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Welcome to the WHEA’s Lunch & Learn Nov 2019 What Regulators Expect with Fire Drills & Fire Plans Presented by 1

What Regulators Expect with Fire Drills & Fire Plans · 18/19.7.1.6 –FIRE DRILLS. Conduct Under “Varied Conditions” 46 WHEN are drills conducted? Patterns are easy to spot by

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Page 1: What Regulators Expect with Fire Drills & Fire Plans · 18/19.7.1.6 –FIRE DRILLS. Conduct Under “Varied Conditions” 46 WHEN are drills conducted? Patterns are easy to spot by

Welcome to the WHEA’s

Lunch & LearnNov 2019

What Regulators Expect with

Fire Drills & Fire Plans

Presented by

1

Page 2: What Regulators Expect with Fire Drills & Fire Plans · 18/19.7.1.6 –FIRE DRILLS. Conduct Under “Varied Conditions” 46 WHEN are drills conducted? Patterns are easy to spot by

2

Bill Lauzon (professional engineer)Presenter:

Page 3: What Regulators Expect with Fire Drills & Fire Plans · 18/19.7.1.6 –FIRE DRILLS. Conduct Under “Varied Conditions” 46 WHEN are drills conducted? Patterns are easy to spot by

3

Bill Lauzon (professional engineer)

1973-2006 (33 yrs)

“Facility Engineer”

Tomah – Fargo- Madison

Kenosha - Racine

Presenter:

Page 4: What Regulators Expect with Fire Drills & Fire Plans · 18/19.7.1.6 –FIRE DRILLS. Conduct Under “Varied Conditions” 46 WHEN are drills conducted? Patterns are easy to spot by

4

Bill Lauzon (professional engineer)

2006-2011

DHS-DQA

“Surveyor &

Plan Reviewer”

Presenter:

Wis Liason

Page 5: What Regulators Expect with Fire Drills & Fire Plans · 18/19.7.1.6 –FIRE DRILLS. Conduct Under “Varied Conditions” 46 WHEN are drills conducted? Patterns are easy to spot by

5

Bill Lauzon (professional engineer)

2011-present

Lauzon Life

Safety Consulting

Presenter:

Page 6: What Regulators Expect with Fire Drills & Fire Plans · 18/19.7.1.6 –FIRE DRILLS. Conduct Under “Varied Conditions” 46 WHEN are drills conducted? Patterns are easy to spot by

Agenda

6

Lauzon

Life Safety

Consulting

Presented by

1.Fire Drills• Codes• Documents

2.Fire Plans • Codes • Documents

3.Fire Training• Codes • Documents

What Regulators Expect with

Fire Drills & Fire Plans

Page 7: What Regulators Expect with Fire Drills & Fire Plans · 18/19.7.1.6 –FIRE DRILLS. Conduct Under “Varied Conditions” 46 WHEN are drills conducted? Patterns are easy to spot by

7

Lauzon

Life Safety

Consulting

Presented by

Ask Questions

any time via the Chat Feature

What Regulators Expect with

Fire Drills & Fire Plans

Page 8: What Regulators Expect with Fire Drills & Fire Plans · 18/19.7.1.6 –FIRE DRILLS. Conduct Under “Varied Conditions” 46 WHEN are drills conducted? Patterns are easy to spot by

Part 1 - Fire Drills

8

Requirements of two AHJs

Based on:

1

Page 9: What Regulators Expect with Fire Drills & Fire Plans · 18/19.7.1.6 –FIRE DRILLS. Conduct Under “Varied Conditions” 46 WHEN are drills conducted? Patterns are easy to spot by

EC.02.03.03

9

(Same as CMS, but fewer)

Page 10: What Regulators Expect with Fire Drills & Fire Plans · 18/19.7.1.6 –FIRE DRILLS. Conduct Under “Varied Conditions” 46 WHEN are drills conducted? Patterns are easy to spot by

EC.02.03.03

10

EP 1: 1/Qtr/ShiftEP 2: Annual in BusinessEP 3: Unannounced, > 1 hr apart,

w/ TransmissionEP 4: Staff ParticipationEP 5: Drill Critiqued

(Same as CMS, but fewer)

Page 11: What Regulators Expect with Fire Drills & Fire Plans · 18/19.7.1.6 –FIRE DRILLS. Conduct Under “Varied Conditions” 46 WHEN are drills conducted? Patterns are easy to spot by

11

LS.01.02.01EP 11

ILSM

(Not a CMS requirement)

Page 12: What Regulators Expect with Fire Drills & Fire Plans · 18/19.7.1.6 –FIRE DRILLS. Conduct Under “Varied Conditions” 46 WHEN are drills conducted? Patterns are easy to spot by

12

LS.01.02.01EP 11

ILSM

(Not a CMS requirement)

Page 13: What Regulators Expect with Fire Drills & Fire Plans · 18/19.7.1.6 –FIRE DRILLS. Conduct Under “Varied Conditions” 46 WHEN are drills conducted? Patterns are easy to spot by

Part 1 - Fire Drills

13

Requirements of two AHJs

2

Page 14: What Regulators Expect with Fire Drills & Fire Plans · 18/19.7.1.6 –FIRE DRILLS. Conduct Under “Varied Conditions” 46 WHEN are drills conducted? Patterns are easy to spot by

14

CMS Tag K712 (2786 form)

A summary of NFPA 101 requirements

Page 15: What Regulators Expect with Fire Drills & Fire Plans · 18/19.7.1.6 –FIRE DRILLS. Conduct Under “Varied Conditions” 46 WHEN are drills conducted? Patterns are easy to spot by

15

CMS Tag K712 (2786 form)

A summary of NFPA 101 requirements

Based on NFPA 101. Will cover in detail in next section

Page 16: What Regulators Expect with Fire Drills & Fire Plans · 18/19.7.1.6 –FIRE DRILLS. Conduct Under “Varied Conditions” 46 WHEN are drills conducted? Patterns are easy to spot by

Code RequirementsFor Fire Drills

are found in 2 Locations

Fire Drill Codes

16

Page 17: What Regulators Expect with Fire Drills & Fire Plans · 18/19.7.1.6 –FIRE DRILLS. Conduct Under “Varied Conditions” 46 WHEN are drills conducted? Patterns are easy to spot by

Code RequirementsFor Fire Drills

are found in 2 Locations

1. Core Codes – Chapter 4

2. Occupancy Chapters – Chapter 12-42

Fire Drill Codes

17

Page 18: What Regulators Expect with Fire Drills & Fire Plans · 18/19.7.1.6 –FIRE DRILLS. Conduct Under “Varied Conditions” 46 WHEN are drills conducted? Patterns are easy to spot by

Core Drill Requirements – 4.7

18

CODE RULE: ALWAYS START WITH THE OCCUPANCY CHAPTER

Page 19: What Regulators Expect with Fire Drills & Fire Plans · 18/19.7.1.6 –FIRE DRILLS. Conduct Under “Varied Conditions” 46 WHEN are drills conducted? Patterns are easy to spot by

LSC 4.7 applies ONLY if directed by the occupancy chapter, x.7.x

Core Drill Requirements – 4.7

19

3 Situations

CODE RULE: ALWAYS START WITH THE OCCUPANCY CHAPTER

Page 20: What Regulators Expect with Fire Drills & Fire Plans · 18/19.7.1.6 –FIRE DRILLS. Conduct Under “Varied Conditions” 46 WHEN are drills conducted? Patterns are easy to spot by

Follow Occupancy Chapter, x.7.x

1. Follow 4.7 Requirements• Assembly (12/13)• Education (14/15)• Day Care (15/16)• Hotels & Dorms (28/29)• Mercantile (36/37)• Business-Hi-Rise (38-39)

Core Drill Requirements – 4.7

20

Page 21: What Regulators Expect with Fire Drills & Fire Plans · 18/19.7.1.6 –FIRE DRILLS. Conduct Under “Varied Conditions” 46 WHEN are drills conducted? Patterns are easy to spot by

Follow Occupancy Chapter, x.7.x

1. Follow 4.7 Requirements• Assembly (12/13)• Education (14/15)• Day Care (15/16)• Hotels & Dorms (28/29)• Mercantile (36/37)• Business-Hi-Rise (38-39)

