1. For: Assisted Living and Specialty Care Facilities (Alabama)

2. ALABAMA STATE BOARD OF HEALTH Alabama Department of Public Health (ADPH) Tech Services and/or State Fire Marshal “Authority Having Jurisdiction” Assisted Living Chapter 420-5-4 Specialty Care Chapter 420-5-20

3. NFPA 101-Life Safety Code (2000) Congregate Chapters 18/19 “Health Care Occupancies (limited care)” Group Chapters 32/33 “Residential Board and Care Occupancies, Impractical Evacuation Capability” Family Chapter 24 “One and Two Family Dwellings”

4. NFPA “Systems” Compliance : NFPA 72 (1999) National Fire Alarm Code NFPA 25 (1998) Sprinkler Systems Test/Inspection Water based systems NFPA 13 (1999) Sprinkler Systems Installation

5. NFPA Continued: NFPA 17/17A & 96 (1998) Range Hood Extinguishing Systems Ventilation Control/Extinguishment NFPA 10 (1998) Portable Fire Extinguishers NFPA 110 (1999 ) Standby and E-Power Systems

6. RED: 420-5-4.12 (3s,t)/420-5-20-.12 (3s,t) Sprinkler System Function Per NFPA 25 or BY RULE Fire Alarm System Function Per NFPA 72 (1999) or BY RULE

7. YELLOW: 420-5-4-.12(3o,r,s,t) 420-5-20-.12(3o,r,s,t) Failure to provide Fire Extinguishers Failure to Inspect/Test: Extinguishers Sprinkler Systems Alarm Systems

8. YELLOW: 420-5-4-.11(1a)/420-5-20-.11(1a) Evacuation Plan Written Plan Posted Floor Plan Revision Effectiveness Observation Documented….. Documentation=Fire Drills  One per month/Varying times and conditions  Employee participation/System function  Actual evacuation AS required  After hours drills

9. YELLOW: 420-5-4-.12(3v)/420-5-20-.12(3v) Properly Marked Exits/Paths of Egress Actual Exit Locations Path to Exit Location/Path of Egress  Leading to “right of way” Illuminated (Battery or E-power)  Both bulbs burning

10. An emergency action plan, which details what to do when a disaster or fire occurs. A disaster/fire prevention plan which describes what to do to prevent a fire from occurring. *These two components overlap and are inseparable.

11. Employers are required to review the emergency action plan with each employee at the following times: when the plan is developed. when the employee’s responsibilities or designated actions under the plan change. whenever the plan changes.

12. Eight/Nine Requirements of Fire Plan: Use of alarms Auto-transmission of alarm to fire department response to alarms Emergency Call to Fire Department (2003) Isolation of fire Evacuation of immediate area Evacuation of a smoke compartment Prep for floor and building evacuation Extinguishment of fire

13. Components of Fire Watch Plan 1. Notification of Tech Services 2. Notification of Staff 3. Fire Watch Approval 4. Acceptable Plan 5. Fire Watch Activity/Assignment 6. Fire Watch Log

14. Fire watch: Where a required fire alarm system or sprinkler system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified (Alabama Dept. of Public Health- 334-206-5890), and the building shall be evacuated or an approved fire watch shall be provided for all parts of the facility left unprotected by the shutdown until the fire alarm system has been returned to service.

15. Fire watch: A fire watch will include a fire watch plan approved by the local fire official indicated on a letter from that said official indicating he or she is aware of the program and has approved the facilities response plan. A log by the individual doing the fire watch showing that the zones or areas of the facility under the watch has been checked every 15- 30 minutes will be kept on site and a copy faxed to Tech Services every 4-6 hours until the problem is corrected.

16. Fire watch: A fire watch should involve some special action beyond normal staffing, such as assigning an additional security guard or maintenance person to walk the areas affected. Individuals should be specially trained in fire prevention and in occupant and fire department notification techniques, and they should understand the particular fire safety situation for public education purposes

17. Alarm System Functions: (For the purposes of the code, a complete fire alarm system shall be used for initiation, notification, and control and shall provide the following) (1)Initiation. The initiation function provides the input signal to the system. (2)Notification. The notification function is the means by which the system advises that human action is required in response to a particular situation.

