For an extended period, ensuring compliance with fire drill scheduling, particularly concerning the timing discrepancies between drills, has posed a recurring challenge highlighted during Joint Commission surveys.
According to Section 19.7.1.6 of the 2012 Life Safety Code (LSC), fire drills are required to be conducted under varied conditions. This phrase, "varied conditions," has been interpreted by both the Centers for Medicare & Medicaid Services (CMS) and accreditation organizations (AOs) to mean that fire drills on each shift should not commence at or near the same time each quarter.
Consequently, CMS and the AOs have established either a 1-hour or 2-hour difference in starting times as acceptable for fire drills held on the same shift in subsequent quarters. As the Authority Having Jurisdiction (AHJs), CMS and the AOs possess the authority to interpret the LSC when its directives are unclear. Their determination of the 1-hour or 2-hour difference as acceptable reflects their regulatory stance, obliging healthcare organizations to comply accordingly.
However, it would have been advantageous for them to provide advance notice, ideally at least one year in advance, before enforcing this requirement uniformly.