2. No Requirements

• 1 & 2 Family (24)• Lodging/Rooming(26)• Industrial (40)• Storage (42)

Core Drill Requirements – 4.7

21

Page 22: What Regulators Expect with Fire Drills & Fire Plans · 18/19.7.1.6 –FIRE DRILLS. Conduct Under “Varied Conditions” 46 WHEN are drills conducted? Patterns are easy to spot by

Follow Occupancy Chapter, x.7.x

1. Follow 4.7 Requirements• Assembly (12/13)• Education (14/15)• Day Care (15/16)• Hotels & Dorms (28/29)• Mercantile (36/37)• Business-Hi-Rise (38-39)

3. Follow Chapter Requirements• Health Care (18/19)• Ambulatory (20/21)• Detention (23/24)• Apartments (30/31)• Board & Care (32/33)

2. No Requirements

• 1 & 2 Family (24)• Lodging/Rooming(26)• Industrial (40)• Storage (42)

Core Drill Requirements – 4.7

22

Page 23: What Regulators Expect with Fire Drills & Fire Plans · 18/19.7.1.6 –FIRE DRILLS. Conduct Under “Varied Conditions” 46 WHEN are drills conducted? Patterns are easy to spot by

Follow Occupancy Chapter, x.7.x

1. Follow 4.7 Requirements• Assembly (12/13)• Education (14/15)• Day Care (15/16)• Hotels & Dorms (28/29)• Mercantile (36/37)• Business-Hi-Rise (38-39)

3. Follow Chapter Requirements• Health Care (18/19)• Ambulatory (20/21)• Detention (23/24)• Apartments (30/31)• Board & Care (32/33)

2. No Requirements

• 1 & 2 Family (24)• Lodging/Rooming(26)• Industrial (40)• Storage (42)

Core Drill Requirements – 4.7

23

Ignore 4.7

Page 24: What Regulators Expect with Fire Drills & Fire Plans · 18/19.7.1.6 –FIRE DRILLS. Conduct Under “Varied Conditions” 46 WHEN are drills conducted? Patterns are easy to spot by

24

FIRE DRILLS records are checked During every Health Care inspection

DON’T MISS ANY !

Fire Drill & Plan cites are consistently in the TOP 10 !

Page 25: What Regulators Expect with Fire Drills & Fire Plans · 18/19.7.1.6 –FIRE DRILLS. Conduct Under “Varied Conditions” 46 WHEN are drills conducted? Patterns are easy to spot by

Same Requirements in both New & Existing

18/19.7.1.4 – FIRE DRILLS. Shall include: Simulation of emergency fire condition

25

Page 26: What Regulators Expect with Fire Drills & Fire Plans · 18/19.7.1.6 –FIRE DRILLS. Conduct Under “Varied Conditions” 46 WHEN are drills conducted? Patterns are easy to spot by

Same Requirements in both New & Existing

18/19.7.1.4 – FIRE DRILLS. Shall include: Simulation of emergency fire condition

26

Page 27: What Regulators Expect with Fire Drills & Fire Plans · 18/19.7.1.6 –FIRE DRILLS. Conduct Under “Varied Conditions” 46 WHEN are drills conducted? Patterns are easy to spot by

Same Requirements in both New & Existing

18/19.7.1.4 – FIRE DRILLS. Shall include: Transmission of a fire alarm signal

27

Transmit to Monitoring Station (not Fire Dept)

Page 28: What Regulators Expect with Fire Drills & Fire Plans · 18/19.7.1.6 –FIRE DRILLS. Conduct Under “Varied Conditions” 46 WHEN are drills conducted? Patterns are easy to spot by

Same Requirements in both New & Existing

18/19.7.1.4 – FIRE DRILLS. Shall include: Transmission of a fire alarm signal

28

Transmit to Monitoring Station (not Fire Dept)

Page 29: What Regulators Expect with Fire Drills & Fire Plans · 18/19.7.1.6 –FIRE DRILLS. Conduct Under “Varied Conditions” 46 WHEN are drills conducted? Patterns are easy to spot by

Same Requirements in both New & Existing

18/19.7.1.5 – FIRE DRILLS.

Infirm or bedridden patients shall not be required to

be moved during drills to safe areas or to the exterior of the building

29

Page 30: What Regulators Expect with Fire Drills & Fire Plans · 18/19.7.1.6 –FIRE DRILLS. Conduct Under “Varied Conditions” 46 WHEN are drills conducted? Patterns are easy to spot by

Same Requirements in both New & Existing

18/19.7.1.5 – FIRE DRILLS.

Infirm or bedridden patients shall not be required to

be moved during drills to safe areas or to the exterior of the building

XX30

Page 31: What Regulators Expect with Fire Drills & Fire Plans · 18/19.7.1.6 –FIRE DRILLS. Conduct Under “Varied Conditions” 46 WHEN are drills conducted? Patterns are easy to spot by

18/19.7.1.6 – FIRE DRILLS - Purpose is …To familiarize staff with signals and emergency actions

31

Page 32: What Regulators Expect with Fire Drills & Fire Plans · 18/19.7.1.6 –FIRE DRILLS. Conduct Under “Varied Conditions” 46 WHEN are drills conducted? Patterns are easy to spot by

18/19.7.1.6 – FIRE DRILLS - Purpose is …To familiarize staff with signals and emergency actions

32

Page 33: What Regulators Expect with Fire Drills & Fire Plans · 18/19.7.1.6 –FIRE DRILLS. Conduct Under “Varied Conditions” 46 WHEN are drills conducted? Patterns are easy to spot by

18/19.7.1.6 – FIRE DRILLS - Purpose is …To familiarize staff with signals and emergency actions

33

Code expects staff to respond automatically on all

shifts & at all locations

Page 34: What Regulators Expect with Fire Drills & Fire Plans · 18/19.7.1.6 –FIRE DRILLS. Conduct Under “Varied Conditions” 46 WHEN are drills conducted? Patterns are easy to spot by

18/19.7.1.6 – FIRE DRILLS. Conducted quarterly on each shift

1st

2nd

3rd

1st Quarter

1st

2nd

3rd

2nd Quarter

1st

2nd

3rd

3rd Quarter

1st

2nd

3rd

4th Quarter

34

1st Shift

2nd Shift

3rd Shift

Page 35: What Regulators Expect with Fire Drills & Fire Plans · 18/19.7.1.6 –FIRE DRILLS. Conduct Under “Varied Conditions” 46 WHEN are drills conducted? Patterns are easy to spot by

18/19.7.1.6 – FIRE DRILLS. Conducted quarterly on each shift

1st

2nd

3rd

1st Quarter

1st

2nd

3rd

2nd Quarter

1st

2nd

3rd

3rd Quarter

1st

2nd

3rd

4th Quarter

35

1st Shift

2nd Shift

3rd Shift

Page 36: What Regulators Expect with Fire Drills & Fire Plans · 18/19.7.1.6 –FIRE DRILLS. Conduct Under “Varied Conditions” 46 WHEN are drills conducted? Patterns are easy to spot by

18/19.7.1.6 – FIRE DRILLS. Conduct Under “Varied Conditions”

36

Lack of Uniform Definition of “VARIED”

Page 37: What Regulators Expect with Fire Drills & Fire Plans · 18/19.7.1.6 –FIRE DRILLS. Conduct Under “Varied Conditions” 46 WHEN are drills conducted? Patterns are easy to spot by

18/19.7.1.6 – FIRE DRILLS. Conduct Under “Varied Conditions”

37

Lack of Uniform Definition of “VARIED”

No Pattern

Not Predictable

Page 38: What Regulators Expect with Fire Drills & Fire Plans · 18/19.7.1.6 –FIRE DRILLS. Conduct Under “Varied Conditions” 46 WHEN are drills conducted? Patterns are easy to spot by

18/19.7.1.6 – FIRE DRILLS. Conduct Under “Varied Conditions”

38

Lack of Uniform Definition of “VARIED”

No Pattern

Not Predictable

Different• Days• Times• Locations

Spread Out

Page 39: What Regulators Expect with Fire Drills & Fire Plans · 18/19.7.1.6 –FIRE DRILLS. Conduct Under “Varied Conditions” 46 WHEN are drills conducted? Patterns are easy to spot by

