Fire Safety in Health Care FacilitiesAPRIL 2011

Applicable codes

For Federal Medicare/Medicaid certification, healthcare facilities must be in compliance with National Fire Protection Association (NFPA) Standard 101 The Life Safety Code® (2000 edition) (LSC)

With state licensure requirements which requires being in compliance with the 2007 Minnesota State Fire Code (MSFC)

For purposes of federal certification

EXISTING: Buildings constructed or for which plans were reviewed or a permit issued prior toMarch 11, 2003 must meet LSC Chapter 19 Before July 10, 2007 for MSFC and MSBC

NEW: Buildings constructed or for which plans were reviewed or a permit issued on or afterMarch 11, 2003 must meet LSC Chapter 18 After July 10 2007 for MSFC and MSBC

Documentation Project

Documentation � the basics

Everything must be properly documented � if it isn�t documented, it didn�t happen.

The State Fire Marshal Division recommends that all documentation subject to review during a facility�s annual fire/life safety survey be kept in an indexed 3-ring binder

Documentation � the basics

It�s important that at least two people in your facility know where your fire safety records and documentation are kept.

1 Building Information

An up-to-date 8½� x 11� floor plans, highlighting all fire barriers

Date(s) of construction of the building and any additions

Construction type(s) of the building and any additions

Building Documents Include

Construction Types

Existing

Additions Need 2 hour Separation

Construction Types

New Construction

Sprinkler Protected

Quick Response Heads

Smoke Detection

Major Renovations

Renovations, alterations or modernizationsSprinkler requirements of Chapter 18 applyAlso requires meeting 19.1.6 (sprinklers)Also requires meeting 19.3.2.3 (exiting)Damper exception in smoke barriers

2 Emergency Plan

Fire Plans are Required

Administration is responsible to have a written fire plan

Fire plan must is available to all supervisory staff (MSFC 404.5)

Copy of the fire plan is at the telephone operator�s position or at security center

(MSFC 404.5)

Fire Plans Must Include

Protection of all persons

Evacuation to areas of refuge

Evacuation of the building when necessary(LSC 19.7.1.1 & MSFC 404.3)

Fire Plans Must Include

A written health care occupancy fire safety plan shall provide for the following:

1) Use of alarms 2) Transmission of alarm to fire department 3) Response to alarms 4) Isolation of fire 5) Evacuation of immediate area 6) Evacuation of smoke compartment 7) Preparation of floors and building for evacuation 8) Extinguishment of fire (LSC 19.7.2.2)

The Basic Response (LSC 19.7.2.1)

R.A.C.E. Rescue (get people out of immediate danger)

Alarm (use code word, sound alarm)

Confine (close doors)

Extinguish

Rescue and Alarm

Rescue (Evacuation of immediate area) Remove all occupants directly involved with the fire emergency (Response to alarms)

Duties of staff Many facilities break these down

Alarm (Use of alarms) Pull Stations Room Smoke Detectors

Transmission of fire alarm signal to warn other building occupants and summon staff (Transmission of alarm to fire department)

Confine and Extinguish

ConfineConfinement of the effects of the fire by

closing doors to isolate the fire area(Isolation of fire) Close doors, Automatic

sprinkler

Extinguish (Extinguishment of fire)

Fire Plans

Relocation of patients or residents Evacuation of smoke compartment

Move people through cross corridor doors Move people to specified areas

Preparation of floors and building for evacuation Gather Medical records Residents/ Patients glasses, hearing aids,

walkers, wheel chairs, etc. How are you getting from here to there

Fire Plans Minnesota Shall Include

The procedure for: Reporting a fire Notifying, relocating, or evacuating occupants

A site plan indicating the following: The occupancy assembly point The locations of fire hydrants The normal routes of fire department vehicle

access (MSFC 404.3.2)

3 In-service Records

Fire and evacuation training

Records indicate individual staff Summary of topics covered Include any fire safety training Training shall be more than drills

4 Smoking Policy

Include where smoking is allowedControl of smoking materials

5 Oxygen Use Policy

Why do we need to worryabout Oxygen?

