Fire Watch, Fire Plan, and Fire Reporting Update
PDF Version DQA 12-013
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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.
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Last Updated:
August 21, 2012
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