Fire Safety and Emergency Preparedness Standards | MO

19 CSR 30-86.022 Fire Safety and Emergency Preparedness Standards for Residential Care Facilities and Assisted Living Facilities

 

PURPOSE: This rule establishes fire safety and emergency preparedness standards for residential care facilities and assisted living facilities.

  

  • For the purpose of this rule, the following definitions shall apply:
    • Accessible spaces—shall include all rooms, halls, storage areas, basements, attics, lofts, closets, elevator shafts, enclosed stairways, dumbwaiter shafts, and chutes;
    • Area of refuge—a space located in or immediately adjacent to a path of travel leading to an exit that is protected from the effects of fire, either by means of separation from other spaces in the same building or its location, permitting a delay in evacuation. An area of refuge may be temporarily used as a staging area that provides some relative safety to its occupants while potential emergencies are assessed, decisions are made, and, if applicable, evacuation has begun;
    • Major renovation—shall include the following:
      1. Addition of any room(s), accessible by residents, that either exceeds fifty percent (50%) of the total square footage of the facility or exceeds four thousand five hundred (4,500) square feet;
      2. Repairs, remodeling, or renovations that involve structural changes to more than fifty percent (50%) of the building;
      3. Repairs, remodeling, or renovations that involve structural changes to more than four thousand five hundred (4,500) square feet of a smoke section; or
  1. If the addition is separated by two- (2-) hour fire- resistant construction, only the addition portion shall meet the requirements for NFPA 13, 1999 edition, sprinkler system, unless the facility is otherwise required to meet NFPA 13, 1999 edition;
  • Fire-resistant construction—type of construction in residential care and assisted living facilities in which bearing walls, columns, and floors are of noncombustible material in accordance with NFPA 101, 2000 edition. All load-bearing walls, floors, and roofs shall have a minimum of a one- (1-) hour fire-resistant rating; and
  • Concealed spaces—shall include areas within the building that cannot be occupied or used for

 

  • General
    • All National Fire Protection Association (NFPA) codes and standards cited in this rule: NFPA 10, Standard for Portable Fire Extinguishers, 1998 edition; NFPA 13R, Installation of Sprinkler Systems, 1996 edition; NFPA 13, Installation of Sprinkler Systems, 1976 edition; NFPA 13 or NFPA 13R, Standard for the Installation of Sprinkler Systems in Residential Occupancies Up to and Including Four Stories in Height, 1999 edition; NFPA 13, Standard for the Installation of Sprinkler Systems, 1999 edition; NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 1998 edition; NFPA 101, The Life Safety Code, 2000 edition; NFPA 72, National Fire Alarm Code, 1999 edition; NFPA 72A, Local Protective Signaling Systems, 1975 edition; NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 edition; and NFPA 101A, Guide to Alternative Approaches to Life Safety, 2001 edition, with regard to the minimum fire safety standards for residential care facilities and assisted living facilities are incorporated by reference in this rule and available for purchase from the National Fire Protection Agency, 1 Batterymarch Park, Quincy, MA 02269-9101; www.nfpa.org; by telephone at (617) 770- 3000 or 1-800-344-3555. This rule does not incorporate any subsequent amendments or additions to the materials listed above. This rule does not prohibit facilities from complying with the standards set forth in newer editions of the incorporated by reference material listed in this subsection of this rule, if approved by the
    • Facilities that were complying prior to the effective date of this rule with prior editions of the NFPA provisions referenced in this rule shall be permitted to continue to comply with the earlier editions, as long as there is not an imminent danger to the health, safety, or welfare of any resident or a substantial probability that death or serious physical harm would result as determined by the department.
    • All facilities shall notify the department immediately after the emergency is addressed if there is a fire in the facility or premises and shall submit a complete written fire report to the department within seven (7) days of the fire, regardless of the size of the fire or the loss involved. II/II

 

