New Hampshire Code of Administrative Rules
He - Department of Health and Human Services
Subtitle He-P - Former Division of Public Health Services
Chapter He-P 800 - RESIDENTIAL CARE AND HEALTH FACILITY RULES
Part He-P 807 - RULES FOR RESIDENTIAL TREATMENT AND REHABILITATION FACILITIES
Section He-P 807.24 - Fire Safety

Universal Citation: NH Admin Rules He-P 807.24

Current through Register No. 13, March 27, 2025

(a) All RTRFs shall meet at a minimum the residential board and care chapter of NFPA 101 as adopted by the department of safety in Saf-C 6000, as amended pursuant to RSA 153:5, I, by the state fire marshal with the board of fire control.

(b) All RTRFs, including those with 3 or fewer clients, shall have:

(1) Smoke detectors on every level and in every bedroom that are interconnected and either hardwired, powered by the RTRF's electrical service, or wireless, as approved by the state fire marshal for the RTRF;

(2) At least one UL Listed, ABC type portable fire extinguisher, with a minimum rating of 2A-10BC installed on every level of the building with a maximum travel distance to each extinguisher not to exceed 50 feet and maintained as follows:
a. Fire extinguishers shall be inspected either manually or by means of an electronic monitoring device or system at least once per calendar month, at intervals not exceeding 31 days;

b. Records for manual inspection, or electronic monitoring shall be kept to demonstrate that at least 12 monthly inspections have been performed;

c. Annual maintenance shall be performed on each extinguisher by trained personnel, and a tag or label shall be securely attached that indicates that maintenance was performed; and

d. The components of the electronic monitoring device or system in a. above, if used, shall be tested and maintained annually in accordance with the manufacturers listed maintenance manual; and

(3) An approved carbon monoxide monitor on every level.

(d) An emergency and fire safety program shall be developed and implemented to provide for the safety of clients and personnel.

(e) Immediately following any fire or emergency, including but not limited to, gas leak or evacuation of the facility due to flooding or an explosion, licensees shall notify the department by phone to be followed by written notification within 72 hours, with the exception of a false alarm or emergency medical services (EMS) transport for a non-emergent reason.

(f) The written notification required by (e) above shall include:

(1) The date and time of the incident;

(2) A description of the location and extent of the incident, including any injury or damage;

(3) A description of events preceding and following the incident;

(4) The name of any personnel or clients who were evacuated as a result of the incident, if applicable;

(5) The name of any personnel or clients who required medical treatment as a result of the incident, if applicable; and

(6) The name of the individual the licensee wishes the department to contact if additional information is required.

(g) A copy of the fire safety plan including fire drill actions shall be made available to and reviewed with the client, or the client's guardian or a person with durable power of attorney (DPOA) over the client, at the time of admission and a summary of the client's responsibilities shall be provided to the client. Each client shall receive an individual fire drill walk-through within 5 days of admission, as appropriate.

(h) The fire safety plan shall be reviewed and approved as follows:

(1) A copy of the fire safety plan shall be made available annually, and whenever changes are made, to the local fire chief for review and approval;

(2) The local fire chief shall give written approval initially to all fire safety plans; and

(3) If changes are made to the plan, they shall be submitted to the local fire chief for review and approval, prior to the change.

(i) Fire drills shall be conducted as follows:

(1) For buildings constructed to the residential board and care or one and two family dwelling chapters of the life safety code (NFPA 101), the following shall be required:
a. The administration of every residential board and care facility shall have, in effect and available to all supervisory personnel, written copies of a plan for protecting all persons in the event of fire, for keeping persons in place, for evacuating persons to areas of refuge, and for evacuating persons from the building when necessary;

b. Clients shall be trained to assist each other in case of fire or emergency to the extent that their physical and mental abilities permit them to do so, without additional personal risk;

c. All RTRF facilities shall conduct fire drills not less than 6 times per year on a bimonthly basis, with not less than 2 drills conducted during the night when clients are sleeping. Actual exiting from windows shall not be required, however opening the window and signaling for help shall be an acceptable alternative;

d. The drills shall involve the actual evacuation of all clients to an assembly point, as specified in the emergency plan, and approved by the department and the local fire authority based on construction of the building and shall provide clients with experience in egressing through all exits and means of escape, except as noted in c. above;

e. shall complete a written record of fire drills that include the following:
1. The date and time, including AM/PM, the drill was conducted and if the actual fire alarm system was used;

