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The Joint Commission Releases New Life Safety Code Business Occupancy Requirements

The Joint Commission has released new expectations related to the Life Safety Code for Business Occupancy. These new requirements take effect July 1, 2021, for organizations accredited through their Hospital, Critical Access Hospital and Behavioral Health and Human Services programs. These standards address fire safety and means of egress during fire emergencies. This marks the first time that Life Safety Requirements will be applicable to Business Occupancies during the accreditation process.

Per NFPA 101 Section 3.3.134.3, a business occupancy is “used for account and record keeping or the transaction of business other than mercantile.” As it applies to health care, the definition refers to an area where there are no overnight stays and where three or fewer individuals are cared for and are rendered incapable of self-preservation at any given time by virtue of their treatment. Being incapable of self-preservation is further defined as a person who is unable to leave the building of their own accord with or without mechanical assistance, i.e., a wheelchair.

Once a building has been determined to be a business occupancy, these new expectations for Life Safety Business Occupancy Requirements are to comply forthwith. The new revisions cover building and fire protections, features that protect individuals from fire and smoke, protection of vertical openings, maintaining alarm systems and equipment for extinguishing fires, and clearing means of egress. “A corrective maintenance program should be put in place that will identify deficiencies and define a plan of correction which will correct those deficiencies within 45 days. If this cannot be accomplished within the 45-day period, a Plan for Improvement (PFI) must be created to address the issue.” says George Mills, M.B.A., F.A.S.H.E., C.E.M., C.H.F.M., senior engineer, Standards Interpretation Group, Joint Commission.

Although not required, The Joint Commission recommends creating a Building Maintenance Program (BMP) as best practice, to address the issues identified. This BMP, or the process that is developed, needs to be structured and planned to meet compliance with these new standards. The new standards need to address the following:

• The assessment of fire doors and barriers.

• The protection of vertical openings.

• The protection of pipes, conduit, cables, etc. with approved fire rated material.

• Doors free of coverings, decorations, or other objects applied to the door face, except for informational signs.

• The means of egress corridors or passageways must be a minimum of 44 inches of clear width.

• Dead-end corridors cannot exceed 50 feet in existing facilities.

• Providing compliant travel distance to exits.

• Providing emergency powered lighting, means of egress must be continuously illuminated while occupied.

• Alcohol-based hand rubs (ABHR) are stored and handled in accordance with NFPA 101-2012.

• The installation of compliant locking configurations, and other modifications, that will take time and expertise to meet compliance.

• Fire alarm systems for existing construction three or more stories in height, that has 100 occupants or more below or above the level of exit discharge or the building has 1000 or more occupants, and for new construction if the building is three or more stories in height, has 50 occupants or more below or above the level of exit discharge, or the building has 300 or more occupants.

• The travel distance from any point to the nearest portable fire extinguisher should be 75 feet or less.

• No damage to sprinklers and there is 18 inches or more of open space maintained below the sprinkler to the top of storage.

Engaging leadership in providing funding for these projects will also need to be performed, as depending on the specific modifications identified, can be very expensive

Please refer to the following link below for access to the Prepublication Standards for specific, detailed requirements and be certain to share this with your Safety Officer and Physical Plant team.

https://www.courtemanche-assocs.com/wp-content/uploads/2021/01/Business-Occ-Life-Safety-Changes-Hospitals-7-1-21.pdf

* Life Safety Code® is a registered trademark of the National Fire Protection Association, Quincy, MA

Kimothy M. Sparks, J.D., RN

Author Kimothy M. Sparks, J.D., RN

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