Beruflich Dokumente
Kultur Dokumente
APRIL 2011
Applicable codes
For Federal Medicare/Medicaid certification, healthcare facilities must be in compliance with National Fire Protection Association (NFPA) Standard 101 The Life Safety Code (2000 edition) (LSC) With state licensure requirements which requires being in compliance with the 2007 Minnesota State Fire Code (MSFC)
EXISTING: Buildings constructed or for which plans were reviewed or a permit issued prior to March 11, 2003 must meet LSC Chapter 19
Before
NEW: Buildings constructed or for which plans were reviewed or a permit issued on or after March 11, 2003 must meet LSC Chapter 18
After
Documentation Project
Everything must be properly documented if it isnt documented, it didnt happen. The State Fire Marshal Division recommends that all documentation subject to review during a facilitys annual fire/life safety survey be kept in an indexed 3-ring binder
Its important that at least two people in your facility know where your fire safety records and documentation are kept.
1 Building Information
Construction Types
Construction Types
Major Renovations
Renovations, alterations or modernizations Sprinkler requirements of Chapter 18 apply Also requires meeting 19.1.6 (sprinklers) Also requires meeting 19.3.2.3 (exiting) Damper exception in smoke barriers
2 Emergency Plan
Administration is responsible to have a written fire plan Fire plan must is available to all supervisory staff (MSFC 404.5) Copy of the fire plan is at the telephone operators position or at security center
(MSFC 404.5)
Protection of all persons Evacuation to areas of refuge Evacuation of the building when necessary
(LSC 19.7.1.1 & MSFC 404.3)
(LSC 19.7.2.1)
R.A.C.E. Rescue
Alarm Confine Extinguish
Remove all occupants directly involved with the fire emergency (Response to alarms)
Duties of staff Many facilities break these down Pull Stations Room Smoke Detectors
Transmission of fire alarm signal to warn other building occupants and summon staff (Transmission of alarm to fire department)
Confine
Confinement
of the effects of the fire by closing doors to isolate the fire area (Isolation of fire) Close doors, Automatic sprinkler
Fire Plans
Relocation
of patients or residents Evacuation of smoke compartment Move people through cross corridor doors Move people to specified areas Preparation of floors and building for evacuation Gather Medical records Residents/ Patients glasses, hearing aids, walkers, wheel chairs, etc. How are you getting from here to there
occupancy assembly point The locations of fire hydrants The normal routes of fire department vehicle access (MSFC 404.3.2)
3 In-service Records
Records indicate individual staff Summary of topics covered Include any fire safety training Training shall be more than drills
4 Smoking Policy
Include where smoking is allowed Control of smoking materials
FIRE IS
The Rapid Self- Sustaining OXIDATION of a FUEL that gives off Light and HEAT
FIRE TETRAHEDRON
Oxygen
OXYGEN SOURCES
Air
21 % oxygen
Compressed Cylinders
Common
in Health Care and Home Use in Health Care and Home Use in Industry
Liquid
Common
Combined gases
Common
Marking Containers
Stationary Containers
with
Markings Labeled
Each valve Wall, floor or ceiling penetrations Each change of direction A minimum of every 20 feet or fraction thereof throughout run 3003.4
Security Cylinders
Shall be secured against accidental dislodgement and against unauthorized personnel Areas used for the storage, use and handling of compressed gas containers and systems shall be secured against unauthorized entry 3003.5.1 Shall be protected indoors and outdoors from vehicular damage (Guard posts or other approved means and shall comply with Section 312) 3003.5.2
Security Cylinders
Shall be secured to prevent falling Secured to a fixed object with one or more restraints
On a cart or other mobile device designed for the movement of containers Label Locations
Containers In Use
trucks or other mobile devices shall be designed to secure containers during movement Compressed gas cylinders placed on carts and trucks shall be individually restrained 3005.10.1
Containers In Use
Ropes, chains or slings shall not be used to suspend compressed gas containers, unless provisions at time of manufacture have been made on the container (such as lugs) 3005.10.2
Containers In Use
by qualified personnel only use equipment and operating procedures in accordance with CGA P-1
Inflatable equipment, devices or balloons shall only be pressurized or filled with compressed air or inert gases 3005.8
If the system is down for more than 4 hours within a 24 hour period:
Contact
OR
A responsible person dedicated to the watch Keep records Continue until system is functional again
LSC 9.6.1.8
Fire Watch
Impairment coordinator Tag the system is out of service Notify all supervisory staff Preplanned impairment programs Emergency impairments
Walk the facility or area assigned to them continually, insuring every room, closet and area Must have an approved means of contacting the local Fire Department This shall be their only duty The assigned staff shall document that all areas are observed and how often it is done All areas shall be observed every 15 minutes or more often
Trained in Fire Prevention Trained in the use of portable fire extinguishers Have the ability to notify the FD (phones and or radios) How to sound the fire alarm system Understanding the reason the system is impaired and the problems caused by that
7 Fire Drills
Conducted monthly with each shift being drilled at least once a quarter
interns, doctors, maintenance engineers, and administrative staff familiarize facility personnel with the signals and emergency action required under varied conditions (MSFC 406.3) (LSC 19.7.1.2)
(MSFC 405.2)
The purpose of a fire drill is to test the efficiency, knowledge and response of staff Health care facilities can conduct fire drills without disturbing patients by:
Schedule on a random basis Drills should include simulated movement of patients to another smoke compartment
Relocation can be practiced using simulated patients or empty wheelchairs (MSFC 408.6.1)
Transmission of fire alarm signal to monitoring company (LSC 19.7.1.2) Simulation of emergency fire conditions
