1. (a) All ESRDDCs shall meet the applicable chapters of NFPA 101, the applicable chapters of the state fire code pursuant to RSA 153:5, and the applicable chapters of the state building code.
2. (b) The licensee shall provide and maintain a complete fire alarm system installed and maintained in accordance with the state fire code, regardless of the size of the facility.

3. (c) The licensee shall comply with all state and local codes and ordinances for:

   1. (1) State building code;
   2. (2) Health;
   3. (3) State fire code;
   4. (4) Waste disposal; and
   5. (5) Water, including the requirements of He-P 811.07(d).

4. (d) All ESRDDCs shall have:

   1. (1) Smoke detectors on every level, powered by the ESRDDC’s electrical service, or wireless, as approved by the state fire marshal for the ESRDDC;

   2. (2) At least one ABC type fire extinguisher on every level or every 75 feet of corridor as required by NFPA 10 that shall:

      1. a. Be manually inspected when initially placed in service;
      2. b. Be inspected either manually or by means of an electronic monitoring device or system at intervals not exceeding 31 days; and

      3. c. Be inspected at least once per calendar month and include:

         1. 1. Documentation of the manual fire extinguisher inspections which shall be maintained on-site in accordance with NFPA 10 and available at the time of the inspection or investigation; and
         2. 2. Documentation of electronically monitored fire extinguishers which shall be provided to the department within 2 business days of the completion of the inspection or investigation; and
   3. (3) An approved carbon monoxide monitor on every level.

5. (e) The ESRDDC shall:

   1. (1) Have all entrances and exits to the licensed premises accessible at all times;
   2. (2) Be maintained in good repair and kept free of hazards to personnel and patients, including but not limited to hazards from falls, burns, or electrical shocks;
   3. (3) Be free from environmental nuisances, including noise and odors;

   4. (4) Take measures to prevent the presence of rodents, insects, and vermin including, but not limited to:

      1. a. Having tightly fitting screens to all doors, windows, or other openings to the outside unless the door is self-closing and remains closed unless in use;
      2. b. Repairing holes and caulking of pipe channels; and
      3. c. Extermination by a pesticide applicator licensed under RSA 430; and
   5. (5) Keep all corridors free from obstructions.

6. (f) Each licensee shall develop a fire safety plan, which provides for the following:

   1. (1) Use of alarms;
   2. (2) Transmission of alarms 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;
   9. (9) Extinguishment of fire; and
   10. (10) Written emergency telephone numbers for key staff, fire and police departments, poison control center, 911, and ambulance service(s).

7. (g) The fire safety plan shall be reviewed and approved as follows:

   1. (1) The ESRDDC shall obtain written approval initial from the local fire chief for all fire safety plans; and
   2. (2) If changes are made to the fire safety plan, they shall be submitted to the local fire chief for review and approval, as appropriate, prior to the change.

8. (h) Immediately following any fire or emergency situation, licensees shall notify the department by phone to be followed by written notification within 72 hours, with the exception of:

   1. (1) A false alarm or emergency medical services (EMS) transport for a non-emergent reason; or
   2. (2) Emergency EMS transport related to pre-existing conditions.

9. (i) The written notification required by (h) above shall include:

   1. (1) The date and time of the incident;
   2. (2) A description of the location and extent of the incident, including any injury or damage;
   3. (3) A description of events preceding and following the incident;
   4. (4) The name of any personnel or patients who were evacuated as a result of the incident, if applicable;
   5. (5) The name of any personnel or patients who required medical treatment as a result of the incident, if applicable; and
   6. (6) The name of the individual the licensee wishes the department to contact if additional information is required.

