N.H. Admin. Code § He-P 824.25

Current through Register No. 45, November 7, 2024

Section He-P 824.25 - Emergency and Fire Safety

(a) All HHs shall meet the appropriate chapters of the state fire code and state building code.

(b) All HH's shall have:

(1) Smoke detectors on every level and in every bedroom that are interconnected and either hardwired, powered by the HH's electrical service, or wireless, as approved by the state fire marshal for the HH;

(2) At least one ABC type fire extinguisher on every level or every 75 feet of corridor as required by NFPA 10 that shall:

a. Be manually inspected when initially placed in service;

b. Be inspected either manually or by means of an electronic monitoring device/system at intervals not exceeding 31 days; and

c. Be inspected at least once per calendar month and include:

1. Documentation of the manual fire extinguisher inspections which shall be maintained on-site in accordance with NFPA 10 and available at the time of the inspection or investigation; and

2. Documentation of electronically monitored fire extinguishers which shall be provided to the department within 2 business days of the completion of the inspection or investigation; and

(3) An approved carbon monoxide monitor on every level.

(c) Immediately following any fire or emergency situation, licensees shall notify the department by phone to be followed by written notification within 72 hours, with the exception of:

(1) A false alarm or emergency medical services (EMS) transport for a non-emergent reason; or

(2) Emergency EMS transport related to pre-existing conditions.

(d) The written notification under (c) above shall include:

(1) The date and time of the incident;

(2) A description of the location and extent of the incident, including any damage;

(3) A description of events preceding and following the incident;

(4) The name of any personnel or patients who were evacuated as a result of the incident, if applicable;

(5) The name of any personnel or patients who required medical treatment as a result of the incident, if applicable; and

(6) The name of the individual the licensee wishes the department to contact if additional information is required.

(e) For the use and storage of oxygen and other related gases, HHs shall comply with NFPA 99, Health Care Facilities Code including, but not limited to, the following:

(1) All freestanding compressed gas cylinders shall be firmly secured to the adjacent wall or secured in a stand or rack;

(2) Storage locations shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limited-combustible construction, with doors, or with gates if outdoors, that can be secured against unauthorized entry;

(3) Oxidizing gases, such as oxygen and nitrous oxide, shall:

a. Not be stored with any flammable gas, liquid, or vapor;

b. Be separated from combustibles or incompatible materials by:

1. A minimum distance of 20 ft (6.1 m);

2. A minimum distance of 5 ft (1.5 m) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems; or

3. An approved, enclosed flammable liquid storage cabinet of noncombustible construction having a minimum fire protection rating of one-half hour for cylinder storage; and

c. Shall be secured in an upright position, such as with racks or chains;

(4) A precautionary sign, readable from a distance of 5 ft (1.5 m), shall be conspicuously displayed on each door or gate of the storage room or enclosure, and shall include, at a minimum, the following: "CAUTION, OXIDIZING GAS(ES) STORED WITHIN - NO SMOKING";

(5) Precautionary signs, readable from a distance of 5 ft (1.5 m), and with language such as "OXYGEN IN USE, NO SMOKING", shall be conspicuously displayed wherever supplemental oxygen is in use and in aisles and walkways leading to the area of use, and shall be attached to adjacent doorways or to building walls or be supported by other appropriate means; and

(6) Flammable gases and liquids shall be stored in metal fire retardant cabinets.

(f) If the licensee has chosen to allow smoking, a designated smoking area shall be provided which has, at a minimum:

(1) A dedicated ventilation system, so that smoke or odors cannot escape or be detected outside the designated smoking room;

(2) Walls and furnishings constructed of non-combustible materials; and

(3) Metal waste receptacles and safe ashtrays.

(g) A copy of the fire safety plan including fire drill actions shall be made available to and reviewed with the patient, or the patient's guardian or a person with durable power of attorney (DPOA), at the time of admission and a summary of the patient's responsibilities shall be provided to the patient. Each patient shall receive an individual fire drill walk-through within 5 days of admission, as appropriate.

(h) The fire safety plan shall be reviewed and approved as follows:

(1) A copy of the fire safety plan shall be made available, annually and whenever changes are made, to the local fire chief for review and approval;

(2) The local fire chief shall give written approval initially to all fire safety plans; and

(3) If changes are made to the plan, they shall be submitted to the local fire chief for review and approval, as appropriate, prior to the change.

(i) Fire drills shall be conducted as follows:

(1) For all HHs which are constructed to meet the Health Care Occupancy Chapter of Life Safety Code, NFPA 101 as defined in RSA 153:1, VI-a, except as modified in Saf- FMO 300, and the rules and regulations adopted and enforced by the state fire marshal's office and/or the municipality or have been physically evaluated, renovated, and approved by a New Hampshire licensed fire protection engineer, the NH state fire marshal's office and the department to meet the Health Care Occupancy Chapter, the following shall be required:

a. The facility shall develop a fire safety plan, which provides for the following:

1. Use of alarms;

2. Transmission of alarms to fire department;

3. Emergency phone call to fire department;

4. Response to alarms;

5. Isolation of fire;

6. Evacuation of immediate area;

7. Evacuation of smoke compartment;

8. Preparation of floors and building for evacuation;

9. Extinguishment of fire; and

10. Written emergency telephone numbers for key staff, fire and police departments, poison control center, 911, and ambulance service(s);

b. Fire drills shall be conducted quarterly on each shift to familiarize facility personnel including, but not limited to, medical personnel, maintenance engineers, and administrative staff, with the signals and emergency action required under varied conditions;

c. Fire drills shall include the transmission of a fire alarm signal and simulation of emergency fire conditions;

d. Buildings that have a shelter in place, also known as defend in place, shall have this plan approved by the department and their local fire chief and shall be constructed to meet the Health Care Occupancy Chapter of the Life Safety Code;

e. When drills are conducted between 9:00 p.m. and 6:00 a.m., a coded announcement shall be permitted to be used instead of audible alarms;

f. If the facility has an approved defend or shelter in place plan, then all personnel, patients, and visitors shall evacuate to that appropriate location or to the outside of the building to a selected assembly point and drills shall be designed to ensure that patients shall be given the experience of evacuating to the appropriate location or exiting through all exists;

g. Facilities shall complete a written record of fire drills and include the following:

1. The date and time, including AM or PM, the drill was conducted and if the actual fire alarm system was used;

2. The location of exits used;

3. The number of people, including patients, personnel, and visitors, participating at the time of the drill;

4. The amount of time taken to completely evacuate the facility, evacuate to an approved area of refuge, or evacuate through a horizontal exit;

5. The name and title of the person conducting the drill;

6. A list of problems and issues encountered during the drill;

7. A list of improvements and resolution to the issues encountered during the fire drill;

8. The names of all staff members participating in the drill; and

9. Written records of the fire drills shall be maintained on site and available to the department during an inspection or investigation conducted in accordance with RSA 151:6 and RSA 151:6-a; and

h. At no time shall a staff member who has not participated in a fire drill be the only staff member on duty within the facility; and

(2) The facility shall conduct a fire drill in the presence of a representative of the department, state fire marshal's office, or the local fire department upon request.

N.H. Admin. Code § He-P 824.25

Derived from Number 15, Filed April 13, 2023, Proposed by #13572, Effective 3/1/2023, Expires 3/1/2033.