The Joint Commission, Fire Protection & YOU: Everything You Need to Know about Fire Protection in your Healthcare Facility

Keeping your healthcare facility in constant preparedness for Fire and Life Safety surveys can be a challenge. It’s important that you be ready, but it can be easy to get overwhelmed.

The Joint Commission accreditation is the gold standard in healthcare certification, and as a facility professional, the responsibility for Fire and Life Safety Code compliance falls to you. That means that you’re on the spot when The Joint Commission surveyors, including a Life Safety Code surveyor, arrive unannounced.

It’s important for hospitals to demonstrate their dedication to safe, effective, and comprehensive patient care. While they can display this in their day-to-day operations, most choose to take things a step further by earning accreditation from The Joint Commission (JCAHO) or another accrediting organization. 

Accrediting organizations have applied for and received “deeming authority” from the Centers for Medicaid and Medicare Services (CMS). This means they can determine which healthcare facilities meet Medicare and Medicaid certification requirements. However, each of them goes about determining that in their own way, with a different set of standards. 

In the United States, nearly 23,000 health care organizations are evaluated and accredited through the Joint Commission, one of the few accreditation organizations accepted by the Centers for Medicare and Medicaid Services (CMS).

At A P Fire we will help you understand and tackle JCAHO and the standards it uses to determine fire safety in hospitals – large and small.

What Is the Joint Commission?

The Joint Commission is an accreditation body that focuses on quality care for the American public through a voluntary and independent evaluation process. It is governed by a 21-member Board of Commissioners that includes physicians, administrators, nurses, employers, quality experts, a consumer advocate and educators. They also employ approximately 1,000 people in its surveyor force.

All of these people work together to influence national healthcare policy, funding priorities, performance measurement, and future legislation. In addition, they establish standards for safe, effective, and comprehensive patient care. 

What Are jcaho Standards?

The Joint Commission performs on-site surveys once every three years, but hospitals must also perform annual self-assessments.  These standards are all focused on setting hospital performance expectations that are reasonable, achievable, and surveyable. Together they are aimed at holding healthcare facilities responsible for high-quality care.

Over the years, JCAHO has established hundreds of standards, with categories, or chapters, ranging from Document and Process Control (DC), to Infection Prevention and Control (IC), to Medication Management (MM), and many more. When it comes to fire safety in hospitals, these standards are found in The Joint Commission’s Life Safety (LS) Chapter. 


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


The elements of performance:

Corridor clutter
Doors unlocked in the direction of egress


The elements of performance:

Hazardous storage area issues
Corridor doors
Smoke barriers do not have unsealed penetrations


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

How The Joint Commission Evaluates Facilities for Fire Safety

JCAHO standards provide the basis for an evaluation process to measure, assess, and improve hospital performance. They conduct 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:

How Joint Commission Standards relate to the National Fire Protection Association Standards

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

If you work in a hospital or healthcare setting that’s accredited by The Joint Commission, it’s important to know what these standard updates mean for your facility. In order to pass your annual self-assessment or triennial survey from The Joint Commission, you need to ensure full compliance with protocol. 

The Joint Commission helps hospitals become reliable organizations for delivering safe and effective care. A large component of that is adhering to their standards on effective fire protection.

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 results of The Joint Commission surveys in 2018, almost half of the top compliance issues for hospitals and ambulatory 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.

APFP Can Help You Meet The JCAHO and NFPA Standards

A P Fire Protection is one of the few fire protection companies in Arizona 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 JCAHO and NFPA standards.

Fire protection Services for Healthcare Accreditation

Keeping your healthcare facility in constant preparedness for Fire and Life Safety surveys can be a challenge. It’s important that you be ready, but it can be easy to get overwhelmed.

The Joint Commission accreditation is the gold standard in healthcare certification, and as a facility professional, the responsibility for Fire and Life Safety Code compliance falls to you. That means that you’re on the spot when The Joint Commission surveyors, including a Life Safety Code surveyor, arrive unannounced.

With the overwhelming number of operating challenges you face on any given day, it’s unlikely you have time to continually think about Fire and Life Safety documentation. APFP services for The Joint Commission accreditation are designed to give you the peace of mind knowing that a sudden visit is never a cause for alarm.

Leave the documentation management to us

The Joint Commission’s accreditation program requires that you maintain an extensive set of Fire and Life Safety documentation, properly completed, appropriately organized and easily accessible. Missing paperwork or incomplete entries are more than embarrassing; they can trigger non-compliance requiring corrective action.

 A P Fire Protection Fire Services for The JCAHO Accreditation ensure proper documentation of all inspection and test reports related to Fire and Life Safety systems in your buildings and are designed to simplify and streamline the survey process. The program provides you with an annual delivery schedule to ensure no test is overlooked. Regular review meetings will be included to familiarize your staff members with all related documentation and paperwork as well as prepare them to speak knowledgeably with surveyors during a survey.

Our goal is to help you avoid unpleasant surprises, and free you up to devote more of your resources to daily operations.

Our highly trained professionals speak “The Joint Commission” language.

You can depend on A P Fire Protection testing, inspection and documentation to mirror the very latest requirements including The Joint Commission Environment of Care and Life Safety requirements. The APFP team maintains in-depth knowledge of The Joint Commission standards, as well as National Fire Protection Association codes as it relates to healthcare.

Make A P Fire Protection your single source for Fire and Life Safety

When A P Fire Protection partners with your facility, you can end the hassle of managing multiple life-safety vendors. With one service agreement, you can consolidate testing and maintenance processes, scheduling and documentation for all your Fire and Life Safety systems.

Testing and maintenance services can include fire alarm systems, sprinklers, kitchen hoods, portable extinguishers, fire pumps, fire suppression systems and more. Learn more about A P Fire Protection Fire Services.

A P Fire Protection services for The Joint Commission Accreditation Program can be tailored to your exact needs:

Testing of Fire and Life Safety systems to The Joint Commission and other regulatory standards

Easy-to-read, customized test reports, created per each applicable Element of Performance standard established by The Joint Commission

Comprehensive inspection management in the form of a detailed inspection schedule, structured around The Joint Commission Elements of Performance standards

Deficiencies tracking and repairs in full accordance with applicable standards and deadlines of The Joint Commission

Account management services including frequent review meetings to discuss present and future needs

Assistance with interpretation of The Joint Commission standards and requirements

If you’d like to know more about The Joint Commission’s Standards, check out these publications: Joint Commission resources2023 Environment of Care® Essentials for Health Care,  Life Safety Made Easy: Your Key to Understanding Fire Safety in Health Care Facilities and The Joint Commission Big Book of EC, EM, and LS Checklists

At A P Fire Protection, we’re experts on The Joint Commission’s standards. We can help you ensure you’re always in compliance. Contact us to learn more.

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