In healthcare facilities, fire emergencies can jeopardize more than property—they can endanger vulnerable patients and disrupt critical care. Fire drills are a required element of hospital life safety programs, mandated by both national codes and accreditation bodies.
At Pye-Barker Fire & Safety, we work with hospitals and healthcare systems to ensure fire drill protocols meet standards set by NFPA, CMS, and accrediting agencies such as The Joint Commission and DNV. This guide breaks down what’s required and how to stay compliant.
WHY HOSPITAL DRILLS ARE ESSENTIAL
Hospitals are considered defend-in-place facilities. Evacuation is not always feasible, especially for patients in surgery, critical care, or isolation. Instead, staff must be trained to:
- React quickly to alarms
- Relocate patients safely within the facility
- Contain fire and smoke
- Communicate with emergency services and internal command structures
Regular fire drills ensure these actions can be carried out under pressure and that staff remain prepared.
REGULATORY REQUIREMENTS
Fire drill requirements for hospitals are governed by multiple codes and standards:
NFPA 101: Life Safety Code (2021 Edition) Section 18.7.1.6 requires healthcare occupancies to conduct fire drills quarterly on each shift.
CMS Emergency Preparedness Rule Requires all Medicare- and Medicaid-participating providers to maintain and test emergency response plans, including fire events.
The Joint Commission EC.02.03.03 Mandates that fire drills be evaluated, documented, and critiqued, with improvements tracked over time.
DNV NIAHO Standard PE.5 Reinforces fire drill frequency and documentation as part of the physical environment audit.
DRILL FREQUENCY REQUIREMENTS
| Facility Type | Frequency Requirement | Notes |
| Acute Care Hospitals | Quarterly on each shift | At least one drill per shift per quarter |
| Outpatient Clinics | Semi-annually or per AHJ | May depend on occupancy and building type |
| Long-Term Care | Quarterly, with variable shift coverage | Some drills may be announced per regulations |
| Ambulatory Surgery | Semi-annual to quarterly (based on accreditation) | Follow CMS and local codes |
Drills must reflect real scenarios and not be limited to front-desk or administrative-only participation.
ESSENTIAL FIRE DRILL COMPONENTS
A well-executed fire drill includes:
- Alarm activation or simulation
- Notification of appropriate staff and departments
- Execution of R.A.C.E. procedures (Rescue, Alarm, Confine, Extinguish)
- Testing of fire doors, smoke compartments, and egress routes
- Relocation or simulated movement of patients
- Communication with security, engineering, and the fire department
- Post-drill critique and documentation
Fire drills should be unannounced at least once per year and include written evaluations to identify gaps and implement corrective actions.
COMMON COMPLIANCE ISSUES
Citations often result from:
- Drills conducted inconsistently across shifts
- Inadequate documentation of time, participants, or outcomes
- Failure to address deficiencies from prior drills
- Lack of staff knowledge about fire response procedures
- Drills performed in administrative areas only, excluding patient care zones
HEALTHCARE FIRE PROTECTION SERVICES
Pye-Barker offers consultative support and fire protection services tailored to healthcare environments. Our team helps facilities:
- Plan and execute code-compliant fire drills
- Conduct mock Joint Commission surveys and readiness walkthroughs
- Maintain life safety documentation required for surveys
- Inspect and maintain fire alarms, sprinklers, extinguishers, and egress systems
- Train staff in R.A.C.E. and fire extinguisher use
We understand that no two facilities are alike, and our services reflect the complexity of healthcare operations.
PROFESSIONAL CONSULTATION SERVICES
Preparing for your next CMS survey or accreditation visit? Let Pye-Barker help you meet requirements with confidence. From fire drill planning to complete life safety system management, we’re here to support your team every step of the way.
Contact Pye-Barker Fire & Safety to request a healthcare fire protection consultation and explore our comprehensive life safety services for healthcare facilities.