2. The location of exits used;

3. The number of people, including clients, personnel, and visitors, participating at the time of the drill;

4. The amount of time taken to completely evacuate the facility;

5. The name and title of the person conducting the drill;

6. A list of problems and issues encountered during the drill;

7. A list of improvements and resolution to the issues encountered during the fire drill; and

8. The names of all staff members participating in the drill;

f. At no time shall a staff member who has not participated in a fire drill be the only staff member on duty within the facility;

g. At admission, the facility shall conduct a client Fire Safety Evacuation Scoring System (FSES) as listed in NFPA 101A, Alternatives to Life Safety, to determine the clients' needs during a fire drill including mobility, assistance to evacuate, staff needed, risk of resistance, clients ability to evacuate on his or her own, and choosing an alternate exit; and

h. The fire drills for facilities built to the residential board and care chapter of the life safety code (NFPA 101), shall be permitted to be announced, in advance, to the clients just prior to the drill; and

(2) For RTRFs originally constructed to the health care occupancy chapter of the life safety code and to the codes, rules and regulations adopted and enforced by the state fire marshal's office and/or the municipality, or which have been physically evaluated, rehabilitated, and approved by a New Hampshire licensed engineer qualified in fire protection, the state fire marshal's office, and the department pursuant to He-P 807.07, to meet the health care occupancy chapter, the following shall be required:
a. The facility shall develop a fire safety plan, which provides for the following:
1. Use of alarms;

2. Transmission of alarms to fire department;

3. Emergency phone call to fire department;

4. Response to alarms;

5. Isolation of fire;

6. Evacuation of immediate area;

7. Evacuation of smoke compartment;

8. Preparation of floors and building for evacuation;

9. Extinguishment of fire; and

10. Written emergency telephone numbers for key staff, fire, and police departments, poison control center, 911, and ambulance service(s);

b. Fire drills shall be conducted quarterly on each shift to familiarize facility personnel such as medical personnel, maintenance engineers, and administrative staff with the signals and emergency action required under varied conditions;

c. Fire drills shall include the transmission of a fire alarm signal and simulation of emergency fire conditions;

d. Buildings that have a shelter-in-place plan, also known as defend-in-place plan, shall have this plan approved by the department per the state fire code, Saf-C-6000, as amended pursuant to RSA 153:5, I by the state fire marshal with the board of fire control, and their local fire chief and shall be constructed to meet the health care occupancy chapter of the life safety code;

e. When drills are conducted between 9:00 p.m. and 6:00 a.m., a coded announcement shall be permitted to be used instead of audible alarms;

f. I f the facility has an approved defend or shelter in place plan, then all personnel, clients, and visitors shall evacuate to that appropriate location or to the outside of the building to a selected assembly point, and drills shall be designed to ensure that clients shall be given the experience of evacuating to the appropriate location or exiting through all exists;

g. Facilities shall complete a written record of fire drills and include the following:
1. The date and time, including AM/PM, the drill was conducted and if the actual fire alarm system was used;

2. The location of exits used;

3. The number of people, including clients, personnel, and visitors, participating at the time of the drill;

4 . The amount of time taken to completely evacuate the facility to an approved area of refuge or through a horizontal exit;

5. The name and title of the person conducting the drill;

6. A list of problems and issues encountered during the drill, if any;

7. A list of improvements and resolution to the issues encountered during the fire drill; and

8. The names of all staff members participating in the drill; and

h. At no time shall a staff member who has not participated in a fire drill be the only staff member on duty within the facility.