18/19.7.1.6 – FIRE DRILLS. Conduct Under “Varied Conditions”

39

WHEN?• Month• Week• Day• TIme

WHEN are drills conducted? Patterns are easy to spot by inspectors

Page 40: What Regulators Expect with Fire Drills & Fire Plans · 18/19.7.1.6 –FIRE DRILLS. Conduct Under “Varied Conditions” 46 WHEN are drills conducted? Patterns are easy to spot by

18/19.7.1.6 – FIRE DRILLS. Conduct Under “Varied Conditions”

40

MONTH PATTERN to avoid • 1st shift → 1st month• 2nd shift → 2nd month• 3rd shift → 3rd month

WHEN are drills conducted? Patterns are easy to spot by inspectors

Page 41: What Regulators Expect with Fire Drills & Fire Plans · 18/19.7.1.6 –FIRE DRILLS. Conduct Under “Varied Conditions” 46 WHEN are drills conducted? Patterns are easy to spot by

18/19.7.1.6 – FIRE DRILLS. Conduct Under “Varied Conditions”

41

WEEK PATTERN to avoid • Always first or last week of month• Always first or last week of quarter

WHEN are drills conducted? Patterns are easy to spot by inspectors

Page 42: What Regulators Expect with Fire Drills & Fire Plans · 18/19.7.1.6 –FIRE DRILLS. Conduct Under “Varied Conditions” 46 WHEN are drills conducted? Patterns are easy to spot by

18/19.7.1.6 – FIRE DRILLS. Conduct Under “Varied Conditions”

42

WHEN are drills conducted?

DAY PATTERN to avoid • Frequently on 1st or last week of month• Frequently on 1st or last week of quarter• Frequently on same day of month• Frequently on same day of week• Multiple drills on same day

Patterns are easy to spot by inspectors

Page 43: What Regulators Expect with Fire Drills & Fire Plans · 18/19.7.1.6 –FIRE DRILLS. Conduct Under “Varied Conditions” 46 WHEN are drills conducted? Patterns are easy to spot by

18/19.7.1.6 – FIRE DRILLS. Conduct Under “Varied Conditions”

43

WHEN are drills conducted? Patterns are easy to spot by inspectors

HOUR PATTERN to avoid • Within 1 hr of any drill during past 12 months*

Page 44: What Regulators Expect with Fire Drills & Fire Plans · 18/19.7.1.6 –FIRE DRILLS. Conduct Under “Varied Conditions” 46 WHEN are drills conducted? Patterns are easy to spot by

18/19.7.1.6 – FIRE DRILLS. Conduct Under “Varied Conditions”

44

WHEN are drills conducted? Patterns are easy to spot by inspectors

HOUR PATTERN to avoid • Within 1 hr of any drill during past 12 months*

*2 within an hr of each other is normally accepted, BUT a 3rd drill within an 1 hr of any drill will get cited

Page 45: What Regulators Expect with Fire Drills & Fire Plans · 18/19.7.1.6 –FIRE DRILLS. Conduct Under “Varied Conditions” 46 WHEN are drills conducted? Patterns are easy to spot by

18/19.7.1.6 – FIRE DRILLS. Conduct Under “Varied Conditions”

45

WHEN are drills conducted? Patterns are easy to spot by inspectors

HOUR PATTERN to avoid • Within 1 hr of any drill during past 12 months*

*2 within an hr of each other is normally accepted, BUT a 3rd drill within an 1 hr of any drill will get cited

EC.02.03.03, EP 3 – puts it in writing

Page 46: What Regulators Expect with Fire Drills & Fire Plans · 18/19.7.1.6 –FIRE DRILLS. Conduct Under “Varied Conditions” 46 WHEN are drills conducted? Patterns are easy to spot by

18/19.7.1.6 – FIRE DRILLS. Conduct Under “Varied Conditions”

46

WHEN are drills conducted? Patterns are easy to spot by inspectors

HOUR PATTERN to avoid • Within 1 hr of any drill during past 12 months*

*2 within an hr of each other is normally accepted, BUT a 3rd drill within an 1 hr of any drill will get cited

This is a common sense allowance by DHS,

agreeing there will be repeats in random events

EC.02.03.03, EP 3 – (2 not permitted)

Page 47: What Regulators Expect with Fire Drills & Fire Plans · 18/19.7.1.6 –FIRE DRILLS. Conduct Under “Varied Conditions” 46 WHEN are drills conducted? Patterns are easy to spot by

18/19.7.1.6 – FIRE DRILLS. Conduct Under “Varied Conditions”

47

WHEN are drills conducted? Patterns are easy to spot by inspectors

HOUR PATTERN to avoid • Within 1 hr of any drill during past 12 months*

*2 within an hr of each other is normally accepted, BUT a 3rd drill within an 1 hr of any drill will get cited

Just like throwing dice

This is a common sense allowance by DHS,

agreeing there will be repeats in random events

EC.02.03.03, EP 3 – (2 not permitted)

Page 48: What Regulators Expect with Fire Drills & Fire Plans · 18/19.7.1.6 –FIRE DRILLS. Conduct Under “Varied Conditions” 46 WHEN are drills conducted? Patterns are easy to spot by

18/19.7.1.6 – FIRE DRILLS. Conduct Under “Varied Conditions”

48

More HOUR PATTERNS to avoid • Same sequence of times during day• Must spread out any “extra” drills (ILSM, etc)• If use a false alarm, must schedule to compensate

WHEN are drills conducted? Patterns are easy to spot by inspectors

Page 49: What Regulators Expect with Fire Drills & Fire Plans · 18/19.7.1.6 –FIRE DRILLS. Conduct Under “Varied Conditions” 46 WHEN are drills conducted? Patterns are easy to spot by

18/19.7.1.6 – FIRE DRILLS. Conduct Under “Varied Conditions”

49

HOUR PATTERN to avoid • Same sequence of times during day• Must spread out the “extra” drills (ILSM, etc)• If use a false alarm, must schedule to compensate

WHEN are drills conducted? Patterns are easy to spot by inspectors

Page 50: What Regulators Expect with Fire Drills & Fire Plans · 18/19.7.1.6 –FIRE DRILLS. Conduct Under “Varied Conditions” 46 WHEN are drills conducted? Patterns are easy to spot by

50

Typically many work shifts (especially nursing)

8-4:30

6-10

7-noon10-1:30

6-9:307-9:30

Page 51: What Regulators Expect with Fire Drills & Fire Plans · 18/19.7.1.6 –FIRE DRILLS. Conduct Under “Varied Conditions” 46 WHEN are drills conducted? Patterns are easy to spot by

51

Typically many work shifts (especially nursing)

Code wants ALL persons to experience an annual drill

8-4:30

6-10

7-noon10-1:30

6-9:307-9:30

Page 52: What Regulators Expect with Fire Drills & Fire Plans · 18/19.7.1.6 –FIRE DRILLS. Conduct Under “Varied Conditions” 46 WHEN are drills conducted? Patterns are easy to spot by

52

Typically many work shifts (especially nursing)

Code wants ALL persons to experience an annual drill

8-4:30

6-10

7-noon10-1:30

6-9:307-9:30

Drills MUST be spread out so more people are “trained”

Page 53: What Regulators Expect with Fire Drills & Fire Plans · 18/19.7.1.6 –FIRE DRILLS. Conduct Under “Varied Conditions” 46 WHEN are drills conducted? Patterns are easy to spot by

18/19.7.1.6 – FIRE DRILLS. Conduct Under “Varied Conditions”

53

HOW are drills conducted?

Page 54: What Regulators Expect with Fire Drills & Fire Plans · 18/19.7.1.6 –FIRE DRILLS. Conduct Under “Varied Conditions” 46 WHEN are drills conducted? Patterns are easy to spot by

18/19.7.1.6 – FIRE DRILLS. Conduct Under “Varied Conditions”

54

HOW are drills conducted?

• Same ‘ol drill every month?• Sometimes a smoke detector alarm?• Sometimes a simulated casualty?• Sometimes a simulated sprinkler?