18. Alarm systems: (3) Control. The control function provides outputs to control building equipment to enhance protection of life. The loss of any one of these functions of a fire alarm system would require the need for a fire watch if the loss as for a period of 4 hours or more in a 24 hour period.

19. REFERENCES: NFPA 101 2000 Edition sec. 9.6.1.8, Fire alarm system out of service NFPA 101 2000 sec. 9.7.6.1, Sprinkler system shutdown

20. Fire Drill Procedures: Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted at least once MONTHLY (Per Rule) at varying times, days and Quarterly on each shift of Group and Congregate facilities.

21. Fire Drill Procedures: Requires initiation of fire alarm system unless otherwise noted Drills may be announced in advance to residents Drills shall involve actual evacuation of residents to assembly areas in adjacent smoke compartments or to exterior location

22. Procedure in case of fire: When drills are conducted between 9:00pm (2100 hours) and 6:00am (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms. EXCEPTION: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building. Employees of health care occupancies shall be instructed in life safety procedures and devices.

23. No requirement for Annual 90 minute run No requirement for weekly 30 minute run Monthly operation for 30 minutes under load Run cannot include cool down

24. Battery Lighting Requirements: Monthly functional test for 30 seconds Battery lighting back-up for generator Generator: Annual 90 minute test to include documentation of the test and level of illumination upon completion.

25. D.A.C.T. (digital alarm communicator/transmitter) Note: Secondary audible signal requirement Battery backup Complete System Test EVERY month Fire Drill vs. Alarm System Test

26. Types of Portable Extinguishers ABC Universal Type K Kitchen Applications Access to extinguishers Travel no more than 75 feet in any direction Access clear of ALL obstructions

27. Types: Re-circulating Exterior vent Inspection/Tests: Per NFPA 96 and Facility Application Typically not to exceed 180 days Cleaning: Twice per year, OR As required per inspection documents

28. 1. Smoking prohibited in any room, ward, or compartment where flammable liquids, combustible gases or oxygen is used or stored and in any other hazardous location. All such areas shall be posted with NO SMOKING signs. 2. Smoking by residents classified as not responsible is prohibited unless directly supervised. 3. Ashtrays of non-combustible material and safe design shall be provided in all areas where smoking is permitted. 4. A metal container/device with self-closing cover intended only for emptying ashtrays shall be readily available to all areas where smoking is permitted.

29. Applicable Systems ( vary per facility license ) Alarm Systems FORM 72-101 (2002 Edition) 4 page handout Sprinkler Systems Exhaust/Range Hood Fire Extinguishing Equipment VERIFY Completeness of ALL Forms (yes, no, n/a)

30. Recommended References: Compressed Gas Association (CGA) Publications for Handling, Trans-filling, Storage, Labeling, Etc. NFPA 99 (1999) Standard For Health Care Facilities Storage Requirements Chapter 8 <3000cf Chapter 4 >3000cf

31. Basic Oxygen Info: Colorless, Odorless, Tasteless Gas NOT Flammable….But Enriches Atmosphere (saturates linens, clothes, etc.) Liquid O2 release can cause frostbite and/or cryogenic burns Contents (Liquid & Gas) under pressure Avoid Trans-filling if Possible

32. Overview of Oxygen Rules: Employees and Residents must be properly trained on hazards and safety Operate equipment per manufacturer and/or supplier instruction Maintain Policy for storage and handling of Oxygen products Posting of Non-smoking signs required (where applicable)

33. Overview of Oxygen Rules : Limit repairs of equipment to manufacturers and suppliers Limit storage quantities per “NFPA 99” Never store: Near Electrical, Excessive Heat, Unsecured, Horizontal, Confined or Unventilated Areas

34. Michael Arther, NHA MCA Consulting, LLC PO Box 5145 Glencoe, AL 35905 256-390-0554 michael@mcaconsult.net