(j) Storage and use of oxygen cylinders or systems shall comply with NFPA 99, Health Care Facilities Code including but not limited to:

(1) Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or flammable materials by one of the following:
a. Minimum distance of 6.1 m (20 ft);

b. Minimum distance of 1.5 m (5 ft) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems; or

c. A gas cabinet constructed per NFPA 30, Flammable and Combustible Liquids Code, or NFPA 55, Compressed Gases and Cryogenics Fluids Code, if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13;

(2) Cylinders shall be protected from damage by means of the following specific procedures:
a. Oxygen cylinders shall be protected from abnormal mechanical shock which is liable to damage the cylinder, valve, or safety device;

b. Oxygen cylinders shall not be stored near elevators or gangways or in locations where heavy moving objects will strike them or fall on them;

c. Cylinders shall be protected from tampering by unauthorized individuals;

d. Cylinders or cylinder valves shall not be repaired, painted, or altered;

e. Safety relief devices in valves or cylinders shall not be tampered with;

f. Valve outlets clogged with ice shall be thawed with warm, not boiling, water;

g. A torch flame shall not be permitted, under any circumstances, to come in contact with a cylinder, cylinder valve, or safety device;

h. Sparks and flame shall be kept away from cylinders;

i. Even if they are considered to be empty, cylinders shall not be used as rollers or supports or for any purpose other than that for which the supplier intended them;

j. Cylinders exceeding size E and containers larger than 45 kg (100 lb) weight shall be transported on a proper hand truck or cart complying with NFPA 99, section 11.4.3.1;

k. Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart; and

l. Cylinders shall not be supported by radiators, steam pipes, or heat ducts; and

(3) Cylinders and their contents shall be handled with care, which shall include the following specific procedures:
a. Oxygen fittings, valves, pressure reducing regulators, or gauges shall not be used for any service other than that of oxygen;

b. Gases of any type shall not be mixed in an oxygen cylinder or any other cylinder;

c. Oxygen shall always be dispensed from a cylinder through a pressure reducing regulator;

d. The cylinder valve shall be opened slowly, with the face of the indicator on the pressure reducing regulator pointed away from all persons;

e. Oxygen shall be referred to as "oxygen", not air, and liquid oxygen shall be referred to as "liquid oxygen", not liquid air;

f. Oxygen shall not be used as a substitute for compressed air;

g. The markings stamped on cylinders shall not be tampered with, because it is against federal statutes to change these markings;

h. Markings used for the identification of contents of cylinders shall not be defaced or removed, including decals, tags, and stenciled marks, except those labels/tags used for indicating cylinder status, for example, full, in use, and empty;

i. The owner of the cylinder shall be notified if any condition has occurred that might allow any foreign substance to enter a cylinder or valve, giving details and the cylinder number;

j. Neither cylinders nor containers shall be placed in the proximity of radiators, steam pipes, heat ducts;

k. Very cold cylinders or containers shall be handled with care to avoid injury; and

l. A precautionary sign, readable from a distance of 1.5 m (5 ft), shall be displayed on each door or gate of the storage room or enclosure, and shall include the following wording at a minimum:

CAUTION:

OXIDIZING GAS(ES) STORED WITHIN

NO SMOKING

(k) If the licensee has chosen to allow smoking under He-P 807.14(w) , an outside location or a room used only for smoking shall be provided which:

(1) Has a dedicated ventilation system, so that smoke or odors cannot escape or be detected outside the designated smoking room;

(2) Has walls and furnishings constructed of non-combustible materials;

(3) Has metal waste receptacles and safe ashtrays; and

(4) Is in compliance with the requirements of RSA 155:64-77, the Indoor Smoking Act and He-P 1900.

(l) Each licensee shall develop a written emergency plan that covers:

(1) Loss of electricity;

(2) Loss of water;

(3) Loss of heat;

(4) Bomb threat;

(5) Severe weather;

(6) Fire;

(7) Gas leaks;

(8) Unexplained client absences; and

(9) Any situation that requires evacuation of the RTRF.

(m) Each licensee shall:

(1) Annually review and revise, as needed, its emergency plan;

(2) Submit its emergency plan to the local emergency management director for review and approval when initially written and whenever the plan is revised; and

(3) Maintain documentation on-site which establishes that the emergency plan has been approved as required under (2) above.

(n) Each RTRF that has been pre-approved in writing by the local emergency management director as an emergency shelter may accept, on an emergency basis, clients of the RTRF's their local community provided that:

(1) It has a generator capable of supplying the entire facility;

(2) It has sufficient personnel and food to meet the needs of both the clients and any evacuees; and

(3) It makes arrangements to transfer the evacuee as soon as practicable if they learn after accepting the evacuee that they cannot meet his or her needs.

#9873-A, eff 2-24-11

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