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Compliance News: Don’t Forget Your Business Occupancies

Healthcare systems may be struggling to comply with the fact that the physical environments of their business occupancies are surveyable.  In many accredited healthcare systems, the quantity of business occupancies that are part of that entity’s CMS Certification Number is substantial. Although the potential for surveys of business occupancy physical environments has been there for some time, the probability that some of those physical environments will indeed be surveyed appears now to be increasing.  The challenge is that healthcare systems do not know which of their numerous business occupancies could be surveyed.

The applicable NFPA codes have had something to say about the issue for some time:

NFPA 101-2012 (Life Safety Code) has included both new business occupancies (Chapter 38) and existing business occupancies (Chapter 39) for as long as this writer can remember.  Both chapters have subchapters that include (1) General Requirements, (2) Means of Egress Requirements,  (3) Protection, (4) Special Provisions, (5) Building Services, (6) Reserved, and (7) Operating Features.

For organizations accredited by The Joint Commission, page 1 of TJC’s Life Safety Chapter includes, among others, the following three statements:

“Many hospitals also have other settings where outpatients are served, which are considered ambulatory health care occupancies or business occupancies.”

“Outpatient clinics, administrative offices, and other functions that do not meet the more stringent definitions of health care occupancy or ambulatory health care occupancy are considered business occupancies. These requirements begin with Standard LS.05.01.10.”

“Note: The first two standards, LS.01.01.01 and LS.01.02.01, apply to all occupancy types.”

That last TJC note above has invoked LS.01.01.01 and LS.01.02.01 within business occupancies for many years.  Those two life safety standards include the building life safety assessment, current and accurate life safety drawings, and the Interim Life Safety Measures (ILSM) policy among other requirements.

By now, TJC-accredited organizations are also aware that TJC has recently added five new Life Safety Chapter standards that among them include 29 new elements of performance.  These new standards take effect and are surveyable starting July 1, 2021.

Standard LS.05.01.10 – Building & fire protection features

Standard LS.05.01.20 – Means of egress

Standard LS.05.01.30 – Building features

Standard LS.05.01.34 – Fire alarm systems

Standard LS.05.01.35 – Fire extinguishing equipment & systems


NFPA 99-2012 (Health Care Facilities Code) states:

“1.3 Application”

“1.3.1 This code shall apply to all health care facilities other than home care.”

For organizations accredited by The Joint Commission, page 1 of TJC’s Environment of Care Chapter includes the following (in part):

“The hospital that provides care, treatment, and services in space it does not own … may want to communicate with the property owner about maintenance expectations for building equipment and features not under its control. … a hospital may need access to the maintenance documents.”

Those maintenance documents referenced above could include requirements identified elsewhere in the EC Chapter.

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