Quarterly Fire Drills

Q: There is a matrix floating around on the web that describes Joint Commission’s compliance for fire drills. It breaks the quarters down as Q1=January, February, March, and Q2=April, May, June, etc. Does this mean that for a first shift drill last run in April, we can have the next drill run in September and still be compliant, + or – 10 days?

A: No, not for Joint Commission. In their Overview to the Environment of Care chapter in the Hospital Accreditation Standards manual, Joint Commission says quarterly or once per quarter means “every three months, plus or minus 10 days”. Now, I’ve heard Joint Commission engineers say they will allow this to be interpreted as follows: If the drill was conducted on April 15, that means three months from April is July. July plus 10 days means August 10 and July minus 10 days means June 20. So, according to the engineers from The Joint Commission, the window of opportunity is 51 days: from June 20 to August 10. That scenario would apply to any date the drill was conducted in April.

But to be honest, the Overview of the Joint Commission manual doesn’t say that. Other people are interpreting the Overview to mean if the drill was conducted on April 15, then 3 months after that is July 15. July 15 plus 10 days is July 25, and July 15 minus 10 days is July 5. That leaves you with a 20-day window of opportunity. 20 days is significantly less than 51 days, so you will be at the mercy of the surveyor to determine which one they enforce.

But in the past year, CMS has stated unofficially that they do not like any scenario that allows more than 3 months for a fire drill. In other words, they don’t mind the “every three months, minus 10 days”, but they don’t like the “every three months, plus 10 days”.