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Evacuation Drills Requirements and Interpretation in ICF/MRs

PDF Version 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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