N.H. Admin. Code § He-P 826.25

Current through Register No. 50, December 12, 2024

Section He-P 826.25 - Fire Safety

(a) All new SUD-RTF's shall meet at a minimum the residential board and care chapter of NFPA 101 as adopted by the department of safety in Saf-C 6000, as amended pursuant to RSA 153:5, I, by the state fire marshal with the board of fire control.

(b) If providing withdrawal management, the new SUD-RTF's shall meet at a minimum the health care occupancy chapter of NFPA 101 as adopted by the department of safety in Saf-C 6000, as amended pursuant to RSA 153:5, I, by the state fire marshal with the board of fire control.

(c) All SUD-RTF's shall have:

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

(2) At least one UL Listed, ABC type portable fire extinguisher, with a minimum rating of 2A-10BC installed on every level of the building with a maximum travel distance to each extinguisher not to exceed 50 feet and maintained as follows:

a. Fire extinguishers shall be inspected either manually or by means of an electronic monitoring device or system at least once per calendar month, at intervals not exceeding 31 days;

b. Records for manual inspection, or electronic monitoring shall be kept to demonstrate that at least 12 monthly inspections have been performed;

c. Annual maintenance shall be performed on each extinguisher by trained personnel, and a tag or label shall be securely attached that indicates that maintenance was performed; and

d. The components of the electronic monitoring device or system in a. above, if used, shall be tested and maintained annually in accordance with the manufacturers listed maintenance manual; and

(3) A carbon monoxide monitor on every level of the SUD-RTF, in accordance with Saf-C 6015.04.

(d) An emergency and fire safety program shall be developed and implemented to provide for the safety of clients and personnel.

(e) 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 a false alarm or emergency medical services (EMS) transport for a non-emergent reason.

(f) The written notification required by (e) above shall include:

(1) The date and time of the incident;

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

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

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

(5) The name of any personnel or clients 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.

(g) If the licensee has chosen to allow smoking on the premises of the SUD-RTF, a designated smoking area shall be provided which:

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

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

(3) Has metal waste receptacles and safe ashtrays; and

(4) Is in compliance with the requirements of RSA 155:64-77, the Indoor Smoking Act.

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

(i) 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.

(j) Fire drills shall be conducted as follows:

(1) For buildings constructed to the Residential Board and Care or One and Two Family Dwelling Chapters of the Life Safety Code (NFPA 101), the following shall be required:

a. The administration of every residential board and care facility shall have, in effect and available to all supervisory personnel, written copies of a plan for protecting all persons in the event of fire, for keeping persons in place, for evacuating persons to areas of refuge, and for evacuating persons from the building when necessary;

b. Clients shall be trained to assist each other in case of fire or emergency to the extent that their physical and mental abilities permit them to do so, without additional personal risk;

c. All SUD-RTF Tier 1, 2, and 3 facilities shall conduct fire drills not less than 6 times per year on a bimonthly basis, with not less than 2 drills conducted during the night when clients are sleeping. Actual exiting from windows shall not be required, however opening the window and signaling for help shall be an acceptable alternative;

d. The drills shall involve the actual evacuation of all clients to an assembly point, as specified in the emergency plan, and approved by the department and the local fire authority based on construction of the building and shall provide clients with experience in egressing through all exits and means of escape;

e. Facilities shall complete a written record of fire drills that includes the following:

1. The date and time including AM/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 clients, personnel, and visitors, participating at the time of the drill;

4. The amount of time taken to completely evacuate the facility;

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; and

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

f. 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;

g. At admission, the facility shall conduct a client Fire Safety Evacuation Scoring System (FSES) as listed in NFPA 101A, Alternatives to Life Safety, to determine the clients' needs during a fire drill including mobility, assistance to evacuate, staff needed, risk of resistance, clients ability to evacuate on his or her own, and choose an alternate exit; and

h. The fire drills for facilities built to the Residential Board and Care chapter of the Life Safety Code (NFPA 101), shall be permitted to be announced, in advance, to the clients just prior to the drill;

(2) For SUDS-RTF's originally constructed to the Health Care Occupancy chapter of the life safety code and to the rules and regulations adopted and enforced by the state fire marshal's office and/or the municipality, or which have been physically evaluated, rehabilitated, and approved by a New Hampshire licensed fire protection engineer, the 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 such as 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, clients, 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 clients 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/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 clients, personnel, and visitors, participating at the time of the drill;

4. The amount of time taken to completely evacuate the facility or to an approved area of refuge or 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; and

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

(3) 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 826.25

Derived From Volume XXXVIII Number 45, Filed November 8, 2018, Proposed by #12658, Effective 11/1/2018, Expires 11/1/2028.