Use your imagination; “Spice” it up; Add variety

Page 55: What Regulators Expect with Fire Drills & Fire Plans · 18/19.7.1.6 –FIRE DRILLS. Conduct Under “Varied Conditions” 46 WHEN are drills conducted? Patterns are easy to spot by

18/19.7.1.6 – FIRE DRILLS. Conduct Under “Varied Conditions”

55

WHERE are drills conducted?

• Are they often in the same place?• Consider where fires are more potential• Sometimes a kitchen fire?• Sometimes a laundry fire?• Don’t always conduct where people are located

Page 56: What Regulators Expect with Fire Drills & Fire Plans · 18/19.7.1.6 –FIRE DRILLS. Conduct Under “Varied Conditions” 46 WHEN are drills conducted? Patterns are easy to spot by

18/19.7.1.6 – FIRE DRILLS. Conduct Under “Varied Conditions”

56

WHERE are drills conducted?

Page 57: What Regulators Expect with Fire Drills & Fire Plans · 18/19.7.1.6 –FIRE DRILLS. Conduct Under “Varied Conditions” 46 WHEN are drills conducted? Patterns are easy to spot by

18/19.7.1.7 – PM FIRE DRILLS. If conducted between 9 pm and 6 am, a coded

announcement shall be permitted instead of audible alarms

X57

Page 58: What Regulators Expect with Fire Drills & Fire Plans · 18/19.7.1.6 –FIRE DRILLS. Conduct Under “Varied Conditions” 46 WHEN are drills conducted? Patterns are easy to spot by

18/19.7.1.7 – PM FIRE DRILLS. If conducted between 9 pm and 6 am, a coded

announcement shall be permitted instead of audible alarms

X58

Drills can be silent BUT

still need to Operate

Visuals & Transmit

Alarm

Page 59: What Regulators Expect with Fire Drills & Fire Plans · 18/19.7.1.6 –FIRE DRILLS. Conduct Under “Varied Conditions” 46 WHEN are drills conducted? Patterns are easy to spot by

18/19.7.1.7 – PM FIRE DRILLS. If conducted between 9 pm and 6 am, a coded

announcement shall be permitted instead of audible alarms

X(You must have a FA system that is

capable of turning off audibles)

59

Drills can be silent BUT

still need to Operate

Visuals & Transmit

Alarm

Page 60: What Regulators Expect with Fire Drills & Fire Plans · 18/19.7.1.6 –FIRE DRILLS. Conduct Under “Varied Conditions” 46 WHEN are drills conducted? Patterns are easy to spot by

60

FIRE DRILLS records are checked During every Health Care inspection

DON’T MISS ANY !

Follow the precise

requirements

Page 61: What Regulators Expect with Fire Drills & Fire Plans · 18/19.7.1.6 –FIRE DRILLS. Conduct Under “Varied Conditions” 46 WHEN are drills conducted? Patterns are easy to spot by

The drill is meant to test & train the staff:

(not maintenance)

• On how to activate the fire alarm • On how to respond to alarms

Fire Drill Documents

61

Page 62: What Regulators Expect with Fire Drills & Fire Plans · 18/19.7.1.6 –FIRE DRILLS. Conduct Under “Varied Conditions” 46 WHEN are drills conducted? Patterns are easy to spot by

The drill is meant to test & train the staff:

(not maintenance)

• On how to activate the fire alarm • On how to respond to alarms

Fire Drill Documents

62

Fire Drill Checklist

Specific Requirements

1. 1/Shift/Quarter

2. Varied Days (max 2 within a

day of each other)

3. Varied Times (max 2 within

an hr of each other)

4. Varied Locations (none in

same smoke compart)

5. Staff/auto activate alarm

6. Include Transmission of

Alarm

7. Include Back Up Call to FD or

Monitoring

8. Documented staff

participation

9. Documented evaluation of

drill

Page 63: What Regulators Expect with Fire Drills & Fire Plans · 18/19.7.1.6 –FIRE DRILLS. Conduct Under “Varied Conditions” 46 WHEN are drills conducted? Patterns are easy to spot by

Available for free download in Nov at

www.Lauzon.LSC.com

Recommended Fire Drill Grid

63

Page 64: What Regulators Expect with Fire Drills & Fire Plans · 18/19.7.1.6 –FIRE DRILLS. Conduct Under “Varied Conditions” 46 WHEN are drills conducted? Patterns are easy to spot by

• Code Ref• Checkpoints• Grid

Recommended Fire Drill Grid

64

Page 65: What Regulators Expect with Fire Drills & Fire Plans · 18/19.7.1.6 –FIRE DRILLS. Conduct Under “Varied Conditions” 46 WHEN are drills conducted? Patterns are easy to spot by

• Code Ref• Checkpoints• Grid

Recommended Fire Drill Grid

It’s how surveyors spot issues

65

This is MOST important

Citation Prevention Form

Page 66: What Regulators Expect with Fire Drills & Fire Plans · 18/19.7.1.6 –FIRE DRILLS. Conduct Under “Varied Conditions” 46 WHEN are drills conducted? Patterns are easy to spot by

Recommended Fire Drill Grid

66

Page 67: What Regulators Expect with Fire Drills & Fire Plans · 18/19.7.1.6 –FIRE DRILLS. Conduct Under “Varied Conditions” 46 WHEN are drills conducted? Patterns are easy to spot by

67

Using the Fire Drill Grid

Scan DOWN each column

Page 68: What Regulators Expect with Fire Drills & Fire Plans · 18/19.7.1.6 –FIRE DRILLS. Conduct Under “Varied Conditions” 46 WHEN are drills conducted? Patterns are easy to spot by

Look for PATTERN in DATES

• “Same” day of month• Early or late in month(Max 2 within a day of each other)

• Vary Month of Drill(not always 1st shift in 1st month, etc.)

68

Using the Fire Drill Grid

Scan DOWN each column

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69

Using the Fire Drill Grid

Scan DOWN each column

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70

Using the Fire Drill Grid

Scan DOWN each column

Look for PATTERN WITH TIME

• “Similar” time of day

(Max 2 within an hour of each other)

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71

Using the Fire Drill Grid

Scan DOWN each column

Look for PATTERN WITH TIME

• “Similar” time of day

(Max 2 within an hour of each other)

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72

Using the Fire Drill Grid

Scan DOWN each column

Page 73: What Regulators Expect with Fire Drills & Fire Plans · 18/19.7.1.6 –FIRE DRILLS. Conduct Under “Varied Conditions” 46 WHEN are drills conducted? Patterns are easy to spot by

Look for PATTERN WITH LOCATION

• Vary locations(Not more than one in a department/

smoke compartment on same shift per year, unless a small facility)

73

Using the Fire Drill Grid

Page 74: What Regulators Expect with Fire Drills & Fire Plans · 18/19.7.1.6 –FIRE DRILLS. Conduct Under “Varied Conditions” 46 WHEN are drills conducted? Patterns are easy to spot by

Using the Fire Drill Grid

One Valid Drill = Okay

One Valid Drill = Okay

One Valid Drill = Okay

One Valid Drill = Okay

One Valid Drill = Okay

One Valid Drill = Okay

One Valid Drill = Okay

One Valid Drill = Okay

One Valid Drill = Okay

One Valid Drill = Okay

74

One Valid Drill = Okay

One Valid Drill = Okay

Page 75: What Regulators Expect with Fire Drills & Fire Plans · 18/19.7.1.6 –FIRE DRILLS. Conduct Under “Varied Conditions” 46 WHEN are drills conducted? Patterns are easy to spot by

Using the Fire Drill Grid

One Valid Drill = Okay

One Valid Drill = Okay

One Valid Drill = Okay

One Valid Drill = Okay

One Valid Drill = Okay

One Valid Drill = Okay

One Valid Drill = Okay

One Valid Drill = Okay

One Valid Drill = Okay

One Valid Drill = Okay

75

One Valid Drill = Okay

One Valid Drill = Okay

Page 76: What Regulators Expect with Fire Drills & Fire Plans · 18/19.7.1.6 –FIRE DRILLS. Conduct Under “Varied Conditions” 46 WHEN are drills conducted? Patterns are easy to spot by

Check Forms Against Code Requirements

Fire Doc Review

76

Page 77: What Regulators Expect with Fire Drills & Fire Plans · 18/19.7.1.6 –FIRE DRILLS. Conduct Under “Varied Conditions” 46 WHEN are drills conducted? Patterns are easy to spot by

