Fire Safety Requirements for Peer Review
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1 Fire Safety Requirements for Peer Review SITE: DATE: REVIEWER: Focus Area 1. Fire Safety Binder Section A. Is there a Fire Safety Binder on site? B. Is the Table of Contents the most recent edition? C. Is the binder organized according to the prescribed Table of Contents? 2. Fire Drill Training Section A. Is there an Annual Fire Drill Schedule in place? i. Does the schedule include a fire drill per shift per quarter? ii. Are the conditions varied? (every exit used at least 1 time per year, every exit blocked at least 1 time per year, times varied) B. Dates/times of the past 12 months of Fire Drills (Supervised: 12 drills/year 1 per shift per quarter; Supported: 1 Fire Drill/quarter) Fire Drills C. For newly admitted individuals: Did he/she participate in at least 3 drills (1 per shift) in the 1 st 48 hours? D. Are the individuals evacuating within the allotted time frame (IRA Evacuation time: )? Note: Life Safety Code IRA Chapter 33 sites = 8 minutes; 13 minutes with pull stations; or, 20 minutes with Sprinklers. Non Life Safety Code IRA 8 bed or less IRA = 3 minutes or less. i. Are any individuals having difficulty evacuating? a. Is this reflected on the Bi-monthly? ii. Have there been any failed Fire Drills within the past year? a. If yes, was a Fire Drill repeated within 24 hours?
2 Focus Area iii. Has there been 2or more failed Fire Drills by the same individual in the six months? a. If yes, was a protocol developed regarding the refusals? Staff Participation A. Is there a Staff Fire Drill Participation form being utilized? B. Has every staff participated at least 1 time in a Fire Drill? C. Have all newly hired staff participated in a Fire Drill within the 1 st 30 days of employment? D. Has all staff received the Fire Safety training as outlined on the Fire Safety Training curriculum? E. Is the IRA currently utilizing the Staff Assignment Sheets designating staff fire zone responsibilities? Fire Evacuation Form A. Is the correct Fire Evacuation Form being used at the IRA? B. Is the Fire Evacuation form being filled out correctly? (filled out completely, times all tie out) C. Is there documentation that follow up, if needed, was done? D. Are all the Fire Evacuation forms reviewed, signed and dated: i. By the Residential Habilitation Manager or designee within 24 hours? ii. By the Supervisor of Residential Services within 1 Business day (7 days prior to 11/1/2011)? Bi-Monthly A. Is there a current Fire Evacuation Plan in the Fire Safety Binder? B. Are all the individuals needs and supports being identified On the Bi-Monthly? C. Is the Bi-Monthly reflective of any changes of the mental status or health of the individual? D. Is the Bi-Monthly reflective of each individuals past 12 months of responses documented on the Fire Evacuation Records? E. Have all the staff been trained on and signed off on the current Bi-Monthly? Fire Safety Requirements for Peer Review 2
3 3. spection Section A. Has the Maintenance Department/Vendor conducted quarterly Fire Alarm inspections of the following: i. Fire Extinguishers? a. Does the Fire Extinguisher have 2 inspection tags attached to it? b. Are the fire extinguisher s fully charged? ii. Smoke Detectors? iii. Fire Alarm Pull Stations? iv. Testing/Maintaining Emergency Lights? v. Sprinkler System? B. Has the Maintenance Department conducted monthly checks on the hot water temperatures? C. Has the Manager/Assistant Manager conducted monthly checks on the hot water temperatures? D. For those Sites with Battery Operated CO Detectors, has the Manager/Assistant Manager conducted monthly checks? E. For those Sites with Hard Wired CO Detectors, was an annual inspection completed by an outside vendor? F. Have the fire extinguishers been inspected by an approved outside vendor at least annually? F. Is the annual inspection of the fire alarm system by an approved service company maintained in the Fire Safety Binder? G. For those Sites with a sprinkler system, was the annual inspection done? Is the paperwork on site? H. Compare & Match the agency s Fire Protection spection form with the outside vendor s annual inspection form. Do the certification numbers and fire extinguisher classifications match? 4. Plan of Protective Oversight Section A. Is the Plan of Protective Oversight for the IRA current and maintained in the Fire Safety Binder? B. Does the Facility Plan of Protective address the IRA s evacuation plan and staff and individuals training? Fire Safety Requirements for Peer Review 3
4 C. Does the individuals Plan of Protective Oversight contain specific information regarding the individual s evacuation needs? i. If so, are those actions reflected on the Bi-Monthly Evacuation form? 5. dividuals Section A. Does each individual have a current (within the past year) Fire Safety Questionnaire completed? 6. Life Safety Code Section A. Are the F-1 score sheets completed for each individual? B. Are the F-1 sheets current within 1 year? i. For individuals 50+ years of age (40+ for individuals with Down s Syndrome), have the F-1 score sheets been reviewed at a minimum, every 6 months? C. Is the F-1 score sheets reflective of each individuals past 12 months of responses documented on the Fire Evacuation Records? D. Was the F-1 score sheet completed if the individual s evacuation performance changed? (Due to medical issues, medications, etc) E. Are the following worksheets completed and current? i. F-2 (worksheet for calculating evacuation difficulty score) ii. F-2A (finding the total individuals score) iii. F-2B (finding the staff shift score) iv. F-2C ( E score. Is it recomputed when necessary?) F. Is there a current (annually updated) E-Score completed for the IRA? 7. Fire Evacuation Plan Section A. Is the site specific Evacuation Plan current and maintained in the Fire Safety Binder? B. Is there a current site specific Staffing Rationale in the Fire Safety Binder? C. Are the individuals needs & supports identified in the Fire Safety Plan? Do the needs & supports match the needs & Supports identified in the Bi-Monthly? Fire Safety Requirements for Peer Review 4
5 D. Is the evacuation routes/floor plans posted (HUD sites requirement) E. Are evacuation routes/floor plans available in the Fire Safety Binder? 8. Fire Systems/Alarm Company Section A. Are the directions for use of the fire system available for staff use? 9. Fire Safety General Section A. How many fire extinguishers are there total in the IRA? i. Does the total number of fire extinguishers found match the maintenance records of number of fire extinguishers? ii. Is there a fire extinguisher on each floor? B. Are all stairways & halls clear (free of obstructions)? C. Are all fire exits safe, continuous and unobstructed? D. Do all fire doors release and positively latch? E. Are all of the emergency exit lights working? F. Are the sprinkler heads unobstructed (no objects within an 18 radius)? Are they free from dust & debris? G. Are all smoke detectors free of debris (dusted off)? H. Door stops, wedges, etc are not used on openings in fire walls, fire separations or smoke stops? I. Is the IRA designated Smoking location/cigarette disposal receptacle at least 30 feet from the IRA? Any evidence that\ staff are violating that rule (cigarette butts in different spots)? Additional /Comments: Reviewer Signature/Title: Date: Management Folder F:\Docs\Clerical\Residential Forms\Fire Safety Requirements for Peer Review September 5, 2012 Fire Safety Requirements for Peer Review 5
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