to main content Free-Standing Emergency Department - Occupancy | Hospital and Hospital Clinics | Life Safety LS | The Joint Commission
Free-Standing Emergency Department - Occupancy

What type of occupancy is a free-standing emergency department?

Any examples are for illustrative purposes only. 

The criteria for determining the occupancy of free-standing emergency departments depends on whether the organization is deemed by CMS (accepts funding from Medicare and/or Medicaid).

For non-deemed organizations, The Joint Commission uses the definition of NFPA 101 (2012 edition) Life Safety Code which defines Ambulatory Health Care Occupancy as facilities that provide care to patients with less than a 24-hour stay wherein there are 4 or more patients mostly incapable of self-preservation.  This includes 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.

For non-deemed organizations where fewer than 4 patients are mostly incapable of self-preservation in a freestanding emergency department, the facility would be classified as a Business Occupancy.

For deemed organizations, CMS uses the same definitions as described above, except that the threshold is 1 or more patients mostly incapable of self-preservation.  Effectively for deemed organizations, all freestanding emergency departments would be considered Ambulatory Health Care Occupancy.
Last updated on June 04, 2020
Manual: Hospital and Hospital Clinics
Chapter: Life Safety LS

If no, please comment on how we could improve this response.

If you have additional standards-related questions regarding this topic, please use the Standards Online Submission Form
Surgeons in an operating room

Additional Resources

Train your staff with a tool to quickly and efficiently assess standards compliance with our 2021 Hospital Compliance Assessment Workbook.

A group of medical professionals have a discussion in a meeting room

Hospital Webinars

Keep learning with our Hospital Breakfast Briefings Webinar Series. Get a deep dive into our standards, chapter-by-chapter, individually or as a team.

Female doctor using digital tablet in her office.

Looking for Standards?

Get key information your hospital needs to achieve and maintain continuous standards compliance and experience operational improvement.