For those of us that work in healthcare, we are used to regular adjustments in regulatory and code compliance requirements. Starting July 1, 2021, hospitals that are accredited by The Joint Commission will face major changes related to business occupancies (typically Medical Office Buildings or outpatient clinics) that are tied to the hospital or health system accreditation. While there have always been requirements impacting business occupancies in the Environment of Care (EOC) Chapter, life safety requirements were not specifically referenced. These changes will impact both Hospital and Critical Access Hospital standards.

2012 NFPA 101 – Life Safety Code as currently adopted by Centers for Medicare & Medicaid Services (CMS) defines a business occupancy as “an occupancy used for the transaction of business other than mercantile.” In healthcare, business occupancies consist of occupancies/facilities where patients are capable of self-preservation (3 or less incapable of self-preservation allowed) and do not remain in the facility overnight. Typically, this is will include medical office buildings (MOB), outpatient facilities, and clinics.

Moving forward, there will be five new life safety (LS) standards focused on business occupancies:

  • 05.01.10: Building maintained to minimize the effects of fire, smoke and heat
  • 05.01.20: Maintaining the integrity of the means of egress
  • 05.01.30: Protecting individuals from hazards of fire and smoke
  • 05.01.34: Maintaining fire alarm systems
  • 05.01.35: Maintaining fire extinguishing equipment

These standards include a handful of Elements of Performance (EPs) focused on general life safety in business occupancies including means of egress, hazardous areas, fire sprinkler systems, fire alarm systems, and fire extinguishers.  Additionally, all requirements that exist within LS.01.xx.xx apply to all three occupancies – healthcare, ambulatory healthcare, and business.

What does this mean?

In general, it means that there will be some changes coming for business occupancies that are included under the hospital/health system accreditation:

  • 01.01.01 will require a building assessment for business occupancies, similar to what is already required for healthcare and ambulatory healthcare occupancies. This will likely include Life Safety Plans as the main method to demonstrate the life safety features of the facility (means of egress, hazardous areas, fire or smoke barriers, etc.).
  • There will be an increased focus on business occupancies from any required inspection, testing and maintenance (IT&M) documentation for fire sprinkler, fire alarm or fire doors to additional survey time for life safety features in business occupancies.
  • As most of us have probably experienced, it has been difficult to get through a full life safety building tour of some larger facilities. How can Joint Commission add more space to be surveyed without lengthening the on-site survey? While nothing is definitive yet, we are hearing that life safety surveyors may not be the prime surveyors for business occupancies. It is likely that this responsibility will fall upon other members of the team. All surveyors will be receiving additional life safety training and will be in constant contact with the life safety surveyor while on site.
  • It will likely be a good idea to review all requirements located in the Environment of Care (EC) chapter that may apply to your business occupancies. You will want to ensure that existing policies and IT&M documentation are in place to show compliance.

Why is this happening?

Joint Commission has always been required to at least meet the minimum requirements of the Conditions of Participation (CoPs) set forth by CMS. They have always had the ability to increase the requirements beyond these minimum levels, which may be what is happening in this instance. While we have not seen an official position to date, some of these requirements may also be considered by some of the other accrediting organizations.

About the Authors

Mark Chrisman

Healthcare Practice Director | Principal
Mark Chrisman is a rare breed of smart. Not only does he love to learn, but he also naturally teaches those around him. Mark joined Henderson Engineers in 2004 and quickly began establishing client relationships that he still maintains today. A vice president and our healthcare practice director, Mark coordinates strategy for Henderson’s healthcare practice across the country. He has designed healthcare environments for some of the biggest names in the industry, providing technical expertise on fire protection and code consulting. He is known for his uncanny ability to recall specific codes and uses his immense knowledge of regulatory compliance requirements to help save clients’ money and time on projects. Mark often works in tandem with our team of healthcare specialists at Henderson Building Solutions. Don’t let his smarts fool you; this Ph.D. is creatively talented too. His party trick is spouting off the most recent code updates while busting out killer dance moves at the same time.