1. (a) All hospitals shall meet the appropriate chapter of NFPA 101, the appropriate chapters of the state fire code pursuant to RSA 153:5 and the appropriate chapters of the state building code.
2. (b) The administrator or designee shall appoint a safety committee which shall include representatives from administration, clinical services, and support services.

3. (c) The safety committee shall:

   1. (1) Appoint a safety officer who shall:

      1. a. Inspect the premises at least semi-annually to assure that all safety precautions are met; and
      2. b. Report to the safety committee any findings noted during the inspections;

   2. (2) Develop or approve written policies and procedures covering all matters of safety and fire protection and an emergency response plan, including:

      1. a. The emergency procedures required by the emergency response plan shall include, but not be limited to, evacuation routes, emergency notification numbers, and emergency instructions and shall be available in locations accessible to personnel and visitors; and

      2. b. The fire safety plan shall provide for the following:

         1. 1. Use of alarms;
         2. 2. Transmission of alarm to fire department;
         3. 3. Emergency phone call to fire department;
         4. 4. Response to alarms;
         5. 5. Isolation of fire;
         6. 6. Evacuation of immediate area;
         7. 7. Evacuation of smoke compartment;
         8. 8. Preparation of floors and building for evacuation; and
         9. 9. Extinguishment of the fire;
   3. (3) Ensure that the fire safety and evacuation plans are available to all supervisory personnel;
   4. (4) Ensure that all employees receive in-service biennial training to clarify their responsibilities in carrying out the emergency plan;
   5. (5) Ensure the required plan shall be readily available at all times in the telephone operator’s location or at the security center; and

   6. (6) Conduct fire drills, including the transmission of a fire alarm signal and simulation of emergency fire situation, as follows:

      1. a. Infirm or bedridden patients shall not be required to be moved during drills to safety areas or to the exterior of the building;
      2. b. Drills shall be conducted quarterly on each shift to familiarize hospital personnel with the signals and emergency action required under varied conditions; and
      3. c. When drills are conducted between 9:00 p.m. and 6:00 a.m., a coded or plain language announcement may be used instead of audible alarms.
4. (d) The licensee shall notify the department and local fire department when a required sprinkler or fire alarm system is out of service for more than 4 hours in a 24-hour period.
5. (e) The licensee shall be evacuated or an approved dedicated fire watch shall be provided for all parties left unprotected by the shutdown until the sprinkler or alarm system has been returned to service.
6. (f) If a facility loses fire sprinkler coverage for more than 10 hours a fire watch shall be instituted pursuant to NFPA.
7. (g) If a facility loses fire alarm coverage for more than 8 hours a fire watch shall be instituted pursuant to NFPA.
8. (h) The licensee shall notify the department when the emergency power has been utilized for 6 or more hours due to power outage.
9. (i) If there is an incident including, but not limited to, fire, or toxic fumes including smoke that requires the evacuation of the hospital all or in part, the hospital shall notify the department immediately by phone and within 72 hours in writing.
10. (j) A full follow-up written report on the incident shall be completed and submitted to the department when the investigation has been conducted and completed, including what the incident was, action taken, injuries or deaths, or both, that occurred during incident including during evacuation, emergency procedures followed, notification of emergency services including local fire departments, and the corrective actions taken.

Source. #9580, eff 10-24-09; ss by #12407, INTERIM, eff 10-24-17, EXPIRED: 4-22-18 New. #13166, eff 1-28-21 (formerly He-P 802.26); ss by #14081, eff 9-25-24, EXPIRES: 9-25-34 (formerly He-P 802.28)