  • The department shall have the right of inspection of any portion of a building in which a licensed facility is located unless the unlicensed portion is separated by two- (2-) hour fire-resistant construction. No section of the building shall present a fire hazard. I/II
  • Following the discovery of any fire, the facility shall monitor the area and/or the source of the fire for a twenty- four- (24-) hour period. This monitoring shall include, at a minimum, hourly visual checks of the area. These hourly visual checks shall be documented. I/II
  • The facility shall maintain the exterior premises in a manner as to provide for fire safety. II
  • Residential care facilities that accept deaf residents shall have appropriate assistive devices to enable each deaf person to negotiate a path to safety, including, but not limited to, visual or tactile alarm systems. II/III
  • Facilities shall not use space under stairways to store combustible materials. I/II
  • Fire
    • Fire extinguishers shall be provided at a minimum of one (1) per floor, so that there is no more than seventy-five feet (75′) travel distance from any point on that floor to an extinguisher. I/II
    • All new or replacement portable fire extinguishers shall be ABC-rated extinguishers, in accordance with the provisions of NFPA 10, 1998 edition. A K-rated extinguisher or its equivalent shall be used in lieu of an ABC-rated extinguisher in the kitchen cooking areas. II
    • Fire extinguishers shall have a rating of at least:
      1. Ten pounds (10 lbs.), ABC-rated or the equivalent, in or within fifteen feet (15′) of hazardous areas as defined in 19 CSR 30-83.010; and
      2. Five pounds (5 lbs.), ABC-rated or the equivalent, in other areas. II
    • All fire extinguishers shall bear the label of the Underwriters’ Laboratories (UL) or the Factory Mutual (FM) Laboratories and shall be installed and maintained in accordance with NFPA 10, 1998 edition. This includes the documentation and dating of a monthly pressure
  • Range Hood Extinguishing
    • In facilities licensed on or before July 11, 1980, or in any facility with fewer than twenty-one (21) beds, the kitchen shall provide either:
      1. An approved automatic range hood extinguishing system properly installed and maintained in accordance with NFPA 96, 1998 edition; or
      2. A portable fire extinguisher of at least ten pounds (10 lbs.) ABC-rated, or the equivalent, in the kitchen area in accordance with NFPA 10, 1998 edition. II/III
    • In licensed facilities with a total of twenty-one (21) or more licensed beds and whose application was filed after July 11, 1980, and prior to October 1, 2000:
  1. The kitchen shall be provided with a range hood and an approved automatic range hood extinguishing system unless the facility has an approved sprinkler system. Facilities with range hood systems shall continue to maintain and test these systems; and
  2. The extinguishing system shall be installed, tested, and maintained in accordance with NFPA 96, 1998
  • The range hood and its extinguishing system shall be certified at least twice annually in accordance with NFPA 96, 1998 edition. II/III

 

  • Fire Drills and Emergency
    • All facilities shall have a written plan to meet potential emergencies or disasters and shall request consultation and assistance annually from a local fire unit for review of fire and evacuation plans. If the consultation cannot be obtained, the facility shall inform the state fire marshal in writing and request assistance in review of the plan. An up-to-date copy of the facility’s entire plan shall be provided to the local jurisdiction’s emergency management director. II/III
    • The plan shall include, but is not limited to, the following:
      1. A phased response ranging from relocation of residents to an immediate area within the facility; relocation to an area of refuge, if applicable; or to total building evacuation. This phased response part of the plan shall be consistent with the direction of the local fire unit or state fire marshal and appropriate for the fire or emergency;
      2. Written instructions for evacuation of each floor including evacuation to areas of refuge, if applicable, and a floor plan showing the location of exits, fire alarm pull stations, fire extinguishers, and any areas of refuge;
      3. Evacuating residents, if necessary, from an area of refuge to a point of safety outside the building;
      4. The location of any additional water sources on the property such as cisterns, wells, lagoons, ponds, or creeks;
      5. Procedures for the safety and comfort of residents evacuated;
      6. Staffing assignments;
      7. Instructions for staff to call the fire department or other outside emergency services;
      8. Instructions for staff to call alternative resource(s) for housing residents, if necessary;
      9. Administrative staff responsibilities; and
      10. Designation of a staff member to be responsible for accounting for all residents’ whereabouts. II/III
    • The written plan shall be accessible at all times and an evacuation diagram shall be posted on each floor in a conspicuous place so that employees and residents can become familiar with the plan and routes to safety. II/III
  • A minimum of twelve (12) fire drills shall be conducted annually with at least one (1) every three (3) months on each shift. At least four (4) of the required fire drills must be unannounced to residents and staff, excluding staff who are assigned to evaluate staff and resident response to the fire drill. The fire drills shall include a resident evacuation at least once a year. II/III
  • The facility shall keep a record of all fire drills. The record shall include the time, date, personnel participating, length of time to complete the fire drill, and a narrative notation of any special problems. III
  • The fire alarm shall be activated during all fire drills unless the drill is conducted between 9 p.m. and 6 a.m., when a facility-generated predetermined message is acceptable in lieu of the audible and visual components of the fire alarm. II/III