Check Forms Against Code Requirements

Drill Log Checklist

Specific Requirements

1. 1/Shift/Quarter

2. Varied Days (max 2 within a

day of each other)

3. Varied Times (max 2 within

an hr of each other)

4. Varied Locations (none in

same smoke compart)

Fire Doc Review

77

Page 78: What Regulators Expect with Fire Drills & Fire Plans · 18/19.7.1.6 –FIRE DRILLS. Conduct Under “Varied Conditions” 46 WHEN are drills conducted? Patterns are easy to spot by

Check Forms Against Code Requirements

Drill Report Checklist

Specific Requirements

1. Staff/auto activate alarm

2. Include Transmission of

Alarm

3. Include Back Up Call to FD or

Monitoring

4. Documented staff

participation

5. Documented evaluation of

drill

Drill Log Checklist

Specific Requirements

1. 1/Shift/Quarter

2. Varied Days (max 2 within a

day of each other)

3. Varied Times (max 2 within

an hr of each other)

4. Varied Locations (none in

same smoke compart)

Fire Doc Review

78

Page 79: What Regulators Expect with Fire Drills & Fire Plans · 18/19.7.1.6 –FIRE DRILLS. Conduct Under “Varied Conditions” 46 WHEN are drills conducted? Patterns are easy to spot by

Check Form Against Code

Requirements

Date shows drill was in 4th

Qtr; If so, non-compliant …

79

Drill Log Checklist

Specific Requirements

1. 1/Shift/Quarter

2. Varied Days (max 2 within a

day of each other)

3. Varied Times (max 2 within

an hr of each other)

4. Varied Locations (none in

same smoke compart)

Page 80: What Regulators Expect with Fire Drills & Fire Plans · 18/19.7.1.6 –FIRE DRILLS. Conduct Under “Varied Conditions” 46 WHEN are drills conducted? Patterns are easy to spot by

Check Form Against Code

Requirements

Date shows drill was in 4th

Qtr; If so, non-compliant …

80

Drill Log Checklist

Specific Requirements

1. 1/Shift/Quarter

2. Varied Days (max 2 within a

day of each other)

3. Varied Times (max 2 within

an hr of each other)

4. Varied Locations (none in

same smoke compart)

X

Page 81: What Regulators Expect with Fire Drills & Fire Plans · 18/19.7.1.6 –FIRE DRILLS. Conduct Under “Varied Conditions” 46 WHEN are drills conducted? Patterns are easy to spot by

Missing May trigger closer look at

drill forms. Should have logs

for prior 12 months

81

Drill Log Checklist

Specific Requirements

1. 1/Shift/Quarter

2. Varied Days (max 2 within a

day of each other)

3. Varied Times (max 2 within

an hr of each other)

4. Varied Locations (none in

same smoke compart)

Check Form Against Code

Requirements

Page 82: What Regulators Expect with Fire Drills & Fire Plans · 18/19.7.1.6 –FIRE DRILLS. Conduct Under “Varied Conditions” 46 WHEN are drills conducted? Patterns are easy to spot by

Missing May trigger closer look at

drill forms. Should have logs

for prior 12 months

82

Drill Log Checklist

Specific Requirements

1. 1/Shift/Quarter

2. Varied Days (max 2 within a

day of each other)

3. Varied Times (max 2 within

an hr of each other)

4. Varied Locations (none in

same smoke compart)

X

Check Form Against Code

Requirements

Page 83: What Regulators Expect with Fire Drills & Fire Plans · 18/19.7.1.6 –FIRE DRILLS. Conduct Under “Varied Conditions” 46 WHEN are drills conducted? Patterns are easy to spot by

1/14/17

83

Check Form Against Code

Requirements

Drill Log Checklist

Specific Requirements

1. 1/Shift/Quarter

2. Varied Days (max 2 within a

day of each other)

3. Varied Times (max 2 within

an hr of each other)

4. Varied Locations (none in

same smoke compart)

Creates a Pattern:

1st shift during 1 Mo of Qtr

2nd shift during 2 Mo of Qtr

3rd shift during 3 Mo of Qtr

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1/14/17

84

Check Form Against Code

Requirements

Drill Log Checklist

Specific Requirements

1. 1/Shift/Quarter

2. Varied Days (max 2 within a

day of each other)

3. Varied Times (max 2 within

an hr of each other)

4. Varied Locations (none in

same smoke compart)

Creates a Pattern:

1st shift during 1 Mo of Qtr

2nd shift during 2 Mo of Qtr

3rd shift during 3 Mo of Qtr

X

Page 85: What Regulators Expect with Fire Drills & Fire Plans · 18/19.7.1.6 –FIRE DRILLS. Conduct Under “Varied Conditions” 46 WHEN are drills conducted? Patterns are easy to spot by

• Okay per some AHJs because > 1 hr apart

• But, MAY be cited by some AHJ who require

them to be > 2 hrs apart

85

Check Form Against Code

Requirements

Drill Log Checklist

Specific Requirements

1. 1/Shift/Quarter

2. Varied Days (max 2 within a

day of each other)

3. Varied Times (max 2 within

an hr of each other)

4. Varied Locations (none in

same smoke compart)

Review Time of Day

Very Carefully

Page 86: What Regulators Expect with Fire Drills & Fire Plans · 18/19.7.1.6 –FIRE DRILLS. Conduct Under “Varied Conditions” 46 WHEN are drills conducted? Patterns are easy to spot by

• Okay per some AHJs because > 1 hr apart

• But, MAY be cited by some AHJ who require

them to be > 2 hrs apart

86

Check Form Against Code

Requirements

Drill Log Checklist

Specific Requirements

1. 1/Shift/Quarter

2. Varied Days (max 2 within a

day of each other)

3. Varied Times (max 2 within

an hr of each other)

4. Varied Locations (none in

same smoke compart)

P

Review Time of Day

Very Carefully

Page 87: What Regulators Expect with Fire Drills & Fire Plans · 18/19.7.1.6 –FIRE DRILLS. Conduct Under “Varied Conditions” 46 WHEN are drills conducted? Patterns are easy to spot by

Many Forms are Available

Fire Drill Report Form

There isn’t a “Best” Form

87

Page 88: What Regulators Expect with Fire Drills & Fire Plans · 18/19.7.1.6 –FIRE DRILLS. Conduct Under “Varied Conditions” 46 WHEN are drills conducted? Patterns are easy to spot by

Many Forms are Available

Fire Drill Report Form

There isn’t a “Best” Form

Use one that fits facility

culture

Contains Key Checkpoints?

88

Page 89: What Regulators Expect with Fire Drills & Fire Plans · 18/19.7.1.6 –FIRE DRILLS. Conduct Under “Varied Conditions” 46 WHEN are drills conducted? Patterns are easy to spot by

Drill Report Checklist

Specific Requirements

1. Staff/auto activate alarm

2. Include Transmission of

Alarm

3. Include Back Up Call to FD or

Monitoring

4. Documented staff

participation

5. Documented evaluation of

drill

Does not show that a STAFF activated

89

Page 90: What Regulators Expect with Fire Drills & Fire Plans · 18/19.7.1.6 –FIRE DRILLS. Conduct Under “Varied Conditions” 46 WHEN are drills conducted? Patterns are easy to spot by

Drill Report Checklist

Specific Requirements

1. Staff/auto activate alarm

2. Include Transmission of

Alarm

3. Include Back Up Call to FD or

Monitoring

4. Documented staff

participation

5. Documented evaluation of

drill

X

Does not show that a STAFF activated

90

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Drill Report Checklist

Specific Requirements

1. Staff/auto activate alarm

2. Include Transmission of

Alarm

3. Include Back Up Call to FD or

Monitoring

4. Documented staff

participation

5. Documented evaluation of

drillTransmission verification is

Not Shown

91

Page 92: What Regulators Expect with Fire Drills & Fire Plans · 18/19.7.1.6 –FIRE DRILLS. Conduct Under “Varied Conditions” 46 WHEN are drills conducted? Patterns are easy to spot by

