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 815 - INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH INTELLECTUAL DISABILITIES (ICF/IID)
Section He-P 815.22 - Fire Safety

Universal Citation: NH Admin Rules He-P 815.22

Current through Register No. 13, March 27, 2025

(a) All ICF/IID s shall meet the requirements of the appropriate chapter of NFPA 101 as adopted pursuant to RSA 153:1, VI-a and amended in Saf-FMO 300 by the fire marshal with the board of fire control, pursuant to RSA 153:5 and any pertinent chapter and related codes regarding the installation, testing, and maintenance of the fire alarm system.

(b) All ICF/IID's shall have:

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

(2) At least one ABC type fire extinguisher on every level or every 75 feet of corridor as required by NFPA 10; and

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

(c) Immediately following any fire or emergency situation, licensees shall notify the department by phone and in writing within 72 hours, with the exception of:

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

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

(d) The written notification required by (c) above shall include:

(1) The date and time of the incident;

(2) A description of the location and extent of the incident, including any injuries to residents or employees;

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

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

(5) The name of any personnel or residents 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.

(e) 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 or 20 ft;

b. Minimum distance of 1.5 m or 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, 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 or 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 by its proper name, "oxygen", 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 or tags used for indicating cylinder status such as full, in use, or 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, or 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 or 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"

(f) If the licensee has chosen to allow smoking, 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.

(g) Each licensee shall develop a written fire safety plan.

(h) A copy of the fire safety plan including fire drill actions shall be made available to and reviewed with the resident, or the resident's guardian or a person with durable power of attorney (DPOA), at the time of admission and a summary of the resident's responsibilities shall be provided to the resident.

(i) Each resident shall receive an individual fire drill walk-through within 5 days of admission, as appropriate.

(j) 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, as appropriate, prior to the change.

(k) 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. Residents 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 ICF/IID 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 residents 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 residents 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 residents with experience in egressing through all exits and means of escape;

e. Facilities shall complete a written record of fire drills that includes 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 residents, 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 n 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 least annually, the facility shall conduct a resident "Fire Safety Evacuation Scoring System" (FSES) as listed in NFPA 101A, "Alternatives to Life Safety", to determine the resident's needs during a fire drill including, but not limited to, mobility, assistance to evacuate, staff needed, risk of resistance, and residents ability to evacuate on their own and choose 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 residents just prior to the drill;

(2) For all ICF/IID's that were originally constructed to meet the "Health Care Occupancy Chapter of Life Safety Code", NFPA 101 as adopted pursuant to RSA 153:1, VI-a and amended in Saf-FMO 300 by the fire marshal with the board of fire control, pursuant to RSA 153:5, and the rules and regulations adopted and enforced by the state fire marshal's office or the municipality or have been physically evaluated, renovated, and approved by a New Hampshire licensed fire protection engineer, the NH state fire marshal's office and the department 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 including, but not limited to, 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, also known as defend in place, shall have this plan approved by the department 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. If the facility has an approved defend or shelter in place plan, then all personnel, residents, 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 residents 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 residents, personnel, and visitors, participating at the time of the drill;

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

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; and

(3) The facility shall conduct a fire drill in the presence of a representative of the department, state fire marshal's office, or the local fire department upon request.

Disclaimer: These regulations may not be the most recent version. New Hampshire may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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