FIRE IS

The Rapid Self- Sustaining OXIDATION of a FUEL that gives off Light and HEAT

FIRE TETRAHEDRON

Oxygen

OXYGEN SOURCES

Air 21 % oxygen

Compressed Cylinders Common in Health

Care and Home Use

Liquid Common in Health

Care and Home Use

Combined gases Common in Industry

Marking Containers

Stationary Containers with the name of the gas Signs shall be:

in English or in symbols allowed by this code

durable

The size, color and lettering shall be approved

Markings shall be visible from any direction 3003.4.1

Portable containers, cylinders and tanks Labeled in accordance with CGA C-7 3003.4.2

Marking Piping Systems

Must meet ASME A13.1 Shall consist of the name of gasA direction-of-flow arrowMarkings at

Each valve Wall, floor or ceiling penetrations Each change of direction A minimum of every 20 feet or fraction thereof

throughout run 3003.4

Security Cylinders

Shall be secured against accidental dislodgement and against unauthorized personnel

Areas used for the storage, use and handling of compressed gas containers and systems shall be secured against unauthorized entry 3003.5.1

Shall be protected indoors and outdoors from vehicular damage (Guard posts or other approved means and shall comply with Section 312) 3003.5.2

Security Cylinders Shall be secured to prevent

falling Secured to a fixed object

with one or more restraints

On a cart or other mobile device designed for the movement of containers

Label Locations

Containers In Use Shall be moved using an approved method

Carts, trucks or other mobile devices shall be designed to secure containers during movement

Compressed gas cylinders placed on carts and trucks shall be individually restrained 3005.10.1

Containers In Use

Ropes, chains or slings shall not be used to suspend compressed gas containers, unless provisions at time of manufacturehave been made on the container (such as lugs) 3005.10.2

Containers In Use

Transfer of gases between containersperformed by qualified personnel only use equipment and operating procedures in

accordance with CGA P-1

Inflatable equipment, devices or balloons shall only be pressurized or filled with compressed air or inert gases 3005.8

6 Systems Out of Service Policy

Fire Watch

Fire Protection System Out of Service

If the system is down for more than 4 hours within a 24 hour period: Contact AHJ Evacuated the building OR Institute an approved Fire Watch

A responsible person dedicated to the watch Keep records Continue until system is functional again LSC 9.6.1.8

Fire Watch

Impairment coordinator Tag the system is out of service Notify all supervisory staff Preplanned impairment programs Emergency impairments

Fire Watch Staff Shall:

Walk the facility or area assigned to them continually, insuring every room, closet and area

Must have an approved means of contacting the local Fire Department

This shall be their only duty The assigned staff shall document that all areas are

observed and how often it is done All areas shall be observed every 15 minutes or more

often

Fire Watch Staff Must Be:

Trained in Fire Prevention Trained in the use of portable fire extinguishers Have the ability to notify the FD

(phones and or radios) How to sound the fire alarm system Understanding the reason the system is

impaired and the problems caused by that

7 Fire Drills

Conducted monthly with each shift being drilled at least once a quarter

Fire Drills Are Required

For all Staff nurses, interns, doctors, maintenance

engineers, and administrative staff

to familiarize facility personnel with the signals and emergency action required under varied conditions (MSFC 406.3) (LSC 19.7.1.2)

Conducted quarterly on each shift(MSFC 405.2)

Conducting Fire Drills

The purpose of a fire drill is to test the efficiency, knowledge and response of staff

Health care facilities can conduct fire drills without disturbing patients by: choosing the location and time in advance

Schedule on a random basis

Drills should include simulated movement of patients to another smoke compartment Relocation can be practiced using simulated patients or empty

wheelchairs (MSFC 408.6.1)

Fire Drills Must Include

Transmission of fire alarm signal to monitoring company (LSC 19.7.1.2)

Simulation of emergency fire conditions Infirm or bedridden patients shall not be required to

be moved (MSFC 408.6.1)

When drills are between 9:00 pm and 6:00 am (2100 to 0600 hours), A coded announcement shall be permitted to be used instead of audible alarms (LSC 19.7.1.2)

Other Issues on Drills

Drills shall: Be designed in cooperation with the local authorities Be held with sufficient frequency to familiarize

occupants with the drill procedure and to establish conduct of the drill as a matter of routine (MSCF 406.2)

