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Firesafety Disaster Plan

To describe the processes implemented to effectively management of fire safety and minimize risks.

This plan applies to staff, guest, patients, and visitors and property of Sandhills Regional Medical Center, especially those in or adjacent to construction or alteration areas.

A. Identify and implement the proactive processes to protect staff, guest, patients, and visitors and property from fire and fire byproducts.
B. Identify and implement processes for regular inspecting, testing, and maintaining fire protection and fire safety systems, equipment and components.
C. Develop and implement a fire response plan that addresses:

1. Hospital wide fire response,
2. Area specific needs including fire evacuation routes,
3. Specific roles and responsibilities for staff, licensed independent practitioners, and volunteers at the fires point of origin,
4. Specific roles and responsibilities for staff, licensed independent practitioners, and volunteers away from the fires point of origin,
5. Specific roles and responsibilities for staff, licensed independent practitioners, and volunteers in preparing for building evacuation.

Emergency – A natural or manmade event that significantly disrupts the environment of care significantly disrupts care, treatment and services or results in sudden significantly changed or increased demands for the hospital’s services.

Authority Having Jurisdiction – Local Fire Marshall or a designated representative. (Fire Chief)

Fire Emergency – a specialized form of internal disaster characterized by the release of intense heat, dense smoke and toxic gases.  

Internal Disaster – any event that results in damage to the building creating an immediate threat to the safety of any person, or renders any portion of the structure unsafe for occupancy.

Area of Refuge/Fire Zone – A geographic region of the hospital designed to resist penetration by fire or its by-products for a specific period. These areas are identified on the architectural drawings and the Statement of Conditions.

Department Manager – any person regardless of title who is responsible for the performance or conduct of personnel within a specific work center.

Scene Leader – Person designated to respond to the scene of a fire or internal disaster. (Or the most senior person by position present until the designated scene leader arrives.)

Combustion By-Products – Heat, light, gases and smoke.

Incident Command Center – Location of and person designated to coordinate all activities of the hospital staff during the response to a fire or internal disaster.

Vertical Evacuation - the removal of all patients, visitors and staff from one floor of the hospital to a lower floor.

Horizontal Evacuation – the removal of all patients, visitors and staff from one area of refuge to another area of refuge on the same floor.

Total Evacuation – the removal of all patients, visitors and staff from the hospital.

A. Chief Executive Officer will ensure implementation of the plan.
B. Assistant Administrator will assist the Chief Executive Officer with implementation.
C. Safety Officer will implement and maintain all elements of the plan.
D. Environment of Care Committee will monitor, review and make recommendations on corrective actions for deficiencies, problems, failures and user errors within the program.
E. Department Managers will ensure compliance with this plan.
F. All Hospital Staff will comply with this plan.
G. Outside Contractors will comply with this plan.


A. Policy:

1. This building is designated a smoke free building, there is a separate plan for the accommodation of staff, patients, guests, and visitors who smoke.
2. Employees shall follow the general instructions for their departments, and know where fire extinguishers are located along with the oxygen shut offs and evacuation routes.
3. A comprehensive plan to correct any Life Safety Deficiencies which occur or are identified by any sources will be developed immediately in writing and will address:

a. All Life Safety Code deficiencies.
b. Corrective actions (plan for improvement).
c. Total cost of actions and specific funding information.
d. A reasonable schedule for completion.
e. To be coordinated with available funding.

4. All personnel will have knowledge of their role and responsibilities at the point of origin of a fire and away from the point of origin, use and functioning of fire alarm systems, containing smoke/fire with building compartmentalization. In addition to the initial hospital orientation, all employees will be scheduled for in-services on life safety annually.

B. Statement of Conditions (SOC)

1. The SOC for Sandhills Regional Medical Center is in the custody of the Safety Officer.
2. The SOC will be updated at least every three years or when new construction or renovations are completed.
3. A SOC and Fire Protection shall be completed for every building housing patients.
4. The plan for Improvement (PFI) will be utilized to identify any deficiency in the performance of life safety equipment
5. Notify the Safety Officer immediately.
6. The Safety Officer will ensure suitable equivalent provisions are in place until the deficiency can be corrected.