Drill Report Checklist

Specific Requirements

1. Staff/auto activate alarm

2. Include Transmission of

Alarm

3. Include Back Up Call to FD or

Monitoring

4. Documented staff

participation

5. Documented evaluation of

drillTransmission verification is

Not Shown

X

92

Page 93: What Regulators Expect with Fire Drills & Fire Plans · 18/19.7.1.6 –FIRE DRILLS. Conduct Under “Varied Conditions” 46 WHEN are drills conducted? Patterns are easy to spot by

Drill Report Checklist

Specific Requirements

1. Staff/auto activate alarm

2. Include Transmission of

Alarm

3. Include Back Up Call to FD or

Monitoring

4. Documented staff

participation

5. Documented evaluation of

drill

93

Back-Up call to monitoring

sta during the drill

is Not Shown

Page 94: What Regulators Expect with Fire Drills & Fire Plans · 18/19.7.1.6 –FIRE DRILLS. Conduct Under “Varied Conditions” 46 WHEN are drills conducted? Patterns are easy to spot by

Drill Report Checklist

Specific Requirements

1. Staff/auto activate alarm

2. Include Transmission of

Alarm

3. Include Back Up Call to FD or

Monitoring

4. Documented staff

participation

5. Documented evaluation of

drill

X

94

Back-Up call to monitoring

sta during the drill

is Not Shown

Page 95: What Regulators Expect with Fire Drills & Fire Plans · 18/19.7.1.6 –FIRE DRILLS. Conduct Under “Varied Conditions” 46 WHEN are drills conducted? Patterns are easy to spot by

Drill Report Checklist

Specific Requirements

1. Staff/auto activate alarm

2. Include Transmission of

Alarm

3. Include Back Up Call to FD or

Monitoring

4. Documented staff

participation

5. Documented evaluation of

drill

95

Missing names of all who

participated in drill

Page 96: What Regulators Expect with Fire Drills & Fire Plans · 18/19.7.1.6 –FIRE DRILLS. Conduct Under “Varied Conditions” 46 WHEN are drills conducted? Patterns are easy to spot by

Drill Report Checklist

Specific Requirements

1. Staff/auto activate alarm

2. Include Transmission of

Alarm

3. Include Back Up Call to FD or

Monitoring

4. Documented staff

participation

5. Documented evaluation of

drill

X

96

Missing names of all who

participated in drill

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Drill Report Checklist

Specific Requirements

1. Staff/auto activate alarm

2. Include Transmission of

Alarm

3. Include Back Up Call to FD or

Monitoring

4. Documented staff

participation

5. Documented evaluation of

drillP

97

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Drill Report Checklist

Specific Requirements

1. Staff/auto activate alarm

2. Include Transmission of

Alarm

3. Include Back Up Call to FD or

Monitoring

4. Documented staff

participation

5. Documented evaluation of

drillP

SHOULD REVISE FORM

TO INCLUDE Failed

ITEMS

98

X

X

XX

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99

Part 2 - Fire Plan

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100

Part 2 - Fire Plan

EC.02.03.01EP 9

Same as CMS, but less precise

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101

Fire Plan

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102

Fire Plan

CMS Tag K711

Contains a summary of the NFPA requirements

Page 103: What Regulators Expect with Fire Drills & Fire Plans · 18/19.7.1.6 –FIRE DRILLS. Conduct Under “Varied Conditions” 46 WHEN are drills conducted? Patterns are easy to spot by

Code RequirementsFor Fire Plans

are found in 2 Locations

1. Core Codes – Chapter 4

2. Occupancy Chapters – Chapter 12-42

103

Fire Plan

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Follow Occupancy Chapter, x.8.x

1. Follow 4.7 Requirements• Assembly (12/13)• Education (14/15)• Day Care (15/16)• Hotels & Dorms (28/29)• Mercantile (36/37)• Business-Hi-Rise (38-39)

3. Follow Chapter Requirements• Health Care (18/19)• Ambulatory (20/21)• Detention (23/24)• Apartments (30/31)• Board & Care (32/33)

2. No Requirements

• 1 & 2 Family (24)• Lodging/Rooming(26)• Industrial (40)• Storage (42)

Core Plan Requirements – 4.8

104

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Follow Occupancy Chapter, x.8.x

1. Follow 4.7 Requirements

3. Follow Chapter Requirements• Health Care (18/19)• Ambulatory (20/21)• Detention (23/24)• Apartments (30/31)• Board & Care (32/33)

2. No Requirements

Core Plan Requirements – 4.8

105

Ignore 4.8

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Same Requirements in both New & Existing

106

18/19.7.1.1 – EVACUATION & RELOCATION PLANMust have a written plan

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1. For the protection of all persons in a fire2. For evacuation to areas of refuge3. For evacuation from the building if necessary

Same Requirements in both New & Existing

107

18/19.7.1.1 – EVACUATION & RELOCATION PLANMust have a written plan

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Same Requirements in both New & Existing

108

18/19.7.1.1 – EVACUATION & RELOCATION PLANAvailable to all supervisors

1. Must be the current plan2. If on-line, all supervisors must be able to

demonstrate having quick access

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Same Requirements in both New & Existing

109

18/19.7.1.1 – EVACUATION & RELOCATION PLANReadily available at all times in the

telephone operator’s position or the security center

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Same Requirements in both New & Existing

110

18/19.7.1.1 – EVACUATION & RELOCATION PLANReadily available at all times in the

telephone operator’s position or the security center

1. Must be the current plan2. If on-line, must be able to demonstrate having

quick access

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Same Requirements in both New & Existing

111

18/19.7.1.2 – EVACUATION & RELOCATION PLANPeriodic instruction of all employees on their duties

18/19.7.182 – EVACUATION & RELOCATION PLANInstruction of all employees on life safety procedures

and devices

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112

18/19.7.2 – PROCEDURE IN CASE OF A FIREPrompt and effective fire response

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1. Remove all occupants near fire2. Alarm Transmission to warn occupants and summon staff3. Confinement of fire by closing doors to isolate the fire area4. Evacuation/Relocation of patients

113

18/19.7.2 – PROCEDURE IN CASE OF A FIREPrompt and effective fire response

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R

1. Remove all occupants near fire2. Alarm Transmission to warn occupants and summon staff3. Confinement of fire by closing doors to isolate the fire area4. Evacuation/Relocation of patients

114

18/19.7.2 – PROCEDURE IN CASE OF A FIREPrompt and effective fire response

A EC

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115

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116

Evacuate

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18/19.7.2.2 –FIRE SAFETY PLAN shall include:

1. Use of alarms2. Transmission of alarm to fire dept3. Emergency Call to fire department4. Response to alarms5. Isolation of fire6. Evacuation of immediate area7. Evacuation of smoke compartment8. Preparation of floors & building for

evacuation9. Extinguishment of fire10. Use of Code Phrase

117

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18/19.7.2.2 –FIRE SAFETY PLAN shall include:

1. Use of alarms2. Transmission of alarm to fire dept3. Emergency Call to fire department4. Response to alarms5. Isolation of fire6. Evacuation of immediate area7. Evacuation of smoke compartment8. Preparation of floors & building for

evacuation9. Extinguishment of fire10. Use of Code Phrase

PLAN MUST

HAVE ALL

118

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1. Use of Alarms

All staff must:

119

18/19.7.2.2 –FIRE SAFETY PLAN shall include:

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1. Use of Alarms

All staff must:

120

a. Know the location of pull stations

b. Know how to pull the alarm (best if they’ve done it)

c. Feel authorized to do it

18/19.7.2.2 –FIRE SAFETY PLAN shall include:

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2. Transmission of Alarm to Fire Dept (via Monitoring Sta)

121

18/19.7.2.2 –FIRE SAFETY PLAN shall include:

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2. Transmission of Alarm to Fire Dept (via Monitoring Sta)

122

Simple explanation of how your fire alarm system “talks” to the fire dept via your monitoring service

18/19.7.2.2 –FIRE SAFETY PLAN shall include:

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3. Emergency Call to fire department (new in 2012 LSC)

123

18/19.7.2.2 –FIRE SAFETY PLAN shall include:

NEW

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3. Emergency Call to fire department (new in 2012 LSC)

124

18/19.7.2.2 –FIRE SAFETY PLAN shall include:

NEW

Different from usual Post-Drill call to put sys back on-line

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3. Emergency Call to fire department (new in 2012 LSC)

