Heads up! There’s are new Joint Commission Life Safety standards for business occupancies effective July 1, 2021. They apply to organizations accredited under both the Hospital Manual and the Behavioral Health & Human Services manual.
So, what’s involved and how you can be prepared? Let’s take a look.
Joint Commission Life Safety Standards
The standards in the Life Safety chapter (of the Hospital and Behavioral Health manuals) are based on the National Fire Protection Association (NFPA) Life Safety Code (101-2012). The NFPA Life Safety Code contains structural requirements for buildings to protect occupants from fire. The Code has various occupancy classifications for healthcare facilities:
Medical Facilities (including psychiatric hospitals)
- Health care occupancy
- Ambulatory health care occupancy
- Business occupancy
Behavioral Health Facilities
- Health care occupancy
- Residential board and care occupancy
- Business occupancy
Currently, Joint Commission Life Safety standards address health care occupancies, ambulatory health care occupancies, and residential board and care occupancies – not business occupancies. Thus, this is the first time surveyors will review business occupancies for compliance with Life Safety standards.
Definition of Business Occupancy
The Life Safety Code defines occupancy as “the purpose for which a building or portion thereof is used or intended to be used.” In healthcare settings, the definition of a Business Occupancy is “a facility where no one stays overnight and where three or fewer individuals are rendered incapable of self-preservation at any given time by virtue of their treatment.”
“Incapable of self-preservation” means that in the event of fire, a person is not able to leave the building on his/her own (even if it requires the use of a wheelchair). For the purpose of the occupancy definition, the fact that a person is in a wheelchair does not make him/her incapable of self- preservation.
In behavioral health settings, examples of locations classified as business occupancies are outpatient clinics, partial hospitalization programs, and intensive outpatient programs.
New Joint Commission Life Safety Requirements
The new Life Safety standards for business occupancies are the same in both the Hospital and Behavioral Health manuals. The only difference is the Hospital manual refers to “hospitals” and the Behavioral Health manual refers to “organizations.”
To summarize, there are five new standards and 29 elements of performance:
- LS.05.01.10: Building maintained to minimize effects of fire, smoke, and heat
- LS.05.01.20: Maintaining the integrity of the means of egress
- LS.05.01.30: Protecting individuals from hazards of fire and smoke
- LS.05.01.34: Maintaining fire alarm systems
- LS.05.01.35. Maintaining fire extinguishing equipment
The standards include requirements for means of egress, smoke/fire barriers, electrical panels, corridor widths, and fire extinguishers, among other items
Survey Process
Joint Commission surveyors will only review business occupancies for compliance in locations where services are provided to clients. They will not review administrative settings where there are no client services.
For hospital surveys, the clinical surveyors – not the Life Safety Specialist – will review business occupancies for compliance. For organizations accredited under the Behavioral Health Care & Human Services manual, the Behavioral Health surveyor will review compliance.
How to Prepare
First, make your Facilities Director aware of these new requirements. Next, we recommend you conduct a self-assessment against the new standards to evaluate your current level of compliance. Last, develop an action plan to address any deficiencies.
Although not required, TJC recommends as a best practice that organizations develop a Building Maintenance Program (BMP.) The BMP is a proactive approach to Life Safety Code compliance. It includes written strategies for managing the items covered in the program. And also a documented schedule for maintenance and evaluating the effectiveness of the program.
In addition, be sure to keep your Environment of Care Committee informed about your progress on these new requirements. Also, identify a point person in these settings to answer surveyors’ questions about Life Safety requirements as they’re touring. Your Facilities Director may be tied up with other survey activities. So, you’ll need someone familiar with these Life Safety requirements.
Moreover, if you’re a new Facilities Director, check out the Advice for New Facilities Managers from Herman McKenzie, Acting Director of the Dept. of Engineering at TJC.
Barrins & Associates Consultation
We’re now conducting both onsite and virtual Mock Surveys and Life Safety Reviews. Additionally, we’re covering all these recent updates to the standards and the Joint Commission survey process. As always, our goal is to make sure you’re prepared and confident come survey time!