Your Facility’s Partner in Remaining Compliant with The Life Safety Code

Health Care systems are continually challenged to properly assess their compliance with the Life Safety Code® (NFPA 101), understand the interpretations and exceptions to the Code, and maintain compliance through cost-effective measures. Partnering with our health care safety consultants makes these complex requirements achievable, while bringing positive, reliable outcomes in the event of an emergency.

Fire/Life Safety Code Reviews + AHJ Compliance Services

  • Perform a Fire + Life Safety Code design and plan reviews.
  • Apply appropriate heatlhcare Authority Having Jurisdiction (AHJ) requirements including local, state and Accreditation Organizations (The Joint Commission, DNV, AAAHC, etc.)
  • Prepare Fire + Life Safety Code Report based on the applicable fire and life safety requirements and consistent with the established project objectives.
  • Conduct field inspections, at appropriate intervals, to provide spot-checks as well as verify as-built compliance with appropriate and various AHJ requirements and construction documents.
  • Identify common construction oversights and serve as a third-party field verification before final Certificate of Occupancy.
  • Conduct a post-occupancy, wall-to-wall Life Safety Code® Assessment to incorporate into the existing accreditation organization’s compliance programs.

Life Safety Compliance

Life safety from fire in healthcare facilities is necessary to a state of continual survey readiness. Any of the following situations could lead to Life Safety Code® compliance scrutiny:

  • An incident recently occurred that prompted a surveyor or Fire Marshal to target a problem
  • A surveyor is incorrectly interpreting the Life Safety Code® and therefore citing the facility for something that is not a true deficiency
  • A fire occurred at your facility and the fire protection features of the building failed to function as intended
  • An AHJ changed or refined their interpretation of a Code requirement


The Life Safety Code® Assessment (LSCA, formerly the Statement of Conditions or SOC) is completed to ensure that the building and its inherent fire protection features will protect patients and staff during a fire. This program will be evaluated based on the requirements of the 2012 Edition of the Life Safety Code®. Partnership with our health care safety consultants will help you be prepared for life safety surveys by agencies working on behalf of CMS or accrediting agencies such as The Joint Commission, Det Norske Veritas (DNV), Health Care Facilities Accreditation Program (HFAP) and The Accreditation Association for Ambulatory Health Care (AAAHC).

What's involved?

  • Review and update Basic Building Information
  • Provide a wall-to-wall, roof-to-basement Life Safety Code® compliance survey of field conditions including, but not limited to, required smoke and fire-rated barriers, vertical openings, travel distances, etc.
  • Deliver a comprehensive report of findings and recommendations
  • Prepare waivers / equivalencies as necessary
  • Conduct annual fire and smoke door assembly inspection and inventory (optional)
  • Annual Continuous Readiness Program (Spot Check / Update / Validate – SUV Service)
  • Web-based Life Safety Management Tools

Survey Validation, Education + Equivalencies/Waivers

  • Staff Education and training on the Life Safety Code® and other referenced codes and standards
  • Reviewing survey findings for accuracy and proper application of the Code
  • Support in evaluating post-survey equivalency or waiver options
  • Fire Safety Evaluation System (FSES) — Application and completion of all documentation