Definition of Time
Q: Has there been an update to the definition of time by TJC/CMS? I’m looking at quarterly fire drills right now, but any changes/clarification on the definition for all intervals would be helpful. I...
View ArticleFire Drills During a Pandemic
Q: As the world faces this pandemic, can fire drill requirements be suspended or replaced with staff education type in-services? A: Fire drills are a mandatory requirement that is regulated by the...
View ArticleFire Drills in ASC Located in a Shared MOB
Q: We have 13 off-site Ambulatory Surgery Centers and some are in stand-alone buildings where they are the only occupant and some are in high rise Medical Office Buildings (MOB). For quarterly fire...
View ArticleFalse Alarm Fire Drills
Q: Can accidental fire alarm activations, such as burnt popcorn, be counted toward a quarterly fire drill requirement if documentation of staff response is received in regard to said accidental...
View ArticleFire Drills in the Behavioral Health Unit
Q: I work at a hospital that has just partnered with a Behavioral Health organization. We have renovated a floor and will be opening up soon. My question is this: For fire drills in the main hospital,...
View ArticleILSM Fire Drills
Q: I’ve been conducting two fire drills per month while we are under construction. I am new to the safety role and my understanding of the code is that I should be doing 2 per quarter each on different...
View ArticleFire Drills
Q: There is a lot of confusion on how many fire drills we have to complete. We have 3 towers where there is healthcare, all connected, but different building names. Do we only need to complete 1 fire...
View ArticleAmbulatory Healthcare Occupancy Fire Drills
Q: My question is with an ambulatory healthcare occupancy classification. Do you need just one fire drill per quarter or do you need one fire drill per shift per quarter? The ambulatory healthcare...
View ArticleFire Drills
Q: Is it required to activate the fire alarm system in our hospital whenever a fire drill is conducted for AM or PM Shift? A: Yes. According to section 19.7.1.4 of the 2012 Life Safety Code, fire...
View ArticleFire Drills in ASC Located in a Shared MOB
Q: We have 13 off-site Ambulatory Surgery Centers and some are in stand-alone buildings where they are the only occupant and some are in high rise Medical Office Buildings (MOB). For quarterly fire...
View ArticleFalse Alarm Fire Drills
Q: Can accidental fire alarm activations, such as burnt popcorn, be counted toward a quarterly fire drill requirement if documentation of staff response is received in regard to said accidental...
View ArticleFire Drills in the Behavioral Health Unit
Q: I work at a hospital that has just partnered with a Behavioral Health organization. We have renovated a floor and will be opening up soon. My question is this: For fire drills in the main hospital,...
View ArticleILSM Fire Drills
Q: I’ve been conducting two fire drills per month while we are under construction. I am new to the safety role and my understanding of the code is that I should be doing 2 per quarter each on different...
View ArticleFire Drills
Q: There is a lot of confusion on how many fire drills we have to complete. We have 3 towers where there is healthcare, all connected, but different building names. Do we only need to complete 1 fire...
View ArticleAmbulatory Healthcare Occupancy Fire Drills
Q: My question is with an ambulatory healthcare occupancy classification. Do you need just one fire drill per quarter or do you need one fire drill per shift per quarter? The ambulatory healthcare...
View ArticleFire Drills
Q: Is it required to activate the fire alarm system in our hospital whenever a fire drill is conducted for AM or PM Shift? A: Yes. According to section 19.7.1.4 of the 2012 Life Safety Code, fire...
View ArticleFire Drills in a High-Rise Hospital
Q: A question was brought up today about whether or not what we are doing for fire drills meets code. Currently, as a high-rise hospital (12 floors), we are conducting drills 1 per shift per quarter,...
View ArticleEvacuation During a Fire
Q: We are a hospital and if there was a fire, say at the northeast part of the building does everyone throughout the whole building have to evacuate the building or only the ones on that side of the...
View ArticleWeekend Fire Drills
Q: Do you know anything about fire drills on weekends? What is the requirement? A: Section 19.7.1.6 of the 2012 LSC says fire drills must be conducted quarterly on each shift to familiarize facility...
View ArticleFire Drills in a Hospital
Q: I work in a hospital. When we conduct our routine scheduled fire drills are we required to actually activate the fire alarm pull station, horns or strobes? Are we required, during a fire drill, to...
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