Question: Does the 2000 Life Safety Code require in Sections 18 & 18.104.22.168 that all staff members of a health care facility participate in 4 quarterly fire drills per year?
Discussion: Life safety surveyors have recently been citing facilities in which all staff members did not participate in at least 4 quarterly fire drills per year. Although this may sound like a simple and reasonable requirement, not all staff members are present when their shift has a drill. Staff members may be on vacation, sick, in training outside the facility, etc.
Nowhere in the Life Safety Code does it require that all staff members must participate in a minimum of 4 fire drills per year. The Code does require that a minimum of 4 fire drills per shift per year for a total of 12 fire drills be held by a facility. Sections A18 & 22.214.171.124 states that “The purpose of a fire drill is to test and evaluate the efficiency, knowledge, and response of institutional personnel in implementing the facility fire emergency plan.” The purpose of the drill is to test the capabilities of the staff present during the drill. It is very likely that during actual fires in facilities, all staff on the shift will not be present. During a drill when all staff is not present, is an excellent opportunity to test how staff responds with a reduced staff. The Life Safety Code goes on to state that drills should be “conducted under varied conditions.” One varied condition anticipated is that all staff will not be present during an actual fire emergency.
It is important to note that the Life Safety Code does require that all staff be trained in life safety procedures such as fire drills. This Life Safety Update has been reviewed by the Center for Medicare & Medicaid Services (CMS).