Fire Safety Challenges in Complying with Joint Commission Standards

Posted May 31, 2019 by Koorsen Fire & Security

Hospital Hallway Nurses

Almost 21,000 hospitals and ambulatory care (outpatient) centers, and other healthcare facilities are accredited through The Joint Commission – one of the few accreditation organizations accepted by the Centers for Medicare and Medicaid Services (CMS).

Maintaining accreditation is critically important for any facility that provides services to Medicare and/or Medicaid patients. And, any facility found to have critical violations can find itself on a 90-day termination track toward losing CMS reimbursement.

Fire safety continues to be a significant challenge for health care facilities in their Joint Commission surveys. According to the combined results of The Joint Commission surveys in 2018, almost half of the top compliance issues for both hospitals and ambulatory care facilities were related to fire safety.

Top Fire Safety-Related Compliance Challenges

Here are the top fire safety-related deficiencies that The Joint Commission identified in 2018 with the applicable standard noted in parentheses:

  • Only 35 percent of hospitals were adequately maintaining their fire safety equipment and the fire safety features of their buildings (EC.02.03.05).
  • The building and fire protection features of more than 55 percent of the ambulatory care facilities (LS.03.01.10) and 68 percent of hospitals (LS.02.01.10) evaluated did not adequately protect occupants from the effects of fire, smoke, and heat.
  • In fewer than 28 percent of the hospitals (LS.02.01.30) evaluated, the buildings either did not provide the necessary features to protect occupants from the hazards of fire and smoke or they had the necessary features but were not being properly maintained.
  • Almost 89 percent of rural hospitals designated as critical access hospitals were lacking the required equipment for extinguishing fires. And, in the other hospitals evaluated, that number jumped to 90 percent. More than 55 percent of outpatient facilities did not meet these standards (LS.03.01.35).

Another common area of non-compliance was in the Means of Egress provided by hospitals (LS.02.01.20) with half of those evaluated failing to meet The Joint Commission standards.

How The Joint Commission Evaluates Facilities for Fire Safety

The Joint Commission standards provide the basis for an evaluation process designed to help health care facilities measure, assess, and improve their performance. The Joint Commission conducts surveys for a given facility every three years to determine if they are in compliance with CMS requirements.

Between surveys, health care facilities are required to conduct ongoing self-assessments and make improvements based on their results. This requirement encourages continuous improvement, which – where fire and life safety are concerned – directly contributes to improved occupant safety.

There are two groups of The Joint Commission Standards that pertain specifically to fire and life safety:

The Joint Commission Environment of Care (EC) Standards – These standards address a number of safety and security risks within the facility’s building or space, including fire safety.

The Joint Commission Life Safety (LS) Standards – These standards address all of The Joint Commission requirements in the National Fire Protection Association (NFPA) 101 Life Safety Code for construction and operational conditions to minimize fire hazards and provide safe fire protection systems.

The specific elements of performance relating to fire safety that The Joint Commission evaluates when inspecting hospitals and ambulatory care facilities are presented below along with some examples of improved compliance.

General Building Requirements – LS.02.01.10 (hospitals) and LS.03.01.10 (ambulatory care facilities)

The elements of performance:

  • Unprotected openings in fire rated walls and floors
  • Fire doors hardware and gaps
  • Openings in 2-hour fire rated walls for 1½ hours
Example of Improved Compliance
Compliance Issue

Gaps around fire doors and/or unsealed penetrations in fire rated wall assemblies have compromised the fire barrier system.

Associate Risks

Some patients cannot be evacuated during fire emergencies because they are connected to life support equipment. These patients must “defend in place” during a fire emergency, which requires that their care environment be adequately protected from heat and smoke.

How to Mitigate the Risks

Check to ensure that all fire doors have properly functioning hardware and that there are no gaps around their them when closed. Provide compartmentation by creating fire-resistant barriers around patient care areas to allow sufficient time for emergency response personnel to extinguish the fire or move patients to a safe location within the facility. Evacuation must remain a last resort.


Means of Egress Requirements – LS.02.01.20 (hospitals)

The elements of performance:

  • Corridor clutter
  • Doors unlocked in the direction of egress
Example of Improved Compliance
Compliance Issue

Objects and/or equipment are improperly stored in the Means of Egress.

Associate Risks

Corridor clutter can make it difficult to quickly transport patients out of the building and can prevent other occupants from escaping in the event of an emergency. It can also hamper rescue efforts.

How to Mitigate the Risks

Remove all objects stored in the Means of Egress, including patient corridors. Carts with wheels that are currently in use, including isolation carts outside a patient's room, housekeeping carts, and wheeled computer workstations may remain in a hallway for no more than 30 minutes. Crash carts are an exception and may remain in the corridor at all times.


Protection – LS.02.01.30 (hospitals)

The elements of performance:

  • Hazardous storage area issues
  • Corridor doors
  • Smoke barriers do not have unsealed penetrations
Example of Improved Compliance
Compliance Issue

Breaches are found in the smoke barriers in one or more of the building’s compartments.

Associate Risks

Most fire deaths are caused by smoke inhalation, and smoke can migrate during a fire if not contained by the building’s smoke barriers. Uncontrolled smoke movement during a fire is a risk to all occupants and can reduce their ability to escape to an exit.

How to Mitigate the Risks

Provide compartmentation and ensure all smoke barriers are maintained around patient care areas to allow sufficient time for emergency response personnel to extinguish the fire or relocate patients to a safe compartment within the facility.


