Focus: Fire-Life Safety / Column

Regulations, Codes & Standards Q&A: Documentation of life safety assessment

By Brad Keyes / Special to Healthcare Facilities Today
March 11, 2020

Q: Do you have any suggestions for satisfying the accreditation documentation requirements to prove we conducted a building assessment for compliance with the Life Safety Code? I had thought about an FSES but realized I may be barking up the wrong tree.

A: Yes… you are barking up the wrong tree. Do NOT use an FSES worksheet as evidence of a building assessment to determine compliance with the Life Safety Code. 

In the past, some hospitals utilize the old Part 3 Life Safety Assessment from the Statement of Conditions which is no longer a requirement to be completed. But it can act as a guide in what to look for when conducting a building assessment. Or, you can contract with a consultant to provide a mock survey which is an assessment to determine compliance with the Life Safety Code. 

Ask your accreditation organization for a document assessment tool that they would recommend.

Brad Keyes, CHSP, is the owner of KEYES Life Safety Compliance, and his expertise is in the management of the Life Safety Program, including the Environment of Care and Emergency Management programs.

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Topic Area: Regulations, Codes & Standards

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