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 827 - FREESTANDING MEGAVOLTAGE RADIATION THERAPY FACILITY
Section He-P 827.24 - Fire Safety

Universal Citation: NH Admin Rules He-P 827.24

Current through Register No. 52, December 26, 2024

(a) All FMRTF shall have:

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

(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, and which meets the following requirements:
a. Maximum travel distance to each extinguisher shall not exceed 50 feet;

b. 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;

c. Records for manual inspection or electronic monitoring shall be kept to demonstrate that at least 12 monthly inspections have been performed for the most recent 12-month period;

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

e. The components of the electronic monitoring device or system shall be tested and maintained annually in accordance with the manufacturer's listed maintenance manual; and

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

(b) A fire safety program shall be developed and implemented to provide for the safety of patients and personnel.

(c) 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.

(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 injury or damage;

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

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

(5) The name of any personnel or patients 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) 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.

(f) Fire drills shall be conducted as follows:

(1) For buildings constructed to the health care occupancy chapter of the life safety code and to the 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 fire protection engineer, the 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. 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 patients, 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

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; and

(2) 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.

(g) For the use and storage of oxygen and other related gases, a FMRTF shall comply with NFPA 99 as adopted by the commissioner of the department of safety under Saf-C 6000, as amended pursuant to RSA 153:5, I, by the state fire marshal with the board of fire control, including, but not limited to, the following:

(1) All freestanding compressed gas cylinders shall be firmly secured to the adjacent wall or secured in a stand or rack;

(2) Storage locations shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limited-combustible construction, with doors, or with gates if outdoors, that can be secured against unauthorized entry;

(3) Oxidizing gases, such as oxygen and nitrous oxide, shall:
a. Not be stored with any flammable gas, liquid, or vapor;

b. Be separated from combustibles or incompatible materials by:

1.A minimum distance of 20 ft. (6.1 m);

2.A minimum distance of 5 ft. (1.5 m) 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

3.An enclosed cabinet of noncombustible construction having a minimum fire protection rating of 1/2 hour; and

c. Shall be secured in an upright position, such as with racks or chains;

(4) A precautionary sign, readable from a distance of 5 ft. (1.5 m), shall be conspicuously displayed on each door or gate of the storage room or enclosure, and shall include, at a minimum, the following: "CAUTION, OXIDIZING GAS(ES) STORED WITHIN - NO SMOKING"; and

(5) Precautionary signs, readable from a distance of 5 ft. (1.5 m), and with language such as "OXYGEN IN USE, NO SMOKING", shall be conspicuously displayed wherever supplemental oxygen is in use and in aisles and walkways leading to the area of use, and shall be attached to adjacent doorways or to building walls or be supported by other appropriate means.

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