Difference in Starting Times of Fire Drills

Q: We had our life safety survey from our state agency and received a deficiency for having fire drills too close together. We do one drill each month and rotate shifts. At the end of the year, each shift would have four drills. We had seven fire drills in the past year that were started within 49 minutes of each other. I do not see anything in the Life Safety Code stating how far apart the drills have to be.

A: Section 19.7.1.6 of the 2012 Life Safety Code says the fire drills must be conducted under varied conditions. This term (varied conditions) is interpreted by CMS and the accreditation organizations to mean the drill on each shift cannot start at or near the same time each quarter. Therefore, CMS and the AOs have arbitrarily picked either 1 hour or 2 hours as an acceptable difference in time to start fire drills held on the same shift for subsequent quarters.

Since they are the AHJs, they can interpret the LSC when the code is not clear. They decided the 1-hour or 2-hours difference is acceptable, so that is what healthcare organizations need to do. Would have been nice for them to let everyone know 1 year in advance before they start enforcing it, eh?