The Fire Safety Evaluation System (FSES): A Practical Guide to Alternative Approaches

Understanding the FSES

The Fire Safety Evaluation System (FSES) provides healthcare facilities with a structured method to demonstrate that their current fire safety features are equivalent to or greater than the protection required by strict code compliance. Originally developed by the National Bureau of Standards at a time when Congress began requiring healthcare facilities to adopt NFPA 101, the FSES was created as an assessment method to ensure aging buildings that couldn't meet new healthcare requirements could still demonstrate an equivalent level of safety. The system functions as a risk-based scoring equation that compares positive fire protection features against non-conforming elements to determine if a facility provides an adequate level of safety.

When to Consider the FSES

Healthcare facilities should consider the FSES when they cannot meet specific NFPA 101 requirements due to building constraints, physical arrangements, financial limitations or operational impacts of required corrections. The system is particularly valuable when facilities need to demonstrate equivalent compliance through alternative means and require technical documentation for Authority Having Jurisdiction (AHJ) approval. However, it's critical to understand that the FSES can only be submitted as part of a Plan of Correction in response to a survey-related deficiency.  While preliminary reviews and knowledge of potential deficiencies are important for survey preparation, an FSES can only be conducted and submitted for review after a survey finding has been issued.

Key Requirements + Process

The process begins when an AHJ identifies a deficiency during survey. Facilities must then review and assess which deficiencies can or should be incorporated into the FSES. This is usually determined by the scope, complexity, cost and operational disruption relating to prescriptive deficiency remediation.  Partnering with experienced evaluators is critical to understanding what the FSES can and cannot evaluate. The evaluation must be approved by the AHJ and conducted by someone knowledgeable in the use and application of the FSES.  This often includes a Professional Engineer or Certified Fire Protection Specialist.

Documentation + Submission

Preparing the FSES requires comprehensive documentation. Evaluations are conducted for each fire/smoke zone in the building, with zone selection depending on the type of deficiency being evaluated. For instance, an egress deficiency on the top floor may only require evaluation of impacted zones, while a deficient building construction type would likely require evaluation of all zones in that building. The Fire/Smoke Zone Evaluation Worksheet must be completed for each zone, following detailed instructions within NFPA 101A on how each factor should be scored.

Ongoing Compliance + Important Considerations

A new FSES must be completed and submitted for review and approval each time the annual Life Safety Code® survey is completed by the State Survey Agency and deficiencies are identified, ensuring that any deficiency found is accounted for in the facility's Plan of Correction.

It is essential to understand that the FSES can fail if the resulting values are negative numbers, indicating that conditions in the building are not equivalent to or greater than the minimum factors required by the Life Safety Code®. While it may be possible to add or install features to overcome negative points, final acceptance of the evaluation rests with the AHJ, and approval is not guaranteed. The approval process is subjective by nature and at the discretion of each separate AHJ, meaning an FSES approved by one jurisdiction may be denied by another. Facilities should be prepared for detailed discussions with the AHJ about their findings and understand that past success is not a guarantee of future results on any individual facility or issue.

For more information, consult the Centers for Medicare & Medicaid Services State Operations Manual, NFPA 101A Guide on Alternative Approaches to Life Safety, or contact Jensen Hughes for expert guidance.