C. Interim Life Safety Measures (ILSM)

1. Sandhills Regional Medical Center will institute and document (Enclosure 20) interim Life Safety measures to temporarily compensate for hazards posed to buildings and grounds during construction. These will include, but are not limited to:

a. All exits will be unobstructed and useable.  All personnel will receive training if alternative exits must be designated.  Buildings or areas under construction will maintain escape facilities for construction workers at all times.  The means of egress in construction area will be inspected daily.
b. There will be free and unobstructed access to the Emergency Department/Services for emergency forces.
c. Construction area will be properly restricted from the rest of the building operations.
d. Construction area will be maintained in a clean and fire safe manner.
e. Alternate routes for public access will be provided if normal access routes are affected.
f. Roads and walkways are maintained passable and safe.
g. Before fire-warning systems are taken out of service, plans are instituted to compensate.  The hospital will post a fire watch.
h. Any penetrations in fire separations will be inspected daily during construction and receive high completion priority.
i. A temporary but equivalent system shall be provided.  Temporary systems must be inspected and tested monthly.
j. Temporary construction partitions must be smoke tight and built of noncombustible materials.
k. Provide additional fire fighting equipment and use training for personnel.
l. Smoking shall be prohibited in or adjacent to all construction areas.
m. Develop and enforce storage, housekeeping and debris removal policies and procedures, which reduce flammable and combustible fire load to the lowest level necessary for daily operations.
n. Conduct a minimum of two fire drills per shift per quarter.
o. Increase hazard surveillance of grounds, building, and equipment with special attention to construction areas, storage and field offices.
p. Train personnel when structural or compartment features of fire safety are compromised.
q. Conduct hospital wide safety education programs to ensure awareness of only Life Safety Code deficiencies, construction hazards and these interim life safety measures. 

2. The Safety Officer shall determine which if any of the Interim Life Safety Measures will be implemented based upon an assessment of the impairment of egress and fire detection and extinction.
3. The Safety Officer will conduct periodic (Daily on Interim Life Safety Measures) on site inspections both during and after hours.
4. Additional fire drills and training will be conducted in the affected areas whenever the normal egress routes are changed.
5. Proper barricades (interior and exterior) will be placed for traffic control during construction and renovation.
6. The Safety Officer will make specific assignments for fire watches when cutting and/or brazing torches are being used or when interruptions are made in the fire warning system.
7. Storage of flammable liquids will be under the direct supervision of the Safety Officer.

D. Proposed Acquisitions

1. When receiving a purchase requisition, the Materials Management Department will determine with the Safety Officer and the department originating the purchase request, what fire retardant characteristics are required for the item requested.
2. The Materials Management Department will get the necessary information from the vendor prior to its purchase.
3. The Materials Management Manager will inform the Safety Officer of any inability to purchase items due to fire retardant characteristics and the Environment of Care Committee must approve the purchase.
4. The evaluation of materials for purchase must meet the requirements of NFPA 704 Standard System for the Identification of the Fire Hazards of Materials.
5. All hospital wastebaskets and refuse containers will be made of noncombustible material.
6. Facilities Services Department personnel will maintain Fire resistant coatings and coverings as necessary to retain their effectiveness.
7. Special attention shall be given to heat generating equipment and placement of equipment close to heat sources as to prevent possible ignition.
8. Portable space heaters shall not be allowed inside Sandhills Regional Medical Center.

E. Life Safety Code Compliance

1. All circuits of the Fire Alarm System and Fire Detection Systems will be inspected and tested quarterly and all components will have annual preventative maintenance.
2. The control of all designated fans and/or dampers in air handling and smoke management systems and transmission of fire alarm signal to the local fire department shall be reliable and functional at all times.
3. All automatic fire?extinguishing systems are inspected and tested at least annually.
4. The kitchen range hood shall be cleaned to bare metal at least twice yearly at roughly six-month intervals.
5. All portable fire extinguishers are clearly identified, inspected monthly, and maintained annually.
6. The hospital and all buildings, which serve to treat patients and are under the ownership or control of the Board of Directors, will maintain compliance with the appropriate provisions of the appropriate edition of NFPA 101 Life Safety Code.
7. The Fire Alarm System is supplied with emergency power from the diesel generator and maintained and serviced by Simplex who can be reached twenty four hours a day seven days a week. (See Enclosure 20).
8. The sprinkler system is supplied from city water system and is equipped with a high capacity pump supplied with emergency power from the diesel generator.
9. Sandhills Regional Medical Center is constructed and maintained in accordance with all applicable federal, state and local Life Safety Codes and the Authority Having Jurisdiction.
10. Maintenance and inspections of all Fire Detection, Suppression Alarm and Extinguishing Systems shall be in accordance with federal, state, local and manufacturers requirements and the Authority Having Jurisdiction.
11. The Safety Officer will ensure completion of applicable preventative maintenance and tests and retain documentation of modifications, maintenance, tests and inspections performed on any portion of the Fire Detection, Suppression, Alarm or Extinguishing System.