Include suitable procedures to ensure that all persons subject to the drill participate (MSFC 406.1)

Responsibility for the planning and conduct of drills shall be assigned only to competent persons (MSFC 405.3)

Other Issues on Drills

Emphasis shall be placed on orderly evacuation rather than on speed

Drills shall be: held at expected and unexpected times under varying conditions (MSFC 405.4)

Fire Drill Records

Records shall be maintained of required emergency evacuation drills and include the following information: Identity of the person conducting the drill Date and time of the drill Notification method used Staff members on duty and participating (MSFC 2007 405.5)

Fire Drill Records

Number of occupants evacuatedSpecial conditions simulatedProblems encounteredWeather conditions when occupants were

evacuatedTime required to accomplish complete

evacuation

8 Fire Alarm System

Testing, Service and Maintenance

Fire Alarm Systems

Testing in accordance with NFPA 72 Annually (use form out of NFPA 72) Smoke Detectors

Sensitivity Testing Other

Records of maintenance are requiredLSC 18.3.4, 19.3.4 & 9.6

9 Room Smoke Detector Testing

Sleeping Room Smoke Detectors

Battery detectors Test in accordance with Manufacturer

at least Monthly (some weekly)

Can be done by staff records for each detector

Each detector shall be UL listed

Hardwired detectorsTest at least Monthly (unless on fire alarm)

10 Smoke Detector Sensitivity Testing

Sensitivity Testing

Sensitivity TestingWithin the 1st year Skip a year If it passes twice (in 3

years)than 5 years

Document percentages of each detector

11 Automatic Digital Dialer

Monthly Documented on Drill FormOr from provider

12 Fire Sprinkler System

Annual servicing (company)Quarterly flow testing (staff or company)

Automatic Sprinkler Systems

New requires Complete Coverage In accordance with NFPA 13 Requires Quick Response or Listed Residential

Heads be used in Smoke Compartments that contain sleeping rooms

Required in Existing by construction type and in all by 2013

Only licensed company can work on Minnesota State Statue LSC 18.3.5

13 Kitchen Hood System

Service every 6-months Replace Fusible Links and Heads Annually

14Portable Fire Extinguishers

Portable Fire Extinguishers

Visually monthly (Quick Check)

Service (Annual)

Interior Inspection (6-year)

Hydro Testing (12 years)

15 Emergency Generator

Definitions

Emergency Power Supply (EPS) The source of electric power of the required capacity

and quality for an emergency power supply system

Emergency Power Supply System (EPSS) A EPS coupled to a system of conductors,

disconnecting means and over current protective devices, transfer switches, and all control, supervisory, and support devices NFPA 110, 3.3.2 & 3.3.3

Generator Inspections

Weekly InspectionsInclude Fuel LevelCoolant LevelOil LevelBattery Charge

Generator Testing

Monthly Load Testing (30 minutes) Under operating temperature conditions and at not

less than 30 percent of the EPS nameplate rating OR Loading that maintains the minimum exhaust gas

temperatures as recommended by the manufacturer

The date and time of day shall be decided by the owner, based on facility operations 6-4.2*

Diesel-powered EPS

That do not meet the 30 % monthly load test shall be exercised monthly with the available EPSS load and

exercised annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of 2 continuous hours (LOAD BANK) 6-4.2.2*

Load tests of generator sets shall include complete cold starts

Annually for 1 ½ hour

Emergency Lighting

All emergency lighting will have to last for 1 ½ hour (includes generators) LSC 19.2.9.1

Includes testing requirement Every 30 days for at least 30 seconds and Annually for 1 ½ hour Records to be kept LSC 7.9.3CFR 482 & 483

Generator installation

Level of Equipment

Level 1 shall be installed when failure of the

equipment to perform could result in loss of human life or serious injuries

Level 2 shall be installed when failure of the EPSS is

less critical to human life and safety

Types of EPSSs

Type 10, Class X, Level 1 Type 10 Picks up load in 10 seconds Class X Time it must run in hours, X= Other