 

  • Fire Safety Training
    • The facility shall ensure that fire safety training is provided to all employees:
      1. During employee orientation;
      2. At least every six (6) months; and
      3. When training needs are identified as a result of fire drill evaluations. II/III
    • The training shall include, but is not limited to, the following:
      1. Prevention of fire ignition, detection of fire, and control of fire development;
      2. Confinement of the effects of fire;
      3. Procedures for moving residents to an area of refuge, if applicable;
      4. Use of alarms;
      5. Transmission of alarms to the fire department;
      6. Response to alarms;
      7. Isolation of fire;
      8. Evacuation of immediate area and building;
      9. Preparation of floors and facility for evacuation; and
  1. Use of the evacuation plan as required by section(5) of this rule. II/III
  • Exits, Stairways, and Fire Escapes.
    • Each floor of a facility shall have at least two (2) unobstructed exits remote from each other. I/II
      1. For a facility whose plans were approved on or before December 31, 1987, or a facility licensed for twenty

(20) or fewer beds, one (1) of the required exits from a multi-story facility shall be an outside stairway or an enclosed stairway that is separated by one- (1-) hour rated construction from each floor with an exit leading directly to the outside at grade level. Existing plaster or  gypsum board of at least one-half inch (1/2″) thickness may be considered equivalent to one- (1-) hour rated construction. The other required exit may be an interior stairway leading through corridors or passageways to outside or to a two- (2-)  hour  rated  horizontal  exit  as  defined  by  paragraph

3.3.61 of the 2000 edition NFPA 101. Neither of the required exits shall lead through a furnace or boiler room. Neither of the required exits shall be through a resident’s bedroom, unless the bedroom door cannot be locked. I/II

  1. For a facility whose plans were approved after December 31, 1987, for more than twenty (20) beds, the required exits shall be doors leading directly outside, one- (1-) hour enclosed stairs or outside stairs or a two- (2-) hour rated horizontal exit as defined by paragraph 3.3.61 of 2000 edition NFPA 101. The one- (1-) hour enclosed stairs shall exit directly outside at grade. Access to these shall not be through a resident bedroom or a hazardous area. I/II
  2. Only one (1) of the required exits may be a two- (2-) hour rated horizontal exit. I/II
  • In facilities with plans approved after December 31, 1987, doors to resident use rooms shall not be more than one hundred feet (100′) from an exit. In facilities equipped with a complete sprinkler system in accordance with NFPA 13 or NFPA 13R, 1999 edition, the exit distance may be increased to one hundred fifty feet (150′). Dead-end corridors shall not exceed thirty feet (30′) in length. II
  • In residential care facilities and facilities formerly licensed as residential care facilities II, floors housing residents who require the use of a walker, wheelchair, or other assistive devices or aids, or who are blind, must have two (2) accessible exits to grade or such residents must be housed near accessible exits as specified in 19 CSR 30- 86.042(33) for residential care facilities and 19 CSR 30- 043(31) for facilities formerly licensed as residential care facilities II unless otherwise prohibited by 19 CSR 30-

86.045 or 19 CSR 30-86.047, facilities equipped with a complete sprinkler system, in accordance with NFPA 13 or NFPA 13R, 1999 edition, with sprinkler coverage in attics, and smoke partitions, as defined by subsection (10)(I) of this rule, may house such residents on floors that do not have accessible exits to grade if each required exit is equipped with an area of refuge as defined and described in subsections (1)(B) and (7)(D) of this rule. I/II

