Fire Safety, Evacuation Plan, Fire Drills | Policy

In case of a fire, The agency’s staff will follow the RACE procedure to protect and ensure the safety of residents, staff, and guests.

Fire | Policy

In the event of a fire, staff at the agency will follow the established fire safety plan

Fire | Procedure

In case of a fire, the agency’s staff will follow the RACE procedure to protect and ensure the safety of residents, staff, and guests. This includes rescuing all tenants from danger by evacuating them to the safest exit or behind the nearest set of smoke compartment doors away from the fire or smoke, alerting the fire department by calling 911 and giving them all the necessary information, confining the fire by closing all doors leading towards it, and extinguishing the fire only if safe to do so and all other steps in the procedure have been followed.

Once the fire alarm is triggered, all fire doors on magnetic holders will automatically close to contain smoke and fire, and tenants should stay behind the fire doors. All other doors should be closed immediately to contain the fire or smoke, unless tenants need to be evacuated. The fire department will be dispatched immediately as the system is wired directly to the fire station, and once they arrive, staff will take orders and direction from them as they are in charge. All known fires must be reported to the fire department for investigation.

If the alarm is sounding but there is no apparent fire, staff should remain calm and keep residents as calm as possible until the fire department arrives and shuts off the alarm. Once the alarm is off, staff may open the fire doors and continue operations.

The agency is required to conduct six fire drills per year, with two on each shift and one drill every two months. Staff must contact the fire department and alarm company to let them know about the planned fire drill, gather staff and explain the assignments and goals, plant a fake fire, activate the alarm (optional), allow staff to locate the fake fire, remove tenants from immediate danger by evacuating those closest to the fire and moving outwards, account for all tenants as they gather together in the designated meeting place, call 911 even if the system is automated, make a sweep of the building (except if danger is apparent), and then debrief with staff about how the drill went and discuss areas for improvement.

Residents who are capable of assisting in their own evacuation shall be trained on the proper actions to take in the event of a fire, including movement, evacuation, or relocation, and this training must be made available to residents at least once per year. Staff shall receive training on fire safety and evacuation plans upon hire and then twice per year thereafter.

FGI | Procedure

The FGI Guidelines for design and Construction of Residential Health, Care, and Support Facilities, Assisted Living Facilities Chapter, provide guidance on the design and construction of assisted living facilities to ensure the safety and well-being of residents. The 2018 edition of the Guidelines shall apply to all licensed assisted living facilities with six or more residents, and to those facilities that meet either of the following criteria:

1. The facility has received a provisional assisted living license or a provisional assisted living with dementia care license after August 1, 2021.
2. The Authority Having Jurisdiction (AHJ) has determined that a legacy assisted living building constitutes a distinct hazard to life, and therefore, the Guidelines must be followed during any renovation or expansion of the facility.
3. This means that any assisted living facility that applied for a license and began new construction before July 31, 2021, may use the construction requirements that were in effect at the time they submitted their building permit application, instead of having to comply with the 2018 edition of the FGI Guidelines for design and Construction of Residential Health, Care, and Support Facilities. However, all licensed assisted living facilities with six or more residents that received a provisional license after August 1, 2021, or that are determined to be a distinct hazard to life by the Authority Having Jurisdiction, must comply with the 2018 edition of the FGI Guidelines for design and Construction of Residential Health, Care, and Support Facilities.

FGI | Policy

It is important for assisted living facilities to comply with these Guidelines to ensure the safety and comfort of their residents. Compliance with the Guidelines will help to promote best practices in assisted living facility design and construction, and will help to ensure that these facilities are able to provide high-quality care to their residents

Bomb Threat | Procedure

1. If a bomb threat is received, the person receiving the call should keep the caller on hold (without hanging up) so that the call may be traced.
2. It is important to write down as much information as possible, including the time set for the explosion, the exact location of the bomb, what the bomb looks like, the type of explosive device, and why the bomb was placed. If the caller hesitates to provide this information, justify your request by expressing a desire to save the lives of innocent people. Pay attention to any strange background noises or the voice of the caller.
3. Go to another phone line or use a cell phone to call 911, but do not hang up the phone line on which the call came in.
4. Wait for emergency personnel to advise you regarding the evacuation of the building. It is recommended that the facility be evacuated in all cases, but circumstances may vary in each incident.
5. Do not use radios or walkie-talkies in the bomb threat area, as they may trigger the bomb.
6. If the building is evacuated, make sure everyone is removed at least 500 feet from the building. Ask all visitors to assist residents if they are able.
7. Staff should make a visual check of their areas as they evacuate and report anything unusual to the police.
8. Do not touch anything suspicious.
9. Staff should account for all residents once evacuated.
10. Do not re-enter the building or an area of the building unless cleared by the proper authorities.

