| (a) The facility must have a program to inspect, test,
and maintain the fire alarm system and must execute the program at
least once every three months.
(1) The facility must contract with a company that
is registered by the State Fire Marshal's Office to execute the program.
(2) A person who performs a service under the contract
must be licensed by the State Fire Marshal's Office to perform the
service and must complete, sign and date an inspection form similar
to the inspection and testing form in NFPA 72 for a service provided
under the contract.
(3) The facility must ensure fire alarm system components
that require visual inspection are visually inspected in accordance
with NFPA 72.
(4) The facility must ensure fire alarm system components
that require testing are tested in accordance with NFPA 72.
(5) The facility must ensure fire alarm system components
that require maintenance are maintained in accordance with NFPA 72.
(6) The facility must ensure smoke dampers are inspected
and tested in accordance with NFPA 101.
(7) The facility must maintain onsite documentation
of compliance with this subsection.
(b) A facility must have a program to inspect, test
and maintain the sprinkler system and must execute the program at
least once every three months.
(1) The facility must contract with a company that
is registered by the State Fire Marshal's Office to execute the program.
(2) The person who performs a service under the contract
must be licensed by the State Fire Marshal's Office to perform the
service and must complete, sign and date an inspection form similar
to the inspection and testing form in NFPA 25 for a service provided
under the contract.
(3) The facility must ensure sprinkler system components
that require visual inspection are visually inspected in accordance
with NFPA 13 and 25.
(4) The facility must ensure sprinkler system components
that require testing are tested in accordance with the NFPA 13 and
25.
(5) The facility must ensure sprinkler system components
that require maintenance are maintained in accordance with NFPA 13
and 25.
(6) The facility must ensure that individual sprinkler
heads are inspected and maintained in accordance with NFPA 13 and
25.
(7) The facility must maintain onsite documentation
of compliance with this subsection.
(c) If facility staff verify or suspect a malfunction
of the fire alarm, emergency electrical, or sprinkler system, the
facility must immediately investigate and correct the condition. In
addition, the facility must immediately report the failure of the
fire alarm, emergency electrical, or sprinkler system to all facility
staff and the local fire authority.
(d) If emergency generators are required or provided,
a facility must have a program to maintain, operate, and test all
emergency generators, including all appurtenant components, and must
execute the program at least once every week.
(1) The facility must use a properly instructed person
to oversee and execute the program.
(2) The facility must ensure generator components are
inspected, tested, and maintained in accordance with NFPA 37, 70,
99, and 110.
(3) The facility must ensure all generators are operated,
under load, for at least 30 minutes each week.
(4) The person who executes the program must maintain
a signed and dated record or log of inspections, tests and maintenance
performed.
(5) For each required operation of the generator under
the program, the record or log must include the information necessary
to verify:
(A) the total time taken to transfer the load to emergency
power;
(B) the total time the generator operated under load;
(C) the total time the facility's emergency system
remained on generator power after restoration of normal utility power;
and
(D) the total time the generator operated without load
after the facility's return to normal utility power.
(6) The facility must ensure the condition and proper
operation of all emergency lighting is inspected and tested at least
once every week.
(7) The facility must maintain onsite documentation
of compliance with this subsection.
(e) Duplex receptacles powered through the emergency
electrical system must be installed at each resident bed location
where resident-care-related electrical appliances are in use, unless
a facility can demonstrate that it can provide the diagnostic, therapeutic,
or monitoring benefits of the resident-care-related electrical appliances
through acceptable alternative means in the event of a power outage.
(f) A facility must conduct a functional test on every
required battery emergency lighting system at 30-day intervals for
a minimum of 30 seconds. The facility must also conduct an annual
test for a minimum of 1 1/2 hours. The lighting system must be fully
operational for the duration of the testing. The facility must maintain
an onsite written record of all tests performed and make those records
available to the authority having jurisdiction during an inspection.
(g) A facility must ensure that a person licensed by
the State Fire Marshal's Office inspects and services automatic fixed
fire extinguishment systems mounted in kitchen range hoods at least
once every six months in accordance with NFPA 96. The facility must
maintain, onsite, a written and signed report of the inspection and
service performed. The facility must keep the hood, exhaust ducts,
and filters clean and free of accumulated grease.
(h) A facility must inspect and maintain portable fire
extinguishers.
(1) Facility staff must visually inspect portable fire
extinguishers monthly. Facility staff conducting the monthly visual
inspection must ensure portable extinguishers are protected from damage,
kept on their mounting brackets or in cabinets at all times, and kept
in the proper condition and working order.
(2) A facility must ensure that a person licensed by
the State Fire Marshal's Office inspects and maintains portable fire
extinguishers at least once every 12 months in accordance with NFPA
10.
(3) The facility must maintain, onsite, a record of
all fire extinguisher inspections and maintenance performed.
(i) A facility using gas must have the gas piping lines
between the meter and appliances tested for leaks annually by a person
licensed by the State Board of Plumbing Examiners. The facility must
maintain, onsite, a written and signed report of these tests. The
facility must note and correct any unsatisfactory conditions immediately.
(j) A facility must formulate, adopt, and enforce policies
regarding smoking, smoking areas, and smoking safety that also take
into account non-smoking residents.
(1) The facility's policies must comply with all applicable
federal, state, and local laws and regulations.
(2) The facility is responsible for informing residents,
staff, visitors, and other affected parties of smoking policies through
the distribution and posting of policies.
(3) A facility must prohibit smoking in any room, ward,
or compartment where flammable liquids, combustible gas, or oxygen
are used or stored and in any other hazardous locations. These areas
must be posted with "No Smoking" signs.
(4) A facility must provide ashtrays of noncombustible
material and safe design in all areas where smoking is permitted.
(5) A facility must provide a metal container with
a self-closing cover device into which ashtrays can be emptied in
all areas where smoking is permitted.
(k) A facility must not allow storage of combustible
products in facility rooms with gas-fired equipment.
(l) A facility must not allow storage of volatile or
flammable liquids or materials anywhere within the facility building.
(m) A facility may install alcohol-based hand rub dispensers
if the dispensers are:
(1) installed in a manner that:
(A) does not conflict with any state or local codes
that prohibit or otherwise restrict the placement of alcohol-based
hand rub dispensers in health care facilities;
(B) minimizes leaks and spills that could lead to falls;
(C) adequately protects against access by vulnerable
populations; and
(D) complies with NFPA 101; and
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