  • An “area of refuge” shall have—
    1. An area separated by one- (1-) hour rated smoke walls, from the remainder of the building. This area must have direct access to the exit stairway or access the stair through a section of the corridor that is separated by smoke walls from the remainder of the building. This area may include no more than two (2) resident rooms;
    2. A two- (2-) way communication or intercom system with both visible and audible signals between the area of refuge and the bottom landing of the exit stairway, attendants’ work area, or other primary location as designated in the written plan for fire drills and evacuation;
    3. Instructions on the use of the area during emergency conditions that are located in the area of refuge and conspicuously posted adjoining the communication or intercom system;
    4. A sign at the entrance to the room that states “AREA OF REFUGE IN CASE OF FIRE” and displays the international symbol of accessibility;
  1. An entry or exit door that is at least a one and three- fourths inch (1 3/4″) solid core wood door or has a fire protection rating of not less than twenty (20) minutes with smoke seals and positive latching hardware. These doors shall not be lockable;
  2. A sign conspicuously posted at the bottom of the exit stairway with a diagram showing each location of the areas of refuge;
  3. Emergency lighting for the area of refuge; and
  4. The total area of the areas of refuge on a floor shall equal at least twenty (20) square feet for each resident who is blind or requires the use of a wheelchair or walker housed on the floor. II
  • If it is necessary to lock exit doors, the locks shall not require the use of a key, tool, special knowledge, or effort to unlock the door from inside the building. Only one (1) lock shall be permitted on each door. Delayed egress locks complying with section 7.2.1.6.1 of the 2000 edition NFPA 101 shall be permitted, provided that not more than one (1) such device is located in any egress path. Self-locking exit doors shall be equipped with a hold-open device to permit staff to reenter the building during the evacuation. I/II
  • If it is necessary to lock resident room doors, the locks shall not require the use of a key, tool, special knowledge, or effort to unlock the door from inside the room. Only one (1) lock shall be permitted on each door. Every resident room door shall be designed to allow the door to be opened from the outside during an emergency when locked. The facility shall ensure that facility staff have the means or mechanisms necessary to open resident room doors in case of an emergency. I/II
  • All stairways and corridors shall be easily negotiable and shall be maintained free of obstructions. II
  • Outside stairways shall be constructed to support residents during evacuation and shall be continuous to the ground level. Outside stairways shall not be equipped with a counter-balanced device. They shall be protected from or cleared of ice or snow. II/III
  • Facilities with three (3) or more floors shall comply with the provisions of Chapter 320, RSMo which requires outside stairways to be constructed of iron or steel. II
  • Fire escapes constructed on or after November 13, 1980, whether interior or exterior, shall be thirty-six inches (36″) wide, shall have eight-inch (8″) maximum risers, nine-inch (9″) minimum tread, no winders, maximum height between landings of twelve feet (12′), minimum dimensions of landings of forty-four inches (44″), landings at each exit door, and handrails on both sides and be of sturdy construction, using at least two-inch (2″) lumber. Exit doors to these fire escapes shall be at least thirty-six inches (36″) wide and the door shall swing outward.
  • If a ramp is required to meet residents’ needs under 19 CSR 30-86.042, the ramp shall have a maximum slope of one to twelve (1:12) leading to grade. II/III
  • Exit
    • Signs bearing the word EXIT in plain, legible letters shall be placed at each required exit, except at doors directly from rooms to exit passageways or corridors. Letters of all exit signs shall be at least six inches (6″) high and principle strokes three-fourths of an inch (3/4″) wide, except that letters of internally illuminated exit signs shall not be less than four inches (4″) high. II
    • Directional indicators showing the direction of travel shall be placed in corridors, passageways, or other locations where the direction of travel to reach the nearest exit is not apparent. II/III
    • All required exit signs and directional indicators shall be positioned so that both normal and emergency lighting illuminates them. II/III

 

