Title/Description: Life Safety & Fire Prevention Management Department: Facilities Management Personnel: All Effective Date: 5/97 Revised: 7/00, 7/01, 7/02, 7/03, 7/04, 7/05, 7/08 LIFE SAFETY & FIRE PREVENTION MANAGEMENT PLAN Objectives: To establish an ongoing mechanism for controlling and monitoring a compliant program of maintenance and testing of the equipment, systems and staff knowledge necessary to insure the highest degree of fire prevention & life safety possible. The purpose of the Life Safety & Fire Prevention Management Program is to protect patients, visitors and staff from fire or the effects of fire. The plan includes processes that are designed to prevent fire and to protect individuals in the event of fire. Life Safety & Fire Prevention Systems include general life safety design and building construction, means of egress (including design of space, interior finish, travel distances to exits and/or fire protection equipment, compartmentation, egress illumination & signage), fire alarm notification (including audible alarms), suppression of fires (including fire protection sprinkler systems), building services (including elevators), decorations, furnishings and portable space heaters. Fundamentals & Program Scope: The program s scope includes, but is not limited to: Inspection, Testing, Certification & Maintenance: The Hospital s buildings, structures and life safety related systems are designed, constructed, installed & routinely inspected for compliance with applicable codes, requirements and regulations, including the 2006 AIA Guidelines for Design and Construction of Healthcare Facilities (FGI), 2000 Life Safety Code 101, NFPA 99, Alabama Dept. of Health & the City of Mobile Fire & applicable building codes. Routine inspections of patient and non-patient care areas are performed via Environment of Care Rounds. Patient care areas are inspected on a semi-annual basis, with non-patient care areas inspected on an annual basis. An on-going assessment of compliance with applicable codes and standards minimizes risk and identifies the facility s current condition and is accomplished through the use of the Joint Commission s Statement of Conditions. The Statement of Conditions (SOC and e SOC) is used as the management process that continually identifies, assesses and resolves Life Safety Code deficiencies.
An annual Statement of Conditions inspection is performed and documented in accordance with Hospital policy and TJC requirements. Deficiencies found are documented & submitted in the form of a Plan for Improvement (short or long form depending on severity and length of time for correction). Deficiencies identified are corrected as quickly as practical. Findings & corrective measures are reported to the EOC Committee Plans for Improvement are developed, reported to the Quality Management Department & the Environment of Care Committee and tracked to completion. Deficiencies of a short term nature identified on Environment of Care Rounds are documented and corrected via a BMP-SOC listing. The implementation, documentation and reporting of a comprehensive Building Maintenance Program (BMP) designed to provide a method for an effective process of inspecting, identifying & correcting certain life safety deficiencies through maintenance activities. The BMP consists of the following components: Written strategies to manage the items covered in the program A documented schedule for the frequency of inspecting the items Processes for evaluating the effectiveness of the program. Deficiencies that may be managed through the BMP include: Non-functioning positive latching devices, self-closing or automatic closing devices Excessive gaps and under-cuts on fire rated doors Penetrations in Corridor walls and other rated assemblies Non-functioning egress illumination and exit signs Accumulations of snow and/or ice at means of egress Grease producing devices including exhaust hoods, exhaust duct systems & grease removal devices. Interim Life Safety Measures are considered, evaluated and implemented as determined necessary whenever patients or staff is exposed to an increased risk, either through a failure of an essential life safety system, construction, renovation or unacceptable/deficient features of fire protection. ILSM are reviewed during pre-construction meetings via the ILSM matrix and implemented as necessary during the length of the deficiency or construction related activities. ILSM are identified and addressed via separate policy Fire alarm & warning systems, detection systems & fire suppression systems are maintained in a high state of readiness and are routinely tested at prescribed intervals to assure that the systems will perform as designed. Fire Alarm systems testing includes weekly device functional performance testing & annual sensitivity testing and certification by an approved outside service provider. Test results are documented and maintained in the Facilities Management Department. The testing program is scheduled to insure required scheduled testing of all devices. The results and any corrective actions (if necessary) are reviewed by Formatted: Indent: Left: 0.5"
