corridor doors (i.e. patient room doors)
  • office doors (provided the room does not contain flammable or combustible materials)

Corridor Door Specifications

Egress corridor doors that are not required to be fire-rated door or smoke barrier door assemblies (e.g., patient room doors) are not subject to the NFPA annual inspection and testing, but should be routinely inspected as part of a facility maintenance program. 

Rated Doors in a Lesser or Non-Rated Barrier

Another relatively common occurrence is when an installed door has a higher rating than its accompanying barrier.

Starting with the doors themselves, if the organization has doors that are “superior quality, strength, fire resistance” (see NFPA 101-2012 1.4), they are allowed in the assembly.

Per NFPA 101-2012, section, existing fire protection features that are obvious to the public, if not required by the code, shall be either maintained or removed. Therefore, if a rated door is installed in a barrier that has a lesser requirement, the fire door is to be maintained and inspected annually as a fire-rated door, and the accompanying barrier maintained as appropriate for that barrier assembly.  

n the aforementioned cases where a fire-rated door is used in a non-rated barrier assembly, the fire-rated door must be maintained as a fire door unless its identifying features have been removed in a manner that maintains the opening protective requirements applicable to its installed barrier.

For example, if a 90-minute fire-rated door was installed in an existing smoke barrier, the door will need to be annually inspected and tested as a fire door and the smoke barrier maintained as a smoke barrier. 

However, if the 90-minute door was modified (i.e. removing the bottom rod and floor receiver), by removing all non-required fire door hardware and labeling and maintaining it as a smoke barrier door (see NFPA 105-2010, 5.1.4), the door would then be annually inspected and tested as a smoke barrier door. If a smoke barrier door has positive latching installed, the door must automatically close and positively latch.

Fire Drills Timing

Many organizations also have questions about the appropriate timing between fire drills in order to avoid creating a pattern of drill activity.

Fire drills are to be conducted at varying times, and should not establish a predictable pattern, per 18/ For example, a third-shift drill held at 6 a.m. one quarter and at 6:30 a.m. the next, in order to accommodate schedules of those overseeing the drill (easily establishes a pattern of conducting drills). Therefore, The Joint Commission requires that fire drills vary by at least one hour from quarter to quarter for each shift, through four consecutive quarters. Using a Fire Drill Matrix can make identifying unwanted patterns easier.

For example, consecutive first shift drills of 9 a.m., 10:30 a.m. and 9 a.m., although greater than one hour apart, would be considered a pattern. Fire drills should be spread out over the full shift.

Feel free to share this information about physical environment on your listservs and with your colleagues. If you need more clarification, just ask!