  • Complete Fire Alarm
    • All facilities shall have a complete fire alarm system installed in accordance with NFPA 101, Section 18.3.4, 2000 edition. The complete fire alarm shall automatically transmit to the fire department, dispatching agency, or central monitoring company. The complete fire alarm system shall include visual signals and audible alarms that can be heard throughout the building and a main panel that interconnects all alarm-activating devices and audible signals. Manual pull stations shall be installed at or near each required attendant’s station and each required exit. I/II
  1. For facilities with a sprinkler system in accordance with NFPA 13, 1999 edition, smoke detectors interconnected to the complete fire alarm system shall be installed in all corridors and spaces open to corridors. Smoke detectors shall be no more than thirty feet (30′) apart with no point on the ceiling more than twenty-one feet (21′) from a smoke detector. I/II
    1. In facilities licensed prior to November 13, 1980, smoke detectors located every fifty feet (50’) will be acceptable if the distance is within the manufacturer’s specifications. I/II
  2. For facilities with a sprinkler system in accordance with NFPA 13R, 1999 edition, smoke detectors interconnected to the complete fire alarm system shall be installed in all corridors, spaces open to corridors, and in accessible spaces not protected by the sprinkler system, as required by NFPA 72, 1999 edition. Smoke detectors shall be no more than thirty feet (30′) apart with no point on the ceiling more than twenty-one feet (21′) from a smoke detector. Smoke detectors shall not be installed in areas where environmental influences may cause nuisance alarms. Such areas include, but are not limited to, kitchens, laundries, bathrooms, mechanical air handling rooms, and attic spaces. In these areas, heat detectors interconnected to the complete fire alarm system shall be installed. Bathrooms not exceeding fifty-five (55) square feet and clothes closets, linen closets, and pantries not exceeding twenty-four (24) square feet are exempt from having any detection device if the walls and ceilings are surfaced with limited-combustible or noncombustible material as defined in NFPA 101, 2000 edition. Concealed spaces of noncombustible or limited combustible construction are not required to have detection devices. These spaces may have limited access but cannot be occupied or used for storage. I/II
  1. In facilities licensed prior to November 13, 1980, smoke detectors located every fifty feet (50’) will be acceptable if the distance is within the manufacturer’s specifications. I/II
  1. For facilities that are not required to have a sprinkler system, smoke detectors interconnected to the complete fire alarm system shall be installed in all accessible spaces, as required by NFPA 72, 1999 edition, within the facility. Smoke detectors shall be no more than thirty feet (30′) apart with no point on the ceiling more than twenty-one feet (21′) from a smoke detector. Smoke detectors shall not be installed in areas where environmental influences may cause nuisance alarms. Such areas include, but are not limited to, kitchens, laundries, bathrooms, mechanical air handling rooms, and attic spaces. In these areas, heat detectors interconnected to the fire alarm system shall be installed. Bathrooms not exceeding fifty-five (55) square feet and clothes closets, linen closets, and pantries not exceeding twenty-four (24) square feet are exempt from having any detection device if the walls and ceilings are surfaced with limited- combustible or noncombustible material as defined in NFPA 101, 2000 edition. Concealed spaces of noncombustible or limited-combustible construction are not required to have detection devices. These spaces may have limited access but cannot be occupied or used for storage. I/II
    1. In facilities licensed prior to November 13, 1980, smoke detectors located every fifty feet (50’) will be acceptable if the distance is within the manufacturer’s specifications. I/II
  • Facilities that are required to install a sprinkler system in accordance with section (11) of this rule shall comply with the following requirements:
  1. Until the required sprinkler system is installed, each resident room or any room designated for sleeping shall be equipped with at least one (1) battery-powered smoke alarm installed, tested, and maintained in accordance with manufacturer’s specifications. In addition, the facility shall be equipped with interconnected heat detectors installed, tested, and maintained in accordance with NFPA 72, 1999 edition, with detectors in all areas subject to nuisance alarms, including, but not limited to, kitchens, laundries, bathrooms, mechanical air handling rooms, and attic spaces. I/II
    1. The facility shall maintain a written record of the monthly testing and battery changes. The written records shall be retained for one (1) year. I/II
    2. Upon discovery of a fault with any detector or alarm, the facility shall correct the fault. I/II
  • All facilities shall test and maintain the complete fire alarm system in accordance with NFPA 72, 1999 edition. I/II
  • All facilities shall have inspections and written certifications of the complete fire alarm system completed by an approved qualified service representative in accordance with NFPA 72, 1999 edition, at least
  • Facilities shall test by activating the complete fire alarm system at least once a month. I/II
  • Facilities shall maintain a record of the complete fire alarm tests, inspections, and certifications required by subsections (9)(C) and (D) of this rule. III
  • Upon discovery of a fault with the complete fire alarm system, the facility shall correct the fault. I/II
  • When a complete fire alarm system is to be out-of- service for more than four (4) hours in a twenty-four- (24-) hour period, the facility shall immediately notify the department and the local fire authority and implement an approved fire watch in accordance with NFPA 101, 2000 edition, until the complete fire alarm system has returned to full service. I/II
  • The complete fire alarm system shall be activated by all of the following: sprinkler system flow alarm, smoke detectors, heat detectors, manual pull stations, and activation of the rangehood extinguishment system. II/III