Quality Management and the Environment of Care Committee. Fire alarm and warning systems are inventoried & addressed via separate policy. Fire Suppression systems are designed and tested in accordance with NFPA & Life Safety Code requirements. Fire suppression systems include water based sprinkler suppression systems, dry chemical suppression systems and vapor based suppression systems. Test results are documented and maintained in the Facilities Management Department. The testing program is scheduled to insure required periodic testing of all devices. The results and any corrective actions (if necessary) are reviewed by Quality Management and the Environment of Care Committee. Fire suppression systems are addressed via separate policy. Exits & means of egress, features of compartmentation, smoke & fire boundaries are inspected and corrected as necessary to insure the highest level of protection at smoke and fire boundaries. A current and complete diagram depicting type and location of all boundaries is developed and maintained by the Facilities Management Department. Above ceiling integrity and compliance is enhanced by a program of above ceiling permitting and follow up of all work required to be performed above the ceiling and regularly scheduled inspections of smoke and fire rated barriers and assemblies. Exits and means of egress are routinely checked by security personnel on daily rounds. Separate policies address the removal of snow & ice at exits. Features of fire protection are checked as a criteria item on weekly Environment of Care Rounds. Deficiencies are noted on an SOC/EOC worksheet, work orders are entered and a plan of corrective action is developed. The satisfactory performance of rated door assemblies is monitored as a performance improvement indicator & reviewed by the Facilities Management Department monthly & the Environment of Care Committee quarterly. Staff Education & Readiness: Staff readiness is enhanced and evaluated by required staff training and fire drills. Fire Drills are conducted at intervals not less than 1 per shift per quarter, but may be performed more often as needs dictate. Drills are observed, critiqued and documented. A score of 80 or less requires additional staff training and unannounced re-testing via a fire drill. Drill outcomes and scores are reported to Quality Management and the Environment of Care Committee. Staff participation and attendance at fire drills are documented at the time of the drill. Educational requirements and attendance records are developed and maintained by the Staff Development Department. Staff Educational Requirements New employee orientation & staff educational requirements include: New employee orientation: Specific roles & responsibilities of personnel at the fire's
origin & also away from the fire's origin. Use & functions of the fire alarm system Typical locations of features of fire protection Specific roles and responsibilities in preparing for building evacuation Location & proper use of equipment and routes for evacuation or transporting to areas of safe refuge Compartmentation and defend in place concepts Methods of containing smoke and fire Extinguishing methods Annual (General) recertification which includes: Specific information and questions pertaining to the Life Safety Management Program and proper fire response Departmental specific education which includes: Location of features of fire protection within areas of responsibility. Specific fire response education, based on fire drill performance or lack of demonstrated knowledge on EOC Rounds. Physicians, volunteers, students and independent licensed practitioners are educated in their specific fire response both at, and away from the fire's point of origin. Environment of Care Rounds, Hazard Surveillance & Statement of Conditions: Regularly scheduled multi-disciplinary EOC rounds identifying & documenting the condition of features of fire protection, life safety and compartmentation. All short-term deficiencies cited are documented and corrected through a EOC/SOC matrix as a plan for improvement. The PFI's are tracked via the SOC-BMP matrix spreadsheet and status is regularly reported to the Environment of Care Committee and Quality Management. Deficiencies requiring longer than 45 days to resolve will be listed as a plan for improvement long form. Both long & short term PFI's condition and status shall be documented, monitored, regularly reported and closed when completed. A revised Statement of Conditions form shall be completed whenever the building's condition, construction, use or fire rating changes. Routine SOC completion intervals shall be performed annually with the Quality Management Department submitting the electronic Statement of Conditions. Fire Alarm & Fire Suppression Systems: Fire Alarm System maintenance & inspection includes:
Weekly testing of scheduled components to include annual testing cycle of all smoke detectors and pull stations. Quarterly preventive maintenance is performed by qualified and certified personnel Annual sensitivity testing and system certification by a licensed & certified fire protection service provider. Fire Suppression Systems: Water charged systems testing and maintenance includes: Weekly flow tests performed by a licensed & certified fire protection service provider. Weekly fire pump tests under no-flow conditions are performed by a licensed & certified fire protection service provider or duly approved maintenance personnel who are licensed and certified according to the rules of the Alabama State Fire Marshal. Quarterly testing includes inspection of all fire department water supply connections & supervisory/flow switches. Semi-annual testing includes the inspection of all dry chemical suppression systems Dry chemical suppression systems testing & maintenance includes: Semi-annual certification testing by a licensed & certified service provider. Annual testing includes testing the FPS main drains at the system s lowest point or at all risers & fire pumps under full flow testing capacities. Formatted: Indent: Left: 1", First line: 0.5" Fire Drills & Evaluation: Hand held portable fire extinguishers: Monthly visual inspection performed by maintenance personnel Annual certification by a licensed service provider. Five year certification by a licensed service provider. Fire drills are conducted at least once per shift per quarter. Staff response is timed and scored utilizing a critique sheet. All scores, findings, recommendations and conclusions are reported and reviewed by the Environment of Care Committee and Quality Management. A score of 80% or less requires specific departmental training and re- Formatted: Indent: Left: 0", First line: 0"
testing to verify learning efficacy. Performance Measurement & Process Improvement: The Environment of Care Committee has the overall responsibility for the coordination of performance improvement measures for each of the essential functions associated with the Management of the Environment of Care. The Director of Facilities Management (through the Safety & Compliance Manager) is responsible for the Fire Prevention Management Program performance improvement measurement and documentation. The Director of Facilities Management (through the Safety & Compliance Manager) is also responsible for establishing performance improvement measures which objectively measure the Fire Prevention Management Program. Human, equipment and programmatic characteristics are evaluated as necessary with the goal of improving the organizational performance of the program. As a part of the overall program to establish performance measurement standards, the Director of Facilities Management (in accordance with hospital policy and required code authority) determines the appropriate data sources, documentation methods and frequencies of data collection & analysis to report this information to the Environment of Care Committee & Quality Management. The program includes: Identification of key problems, failures or user errors which require attention or action, aggregation of data and the reporting of relevant trends and patterns to the Environment of Care Committee & Quality Management. Identification of performance improvement opportunities, collection of data and reporting to the Environment of Care Committee & Quality Management. Identification of opportunities to improve the performance of Fire Prevention & Life Safety assemblies, components or systems, preventive maintenance activities, emergency response or staff training. Maintaining and updating as necessary, drawings, plans or diagrams of Life Safety assemblies, components or systems. Conducting an annual evaluation of the Life Safety Management Program's objectives, scope, performance and effectiveness and reporting findings to the Environment of Care Committee & Quality Management.
Organization & Responsibility: The Governing Board receives regular reports concerning the activities of the Life Safety & Fire Prevention Management Program through the Director of Quality Management and the Environment of Care Committee. The Board reviews the reports and as appropriate, and communicates all concerns regarding identified issues and/or regulatory compliance. The Governing Board reviews and authorizes capital expenditures as necessary to correct Life Safety Code deficiencies and to provide and facilitate the ongoing activities & finds/recommendations of the Environment of Care Committee and Life Safety & Fire Prevention Management Program. The Administrator receives regular reports concerning the activities of the Life Safety Management Program. The Administrator reviews the reports and as necessary, communicates concern regarding key issues and regulatory compliance to the Director of Facilities Management or other appropriate staff. Formatted: Indent: Left: 1.13" The Director of Facilities Management and the Administrator establish the operating and capital budgets for the Life Safety & Fire Prevention Management Program. The Utilities & Compliance Manager (U&CM) reports directly to the Plant Operations Supervisor, who reports directly to the Director of Facilities Management. The U&CM, together with the Manager, is responsible for the identification of Life Safety Code deficiencies, development of plans for improvement, maintenance, testing and certification of fire systems, the fire plan, fire drills and fire response. Training of staff, volunteers and physicians is facilitated by the Staff Development Department & Quality Management. Formatted: Font: Not Italic The Director of Facilities Management advises the Environment of Care Committee regarding fire safety issues that may necessitate changes to policies, orientation or education or the expenditure of funds. The Director of Facilities Management is responsible for the overall management of the Fire Prevention & Life Safety Program, policy development and revision, submission of data and evaluation of the program in accordance with its goals and objectives.
