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Keyes Life Safety

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Life Safety Code Compliance at Business Occupancies

by Brad Keyes, CHSP, on Nov 13, 2020 12:00:46 AM

Q: If I have a new freestanding business occupancy that is licensed, would CMS enforce the provisions of the 2012 Edition of NFPA 101 (Life Safety Code)? I wasn't able to find anything in the Conditions of Participation that specifically addresses this. I know that the Joint Commission would not enforce their LS chapter, but wasn't sure if CMS had a different take on this.

A: I don’t agree with your statement that Joint Commission would not enforce their Life Safety chapter at a freestanding business occupancy that is part of the hospital’s CMS Certification Number (CCN). On the contrary, I know that Joint Commission will expect compliance with their Life Safety chapter standards at offsite business occupancies (since I was a TJC surveyor) and their standards EC.02.03.01, EP 4 and EC.02.03.03, EP 2 support that.

What you may be referring to is that Joint Commission will likely not send their Life Safety surveyors to the offsite business occupancies, but instead they will send their other surveyors who will look for basic Life Safety issues.

Likewise, for CMS. I have reviewed hundreds of state agency validation surveys on behalf of CMS and they always go to the offsite business occupancies that are under the same CCN.

Topics:Business OccupanciesJoint CommissionLife Safety CodeAccreditation/CertificationCMS

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