For: Assisted Living and Specialty Care Facilities (Alabama)

For:

Assisted Living and Specialty Care Facilities

(Alabama)

Life Safety/Physical Plant Guidelines

ALABAMA STATE BOARD OF HEALTHAlabama Department of Public Health

(ADPH)Tech Services and/or State Fire Marshal

“Authority Having Jurisdiction”

Assisted LivingChapter 420-5-4

Specialty CareChapter 420-5-20

Rules and Governance

NFPA 101-Life Safety Code (2000)Congregate

Chapters 18/19“Health Care Occupancies (limited care)”

GroupChapters 32/33

“Residential Board and Care Occupancies, Impractical Evacuation Capability”

Family Chapter 24

“One and Two Family Dwellings”


NFPA “Systems” Compliance :NFPA 72 (1999)

National Fire Alarm CodeNFPA 25 (1998)

Sprinkler Systems Test/InspectionWater based systems

NFPA 13 (1999)Sprinkler Systems Installation


NFPA Continued:NFPA 17/17A & 96 (1998)

Range Hood Extinguishing SystemsVentilation Control/Extinguishment

NFPA 10 (1998)Portable Fire Extinguishers

NFPA 110 (1999)Standby and E-Power Systems


RED:420-5-4.12 (3s,t)/420-5-20-.12 (3s,t)

Sprinkler System FunctionPer NFPA 25 or BY RULE

Fire Alarm System FunctionPer NFPA 72 (1999) or BY RULE

Scoring System Deficiencies

YELLOW:420-5-4-.12(3o,r,s,t) 420-5-20-.12(3o,r,s,t) Failure to provide Fire Extinguishers

Failure to Inspect/Test:ExtinguishersSprinkler SystemsAlarm Systems


YELLOW:420-5-4-.11(1a)/420-5-20-.11(1a)

Evacuation PlanWritten PlanPosted Floor PlanRevision Effectiveness Observation

Documented…..Documentation=Fire Drills

One per month/Varying times and conditions

Employee participation/System functionActual evacuation AS requiredAfter hours drills


YELLOW:420-5-4-.12(3v)/420-5-20-.12(3v)

Properly Marked Exits/Paths of Egress

Actual Exit LocationsPath to Exit Location/Path of EgressLeading to “right of way”

Illuminated (Battery or E-power)

Both bulbs burning


An emergency action plan, which details what to do when a disaster or fire occurs.

A disaster/fire prevention plan which describes what to do to prevent a fire from occurring.

Preparedness Plan-Two Essential

Components

*These two components overlap and are inseparable.

Employers are required to review the emergency action plan with each employee at the following times:

when the plan is developed.when the employee’s responsibilities

or designated actions under the plan change.

whenever the plan changes.

Emergency Prep-Fire Plan

Eight/Nine Requirements of Fire Plan:Use of alarmsAuto-transmission of alarm to fire

departmentresponse to alarms

Emergency Call to Fire Department (2003)Isolation of fireEvacuation of immediate areaEvacuation of a smoke compartment Prep for floor and building evacuationExtinguishment of fire

Fire Plan (per NFPA 101 and ADPH )

Components of Fire Watch Plan1. Notification of Tech Services2. Notification of Staff3. Fire Watch Approval4. Acceptable Plan5. Fire Watch Activity/Assignment6. Fire Watch Log

Fire Watch

Fire watch:Where a required fire alarm system or sprinkler system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified (Alabama Dept. of Public Health- 334-206-5890), and the building shall be evacuated or an approved fire watch shall be provided for all parts of the facility left unprotected by the shutdown until the fire alarm system has been returned to service.

Fire Watch

Fire watch:A fire watch will include a fire watch plan

approved by the local fire official indicated on a letter from that said official indicating he or she is aware of the program and has approved the facilities response plan.

A log by the individual doing the fire watch

showing that the zones or areas of the facility under the watch has been checked every 15-30 minutes will be kept on site and a copy faxed to Tech Services every 4-6 hours until the problem is corrected.

Fire Watch

Fire watch:A fire watch should involve some

special action beyond normal staffing, such as assigning an additional security guard or maintenance person to walk the areas affected.

Individuals should be specially trained in fire prevention and in occupant and fire department notification techniques, and they should understand the particular fire safety situation for public education purposes

Fire Watch

Alarm System Functions:(For the purposes of the code, a complete fire alarm system shall be used for initiation, notification, and control and shall provide the following)

(1) Initiation. The initiation function provides the input signal to the system.

(2) Notification. The notification function is the means by which the system advises that human action is required in response to a particular situation.

