FSES and Equivalency Preparation

FSES and Equivalency Preparation

We help you prepare documentation that meets both FSES and Equivalency standards.

TSIG Consulting, Inc. (TSIG) provides assistance in preparation of all documentation required for both FSES and Equivalency preparation.

Traditional Equivalency is basically a formal written request submitted by an organization to TJC for a waiver of an existing code deficiency that cannot be corrected due to hardship or other serious limitations (lack of funding is not an accepted excuse for submitting one). It describes how a facility will offset existing LSC deficiencies without reducing the protection set by the LSC’s requirements. An equivalency is an alternate solution that includes evidence of compliance or an assurance that the organization will address any noncompliance as a high priority. An organization submitting a Traditional Equivalency request to The Joint Commission must also contact its regional CMS office and submit a waiver request, as The Joint Commission Traditional Equivalency is not recognized by CMS. A Fire Safety Evaluation System (FSES) is a NFPA published multiple page documents that place numerical values to specific life safety features of a building. It is found in NFPA 101A, Guide on Alternative Approaches to Life Safety. This document provides alternative approaches to life safety based on the NFPA 101 Life Safety Code. It is intended to be used with the Life Safety Code, not as a substitute. The Life Safety Code permits alternative compliance with the Code under equivalency concepts where such equivalency is approved by the authority having jurisdiction. After assigning a numerical value to specific life safety features based on questions in the FSES, a score is derived in four basic equivalency functions:

  • Containment safety
  • Extinguishment safety
  • People movement
  • General safety

If the score equals 0 or greater in each of the basic functions, then the FSES demonstrates an acceptable level of safety, and the AHJ should approve it as an equivalency. The FSES is accepted and if correctly completed, indisputable by both TJC and CMS. However, CMS requires that it be resubmitted on an annual basis. Therefore, since many things can change from one year to the next, one must assure that the assessment and calculation process of the FSES is re-evaluated each year prior to resubmitting it to CMS.

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