F. Fire Plan:

1. Evaluations (Drills) will be conducted to determine the level of staff readiness to handle fire or other internal disaster at least once per shift, per quarter at facilities that house overnight or non-ambulatory patients.
2. Evaluations (Drills) will be conducted to determine the level of staff readiness to handle fire or other internal disaster at least once per calendar year at all off site locations where there is no overnight or non-ambulatory patients.
3. Evaluations are to be treated as an actual Fire Emergency.
4. The Safety Officer will retain documentation of all evaluations performed, for a period of not less than three years.
5. Familiarity training (Orientation) will be delivered to every employee and contract service provider within 30 days of initial employment. Record of training will be kept in Education.
6. Refresher training will be delivered to each employee and contract service provider at least once per calendar year thereafter. Records will be retained in Education.
7. Visitors will be provided information and basic instruction in the patient handbook and by hospital staff as necessary. 
8. Persons doing or attempting to do business with Sandhills Regional Medical Center will be provided basic orientation to this plan as an integral part of the Check – In procedure. (See Security Management Plan)
9. The Chief Executive Officer, and no other, must order any evacuation, (vertical, horizontal or total). In the event that for any reason, there is no Chief Executive Officer or the Chief Executive Officer cannot be contacted, the order to evacuate shall come from the Command Center. 
10. It shall be the primary responsibility of all hospital staff to rescue anyone in immediate danger from fire or internal disaster.
11. It shall be the responsibility of the person discovering a fire or disaster to employ any means possible to alert the hospital population of the threat of fire or internal disaster. 
12. It shall be the responsibility of all hospital staff to take the necessary steps to contain fire by-products and confine the spread of fire.
13. Any attempt by hospital staff to extinguish a fire shall be made only when the staff member’s personal safety can be assured.
14. It shall be the responsibility of the scene leader to direct operations at the scene until relieved by the command center, or the Authority Having Jurisdiction.
15. When the control center is activated or, the Authority Having Jurisdiction arrives on the scene, the scene leader shall brief the relieving agency then follow the directions of the relieving agency.
16. At least once each calendar year the Safety Officer for will review the Fire/Internal Disaster Plan’s objectives, scope, performance and effectiveness.
17. Each drill will be critiqued and the results presented to the Environment of Care (Safety) Committee at the regularly scheduled meetings.
18. During each drill, staff knowledge will be documented on the drill critique form.
19. It shall be the responsibility of each individual to be familiar with the location and operation of Fire Safety Equipment, Evacuation Routes and Fire Plan for their respective areas.


20. At the scene (Fire Zone) of the fire, staff, licensed independent practitioners, and volunteers shall respond to fire emergencies as long as patient care is not compromised.
21. The following acronym is provided as a method to assist the individual to remember the appropriate actions at the scene of a fire.

a) Rescue – remove anyone at risk of death or injury. 
b) Alarm – alert the hospital to the threat.
c) Confine – close doors & windows seal doors if necessary.
d) Extinguish – attempt to put out fire using available means.

22. If attempting to extinguish the fire using a portable fire extinguisher, the following acronym is provided to assist the individual with remembering the sequence of operation.

a) Pull – remove the safety pin from the handle.
b) Aim - at the base of the fire at its nearest edge.
c) Squeeze – the handle to discharge the agent.
d) Sweep – from side to side.