125

18/19.7.2.2 –FIRE SAFETY PLAN shall include:

Someone must call monitoring company

ASAP after the alarm is sounded to confirm

signal received

NEW

Different from usual Post-Drill call to put sys back on-line

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4. Response to Alarms

126

18/19.7.2.2 –FIRE SAFETY PLAN shall include:

Staff Actions When Alarm Sounds:

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4. Response to Alarms

127

18/19.7.2.2 –FIRE SAFETY PLAN shall include:

Staff Actions When Alarm Sounds:

a. In area of the fire

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4. Response to Alarms

128

18/19.7.2.2 –FIRE SAFETY PLAN shall include:

Staff Actions When Alarm Sounds:

a. In area of the fire

b. In areas away from the fire

c. Other floors/buildings

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5. Isolation of the Fire

129

18/19.7.2.2 –FIRE SAFETY PLAN shall include:

Part of RACE:CLOSE the doors

Very Important Factor to Limit Spread of a Fire

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6. Evacuation of Immediate Area

130

18/19.7.2.2 –FIRE SAFETY PLAN shall include:

Part of RACE:

Remove people in fire area

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Part of RACE:

Evacuation Preparation131

7. Evacuation of Smoke Compartment

18/19.7.2.2 –FIRE SAFETY PLAN shall include:

Smoke Barrier Wall

Smoke Barrier Doors not shown

for clarity

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Part of RACE:

Evacuation Preparation

If fire gets worse, move to next smoke compartment (through smoke barrier doors)

132

7. Evacuation of Smoke Compartment

18/19.7.2.2 –FIRE SAFETY PLAN shall include:

Smoke Barrier Wall

Smoke Barrier Doors not shown

for clarity

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133

8. Prep for floor & building evacuation

18/19.7.2.2 –FIRE SAFETY PLAN shall include:

Get ready, if fire gets worse, to move to (a) Next smoke compartment(b) Another floor(c) Out of the building

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134

9. Extinguishment of fire

18/19.7.2.2 –FIRE SAFETY PLAN shall include:

Use portable extinguisher ONLY if(a) Trained(b) Fire is small(c) Patients already moved away(d) RACE is completed

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135

10. Use of Code Phrase

18/19.7.2.3.2 –FIRE SAFETY PLAN shall include:

“Code 99”

“Mr H”

“Red Party”

Code Red !

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136

10. Use of Code Phrase

18/19.7.2.3.2 –FIRE SAFETY PLAN shall include:

Use designated phase (NOT “fire”) when

(a) Need help when discovered a fire

(b) Fire alarm sys is inoperable

“Code 99”

“Mr H”

“Red Party”

Code Red !

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137

10. Use of Code Phrase

18/19.7.2.3.2 –FIRE SAFETY PLAN shall include:

Use designated phase (NOT “fire”) when

(a) Need help when discovered a fire

(b) Fire alarm sys is inoperable

“Code 99”

“Mr H”

“Red Party”

When staff hear the code phrase, they must • Activate the nearest fire alarm pull• Immediately execute fire duties

Code Red !

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138

Relocation of equipment from corridors during a fire

18/19.2.3.4(4)(b) –FIRE SAFETY PLAN shall include:

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139

Relocation of equipment from corridors during a fire

18/19.2.3.4(4)(b) –FIRE SAFETY PLAN shall include:

Remove obstructions from exit access corridors

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140

Relocation of equipment from corridors during a fire

18/19.2.3.4(4)(b) –FIRE SAFETY PLAN shall include:

Remove obstructions from exit access corridors

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Fire Dept must review LTC Plans DHS 132.92(3)(c )2

141

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Fire Dept must review LTC Plans DHS 132.92(3)(c )2

142

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Fire Dept must review LTC Plans DHS 132.92(3)(c )2

143

However, many do not like to review plans

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Tips to Get Fire Dept to review plan:1. Avoid terms like “certification”2. Understand the limits on FD manpower3. FD are concerned on liability

DHS does not fund fire depts

144

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Tips to Get Fire Dept to review plan:1. Avoid terms like “certification”2. Understand the limits on FD manpower3. FD are concerned on liability 4. Request far in advance5. Link Plan review with Inspection form6. If FD still doesn’t, hire a private reviewer

DHS does not fund fire depts

145

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146

Tips to Get Fire Dept to review plan:Link Plan review with Inspection form

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147

Tips to Get Fire Dept to review plan:Link Plan review with Inspection form

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Want your Fire Plan to PASS?

148

1. Cover the 10 required items

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Want your Fire Plan to PASS?

149

1. Cover the 10 required items

FIRE PLAN CHECKLIST1. Use of alarms2. Transmission of alarm to fire dept3. Emergency Call to fire department4. Response to alarms5. Isolation of fire6. Evacuation of immediate area7. Evacuation of smoke compartment8. Prep of floors & building for evac9. Extinguishment of fire10. Use of Code Phrase

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Want your Fire Plan to PASS?

150

1. Cover the 10 required items

FIRE PLAN CHECKLIST1. Use of alarms2. Transmission of alarm to fire dept3. Emergency Call to fire department4. Response to alarms5. Isolation of fire6. Evacuation of immediate area7. Evacuation of smoke compartment8. Prep of floors & building for evac9. Extinguishment of fire10. Use of Code Phrase

2. Use the required items as headings (so easy to find)

3. Keep the plan short, so quick to digest

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Example Fire Response Plan

151

FIRE PLAN CHECKLIST1. Use of alarms2. Transmission of alarm to fire dept3. Emergency Call to fire department4. Response to alarms5. Isolation of fire6. Evacuation of immediate area7. Evacuation of smoke compartment8. Prep of floors & building for evac9. Extinguishment of fire10. Use of Code Phrase

Available for FREE at:

www.Lauzon-LSC.com

During Nov 2019

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Same Requirements in both New & Existing152

Part 3 - Fire Training

18/19.7.1.2 – EVACUATION & RELOCATION PLANPeriodic instruction of all employees on their duties

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Same Requirements in both New & Existing153

Part 3 - Fire Training

18/19.7.1.2 – EVACUATION & RELOCATION PLANPeriodic instruction of all employees on their duties

18/19.7.182 – EVACUATION & RELOCATION PLANInstruction of all employees on life safety procedures and devices

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Mandatory Training Requirements