 

  • Protection from
    • In assisted living facilities and residential care facilities licensed on or after November 13, 1980, for more than twelve (12) beds, hazardous areas shall be separated by construction of at least a one- (1-) hour fire-resistant rating. In facilities equipped with a complete fire alarm system, the one- (1-) hour fire separation is required only for furnace or boiler rooms. Hazardous areas equipped with a complete sprinkler system are not required to have this one- (1-) hour fire separation. Doors to hazardous areas shall be self-closing and shall be kept closed unless an electromagnetic hold-open device is used which is interconnected with the fire alarm system. When the sprinkler option is chosen, the areas shall be separated from other spaces by smoke-resistant partitions and doors. The doors shall be self-closing or automatic-closing. Facilities formerly licensed as residential care facility I or II, and existing prior to November 13, 1980, shall be exempt from this requirement. II
    • The storage of unnecessary combustible materials in any part of a building in which a licensed facility is located is prohibited. I/II
    • Electric or gas clothes dryers shall be vented to the outside. Lint traps shall be cleaned regularly to protect against fire hazard. II/III
    • In facilities that are required to comply with the requirements of 19 CSR 30-86.043 and were formerly licensed as residential care facilities II on or after November 13, 1980, each floor shall be separated by construction of at least a one- (1-) hour fire-resistant rating. Buildings equipped with a complete sprinkler system may have a nonrated smoke separation barrier between floors. Doors between floors shall be a minimum of one and three- fourths inches (1 3/4″) thick and be solid core wood doors or metal doors with an equivalent fire rating. II
  • In facilities licensed prior to November 13, 1980, and multi-storied residential care facilities formerly licensed as residential care facilities I licensed on or after November 13, 1980, there shall be a smoke separation barrier between the floors of resident-use areas and any floor below the resident-use area. This shall consist of a solid core wood door or metal door with an equivalent fire rating at the top or the bottom of the stairs. There shall not be a transom above the door that would permit the passage of smoke. II
  • Atriums open between floors will be permitted if resident room corridors are separated from the atrium by one- (1-) hour rated smoke walls. These corridors must have access to at least one (1) of the required exits without traversing any space opened to the atrium. II
  • All doors providing separation between floors shall have a self-closing device attached. If the doors are to be held open, electromagnetic hold-open devices shall be used that are interconnected with either an individual smoke detector or a complete fire alarm system. II
  • All facilities shall be divided into at least two (2) smoke sections with each section not exceeding one hundred fifty feet (150′) in length or width. If the floor’s dimensions do not exceed seventy-five feet (75′) in length or width, a division of the floor into two (2) smoke sections will not be required. II
  • In facilities whose plans were approved or which were initially licensed after December 31, 1987, for more than twenty (20) beds and all facilities licensed after August 28, 2007, each smoke section shall be separated by one- (1-) hour fire-rated smoke partitions. The smoke partitions shall be continuous from outside wall-to-outside wall and from floor-to-floor or floor-to-roof deck. All doors in this wall shall be at least twenty- (20-) minute fire- rated or its equivalent, self-closing, and may be held open only if the door closes automatically upon activation of the complete fire alarm system. II
  • In all facilities that were initially licensed on or prior to December 31, 1987, and all facilities licensed for twenty

