Conducting Effective and Compliant Fire Drills

Life Safety; Emergency Preparedness
Fire drills are a key component of any fire safety program. While the Life Safety Code® (LSC) requirements for fire drills are not complicated, fire drill compliance consistently lands on the list of top cited deficiencies during life safety surveys (K-712). As such, let's walk through the key requirements and best practices around fire drills.

Fire drills in healthcare occupancies are required to be conducted quarterly on each shift. This is commonly accomplished by facilitating a fire drill each month on a different shift. However, there is nothing that precludes an organization from running multiple fire drills in a single month as long as each shift receives a drill during the quarter.

Fire drills should be conducted at varying times and under varying conditions. While the LSC is not specific regarding what constitutes “varying times," it is wise to consider varying drills by at least one hour for drills conducted on the same shift. Similarly, drills should be facilitated in different parts of the building and with different scenarios.  Simulating the same fire scenario in the same location limits the involvement of staff from other areas of the building. It can be beneficial to develop a fire drill schedule at the on-set of each year that outlines fire drill dates, time, locations, and scenarios. This will provide a helpful roadmap to the fire drill facilitator and ensure compliance is maintained regarding the variance in time, location, and conditions.

While not specifically required by the LSC, there is an implied expectation that fire drills will be documented. Documentation is your mechanism to prove fire drill compliance during survey. An effective fire drill report will include all the details around the drill including date, time, location, facilitator, and actions taken by staff…specifically any areas for improvement. The reports can be an effective tool for assessing staff competency and identifying trends. It is also wise to maintain a sign-in sheet for each drill to document the staff that were involved.

Fire drills require activation of the fire alarm system including the normal audible and visual notification devices. However, for nighttime fire drills that occur between the hours of 9:00pm-6:00am, a coded announcement (commonly an overhead page) is permitted in lieu of activating the fire alarm system audible devices. Visual devices are still required to be activated. If and when CMS adopts a newer edition of the LSC, both audible and visual devices will be permitted to be omitted during overnight fire drills.  Overnight fire drills always require staff response and implementation of the fire procedures.

Compliance aside, fire drills can be an extremely effective educational opportunity. Realtime implementation of the fire procedures in a staff member's normal work area can be more memorable and impactful than a training lecture, video, or on-line course. Completing the drill may check the compliance box, but investing the time to facilitate a well-organized drill that includes a comprehensive staff critique will pay dividends during a true fire emergency occurrence.  

As always, knowledge of the applicable codes and standards is your best tool for ensuring compliance. You can purchase a copy of the Life Safety Code® (NFPA 101) online at www​ The AHCA/NCAL website is also a good source for on-going life safety education, tools, and resources. ​