Code Compliance

Statement of Conditions – Life Safety Assessment:

A Life Safety Assessment of your facility’s above and below ceilings, smoke and fire barriers, shafts, and life safety compliance with NFPA 101.

• Review current Plan for Improvement status
• Review all buildings by floor and zone for use and occupancy classification
• Review eBBI’s and update as necessary
• Evaluate all zoning
• Identify all suites
• Note the location of all chutes & discharge rooms on prints
• Mark prints for extent of sprinkler protection and smoke detection by zone
• Note any special circumstances on prints for evaluation during inspection
• Evaluate Sleeping and Non-Sleeping Suite sizes
• Conduct a 100% above and below ceiling life safety inspection
• Survey all smoke and fire barriers during life safety survey
• Provide client with report of life safety deficiencies
• Provide a .csv file ready for upload to the Joint Commissions eSOC web site

Background and History

As a field surveyor, policy administrator, fire marshal or other authority having authority, how many times have you received different interpretations from different parties, concerning the same problem? Due to the number and variety of groups that evaluate all aspects of the service, safety, and performance of a healthcare facility, slight (sometimes major) differences in interpretations of applicable codes and standards can arise. The Healthcare Interpretations Task Force (HITF), is now in place to help reconcile organizational differences of opinion.

Formed in July 1998, this Task Force is the by-product of a unique coalition of the major organizations that most impact the healthcare community in terms of fire protection related issues. This coalition, created in 1996, was originally known as the Authority Having Authority Committee, was comprised of representatives from:

• American Health Care Association (AHCA)
• American Society for Healthcare Engineering (ASHE)
• Centers for Medicare/Medicaid Services (CMS)
• International Fire Marshals Association (IFMA)
• The Joint Commission (TJC)
• National Fire Protection Association (NFPA)
• Department of Veterans Affairs (VA)

The purpose was to bring together the organizations that must enforce, implement, abide by, or evaluate the various fire protection measures found in nearly every healthcare occupancy in the U.S. This group has worked on several initiatives, including working to make recognition of the 1997 Edition of the Life Safety Code® the formally adopted reference for CMS. On July 5, 2016, CMS adopted the 2012 edition and is now referenced for this purpose.

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