ASHE: LS.02.01.30

FOCUS on LS.02.01.30

LS.02.01.30 – The hospital Provides and maintains building features to protect individuals from the hazards of fire and smoke



Fire and smoke barriers and their protective opening devices in hospitals and other health care facilities are key elements of the structure. They protect occupants from the products of fire and combustion and are used for the horizontal evacuation of those in compromised areas. These barriers and their protective opening devices form effective compartmentation that allows defend-in-place strategies to be safely employed.

The proper design, installation, and maintenance of these features is critical to maximizing patient safety; facilitating entry and travel for emergency responders; and minimizing death and injury in an emergency incident.  Without these key elements, catastrophic outcomes could result. Since many patients are incapable of self-preservation and cannot independently respond to an emergency, integral passive fire and smoke features, such as fire and smoke barriers and protective opening devices, within the facility are essential to protect these individuals and allow for staff to respond and evacuate these patients.


During emergencies in other types of buildings, evacuation from the structure is typically the best option—but in health care facilities, evacuation could actually be a greater threat to life for many of the occupants. Therefore, a defend-in-place strategy is the most appropriate way to respond to fires and other events within a health care facility. This type of strategy is dependent on three key protection features: active fire protection, passive fire protection, and fire prevention.  This life safety standard focuses on the elements of the passive fire protection features. The failure of any of these features can significantly increase the exposure of patients and staff during a fire or other emergency.  In fire situations generally, the vast majority of deaths result from smoke inhalation.  Being able to confine the fire and the smoke and toxic fumes to the room of origin will not only limit the amount of combustion during the incident but also significantly reduce the risk to patients and staff.


Building features such as fire and smoke barriers along with opening protectives, such as doors, dampers, and glazing, are key components of passive fire protection providing protection from smoke and other byproducts of fire.  The failure to properly maintain and test these features significantly increases the risk to those who cannot take action on their own. Unprotected or improperly protected penetrations in fire and smoke barriers allow for the transfer of fire and products of fire across these barriers, which are intended to compartamentalize health care facilities. The compartments are specifically required to provide the necessary protection for those incapable of self-preservation and a lack of integrity within these barriers puts patients at increased risk to exposure to fire and smoke.  Additionally, protective openings, such as fire doors and all of their features, are key components of these barriers.  If automatic closing devices and latching hardware are not properly functioning on these opening protectives, these devices will not provide sufficient protection in the case of an emergency.


A review of the 2014 Joint Commission survey data indicates key areas of noncompliance to Standard LS.02.01.30 in the areas of penetrations within fire and smoke barriers and fire and smoke barrier door failures. Standard LS.02.01.10 includes many related issues, so Focus on Compliance resources available for these standards can be found on the following pages.

See the following pages for specific mitigation strategies for the following issues:

Were These Resources Helpful? Let Us Know