59A-4.130. Fire Prevention, Fire Protection, and Life Safety, Systems Failure and External Emergency Communications

(1) Each nursing home licensee must provide fire protection through the elimination of fire hazards as evidenced by compliance with the fire codes adopted by the State Fire Marshall. The fire codes adopted by the State Fire Marshal for nursing homes is contained Rule Chapter 69A-53, F.A.C., and is known as “Uniform Fire Safety Standards for Hospitals and Nursing Homes.”

(2) All fires or explosions shall be reported to the Agency’s Office of Plans and Construction by telephone at [phone] or by fax at [phone] by the next working day after the occurrence. The nursing home licensee shall complete and submit a Fire Incident Report, AHCA form 3500-0031, July 2014, incorporated by reference and available at http://www.flrules.org/Gateway/reference.asp?No=Ref-06023, to the Office of Plans and Construction and a copy to the appropriate Agency field office within 15 calendar days of the incident. All reports shall be complete and thorough and shall record the cause of the fire or explosion, the date and time of day it occurred, the location within the facility, how it was extinguished, any injuries which may have occurred and a description of the local fire department participation. The Fire Incident Report is available from the Agency for Health Care Administration, Office of Plans and Construction, 2727 Mahan Drive, Mail Stop #24, Tallahassee, Florida 32308 or at the web address: http://ahca.myflorida.com/plansandconstruction.

(3) If a system failure of the fire alarm system, smoke detection system, or sprinkler system occurs, the following actions shall be taken by the licensee:

(a) Immediately notify the local fire department and document the response and any instructions given by the local fire department.

(b) Notify the Agency’s Office of Plans and Construction and the appropriate Agency field office within one business day after the occurrence.

(c) Assess the extent of the condition, effect corrective action and document the estimated length of time for the corrective action.  If the corrective action will take more than four hours, the following must be completed:

1. Implement a contingency plan to the facility fire plan containing a description of the problem, a specific description of the system failure, and the projected correction period. All staff on the shifts involved must have documented in-service training for the emergency contingency.

2. Begin a documented fire watch until the system is restored. Staff performing the fire watch must be trained in appropriate observations and actions, as well as be able to expeditiously contact the fire department. To maintain a fire watch, the licensee must utilize only certified public fire safety personnel, a security guard service, or facility staff. If facility staff are used for this function, they must meet the following criteria:

a. Be off duty from their regular facility position or assigned only to fire watch duty. The licensee must maintain compliance with direct care staffing requirements at all times;

b. Be trained and competent, as determined by the licensee, in the duties and responsibilities of a fire watch;

c. Have immediate access to two-way electronic communication.

3. If the projected correction period changes or the system is restored to normal operation, the licensee must notify the appropriate Agency’s field office and local fire authorities.

(4) External Emergency Communication. Each newly constructed facility that has not received a Preliminary Stage II Plan Approval from the Office of Plans and Construction by June 1, 2015, shall provide for external electronic communication not dependent on terrestrial telephone lines, cellular, radio, or microwave towers, such as an on-site radio transmitter, satellite communication systems or a written agreement with an amateur radio operator volunteer group. This agreement must provide for a volunteer operator and communication equipment to be relocated into the facility in the event of a disaster until communications are restored. Other methods that can be shown to maintain uninterrupted electronic communications not dependent on a land-based transmission must be approved by the Agency’s Office of Plans and Construction.

Rulemaking Authority 400.23 FS. Law Implemented 400.141, 400.23 FS. History–New 4-1-82, Amended 4-1-84, 8-1-85, Formerly 10D-29.119, 59A-4.119, Amended 12-21-15.