1. Staff Duties - Use & Response to Alarms

2. Life Safety Procedures

154

Part 3 - Fire Training

3. Life Safety Devices

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1. Staff Duties

Train based on your Fire Plan

Make sure eachof your topics is covered in your

training

155

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R-A-C-E

P-A-S-S

AT THE FIRE

156

1. Staff Duties – During a Fire Response

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R-A-C-E

P-A-S-S

AT THE FIRE AWAY FROM THE FIRE

C-H-E-E-R

157

1. Staff Duties – During a Fire Response

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R-A-C-E

R Remove People in Same

Room as the Fire

158

1. Staff Duties – During a Fire Response

AT THE FIRE

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R-A-C-E

RA

Remove People in Same

Room as the Fire

Activate the Alarm

159

1. Staff Duties – During a Fire Response

AT THE FIRE

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R-A-C-E

RAC

Remove People in Same

Room as the Fire

Activate the Alarm

Confine the Fire by

closing the door to the Room

160

1. Staff Duties – During a Fire Response

AT THE FIRE

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R-A-C-E

RACE

Remove People in Same

Room as the Fire

Activate the Alarm

Confine the Fire by

closing the door to the Room

Evacuation Prep

161

1. Staff Duties – During a Fire Response

AT THE FIRE

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P-A-S-SP Pull the Pin

162

1. Staff Duties – During a Fire Response

AT THE FIREExtinguisher Use

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P-A-S-SPA

Pull the Pin

Aim at the Base of the Fire

163

1. Staff Duties – During a Fire Response

AT THE FIREExtinguisher Use

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P-A-S-SPAS

Pull the Pin

Aim at the Base of the Fire

Squeeze the trigger

164

1. Staff Duties – During a Fire Response

AT THE FIREExtinguisher Use

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P-A-S-SPASS

Pull the Pin

Aim at the Base of the Fire

Squeeze the trigger

Sweep the Fire, slowly

165

1. Staff Duties – During a Fire Response

AT THE FIREExtinguisher Use

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P-A-S-SPASS

Pull the Pin

Aim at the Base of the Fire

Squeeze the trigger

Sweep the Fire, slowly

166

1. Staff Duties – During a Fire Response

AT THE FIREExtinguisher Use

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167

1. Staff Duties – During a Fire Response

R-A-C-E

P-A-S-S

AT THE FIRE

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168

1. Staff Duties – During a Fire Response

AWAY FROM THE FIRE

R-A-C-E

P-A-S-S

AT THE FIRE

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169

1. Staff Duties – During a Fire Response

AWAY FROM THE FIRE

R-A-C-E

P-A-S-S

AT THE FIRE

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C-H-E-E-R

170

1. Staff Duties – During a Fire Response

AWAY FROM THE FIRE

R-A-C-E

P-A-S-S

AT THE FIRE

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C-H-E-E-R

C Clear the Corridors

171

1. Staff Duties – During a Fire Response

AWAY FROM THE FIRE

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C-H-E-E-R

CH

Clear the Corridors

Help neighbor zone

172

1. Staff Duties – During a Fire Response

AWAY FROM THE FIRE

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C-H-E-E-R

CHE

Clear the Corridors

Help neighbor zone

Extinguisher brought

173

1. Staff Duties – During a Fire Response

AWAY FROM THE FIRE

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C-H-E-E-R

CHEE

Clear the Corridors

Help neighbor zone

Extinguisher brought

Encourage Patients & Visitors

174

1. Staff Duties – During a Fire Response

AWAY FROM THE FIRE

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C-H-E-E-R

CHEE

Clear the Corridors

Help neighbor zone

Extinguisher brought

Encourage Patients & Visitors

R Relocate Prep175

1. Staff Duties – During a Fire Response

AWAY FROM THE FIRE

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Training Usually given during Dept meeting

176

1. Staff Duties DEPT SPECIFIC TASKS

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Cover such thing as:• Who clears the corridors• How to mark cleared rooms• Who moves med charts & meds• Special dept tasks

Training Usually given during Dept meeting

177

1. Staff Duties DEPT SPECIFIC TASKS

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Mandatory Training Requirements

1. Staff Duties - Use & Response to Alarms

2. Life Safety Procedures

178

Part 3 - Fire Training

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DEFEND-IN-PLACE !

179

2. Life Safety Procedures

1. Explain

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DEFEND-IN-PLACE !

180

2. Life Safety Procedures

1. Explain

COMPARTMENTALIZATION !

2. Explain

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Your Evacuation Procedures

DEFEND-IN-PLACE !

181

2. Life Safety Procedures

1. Explain

COMPARTMENTALIZATION !

2. Explain

3. Review

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Sounds Crazy !

182

2. Life Safety Procedures 1. DEFEND-IN-PLACE !

Stay in Building During a Fire?

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Sounds Crazy !

183

2. Life Safety Procedures 1. DEFEND-IN-PLACE !

Contrary to FD !

Not what we did in school

Stay in Building During a Fire?

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184

2. Life Safety Procedures

Stay in Building During a Fire? It can be Difficult & Dangerous to Exit

Outside

1. DEFEND-IN-PLACE !

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185

2. Life Safety Procedures

Stay in Building During a Fire?

1. Injury during moving2. Medication disruption3. Keeping track4. Outside weather5. Potential lost patients

It can be Difficult & Dangerous to Exit

Outside

1. DEFEND-IN-PLACE !

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186

2. Life Safety Procedures

Stay in Building During a Fire?

Health care buildings are fairly safe during a fire

There are multiple layers of protection

1. DEFEND-IN-PLACE !

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Health Care Has:• Rated Construction-Walls & Floors• Exit Access Corridors• Restrictions on Combustibles• Emergency Power• Full Fire Alarm• Sprinklers• Trained Staff• Fire Drills } Fire Plan & Drills

187

2. Life Safety Procedures

Stay in Building During a Fire?

Health care buildings are fairly safe during a fire

There are multiple layers of protection

1. DEFEND-IN-PLACE !

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Health Care Has:• Rated Construction-Walls & Floors• Exit Access Corridors• Restrictions on Combustibles• Emergency Power• Full Fire Alarm• Sprinklers• Trained Staff• Fire Drills } Fire Plan & Drills

188

2. Life Safety Procedures

Stay in Building During a Fire?

Health care buildings are fairly safe during a fire

YES

There are multiple layers of protection

1. DEFEND-IN-PLACE !

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Staff MUST know about:

189

2. Life Safety Procedures 2. COMPARTMENTALIZATION

Boxes within BoxesSlows down Fires

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Staff MUST know about:

• Smoke Compartments• Smoke Barriers• Rated Walls & Doors• Hazardous Rooms• Automatic Door Closers

190

2. Life Safety Procedures 2. COMPARTMENTALIZATION

Boxes within BoxesSlows down Fires

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4 Typical Evac Levels

1. Evac From Room with Fire (Race)

1

191

2. Life Safety Procedures 3. EVACUATION PROCESS

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4 Typical Evac Levels

2. Evac To next Smoke Compartment (1 hr rating)

2

192

2. Life Safety Procedures 3. EVACUATION PROCESS

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4 Typical Evac Levels

3. Evac To Next Floor (1-2 hr rating)

193

2. Life Safety Procedures 3. EVACUATION PROCESS

3

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4 Typical Evac Levels

4. Evac From Building

4

194

2. Life Safety Procedures 3. EVACUATION PROCESS

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Staff should to trained on LOCATIONS of:

1. Smoke Barriers

195

2. Life Safety Procedures 3. EVACUATION PROCESS

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Staff should to trained on LOCATIONS of:

2. Primary Horizontal Exit Paths (to smoke barriers)

196

2. Life Safety Procedures 3. EVACUATION PROCESS

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Staff should to trained on LOCATIONS of:

3. Secondary Exit Paths (to stairs)

197

2. Life Safety Procedures 3. EVACUATION PROCESS

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In fire situations, DO NOT use elevators

198

2. Life Safety Procedures Evacuation Procedures

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In fire situations, DO NOT use elevators

• Stranded if Loss of Power

• Elevator Buttons may “fuse” in a fire & cause elevator to go to the fire floor

• Smoke in the shaft

• Very slow method to evac large numbers

199

2. Life Safety Procedures Evacuation Procedures

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Mandatory Training Requirements

1. Staff Duties - Use & Response to Alarms

2. Life Safety Procedures

200

Part 3 - Fire Training

3. Life Safety Devices

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Staff should to trained on LOCATIONS of

Pull Stations & Fire Extinguishers

201

3. Life Safety Devices Device Locations

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Don’t restrict access to a fire alarm pull station

202

3. Life Safety Devices Device Obstructions

Pull Sta

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Don’t restrict access to a fire extinguisher

203

3. Life Safety Devices Device Obstructions

Exting.

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Don’tHang things from sprinklers or their pipes

204

3. Life Safety Devices Sprinkler Obstructions

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Don’tStack things within 18” below sprinkler heads

205

3. Life Safety Devices Sprinkler Obstructions

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Don’t prop open any door with a closer

206

3. Life Safety Devices Door Blockage

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Don’t prop open any corridor door

207

3. Life Safety Devices Door Blockage

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Know their LOCATIONS & How/When to operate

Med Gas Zone Valves

208

3. Life Safety Devices Med Gas Valves

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Mandatory Training Requirements

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Part 3 - Fire Training

Have Training Documents on hand

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210

Have Training Documents on hand

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211

Have Training Documents on hand

Training topic = Required topics

Mandatory Training Requirements

1.Staff Duties2.Life Safety Devices3.Life Safety Procedures

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1.Fire Drills• Codes• Documents

2.Fire Plans • Codes • Documents

3.Fire Training• Codes • Documents

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Lauzon

Life Safety

Consulting

Presented by

What Regulators Expect with

Fire Drills & Fire Plans

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1.Fire Drills• Codes• Documents

2.Fire Plans • Codes • Documents

3.Fire Training• Codes • Documents

213

Lauzon

Life Safety

Consulting

Presented by

What Regulators Expect with

Fire Drills & Fire Plans

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Welcome to the WHEA’s

Lunch & LearnNov 2019

What Regulators Expect with

Fire Drills & Fire Plans

Presented by

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