Hospitals and healthcare facilities face some of the strictest fire and life safety regulations in any industry. Beyond local codes and NFPA standards, providers must comply with national accreditation requirements to maintain licensure and federal funding.
At Pye-Barker Fire & Safety, we help hospitals nationwide prepare for inspections and maintain compliance with CMS, NFPA, and accreditation standards. This guide breaks down the differences between three major accreditation bodies—DNV, HFAP, and The Joint Commission—and their approaches to life safety compliance.
WHY HEALTHCARE ACCREDITATION MATTERS
The Centers for Medicare & Medicaid Services (CMS) requires healthcare facilities to maintain accreditation from a recognized organization to receive Medicare reimbursements. These accreditations also ensure consistent patient safety, reliable infrastructure, and operational compliance.
While each organization uses different approaches, they all require facilities to demonstrate compliance with:
- CMS Conditions of Participation (CoPs)
COMPARING THE THREE MAJOR ACREDITORS
| Accreditation Body | Fire/Life Safety Focus | Inspection Model | Standards Referenced | Key Characteristics |
| Joint Commission (TJC) | Strong emphasis on life safety through Environment of Care standards | Announced triennial surveys | NFPA 101, NFPA 99, CMS CoPs | Comprehensive and detailed approach |
| DNV Healthcare | Continuous improvement focus with ISO 9001 integration | Annual surveys | NFPA 101, ISO 9001, CMS CoPs | Process-oriented quality management |
| HFAP (AOA) | Traditional compliance-based approach | Every 3 years | NFPA 101, NFPA 99, CMS CoPs | Straightforward structure, popular with smaller facilities |
LIFE SAFETY REQUIREMENTS ACROSS ALL ACREDITORS
Regardless of your chosen accrediting body, all require:
- Working fire alarm and sprinkler systems
- Properly maintained egress and emergency lighting
- Complete inspection, testing, and maintenance documentation for all fire protection systems
- Full compliance with NFPA 101 and NFPA 99
- Regular fire drills and staff training programs
Life Safety Surveys typically receive intense scrutiny during accreditation visits. Minor issues like blocked exits, expired extinguisher tags, or missing fire door labels can lead to citations or conditional accreditation status.
COMPREHENSIVE HEALTHCARE FIRE PROTECTION SUPPORT
Pye-Barker partners with hospitals and surgical centers nationwide to provide:
- Complete fire alarm, sprinkler, and suppression system inspections
- Life Safety Code consulting and documentation assistance
- Firestop and fire door inspection programs
- Accreditation readiness assessments
- Deficiency resolution and corrective action support
Our technicians understand both NFPA compliance requirements and CMS documentation standards, helping reduce your risk while preparing for successful accreditation outcomes. n services to ensure your kitchen stays code-compliant and protected year-round.
READY FOR YOUR NEXT SURVEY?
Whether your facility has an upcoming accreditation review or you want to ensure ongoing compliance, our healthcare fire protection specialists are here to help.
Need assistance with life safety compliance? Schedule a consultation with our team or check out our comprehensive Guide to Life Safety Systems & Services.