Individual Departmental Managers are responsible for orienting new staff members to the department and, as appropriate, to job specific fire safety procedures. Departmental Managers are responsible for training their individual staff in fire safety procedures. When necessary, the LTSC & Director of Facilities Management provides departmental managers with necessary assistance or resources as necessary in developing specific department fire safety policies. Formatted: Indent: Left: 0" Individual staff members are responsible for learning and adhering to the hospital wide and departmental fire plans. Individual staff members are also responsible for learning and using emergency reporting procedures for reporting fires or fire hazards. Fire Protection: Construction, Fire Watches & Interim Life Safety Measures: Construction: A multi-disciplinary team including the Project Manager, Director of Facilities Management, Director of Infection Control, contractor and other managers or attendees as determined appropriate shall meet prior to and during construction projects. Discussion shall include but not be limited to construction barrier placement, construction management and scheduling, interruptions of services or fire protection systems. Interim Life Safety Measures shall be determined and implemented as necessary, in accordance with physical systems or exit impairments, ILSM Matrix and committee decision. An Infection Control Risk Assessment shall be completed for each construction project. The standard ICRA shall be consistently utilized to assess and prevent the inherent risks of construction to affect the general patient population. The ICRA will be a jointly approved document specifying the requirements of each project based upon the proximity, patient population and extent of construction. The document shall be prepared, amended and approved as necessary by the Project Manager, Director of Infection Control and/or the General Contractor. Impairment of Fire Protection Systems or Services: In the event
New Acquisitions: that fire protection systems are impaired, a fire watch will be established to enhance life safety in the affected areas. The fire watch is performed by security and hospital staff. In the event that systems are not readily repairable, specific ILSM may be instituted to supplement or replace the impaired system. The process to implement fire watch and alternate systems is described in separate policy. The Materials Manager is responsible for reviewing proposed acquisitions or purchases of bedding, window draperies & other curtains, decorations, wastebaskets, wall & floor coverings and other equipment as necessary for fire safety and appropriate ratings. Interior wall & ceiling finish materials shall be classified as required by the 2000 Life Safety Code 101 19.3.3.2 (existing fully sprinklered facility) Existing materials: Class A or Class B New materials: Class A Interior floor finish materials shall be classified as required by the 2000 Life Safety Code 101 19.3.3 (existing fully sprinklered facility) Exits & corridors: Class 1 The Director of Facilities Management is responsible for all fire rated or related products specified or installed during construction projects. Appropriate fire rated products are specified by the architect or interior designer, using standard specifications. Facilities Management maintains documentation of products installed during construction projects. Annual Evaluation: The Environment of Care Committee has overall responsibility for coordinating the annual evaluation of each of the seven functions associated with the Management of the Environment of Care. The Director of Facilities Management is responsible for the preparation and presentation of the annual evaluation of the Life Safety Management Program. In performing the annual evaluation, the Project Manager utilizes a variety of source documents, such as: policy review & evaluation, incident report summaries & statistical information summaries. Additional summary material includes results of monitoring & inspections, reports from regulatory and certification agencies, Statement of Conditions, Plans for Improvement and stated goals & objectives.
The program's objectives, scope, performance and effectiveness are included in the annual evaluation. The annual evaluation is submitted to the Environment of Care Committee & Quality Management not less than annually.