When drills are between 9:00 pm and 6:00 am (2100 to 0600 hours), A coded announcement shall be permitted to be used instead of audible alarms (LSC 19.7.1.2)
Drills shall:
Be Be
designed in cooperation with the local authorities held with sufficient frequency to familiarize occupants with the drill procedure and to establish conduct of the drill as a matter of routine (MSCF 406.2) Include suitable procedures to ensure that all persons subject to the drill participate (MSFC 406.1)
Responsibility for the planning and conduct of drills shall be assigned only to competent persons (MSFC 405.3)
Emphasis shall be placed on orderly evacuation rather than on speed Drills shall be:
held
(MSFC 405.4)
Records shall be maintained of required emergency evacuation drills and include the following information:
Identity
of the person conducting the drill Date and time of the drill Notification method used Staff members on duty and participating (MSFC 2007 405.5)
of occupants evacuated Special conditions simulated Problems encountered Weather conditions when occupants were evacuated Time required to accomplish complete evacuation
Battery detectors
Hardwired detectors
Test
Sensitivity Testing
Sensitivity Testing Within the 1st year Skip a year If it passes twice (in 3 years) than 5 years Document percentages of each detector
New requires
Complete
Coverage In accordance with NFPA 13 Requires Quick Response or Listed Residential Heads be used in Smoke Compartments that contain sleeping rooms
Required in Existing by construction type and in all by 2013 Only licensed company can work on
Minnesota
State Statue
LSC 18.3.5
Visually monthly (Quick Check) Service (Annual) Interior Inspection (6-year) Hydro Testing (12 years)
15 Emergency Generator
Definitions
source of electric power of the required capacity and quality for an emergency power supply system
EPS coupled to a system of conductors, disconnecting means and over current protective devices, transfer switches, and all control, supervisory, and support devices NFPA 110, 3.3.2 & 3.3.3
Generator Inspections
Weekly
Inspections Include Fuel Level Coolant Level Oil Level Battery Charge
Generator Testing
operating temperature conditions and at not less than 30 percent of the EPS nameplate rating OR Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
The date and time of day shall be decided by the owner, based on facility operations 6-4.2*
Diesel-powered EPS
shall be exercised monthly with the available EPSS load and exercised annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of 2 continuous hours (LOAD BANK) 6-4.2.2*
Load tests of generator sets shall include complete cold starts Annually for 1 hour
Emergency Lighting
All emergency lighting will have to last for 1 hour (includes generators) LSC 19.2.9.1 Includes testing requirement
Every 30 days for at least 30 seconds and Annually for 1 hour Records to be kept LSC 7.9.3CFR 482 & 483
Generator installation
Level of Equipment
Level 1
shall be installed when failure of the equipment to perform could result in loss of human life or serious injuries shall be installed when failure of the EPSS is less critical to human life and safety
Level 2
Types of EPSSs
Type 10, Class X, Level 1 Type 10 Picks up load in 10 seconds Class X Time it must run in hours, X= Other Essential Electric System Shall have two separate systems Emergency system Life Safety Branch Critical Branch Equipment system
Stationary Generators
Stationary
emergency and standby power generators shall be listed in accordance with UL 2200 (604.1.1)
Fuel Supply Not used for any other purpose Low fuel sensing switch Main fuel tank is 133% of low fuel switch Must meet NFPA 37 Must have a battery charger Instrument panel
Remote Panel
Remote alarm panels located outside of the generator room A visual indicators for Generator is operating The battery charger is malfunctioning Individual visual display, with a common audible alarm for low oil pressure low coolant temperature excessive coolant temperature low fuel level (less than 3-hour supply) failure to start overspeed NFPA 110 section 35.6.1 in a constantly attended location
Maintenance Records
Shall Include
The
date of service The name of the servicing technician A summary of conditions noted A detailed description of any conditions requiring correction What corrective action was taken
Records shall be kept on the premises Be available for inspection by the fire code official (604.3.2)
Illumination of Exits
Must be reliable
CMS
17 Fire/Smoke Dampers
Inspection, servicing and maintenance done every 4 years (Hospitals 6 years)
18 Interior Finishes
Document flame spread ratings of ceilings, walls and flooring
Interior Finishes
Keep (or find) documentation for all interior finishes (Testing sheets and/or labels)
Wall
Class C can stay in rooms if sprinkler protected Newly installed must be a Class A
Exception: Exception:
a Class B
New flooring in corridors must be a Class 1 unless sprinkler protected LSC 19.3.3.3
Interior Finishes
NEW
Class A or B Allows lower 4 feet of corridor walls to be a Class C Allows Class C in Rooms up to 4 person New flooring no requirement
LSC 18.3.3.2 LSC 18.3.3.3
19 Decorations
Maintain documentation of treatments
Combustible decorations
Draperies, Curtains, including cubical and other loosely hanging fabrics and films shall flame resistant in accordance with NFPA 701
Exception
release of 250 Kw and Total energy release of 40 Mj in 5 minutes Exception: sprinkler protected than not required Exception: belongs to the patient, is in their room, and the room has smoke detection LSC 19.7.5.2 & 10.3.3 Newly Introduced means purchased after March 2003
CMS
Heat release of 250 Kw and Total energy release of 40 Mj in 5 minutes Exception: sprinkler protected than not required Exception: belongs to the patient, is in their room,
CMS
Questions
Everything must be properly documented if it isnt documented, it didnt happen. The State Fire Marshal Division recommends that all documentation subject to review during a facilitys annual fire/life safety survey be kept in an indexed 3-ring binder
Its important that at least two people in your facility know where your fire safety records and documentation are kept.
THATS ALL
FOR NOW
Prepared in cooperation with: Minnesota State Fire Marshals Division Centers for Medicaid Medicare Services National Fire Protection Association