Evacuation
Drills Requirements and Interpretation in ICF/MRs
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of BQA 01-025 (PDF, 8 KB)
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Date: May 25, 2001 DSL-BQA-01-025
To: Facilities for the Developmentally Disabled FDD 12
From: La Vern Woodford, Chief, Resident Care and Review Section
Via: Susan Schroeder, Director, Bureau of Quality Assurance
Federal "look behind" Monitoring Surveys (FMS) have
determined that some Wisconsin Intermediate Care Facilities serving
persons with Mental Retardation (ICF/MR) and some Bureau of Quality
Assurance (BQA) staff are not correctly interpreting 483.470(i)(1) and (2)
as they relate to the need to physically evacuate residents from the
facility. This memo provides clarification of evacuation drill
requirements for an ICF/MR. The Code of Federal Regulations at
483.470(i)(1) and (2) require the following:
The facility must hold evacuation drills at least quarterly for each
shift of personnel and under varied conditions to ensure that all
personnel on all shifts are trained to perform assigned tasks; to ensure
that all personnel on all shifts are familiar with the use of the facility’s
fire protection features; and to evaluate the effectiveness of emergency
and disaster plans and procedures. The facility must actually evacuate
clients during at least one drill each year on each shift and make special
provisions for the evacuation of clients with physical disabilities.
An actual evacuation involves the movement of all clients from inside
to outside the building. This is required, regardless of building
construction certification. An ICF/MR facility may not use "defend in
place" methodologies described in Health Care Occupancies Chapters of
the Life Safety Code for evacuation drills. Fire drills for Health Care
Occupancies do not equate to evacuation drills in ICF/MR facilities.
The intent of the regulations is to ensure that staff on each shift
know, and can do, what is needed to safely evacuate clients from the
building. Staff must understand and practice procedures used in an actual
emergency evacuation. The use of elevators is not permitted for an
evacuation exercise, since electrical power may be disabled in a true
emergency. Staff must be able to safely evacuate all clients regardless of
ambulatory status or medical condition. Room locations for individuals who
require staff assistance for evacuation should be noted by the facility
and actions taken to ensure their efficient removal of these residents
from the facility. Results of evacuation drills may affect staffing
numbers, client room location and/or other problems related to evacuation
of specific clients.
Facility staff are solely responsible for executing effective
evacuation drills. Outside resources, such as the local fire department,
may not be part of the evacuation drill. Facilities with more than one
freestanding building, or defined by two-hour vertical firewalls, may
conduct separate evacuation drills in each building. Note that evacuation
through an adjoining building must still end outside the building.
The above interpretation does not reflect a change in the regulations,
but is a clarification of exactly what a resident evacuation entails in an
ICF/MR. These particular ICF/MR regulations are more stringent than the
requirements in the Health Care Occupancies Chapters of the Life Safety
Code. The regulations cannot be waived. BQA encourages prompt review of
your evacuation process and implementation of the required evacuation
exercises. Failure to have an actual evacuation for each shift within the
year preceding the survey will result in a citation of W tag 445 and/or
other related W tags.
If you have further questions about evacuation requirements, please
contact the Regional Field Operations Director
in
your area; David Soens, P.E., Engineering Consultant (608) 261-5993;
or Jean Kollasch, Provider Regulation Consultant at (608) 267-0466.
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