Alarm Systems

Alarm systems:(3) Control. The control function provides outputs to control building equipment to enhance protection of life.

The loss of any one of these functions of a fire alarm system would require the need for a fire watch if the loss as for a period of 4 hours or more in a 24 hour period.

Alarm Systems

REFERENCES:

NFPA 101 2000 Edition sec. 9.6.1.8, Fire alarm system out of service

NFPA 101 2000 sec. 9.7.6.1, Sprinkler system shutdown

Fire Watch/Alarm Systems

Fire Drill Procedures:Fire drills in health care occupancies

shall include the transmission of a fire alarm signal and simulation of emergency fire conditions.

Drills shall be conducted at least once MONTHLY (Per Rule) at varying times, days and Quarterly on each shift of Group and Congregate facilities.

Fire Drills

Fire Drill Procedures:Requires initiation of fire alarm

system unless otherwise noted Drills may be announced in advance

to residentsDrills shall involve actual evacuation

of residents to assembly areas in adjacent smoke compartments or to exterior location

Fire Drills

Procedure in case of fire:When drills are conducted between

9:00pm (2100 hours) and 6:00am (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.

EXCEPTION: Infirm or bedridden patients shall

not be required to be moved during drills to safe

areas or to the exterior of the building.

Employees of health care occupancies shall be instructed in life safety procedures and devices.

Fire Drills

No requirement for Annual 90 minute run

No requirement for weekly 30 minute run

Monthly operation for 30 minutes under load

Run cannot include cool down

Emergency PowerRef: NFPA 110 Sec. 6-4

Battery Lighting Requirements: Monthly functional test for 30 secondsBattery lighting back-up for generator

Generator:Annual 90 minute test to include

documentation of the test and level of illumination upon completion.

Emergency Lighting Ref: NFPA 110 Sec. 7.9.3

D.A.C.T. (digital alarm communicator/transmitter)Note: Secondary audible signal

requirement

Battery backup

Complete System Test EVERY month

Fire Drill vs. Alarm System Test

Alarm SystemsRef: NFPA 72

Types of Portable ExtinguishersABC

Universal TypeK

Kitchen Applications

Access to extinguishersTravel no more than 75 feet in any

directionAccess clear of ALL obstructions

Portable Fire ExtinguishersRef. NFPA 10

Types:Re-circulatingExterior vent

Inspection/Tests:Per NFPA 96 and Facility ApplicationTypically not to exceed 180 days

Cleaning:Twice per year, ORAs required per inspection documents

Kitchen Range Hood & Duct System

Ref. NFPA 96

1. Smoking prohibited in any room, ward, or compartment where flammable liquids, combustible gases or oxygen is used or stored and in any other hazardous location. All such areas shall be posted with NO SMOKING signs.2. Smoking by residents classified as not responsible is prohibited unless directly supervised.3. Ashtrays of non-combustible material and safe design shall be provided in all areas where smoking is permitted.4. A metal container/device with self-closing cover intended only for emptying ashtrays shall be readily available to all areas where smoking is permitted.

Smoking Policies & ProceduresRef. NFPA 101 19.7.4

Applicable Systems (vary per facility license)Alarm Systems

FORM 72-101 (2002 Edition)4 page handout

Sprinkler SystemsExhaust/Range HoodFire Extinguishing Equipment

VERIFY Completeness of ALL Forms (yes, no, n/a)

Contracted Tests/Inspections

Recommended References:Compressed Gas Association

(CGA)Publications for Handling, Trans-

filling, Storage, Labeling, Etc.NFPA 99 (1999) Standard For

Health Care FacilitiesStorage Requirements

Chapter 8 <3000cfChapter 4 >3000cf

Oxygen Storage/Handling

Basic Oxygen Info:Colorless, Odorless, Tasteless GasNOT Flammable….But Enriches

Atmosphere (saturates linens, clothes, etc.)

Liquid O2 release can cause frostbite and/or cryogenic burns

Contents (Liquid & Gas) under pressure

Avoid Trans-filling if Possible


Overview of Oxygen Rules:Employees and Residents must be

properly trained on hazards and safety

Operate equipment per manufacturer and/or supplier instruction

Maintain Policy for storage and handling of Oxygen products

Posting of Non-smoking signs required (where applicable)


Overview of Oxygen Rules :Limit repairs of equipment to

manufacturers and suppliersLimit storage quantities per “NFPA

99”Never store: Near Electrical,

Excessive Heat, Unsecured, Horizontal, Confined or Unventilated Areas


Michael Arther, NHAMCA Consulting, LLC

PO Box 5145Glencoe, AL 35905

[email protected]

For: Assisted Living and Specialty Care Facilities (Alabama)

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