Weekend Fire Drills

Q: Do you know anything about fire drills on weekends? What is the requirement?

A: Section 19.7.1.6 of the 2012 LSC says fire drills must be conducted quarterly on each shift to familiarize facility personnel with the signals and emergency action required, under varied conditions.

The accreditation organizations (AOs) have standards that say similar things. The term ‘under varied conditions’ is used to mean not only different scenarios are used for fire drills, but the fire drills are conducted in different locations, at different times (up to 2-hours different start time for same-shift drills), and on different days of the week. This is often interpreted by the AOs to mean fire drills must include the weekend and holiday shift personnel.

You will not find a specific standard in the CMS Conditions of Participation, or the AOs manual that states fire drills must be conducted on weekends and holidays, but the expectation of the surveyors is you will. If you fail to include those workers, then you are not conducting drills under ‘varied conditions’.

Brad Keyes
Brad Keyes, CHSP

Brad is a former advisor to Healthcare Facilities Accreditation Program (HFAP) and former Joint Commission LS surveyor. He guides clients through  organizational assessment; management training; ongoing coaching of task groups; and extensive one-on-one coaching of facility leaders. He analyzes and develops leadership effectiveness and efficiency in work processes, focusing on assessing an organization’s preparedness for a survey, evaluating processes in achieving preparedness, and guiding organizations toward compliance. 

As a presenter at national seminars, regional conferences, and audio conferences, Brad teaches the Keyes Life Safety Boot Camp series to various groups and organizations. He is the author or co-author of many HCPro books, including the best-selling  Analyzing the Hospital Life Safety Survey, now in its 3rd edition. Brad has also authored a variety of articles in numerous publications addressing features of life safety and fire protection, as well as white papers and articles on the Building Maintenance Program. Currently serving as the contributing editor of the monthly HCPro newsletter Healthcare Life Safety Compliance  gives Brad further insight into the industry’s trends and best practices.