CMS Life Safety Code Compliance Assessment: RACE/PASS Fire Safety
RACE/PASS Fire Safety products help healthcare organizations support CMS Life Safety Code compliance by reinforcing the essential actions staff should take during a fire emergency. Badge cards, wall signs, posters, banners, and customized materials provide clear, consistent reminders for rescuing people in danger, activating the alarm, containing smoke and fire, evacuating when necessary, and safely operating a portable fire extinguisher.
These materials align particularly well with CMS requirements for staff instruction, awareness of assigned duties, and familiarity with fire-response procedures. When incorporated into a facility-specific fire safety plan, employee orientation, recurring training, and documented fire drills, RACE/PASS products can strengthen staff preparedness and provide visible support for an ongoing fire-safety education program.
RACE/PASS products are compliance-support tools, not a complete compliance program. Facilities must still maintain a written fire safety and evacuation plan, conduct and document required drills, train employees on site-specific procedures, and satisfy all applicable building, fire-protection-system, inspection, testing, and maintenance requirements.
| CMS Life Safety Code Requirement | How RACE/PASS Fire Safety Products Help | Compliance Assessment |
|---|---|---|
| K711: Written Evacuation and Relocation Plan | RACE addresses rescue or removal, alarm activation, containment, fire extinguishment, and evacuation. | Supports compliance but does not satisfy the requirement by itself. The facility must maintain a site-specific written plan covering all required response and evacuation procedures. |
| K711: Periodic Employee Instruction | Badge cards , posters , signs , and banners provide frequent, consistent reminders of employees’ fire-response duties. Customized products can reinforce organization-specific procedures. | Strongly supports compliance when used as part of documented orientation, recurring instruction, and employee competency training. |
| Use of and Response to Fire Alarms | The “Alarm” step instructs staff to activate the building fire alarm, alert others, and notify emergency services. | Directly aligned when the materials reflect the facility’s actual alarm system, emergency telephone numbers, code phrase, and notification procedures. |
| Isolation of Fire and Smoke | The “Contain” step reminds staff to close doors and take other appropriate actions to limit the spread of smoke and fire. | Directly aligned with the required staff response for isolating a fire. |
| Evacuation of the Immediate Area and Smoke Compartment | The “Rescue” and “Evacuate” steps reinforce moving people in immediate danger to a safe location and following designated evacuation procedures. | Partially aligned. Facility training must also address horizontal relocation, smoke-compartment boundaries, patient or resident assistance, and vertical or building evacuation when applicable. |
| Portable Fire Extinguisher Use | PASS teaches the recognized operating sequence: Pull the pin, Aim at the base, Squeeze the handle, and Sweep from side to side. | Directly supports compliance and staff preparedness. Employees must also be trained on when extinguisher use is safe, which extinguisher to use, and the facility’s specific policy. |
| K712: Fire Drills on Every Shift | RACE/PASS provides a consistent response framework that employees can practice during fire drills. | Supports the drill program but does not satisfy the requirement alone. Required drills must be conducted under varying conditions at least quarterly on each shift and properly documented. |
| Staff Familiarity With Fire Procedures | Frequently displayed reminder materials can improve employee recall during training, drills, survey interviews, and actual emergencies. | Strongly supports compliance, but surveyors may still evaluate individual staff knowledge and review training and drill participation records. |
| Building Systems, Inspection, Testing, and Maintenance | RACE/PASS products focus on employee education and emergency response rather than physical building systems. | Does not address requirements involving sprinklers, alarms, smoke barriers, fire doors, exits, generators, medical gas systems, inspections, testing, or maintenance. |