Extinguishment – LS.02.01.35 (hospitals) and LS.03.01.35 (ambulatory care facilities)

The elements of performance:

  • Sprinkler piping is not to be used to support other materials such as cables
  • Sprinkler heads must not be corroded or painted
  • 18” clearance under sprinkler heads
  • Other observations of problems that could hamper/prevent the system from functioning properly
Example of Improved Compliance
Compliance Issue

Stored items are blocking one or more sprinkler heads.

Associate Risks

Sprinklers are designed to quickly suppress a fire to protect the building and its occupants. When any part of the sprinkler system’s function is compromised, the fire protection provided by that system is also reduced putting patients, staff, and visitors at risk.

How to Mitigate the Risks

Ensure that no sprinklers are blocked or have anything hanging from them. There must be at least 18 inches of open space below sprinkler deflectors and the top of any items stored in the protected area, including any shelving and storage located directly below a sprinkler head.


Fire Protection – EC.02.03.05 (hospitals)

The elements of performance:

  • Lack of documentation related to the maintaining, inspecting, and testing
  • Annual testing of smoke detectors, duct detectors, etc.
  • Automatic air handling unit shutdown
  • Annual testing of visual and audible fire alarms
  • Water flow device testing
  • Quarterly testing of fire alarm notification to off-site fire responders
Example of Improved Compliance
Compliance Issue

The facility has not properly maintained all of its fire safety equipment in accordance with the relevant NFPA standards.

Associate Risks

Malfunction of any single device in a fire protection system can compromise its ability to detect a fire and sound the necessary alarms to alert occupants to the danger. Because most fire detection systems trigger fire suppression systems, malfunctions can also allow a fire to spread more rapidly. Without rapid detection, warning and containment, defending in place, which may be necessary for some patients, may not be possible.

How to Mitigate the Risks

Consult with a trusted fire and life safety service company in your area to ensure that you haven't missed any of the required inspections or tests necessary to ensure all components of your fire protection system are functioning properly. Maintain all required documentation of inspections and testing results, and immediately correct any problems identified.


How Joint Commission Standards relate to the National Fire Protection Association (NFPA) Standards

The Joint Commission standards related to fire safety are based on NFPA codes. Most of the codes specific to hospitals and ambulatory care facilities come from NFPA 101 Life Safety Code, while there are a number of different NFPA codes that are applicable to all health care occupancies. The table below provides a crosswalk between The Joint Commission Standards and their corresponding NFPA Codes.

Joint Commission Standard Corresponding NFPA Code(s) Relevant Section(s) of NFPA Code(s)
LS.02.01.10 General Building Requirements NFPA 101 Life Safety Code Sections 18.1 and 19.1
LS.02.01.20 Means of Egress Requirements NFPA 101 Life Safety Code Sections 18.2 and 19.2
LS.02.01.30 Protection NFPA 101 Life Safety Code Sections 18.3 and 19.3
LS.02.01.34 Fire Alarm NFPA 101 Life Safety Code Sections 18.3.4 and 19.3.4
LS.02.01.35 Extinguishment NFPA 101 Life Safety Code Sections 18.3.5 and 19.3.5
LS.02.01.40 Special Provisions NFPA 101 Life Safety Code Sections 18.4 and 19.4
LS.02.01.50 Building Services NFPA 101 Life Safety Code Sections 18.5 and 19.5
LS.02.01.70 Operating Features NFPA 101 Life Safety Code Sections 18.7 and 19.7
Ambulatory Care Facilities
LS.03.01.10 General Building Requirements NFPA 101 Life Safety Code Sections 20.1 and 21.1
LS.03.01.20 Means of Egress Requirements NFPA 101 Life Safety Code Sections 20.2 and 21.2
LS.03.01.30 Protection NFPA 101 Life Safety Code Sections 20.3 and 21.3
LS.03.01.34 Fire Alarm NFPA 101 Life Safety Code Sections 20.3.4 and 21.3.4
LS.03.01.35 Extinguishment NFPA 101 Life Safety Code Sections 20.3.5 and 21.3.5
LS.03.01.40 Special Provisions NFPA 101 Life Safety Code Sections 20.4 and 21.4
LS.03.01.50 Building Services NFPA 101 Life Safety Code Sections 20.5 and 21.5
LS.03.01.70 Operating Procedures NFPA 101 Life Safety Code Sections 20.7 and 21.7
All Health Care Occupancies
EC.02.03.05 Fire Protection NFPA 101 Life Safety Code Sections and
NFPA 80 Standard for Fire Doors and Other Opening Protectives

Sections 4.8.4, 5.2.1, 5.2.3, 5.2.4, 5.2.6, 5.2.7, and

NFPA 105 Standard for Smoke Door Assemblies and Other Opening Protectives Section 5.2.1
NFPA 72 National Fire Alarm and Signaling Code Table 14.4.5 and Section 17.14
NFPA 90A Standard for the Installation of Air-Conditioning and Ventilating Systems Section 6.4
NFPA 25  Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems Table


Koorsen Can Help You Meet The Joint Commission and NFPA Standards

Koorsen Fire & Security is one of the few fire and security companies in the United States that can provide total protection from one source. If your facility is accredited by The Joint Commission, our team of NICET-certified and factory-trained engineers and technicians can provide the knowledge and expertise you need to ensure that your employees and patients are safe – and your facility is compliant with both The Joint Commission and NFPA standards. Contact Koorsen today to learn more.

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Topics: Fire Safety, Healthcare Industry, Long Term Care, The Joint Commission

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Disclaimer: The information in this article is for informational purposes only. It is believed to be reliable, but Koorsen Fire & Security assumes no responsibility or liability for any errors or omissions in the content of this article. It does not constitute professional advice. The user of this article or the product(s) is responsible for verifying the information's accuracy from all available sources, including the product manufacturer. The authority having jurisdiction should be contacted for code interpretations.