Essential Electric System Shall have two separate systems

Emergency system Life Safety Branch Critical Branch

Equipment system

Stationary Generators

Stationary emergency and standby power generators shall be listed in accordance with UL 2200 (604.1.1)

Generator NFPA 110

Fuel Supply Not used for any other purpose

Low fuel sensing switch Main fuel tank is 133% of low fuel switch Must meet NFPA 37 Must have a battery charger Instrument panel

Remote Panel

Remote alarm panels located outside of the generator room

A visual indicators for Generator is operating The battery charger is

malfunctioning Individual visual display, with a

common audible alarm for low oil pressure low coolant temperature excessive coolant temperature low fuel level (less than 3-hour

supply) failure to start overspeed NFPA 110 section 3-

5.6.1 in a constantly attended location

Maintenance Records

Shall Include The date of service The name of the servicing technician A summary of conditions noted A detailed description of any conditions requiring

correction What corrective action was taken

Records shall be kept on the premises Be available for inspection by the fire code

official (604.3.2)

16 Battery-operated Emergency Lights and EXIT Signs

Monthly for 30 secondsAnnually for 90 minutes

Illumination of Exits

Must be reliableCMS requires emergency lighting to be

A 2 bulb fixture or multiple fixtures

CMS requires it to the public way 1 ft candle at floor or walkway

17 Fire/Smoke Dampers

Inspection, servicing and maintenance done every 4 years (Hospitals 6 years)

18 Interior Finishes

Document flame spread ratings of ceilings, walls and flooring

Interior Finishes

Keep (or find) documentation for all interior finishes (Testing sheets and/or labels)Wall coveringsCeiling TilesCarpeting

Note on Documentation of the finishes the location where installed

Interior Finishes EXISTING

Class C can stay in rooms if sprinkler protected Newly installed must be a Class A

Exception: Allows Class B in Rooms up to 4 persons

Exception: Allows lower 4 feet of corridor walls to be a Class B LSC 19.3.3.2

New flooring in corridors must be a Class 1 unless sprinkler protected LSC 19.3.3.3

Interior Finishes NEW

Class A or B

Allows lower 4 feet of corridor walls to be a Class C

Allows Class C in Rooms up to 4 personLSC 18.3.3.2

New flooring no requirement LSC 18.3.3.3

19 Decorations

Maintain documentation of treatments

Combustible decorations

Must be flame retardant Treated or Inherently flame resistive Photographs and

paintings in limited quantities do not

Culture change cannot jeopardize fire safety

20 Drapes & Curtains

Flame Resistant as tested in accordance with NFPA 701

Draperies and Curtains

Draperies, Curtains, including cubical and other loosely hanging fabrics and films shall flame resistant in accordance with NFPA 701Exception for shower curtainsMaintain documentation LSC 19.7.5.1

21 Upholstered Furniture and Mattresses

Newly Introduced Upholstered Furniture

Must meet NFPA 266 Heat release of 250 Kw and Total energy release of 40 Mj in 5 minutes Exception: sprinkler protected than not required Exception: belongs to the patient, is in their room,

and the room has smoke detection LSC 19.7.5.2 & 10.3.3

Newly Introduced means purchased after March 2003 CMS

Newly Introduced Mattresses Must meet NFPA 260

Heat release of 250 Kw and Total energy release of 40 Mj in 5 minutes Exception: sprinkler protected than not required Exception: belongs to the patient, is in their room,

and the room has smoke detection LSC 19.7.5.2 & 10.3.3

Newly Introduced means purchased after March 2003 CMS

Questions

Documentation � the basics

Everything must be properly documented � if it isn�t documented, it didn�t happen.

The State Fire Marshal Division recommends that all documentation subject to review during a facility�s annual fire/life safety survey be kept in an indexed 3-ring binder

Documentation � the basics

It�s important that at least two people in your facility know where your fire safety records and documentation are kept.

Web site contact

For more information on the subjects covered �

www.health.state.mn.us/divs/fpc/fpc.html) OR www.fire.state.mn.us).

THAT�S ALL FOR NOW

Prepared in cooperation with:

Minnesota State Fire Marshals Division

Centers for Medicaid Medicare Services

National Fire Protection Association