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Joint Commission Clarifies Four Life Safety Code Requirements

Life Safety Code

Joint Commission Clarifies Four Life Safety Code Requirements

The Joint Commission (TJC) recently published clarifications to four Life Safety Code requirements.

Annual Door Inspection (EC.02.03.05)

NFPA 80-2010, Standard for Fire Doors and Other Opening Protectives, and NFPA 105-2010 Standard for Smoke Door Assemblies and Other Opening Protectives, per NFPA 101-2012 section requires annual inspection and testing of fire doors and smoke door assemblies.

According to TJC, annual inspection and testing must be completed by July 5, 2017, which is one year after the Centers for Medicare and Medicaid Services (CMS) regulatory adoption of NFPA 101-2012.

In their clarification, TJC lists the following types of doors that, based on, require annual inspection:

  • 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

TJC further clarifies that corridor doors, i.e., patient room doors and office doors (so long as the room doesn’t contain flammable or combustible materials) do not need to be included in the annual inspection. However, TJC states that while corridor doors that are not required to be fire doors or smoke door assemblies are not subject to the NFPA annual inspection and testing, they should still be routinely inspected as part of an organization-wide building maintenance program.

Fire Drills and Varying Times (EC.02.03.03)

TJC requires fire drills to be conducted at unexpected times and under varying conditions.

In their clarification, The Joint Commission states that “…fire drills conducted no closer than one hour apart would be acceptable…” However, TJC further explains that, because of the requirement that fire drills be conducted under varying conditions, organizations should be careful that they do not establish a pattern of drills being conducted one hour apart.

These requirements are also addressed under NFPA 101-2012: 18/19.7.1.

Emergency Department Occupancy Classification (LS.02.01.10, LS.03.01.10)

Emergency Departments could be classified as health care occupancies or ambulatory health care occupancies.

  • NFPA 101-2012, 18/ and 18/ – Facilities that provide housing on a 24-hour basis for occupants are classified as health care occupancy
  • An ambulatory health care occupancy used to treat 4 or more patients at the same time:
    • 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. (NFPA 101-2012.

Rated Fire Door Assembly Installed in Lesser Rated or Non-Rated Barrier (LS.01.01.01, EC.02.03.05)

Per the Joint Commission, if the organization has doors that are of “superior quality, strength, fire resistance” (see NFPA 101-2012 1.4), they would be allowed in the assembly.

  • “Therefore, doors shall be maintained per the barrier assembly requirements, but in cases where a fire-rated door is used in a nonrated barrier assembly, the fire door must be maintained as a fire door unless the features which identify it as a fire door have been removed in a manner that maintains the opening protective requirements applicable to the barrier into which it is installed.”

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