Department of Health Services Logo

 

Wisconsin Department of Health Services

If You Have Complaints about Wisconsin Health Care

Information about Division of Quality Assurance (DQA)

Consumer & Provider Information

Provider Types Regulated by DQA

DQA Listservs

Provider Search

Facility Directories

Provider Training

DQA Numbered Memos

DHS Forms

Construction/
Remodeling of Health Care Facilities

WI Nurse Aide Training and Registry Info

Caregiver Program/ Background Checks

WI Adult Programs Caregiver Misconduct Registry

Fire Watch, Fire Plan, and Fire Reporting Update

PDF Version DQA 12-013  (PDF, 50 KB)

Date: August 20, 2012 
DQA Memo 12-011
Obsolete Memo DSL-BQA-00-017
To: Adult Day Care ADC 05
Adult Family Homes AFH 06
Ambulatory Surgery Centers ASC 03
Community Based Residential Facilities CBRF 07
End Stage Renal Dialysis ESRD 03
Facilities Serving People with Developmental Disabilities FDD 05
Hospices HSPCE 03
Hospitals HOSP 05
Nursing Homes NH 09
Residential Care Apartment Complexes RCAC 06
From: Otis Woods, Administrator
Division of Quality Assurance

Fire Watch, Fire Plan, and Fire Reporting Update

The purpose of this memo is to provide information regarding the response to fire related emergencies in health care facilities. This memo provides regulatory information regarding the development of a fire watch system, fire plan and mandated reporting of a fire event. A Fire Watch Procedure and Fire Report form approved by the Division of Quality Assurance (DQA) is available for use by facilities with links included in this memo. This memo replaces DSL-BQA-00-017.

Fire Watch
Protective systems common to health care facilities are fire alarm and suppression protection systems. When a required fire alarm, sprinkler, or suppression system is taken out of operation, a life threatening situation occurs for all the residents/patients, staff, and visitors of the facility. The National Fire Protection Association (NFPA) 101 Life Safety Code (LSC) requires continuous maintenance and proper operation for these systems.

The method entitled “fire watch” appears in the 2000 edition of NFPA 101 as:

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. LSC § 9.6.1.8

Where a required automatic sprinkler 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. LSC § 9.7.6.1

Listed below are DQA recommended Fire Watch Procedure templates that are available for use: 

Fire Watch Rounds Template
Fire Watch Alarm Outages Template
Fire Watch Sprinkler Outages Template

Fire Plan
Life Safety Code § 19.7.2.2 requires that facilities have a written fire safety plan that outlines the minimal actions required by facility personnel upon discovery of fire. The written fire safety plan shall include the following elements:

(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 for floors and building for evacuation
(8) Extinguishment of fire

Facilities are required to personalize their fire safety plan to make it relevant to their specific facility.

Fire Reporting
Certain health care facilities, listed below, are required to report a fire event to the Division of Quality Assurance within the time specified in Wisconsin Administrative Code. Examples of reportable fire events may include: smoke from an oven, electrical fires, strange burning odors, fire alarm activation, etc.

  • Adult Family Homes: DHS 88.05(4)(e), within 72 hours
  • Community Based Residential Facilities: DHS 83.12(4)(e), within 3 working days
  • Facilities for the Developmentally Disabled: DHS 134.82(4)(e), within 72 hours
  • Hospitals: DHS 124.36(11), within 72 hours
  • Nursing Homes: DHS 132.82(3)(e), within 72 hours

An approved Fire Report form is available online at: http://www.dhs.wisconsin.gov/forms1/F6/F62500.doc. Reporting may be done by other means such as forwarding a copy of a fire department report or a facility letter describing the event and signed by a facility representative.

Contact Information
If you have any questions regarding the information in the memo, please contact Henry Kosarzycki, Division of Quality Assurance Fire Authority, at (414) 227-4951 or at Henry.Kosarzycki@wisconsin.gov.

PDF: The free Acrobat Reader® software is needed to view and print portable document format (PDF) files. Learn more.

Last Updated: August 21, 2012