Regulations, Codes & Standards Q&A: Evacuation Route Maps

By Brad Keyes / Special to Healthcare Facilities Today
September 9, 2020

Q: We have a sister hospital in our health system who places egress route maps in common places. Their facilities manager and I were chatting this morning and I spouted out confidently that egress route maps were not a requirement of CMS or the accreditation organization, likely not even a NFPA requirement. He said that the state department of public health requires it. Can you help me figure out the deal with egress maps?  I always thought egress maps were useless since our staff follows a defend in place strategy and our visitors follow exit signs.  

A: Well... I have no idea where you are located so I can't speak to your state department of health, and whether or not they require evacuation route maps. 

But you are correct: CMS, NFPA, and the accreditation organizations do NOT require evacuation route maps. This all started as an error on an old Health Care Finance Administration (HCFA) assessment sheet that misinterpreted section that requires the healthcare organization to have an evacuation plan, and the plan needs to be readily available. The way this was written in previous editions of the LSC sounded like the plan was a map, so HCFA required an evacuation route map. But in the 1990's a sharp-minded individual challenged HCFA that the LSC really did not require a map but was talking about a written management plan. HCFA agreed and withdrew their requirement to have evacuation route maps. 

But the problem is many hospitals put evacuation route maps up and never took them down. It is okay to have them, but the maps have to be accurate. But to be sure, they are not required by national authorities. Personally, I do not believe evacuation route maps are useless. I often referred to them when conducting on-the-spot training with staff to identify locations of smoke barriers. 

I have received reports from readers that certain OSHA regional offices are requiring evacuation route maps in hospitals. If that is the case, then you would need to provide them. Also, check with your state and local authorities to see if they require them.

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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