23. If no portable fire extinguisher is present, it is possible to extinguish the fire by smothering it with blankets, towels or curtains.
24. When returning to a closed room to attempt to extinguish a fire, check to see if the door is hot to the touch. If it is hot, DO NOT OPEN THE DOOR!
25. The most senior person at the scene (normally the Safety Officer or Charge Nurse) shall announce their name and state they are the scene leader.
26. All personnel will obey the instructions of the scene leader.
27. The scene leader will assess the situation and if necessary ask for the command center to be activated. (Normally will be done only for an internal disaster or out of control fire.)
28. Once the fire is contained or extinguished and activities at the scene are reduced to a clean-up action, the PBX operator will be directed to announce “ Code Red All Clear” three times.
29. Only the scene leader or command center can direct an “All Clear” to be announced.


30. For fires away from the scene staff, licensed independent practitioners, and volunteers shall:

a. Follow respective Departmental Fire Plans,
b. Ensure all doors and windows are closed,
c. Shut down all unnecessary equipment,
d. Be prepared to evacuate if necessary,
e. Listen for overhead announcements,
f. Follow the directions of the person in charge of your area,
g. Attempt to reassure patients and visitors.

G. Drill Procedure

1. Fire drill scheduling and performance will be at the discretion of the Alternate Safety Officer but will be conducted at least once per shift per quarter.
2. First Shift is from 7:30 am until 3:30 pm, Second Shift is from 3:30 pm until 11:30 pm, and Third Shift is from 11:30 pm until 7:30 am. 
3. Fire drills will be unannounced and all personnel will be evaluated for participation, knowledge and deportment.
4. Prior to commencing a drill, the Facilities Services Department will ensure the alarm system is placed in standby mode by calling the monitoring company and having the system placed on test. (See Enclosure 20)
5. The Alternate Safety Officer or designee will initiate the drill by handing a written notice to an individual chosen at random within the designated fire zone.
6. A minimum of two additional compartments will be critiqued, whenever possible, one compartment above or below, and one compartment adjacent to the scene of the drill.
7. Members of the Drill Monitoring Team observe and evaluate the performance of personnel and equipment and report those finding to the environment of care Committee on the Fire Drill Report Form (Enclosure 21)
8. Members of the Environment of Care (Safety) Committee will review drill critiques.
9. The critique will evaluate staff knowledge, performance and participation, procedural compliance, equipment operation and overall effectiveness.
10. The names of all persons present in each monitored area will be recorded on the Critique form. (See Enclosure 21)
11. The PBX operator or Facilities Management staff may silence the audible alarms after sufficient time to ensure horns and strobes function properly.
12. The Safety Officer or designee will ensure the Alarm System is reset and reactivated at the completion of each drill.
13. The Safety Officer will keep documentation for all drills conducted.
14. Problems, errors, malfunctions and all other areas for improvement will be recorded on Enclosure 14 and discussed at the next scheduled Environment of Care (Safety) Committee Meeting.

H. Internal Disaster

1. Response to internal disasters shall initially be by available hospital staff and shall normally be comprised of a representative from each staffed department for that shift providing patient safety is not compromised.
2. Internal disasters will be a consequence of some external agent (natural or manmade) causing a catastrophic failure of structural and/or utility system(s) and will normally be reported to the PBX operator for announcement.
3. The Fire Alarm System will activate the fire suppression system, call the local fire emergency agency and activate audio and visual alarms throughout the hospital.
4. Once notified, the PBX operator will determine the location of the fire or internal disaster, and announce via the overhead paging system, “CODE RED location”, three times.
5. If the fire alarm has not been activated, activate the fire alarm.
6. The Safety Officer if present or the Charge Nurse will proceed to the scene of the fire to be scene leader.
7. The Scene Leader will direct actions at the scene until relieved by competent authority.
8. Personnel designated by their departmental fire plan will proceed to the scene with a portable fire extinguisher.
9. Rescue, first aid and damage control will be performed by competent personnel at the scene.
10. Clear all passageways when the code is announced.
11. No oxygen or medical gas valve will ever be shut without the approval of Cardiopulmonary, and Nursing Administration.
12. Should the order to evacuate be given, refer to Hospital Wide and Department Evacuation Plans.
13. Once activities at the scene are reduced to a clean-up action, the PBX operator will be directed to announce “ Code Red All Clear” three times.
14. Only the scene leader or command center can direct an “All Clear” to be announced.