(20) or fewer beds prior to August 28, 2007, each smoke section shall be separated by a one- (1-) hour fire-rated smoke partition that extends from the inside portion of an exterior wall to the inside portion of an exterior wall and from the floor to the underside of the floor or roof deck above, through any concealed spaces, such as those above suspended ceilings, and through interstitial structural and mechanical spaces. Smoke partitions shall be permitted to terminate at the underside of a monolithic or suspending ceiling system where the following conditions are met: The ceiling system forms a continuous membrane, a smoketight joint is provided between the top of the smoke partition and the bottom of the suspended ceiling and the space above the ceiling is not used as a plenum. Smoke partition doors shall be at least twenty- (20-) minute fire-rated or its equivalent, self-closing, and may be held open only if the door closes automatically upon activation of the complete fire alarm system. II

  • Facilities whose plans were approved or which were initially licensed after December 31, 1987, for more than twenty (20) beds which do not have a sprinkler system, shall have one- (1-) hour rated corridor walls with one and three-quarters inch (1 3/4″) solid core wood doors or metal doors with an equivalent fire rating. II
  • If two (2) or more levels of long-term care or two (2) different businesses are located in the same building, the entire building shall meet either the most strict construction and fire safety standards for the combined facility or the facilities shall be separated from the other(s) by two- (2-) hour fire-resistant construction. In buildings equipped with a complete sprinkler system in accordance with NFPA 13 or NFPA 13R, 1999 edition, this separation may be rated at one (1) hour. II

 

  • Sprinkler Systems.
    • Facilities licensed on or after August 28, 2007, or any section of a facility in which a major renovation has been completed on or after August 28, 2007, shall install and maintain a complete sprinkler system in accordance with NFPA 13, 1999 edition. I/II
    • Facilities that have a sprinkler system installed prior to August 28, 2007, shall inspect, maintain, and test these systems in accordance with the requirements that were in effect for such facilities on August 27, 2007. I/II
    • All residential care facilities, and assisted living facilities that do not admit or retain a resident with a physical, cognitive, or other impairment that prevents the individual from safely evacuating the facility with minimal assistance, that were licensed prior to August 28, 2007, with more than twenty (20) residents, and do not have an approved sprinkler system in accordance with NFPA 13, 1999 edition, or NFPA 13R, 1999 edition, shall have until December 31, 2012, to install an approved sprinkler system in accordance with NFPA 13 or 13R, 1999 edition. I/II
      1. The department shall grant exceptions to this requirement if the facility meets Chapter 33 of NFPA 101, 2000 edition, and the evacuation capability of the facility meets the standards required in NFPA 101A, Guide to Alternative Approaches to Life Safety, 2001 edition. I/II
    • Single-story assisted living facilities that provide care to one (1) or more residents with a physical, cognitive, or other impairment that prevents the individual from safely evacuating the facility with minimal assistance shall install and maintain an approved sprinkler system in accordance with NFPA 13R, 1999 edition. I/II
    • Multi-level assisted living facilities that provide care to one (1) or more residents with a physical, cognitive, or other impairment that prevents the individual from safely evacuating the facility with minimal assistance shall install and maintain an approved sprinkler system in accordance with NFPA 13, 1999 edition. I/I

 

  • All facilities shall have inspections and written certifications of the approved sprinkler system completed by an approved qualified service representative in accordance with NFPA 25, 1998 edition. The inspections shall be in accordance with the provisions of NFPA 25, 1998 edition, with certification at least annually by a qualified service representative. I/II
  • When a sprinkler system is to be out-of-service for more than four (4) hours in a twenty-four- (24-) hour period, the facility shall immediately notify the department and implement an approved fire watch in accordance with NFPA 101, 2000 edition, until the sprinkler system has been returned to full service. I/II
  • Emergency
    • Emergency lighting of sufficient intensity shall be provided for exits, stairs, resident corridors, and required attendants’ station. II
    • The lighting shall be supplied by an emergency service, an automatic emergency generator, or battery- operated lighting system. This emergency lighting system shall be equipped with an automatic transfer switch. II
    • If battery-powered lights are used, they shall be capable of operating the light for at least one and one-half (1 1/2) hours. II

