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Enhancing Understanding of the “Life Safety” Chapter


By Carolyn Schierhorn, MA, executive editor, Global Publications, Joint Commission Resources

For new compliance professionals, the Life Safety chapter of the Comprehensive Accreditation Manual (CAM) can be particularly challenging to understand. 

For one thing, the chapter is based on the 2012 edition of the National Fire Protection Association (NFPA) Life Safety Code® (NFPA 101-2012), which is more technical and detailed than most CAM chapters. For another, the Life Safety chapter is organized differently, as the numbering system used for Joint Commission Life Safety (LS) standards is based on occupancy, a concept defined by the NFPA.

Joint Commission-accredited facilities can be one of four occupancy types, determined by the ability of occupants to evacuate a building (or building compartment) on their own during a fire or other emergency:

1. Health care occupancy—Provides medical care or other treatment to four or more people simultaneously on an inpatient basis, in which most patients are incapable of self-preservation due to physical or mental disability, age, medical condition or treatment provided, or security measures. This classification encompasses:

  • hospitals (including critical access hospitals)
  • nursing care centers
  • inpatient hospices

Behavioral health care and human services facilities that provide sleeping arrangements for 4 to 17 people and lock doors to prevent the individuals served from leaving the building unsupervised are also in this category. The LS standards for this occupancy type begin with “02.”

2. Ambulatory health care occupancy—Provides services or treatment to four or more patients simultaneously on an outpatient basis (no overnight stays), in which the treatment, anesthesia, or nature of the illness or injury renders them incapable of taking action for self-preservation during an emergency. The Centers for Medicare & Medicaid Services (CMS), however, has modified this definition for its certified ambulatory surgical centers (ASCs). If at least one patient is rendered incapable of self-preservation, CMS considers the ASC to be an ambulatory health care occupancy. The LS standards for this occupancy type begin with “03.”

3. Residential board and care occupancy—Provides lodging and boarding to four or more residents who receive personal care services. This classification includes behavioral health care and human services facilities (such as group homes) that provide sleeping arrangements to 4 to 17 individuals who can leave the building without restrictions. Buildings in assisted living communities are often classified as residential board and care as well. (The Joint Commission’s new Assisted Living Communities [ALC] Accreditation Program will debut in mid-2021.) The LS standards for this occupancy type begin with “04.”

4. Business occupancy—Applies to all other health care facilities, including laboratories and office-based surgery practices and ambulatory care centers that don’t render patients incapable of self-preservation through anesthesia or treatment. The Joint Commission is developing LS standards for this occupancy type, which will begin with “05.” (These standards will go into effect July 1, 2021.)

A health care setting may include several occupancy types, each with its own set of requirements. So, grasping the nuances of occupancy is crucial for compliance. 

To comply with The Joint Commission’s LS standards, it is also critical to understand the difference between new and existing construction. Although some requirements are common to both types, there are a number of differences. New buildings (or new construction in older buildings) are defined as those with their plans approved on or after July 5, 2016. Existing buildings are those with their plans approved before July 5, 2016. (This is the date when The Joint Commission began surveying to NFPA 101-2012.) 

Because of the high cost of retrofitting older facilities, existing buildings have more time to comply with certain requirements (such as July 5, 2028, for existing high-rise health care occupancies to be fully sprinklered) or do not have to meet certain requirements as long as specific compensating LS measures are in place or until the facility is renovated.

The fundamental concepts of occupancy and new vs. existing construction are just the tip of the proverbial iceberg, however, when it comes to complying with the LS standards. Even experienced compliance, facilities and safety professionals often have questions about LS requirements. In the FAQs answered by The Joint Commission’s Department of Engineering in the Standards Interpretation Group, , approximately 300 questions pertain to the Life Safety chapter. The Joint Commission’s LS standards are also among those most frequently cited by surveyors for noncompliance. 

Painting a full picture of the LS standards is well beyond the scope of this blog. Joint Commission Resources is publishing a brand-new book in October 2020: Life Safety Made Easy: Your Key to Understanding Fire Safety in Health Care Facilities. This easy-to-read—yet comprehensive—book is organized in order of the LS standards and includes many downloadable tools to facilitate compliance. 

The book is not just for those new to LS. Life Safety Made Easy includes many clarifications that dispel common misconceptions. For example, if a facility has a fire-rated door where one isn't required - it doesn't have to be inspected (with documentation) as a fire door if the fire-rating label isn't obscured.

This is just one circumstance in which accredited organizations sometimes go beyond what is necessary for compliance. Another example is signage for fire extinguishers. If a fire extinguisher is mounted in a corridor and one can clearly tell it’s a fire extinguisher, it doesn’t require an identifying sign.

Of course, due to organizations’ misinterpreting or not rigorously enforcing the LS standards, many of these requirements are frequently scored for noncompliance. Corridor clutter, cables resting on or fastened to sprinkler pipes above the ceiling, and failure to maintain at least 18 inches of clearance below sprinkler deflectors are among the top-cited deficiencies.

If your organization has received Requirements for Improvement (RFIs) in the Life Safety Chapter, Life Safety Made Easy will provide the knowledge to make your facilities safer to deliver high quality care. 

Carolyn Schierhorn, MA, is an executive editor, Global Publications, Joint Commission Resources.