TJC & CMS News Blog
Information for

An important Joint Commission fire drill requirement is you must vary the timing of your drills. Seems simple, right?

Surprisingly, many organizations overlook this requirement. As a result, they get a finding on their survey. So, let’s review what’s needed to be in compliance and avoid that survey finding.

Joint Commission Fire Drill Requirement

The Joint Commission fire drill requirement for varying the timing of drills is EC.02.03.03 Element of Performance # 3. It’s in both the Hospital and Behavioral Health Care & Human Services manuals. It requires that you hold fire drills “at unexpected times and under varying conditions.”

The standard doesn’t define “unexpected times” and “varying conditions.” However, TJC has clarified that in its official Clarification and Guidance on Fire Drills.

In that communication, they state: Drills should be at least over an hour apart and should avoid patterns. For instance, if the drill during first quarter first shift was conducted at 8:30 am, the drills for the first shift for remaining quarters should be before 7:29 am or after 9:31 am and should not repeat times throughout the year.”

Purpose for Varying Fire Drills

So, what’s the purpose of this requirement? Clearly, it’s to avoid predictability around when fire drills will occur. Conducting the drills at varying times helps staff practice how to respond at any time.

Survey Process

How do surveyors review the Joint Commission fire drill requirements during your survey? First,  the surveyor will request documentation of your fire drills over the last 12 months.

Next, they’ll check to see if, indeed, you’ve varied your drills by more than one hour from quarter to quarter for each shift through four consecutive quarters.

If that’s not the case, you’ll receive a Requirement for Improvement (RFI) on your survey report. For example, this recent survey finding: “In reviewing the fire drill times and locations for the calendar year 2021, it was found that the drill for quarter 1 (1st shift) 2021 was completed at 12:40 pm and the drill for quarter 4 (1st shift) 2021 was completed at 12:45 pm. This does not meet the criteria for unexpected time and varying conditions. This finding was confirmed by the Director of EOC and the Regional VP of EOC.”

Fire Drill Matrix

The best way to meet this requirement is to develop an annual written schedule for your fire drills. Make sure it meets the one hour variation requirement. That way, you’ll have the documentation readily available at survey time.

When we do mock surveys, we share the TJC Fire Drill Matrix. It’s a handy tool for planning and documenting your drills from quarter to quarter.


For updates on some other Environment of Care and Life Safety requirements, see our recent posts on the following topics:

Barrins & Associates

When we conduct our mock surveys, we do an Environment of Care tracer. It includes a review of your fire drills and the timing of those drills. It also includes a review of the other EOC documents you’ll need for your survey.

In terms of Mock Surveys and Continuous Readiness Consultations we’re back to business as usual. We’ve incorporated all the new 2022 standards. As always, we’re prepared to support your ongoing survey readiness and best practices for regulatory compliance.