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 811 - END STAGE RENAL DISEASE DIALYSIS CENTERS
Section He-P 811.23 - Emergency and Fire Safety

Universal Citation: NH Admin Rules He-P 811.23

Current through Register No. 52, December 26, 2024

(a) All ESRDDCs shall, at a minimum, meet the Business or Ambulatory Health Care Occupancy chapter of NFPA 101 as adopted by the commissioner of the department of safety in Saf-C 6000 under RSA 153, and as amended pursuant to RSA 153:5, I, by the state fire marshal with the board of fire control.

(b) The licensee shall provide and maintain a complete fire alarm system installed and maintained in accordance with Saf-C 6000 as adopted by the commissioner of the department of safety under RSA 153, and as amended pursuant to RSA 153:5, I by the state fire marshal with the board of fire control, regardless of the size of the facility.

(1) Building, including the International Building Code as adopted by RSA 155-A:2;

(2) Health;

(3) Fire, including but not limited to NFPA 101 and Saf-C 6000 as adopted by the commissioner of the department of safety under RSA 153, and as amended pursuant to RSA 153:5, I by the state fire marshal with the board of fire control;

(4) Waste disposal; and

(5) Water, including the requirements of He-P 811.06(d) .

(d) The ESRDDC shall:

(1) Have all entrances and exits to the licensed premises accessible at all times;

(2) Be maintained in good repair and kept free of hazards to personnel and clients, including but not limited to hazards from falls, burns, or electrical shocks;

(3) Be free from environmental nuisances, including noise and odors; and

(4) Take measures to prevent the presence of rodents, insects, and vermin including, but not limited to:

a. Having tightly fitting screens to all doors, windows, or other openings to the outside unless the door is self-closing and remains closed unless in use;

b. Repairing holes and caulking of pipe channels; and

c. Extermination by a pesticide applicator licensed under RSA 430.

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

(i) Each licensee shall develop a written emergency response 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 disappearances; and

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

(j) 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.

(k) Fire and/or evacuation drills shall be conducted quarterly as follows:

(1) Each employee shall participate in at least one drill every calendar quarter; and

(2) Each drill shall include the transmission of a fire alarm signal and simulation of emergency fire conditions.

(l) Immediately following any fire or emergency situation, licensees shall notify the department by phone to be followed by written notification within 72 hours, with the exception of:

(1) A false alarm or emergency medical services (EMS) transport for a non-emergent reason; or

(2) Emergency EMS transport related to pre-existing conditions.

(m) The written notification required by (l) 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.

(n) For personnel who are unable to participate in the scheduled drill described in (k) above, on the day they return to work the administrator or designee shall, if applicable, instruct them as to any changes in the facility fire and emergency plan and document such instruction in their personnel file.

(o) Personnel who are unable to participate in a drill in accordance with (k) and (n) above shall participate in a drill within the next quarter.

(p) The timing of quarterly drills shall be at varying times to include all shifts and all clients and individuals in the ESRDDC at the time of the drill.

(q) All emergency and evacuation drills shall be documented and include the following information:

(1) The names of the participating personnel and clients;

(2) The time, date, month, and year the drill was conducted;

(3) The exits utilized if the ESRDDC does not comply with the health care chapter of the state fire code;

(4) The total time necessary to evacuate the ESRDDC, when evacuation of the facility is required by the drill;

(5) The time needed to complete the drill; and

(6) Any problems encountered and corrective actions taken to rectify problems.

(r) 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,; or

c. A gas cabinet constructed per NFPA 30,, or NFPA 55,, 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, supports, or for any purpose other than that for which the supplier intended them;

j. Large 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;

(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 by its proper name,, not air, and liquid oxygen shall be referred to by its proper name, 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 (e.g., full, in use, 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;

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

m. The sign shall include the following wording as a minimum:

CAUTION:

OXIDIZING GAS(ES) STORED WITHIN

NO SMOKING

#9963, eff 7-28-11

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