Bomb Threat | Policy

The agency will make every effort to provide secure and organized assistance to residents in the event of a bomb or bomb threat.

Physical Plant Requirements | Procedure

The agency is situated on a property that has access to public utilities and emergency services such as fire department and medical services. The topography of the property allows for natural drainage and is not prone to routine flooding. The agency also has all-weather roads and paths that are regularly maintained for easy access. There is ample space on the property for outdoor activities for residents. The physical environment of the agency will be maintained in a good state of repair and operation in line with an appropriate maintenance and repair program.

In terms of fire protection, the agency will provide and maintain a smoke alarm in every room used for sleeping purposes, as well as outside each sleeping room. Smoke alarms will also be installed on each story within the dwelling unit, including basements (excluding crawl spaces or attics). The smoke alarms within each unit will be interconnected, such that the activation of one alarm in the unit also triggers any other alarm located in the same unit. Smoke alarms may be hard-wired or battery-operated. Additionally, portable fire extinguishers with a minimum 2-A:10-B:C rating will be strategically located such that the travel distance to the nearest fire extinguisher does not exceed 75 feet.

Physical Plant Requirements | Policy

The agency will adhere to the requirements related to the site, physical environment, and fire safety.

Disaster Planning and Emergency Preparedness | Procedure

1. The agency has a written emergency disaster plan that includes a plan for evacuation, sheltering in place, identifying temporary relocation sites, and outlining staff assignments in the event of a disaster or emergency. These elements are in compliance with the requirements of Appendix Z.
2. The agency will provide all residents with a building emergency exit diagram to ensure their safety during an emergency.
3. Emergency exit diagrams will be posted on each floor of the facility to ensure that all residents and staff are aware of emergency evacuation routes.
4. The agency has a written policy and procedure in place to address missing residents and ensure that appropriate actions are taken in the event of a resident going missing.
5. The agency provides emergency and disaster training to all staff during initial staff orientation to prepare them for any emergency or disaster.
6. Staff who have not received emergency and disaster training will only be allowed to work when trained staff are present on site to ensure the safety of residents.
7. The agency provides annual emergency and disaster training to all staff to keep them up-to-date and well-prepared.
8. The agency makes training available to all residents of the facility on an annual basis regarding emergency and disaster response to ensure that they are aware of the procedures and can respond appropriately in case of an emergency.

Disaster Planning and Emergency Preparedness | Policy

The agency will establish a general emergency preparedness plan that is aligned with the facility’s obligation to comply with CMS Appendix Z.

Emergency Preparedness Plan | Procedure

The agency’s emergency preparedness plan is comprehensive, including all the required elements outlined in Appendix Z. It is a written plan that is reviewed annually, based on the agency’s assisted living-based and community-based risk assessments, utilizing an all-hazards approach.

The plan comprises four primary components: risk assessment and planning, policies and procedures, a communication plan, and staff training and exercises/drills. To measure threats and hazards of concern, the agency utilized a hazard vulnerability analysis tool, which considered the probability of events, measurements regarding the context of impact on people, property, and business, preparedness, and mitigation.

Policies and procedures included in the emergency preparedness plan are designed to align with the LTC requirements in Appendix Z. The communication plan focuses on various stakeholders, including staff, entities under arrangement, other LTC providers, volunteers, family members, state and federal contacts, and other sources of assistance. The plan aims to share information and medical documentation regarding residents under the agency’s care to maintain continuity of care during an emergency.

All staff will receive initial training on the emergency preparedness plan, as well as biannual refresher training. The agency will conduct, at minimum, one emergency preparedness drills every 2 months, excluding required fire/evacuation drills. One annual exercise will be a full-scale community-wide exercise, while the second annual exercise will either be a second full-scale community-wide exercise or a tabletop exercise focused on the assisted living setting. The exercises and drills are designed to test the emergency plan and identify gaps and areas for improvement.

Emergency Preparedness Plan | Policy

The agency aims to establish an Emergency Preparedness Plan that is both effective and compliant.

The goal is to ensure that the plan is consistent with the Centers for Medicare and Medicaid Services State Operation Manual Appendix Z, which provides interpretive guidance on Emergency Preparedness for All Providers and Certified Supplier Types.

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