| Life Safety
Informational Release
PDF Version of BQA 00-017
(PDF, 15 KB) - includes attachment
Date: February 11, 2000 -- DSL-BQA-00-017
From: Jan Eakins, Chief, Provider Regulation and Quality
Improvement Section
cc: Susan Schroeder, Director, Bureau of Quality Assurance
The purpose of this memo is to raise awareness and to provide information regarding
emergencies in health care facilities. The information is specific to a Fire Watch Procedure template
for fire alarm system failures and a
Fire Reporting form
(PDF, 23 KB).
A protective device common to health care facilities is a fire alarm system. When
the fire alarm system is taken out of operation, a life threatening situation occurs for
all the residents/patients and staff of the facility. Dating back to 1965, the National
Fire Protection Association (NFPA) 101 Life Safety Code (LSC) standard substantiates our
position:
-
2-1112: Every building shall be so constructed, arranged, equipped, maintained
and operated as to avoid undue danger to the lives and safety of its occupants from fire.
-
2-2121: No existing building shall be occupied during repairs or alterations
unless any existing fire protection is continuously maintained, or other measures are
taken which provide equivalent safety.
-
2-3112: Every required fire detection and alarm system shall be continuously
maintained in proper operating condition.
The method entitled ‘fire watch’ first appears in the LSC 1997 edition:
-
7-6.1.8 Fire Alarm System Shutdown: Where a required fire alarm
system is out of service for more than 4 hours in a 24-hour period, the authority having
jurisdiction shall be notified and the building shall be evacuated or an
approved fire
watch shall be provided for all parties left unprotected by the shutdown until the
fire alarm system has been returned to service.
Please see the first attachment that contains the recommended Fire Watch Procedure template approved by the Bureau. You will
need to fill in relevant information so that it is useful for your facilities.
Health care facilities that experience a fire event are required to report the
event to the Bureau within a specified timeframe. Examples of such health care facilities
are as follows:
-
Hospitals, per section HFS 124.36 (11), within 72 hours;
-
Nursing Homes, per section HFS 132.82(6)(e), within 72 hours;
-
Facilities for the Developmentally Disabled, per section HFS 134.82(4)(e), within 72
hours;
-
Community Based Residential Facilities, per section HFS 83.19(3)(a), within 3 working
days;
-
Adult Family Homes, per section HFS 88.05(4)(e), within 72 hours.
Please refer to the attached Fire Reporting form
(PDF, 23 KB) (approved by
the Bureau) for such incidents. Note that reporting can be via other means, such as a fire
department report or a facility letter, signed by the administrator, describing the event.
If you have any questions regarding this information, please contact David R. Soens,
Quality Assurance Engineer, at (608) 261-5993.
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