Tips for Conducting Effective + Compliant Fire Drills

Fire drills are a fundamental component of any fire safety program. While the Life Safety Code® (LSC) requirements for fire drills are straightforward, fire drill compliance consistently lands on the list of top cited deficiencies during life safety surveys (K-712). 

Learn the Benefits of a Fire Drill Schedule

In healthcare occupancies, fire drills are required to be conducted quarterly on each shift. This is commonly accomplished by facilitating a fire drill each month on a different shift. However, there is nothing that precludes an organization from running multiple fire drills in a single month, provided that each shift receives at least one drill per quarter. 

Fire drills should be conducted at varying times and under varying conditions. While the LSC is not specific regarding what constitutes “varying times,” it is wise to consider varying drills by at least one hour for drills conducted on the same shift.  Similarly, drills should be facilitated in different parts of the building and with different scenarios. Simulating the same fire scenario in the same location limits the involvement of staff from other areas of the building. It can be beneficial to develop a fire drill schedule at the onset of each year that outlines fire drill dates, time, locations and scenarios. This will provide a helpful roadmap to the fire drill facilitator and ensure compliance is maintained regarding the variance in time, location and conditions. 

Document Your Fire Drill

While not specifically required by the LSC, there is an implied expectation that fire drills will be documented. Documentation is your mechanism to prove fire drill compliance during survey. An effective fire drill report will include all the details around the drill including date, time, location, facilitator and actions taken by staff – specifically any areas for improvement. The reports can be an effective tool for assessing staff competency and identifying trends. It is also wise to maintain a sign-in sheet for each drill to document the staff that were involved.   

Understand Audible + Visual Notification Device Parameters

Fire drills require activation of the fire alarm system’s normal audible and visual notification devices. However, for nighttime fire drills that occur between the hours of 9 PM and 6 AM, a coded announcement (commonly an overhead page) is permitted in lieu of activating the fire alarm system audible devices. Visual devices are still required to be activated. If and when CMS adopts a newer edition of the LSC, both audible and visual devices will be permitted to be omitted during overnight fire drills. Overnight fire drills always require staff response and implementation of the fire procedures. 

Educate Your Staff

Compliance aside, fire drills can be extremely effective educational opportunities. Realtime implementation of the fire procedures in a staff member’s normal work area can be more memorable and impactful than a training lecture, video or online course. Completing the drill may check the compliance box but investing the time to facilitate a well-organized drill that includes a comprehensive staff critique will pay dividends during a real emergency.