 

  • Interior Finish and
    • In a facility licensed on or after November 13, 1980, for more than twelve (12) beds, wall and ceiling surfaces of all occupied rooms and all exitways shall be classified either Class A or B interior finish as defined in NFPA 101, 2000 edition. II
    • In facilities licensed prior to November 13, 1980, all wall and ceiling surfaces shall be smooth and free of highly combustible materials. II
    • In facilities licensed for more than twelve (12) beds, the new or replacement floor covering and carpeting in buildings that do not have a sprinkler system shall be Class I in accordance with NFPA 253, 2000 edition. II/III
    • All curtains and drapes in a licensed facility shall be certified or treated to be flame-resistant as defined in NFPA 101, 2000 edition. II
    • Smoking shall be permitted in designated areas only. Areas where smoking is permitted shall be designated as such and shall be supervised either directly or by a resident informing an employee of the facility that the area is being used for smoking. II/III
    • Ashtrays shall be made of noncombustible material and safe design and shall be provided in all areas where smoking is permitted. II/III
    • The contents of ashtrays shall be disposed of properly in receptacles made of noncombustible material. II/III
  • Trash and Rubbish
    • Only metal or UL- or FM-fire-resistant rated wastebaskets shall be used for trash. II
    • Trash shall be removed from the premises as often as necessary to prevent fire hazards and public health nuisance. II
    • No trash shall be burned within fifty feet (50′) of any facility except in an approved incinerator. I/II
    • Trash may be burned only in a masonry or metal container. II
    • The container shall be equipped with a metal cover with openings no larger than one-half inch (1/2″) in size. III

 

  • Standards for Designated Separated Areas.
    • When a resident resides among the entire general population of the facility, the facility shall take necessary measures to provide such residents with the opportunity to explore the facility and, if appropriate, its grounds. When a resident resides within a designated, separated area that is secured by limited access, the facility shall take necessary measures to provide such residents with the opportunity to explore the separated area and, if appropriate, its grounds. If enclosed or fenced courtyards are provided, residents shall have reasonable access to such courtyards. Enclosed or fenced courtyards that are accessible through a required exit door shall be large enough to provide an area of refuge for fire safety at least thirty feet (30′) from the building. Enclosed or fenced courtyards that are accessible through a door other than a required exit shall have no size requirements. II
    • The facility shall provide freedom of movement for the residents to common areas and to their personal spaces. The facility shall not lock residents out of or inside their rooms. I/II
    • The facility may allow resident room doors to be locked providing the residents request to lock their doors. Any lock on a resident room door shall not require the use of a key, tool, special knowledge, or effort to lock or unlock the door from inside the resident’s room. Only one

(1) lock shall be permitted on each door. The facility shall ensure that facility staff has the means or mechanisms necessary to open resident room doors in case of an emergency. I/II

  • The facility may provide a designated, separated area where residents, who are mentally incapable of negotiating a pathway to safety, reside and receive services and which is secured by limited access if the following conditions are met:
    1. Dining rooms, living rooms, activity rooms, and other such common areas shall be provided within the designated, separated area. The total area for common areas within the designated, separated area shall be equal to at least forty (40) square feet per resident; II/III
  1. Doors separating the designated, separated area from the remainder of the facility or building shall not be equipped with locks that require a key to open; I/II
  2. If locking devices are used on exit doors egressing the facility or on doors accessing the designated, separated area, delayed egress magnetic locks shall be used. These delayed egress devices shall comply with the following:
    1. The lock must unlock when the fire alarm is activated;
    2. The lock must unlock when the power fails;
    3. The lock must unlock within thirty (30) seconds after the release device has been pushed for at least three

(3) seconds, and an alarm must sound adjacent to the door;

  1. The lock must be manually reset and cannot automatically reset; and
  2. A sign shall be posted on the door that reads: PUSH UNTIL ALARM SOUNDS, DOOR CAN BE OPENED IN 30 SECONDS; and I/II
  1. The delayed egress magnetic locks may also be released by a key pad located adjacent to the door for routine use by staff. I/II