10. (j) All ESRDDCs shall conduct fire drills as follows:

    1. (1) Fire drills shall be conducted quarterly on each shift to familiarize facility personnel including, but not limited to, medical personnel, maintenance engineers, and administrative staff, with the signals and emergency action required under varied conditions;
    2. (2) Fire drills shall include the transmission of a fire alarm signal and simulation of emergency fire conditions;
    3. (3) When drills are conducted between 9:00 p.m. and 6:00 a.m., a coded announcement shall be permitted to be used instead of audible alarms;
    4. (4) If the facility has an defend or shelter in place plan, then all personnel, patients, and visitors shall evacuate to that appropriate location or to the outside of the building to a selected assembly point and drills shall be designed to ensure that patients shall be given the experience of evacuating to the appropriate location; and
    5. (5) If the facility has an defend or shelter in place plan, the facility shall have this plan approved by the department and their local fire chief and shall be constructed to meet the health care occupancy chapter of the life safety code, as adopted within the state fire code.
11. (k) For personnel who are unable to participate in the scheduled drill described in (j) above, on the day they return to work the administrator or designee shall, if applicable, instruct them as to any changes in the facility fire safety plan and emergency plans and document such instruction in their personnel file.
12. (l) Personnel who are unable to participate in a drill in accordance with (j) and (k) above shall participate in a drill within the next quarter.
13. (m) The timing of quarterly drills shall be at varying times to include all shifts and all patients and individuals in the ESRDDC at the time of the drill.
14. (n) At no time shall a staff member who has not participated in in a fire drill be the only staff member on duty within the facility.
15. (o) The facility shall conduct a fire drill in the presence of a representative of the department, the state fire marshal’s office, or the local fire department upon request.

16. (p) All emergency and evacuation drills shall:

    1. (1) Be documented and the written records maintained on site and available to the department during an inspection or investigation conducted in accordance with RSA 151:6 and RSA 151:6-a; and

    2. (2) Include the following information:

       1. a. The names of the participating personnel and patients;
       2. b. The time, date, including AM or PM, month, and year the drill was conducted and if the actual fire alarm system was used;
       3. c. The exits utilized if the ESRDDC does not comply with the health care chapter of the state fire code;
       4. d. Location of exits used;

       5. e. The total time necessary to;

          1. 1. Completely evacuate the ESRDDC:
          2. 2. Evacuate to an approved area of refuge; or
          3. 3. Evacuate through a horizontal exit;
       6. f. The time needed to complete the drill;
       7. g. The name and title of the person conducting the drill;
       8. h. A list of problems and issues encountered during the drill;
       9. i. A list of improvements and resolution to the issues encountered during the fire drill; and
       10. j. The names of all staff members participating in the drill.

17. (q) For the use and storage of oxygen and other related gases, ESRDDCs shall comply with NFPA 99, health care facilities code including, but not limited to, the following:

    1. (1) All freestanding compressed gas cylinders shall be firmly secured to the adjacent wall or secured in a stand or rack;
    2. (2) Storage locations shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limited-combustible construction, with doors, or with gates if outdoors, that can be secured against unauthorized entry;

    3. (3) Oxidizing gases, such as oxygen and nitrous oxide, shall:

       1. a. Not be stored with any flammable gas, liquid, or vapor;

       2. b. Be separated from combustibles or incompatible materials by:

          1. 1. A minimum distance of 20 ft or 6.1 meters;
          2. 2. A minimum distance of 5 ft or 1.5 meters if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13, standard for the installation of sprinkler systems; or
          3. 3. An approved, enclosed flammable liquid storage cabinet of noncombustible construction having a minimum fire protection rating of one-half hour for cylinder storage; and
       3. c. Shall be secured in an upright position, such as with racks or chains;
    4. (4) A precautionary sign, readable from a distance of 5 feet or 1.5 meters, shall be conspicuously displayed on each door or gate of the storage room or enclosure, and shall include, at a minimum, the following: “CAUTION, OXIDIZING GAS(ES) STORED WITHIN - NO SMOKING”; and
    5. (5) Precautionary signs, readable from a distance of 5 feet or 1.5 meters, and with language such as “OXYGEN IN USE, NO SMOKING”, shall be conspicuously displayed wherever supplemental oxygen is in use and in aisles and walkways leading to the area of use, and shall be attached to adjacent doorways or to building walls or be supported by other appropriate means.
18. (r) Flammable gases and liquids shall be stored in metal fire retardant cabinets.

19. (s) Cylinders shall be protected from damage by means of the following specific procedures:

    1. (1) Oxygen cylinders shall be protected from abnormal mechanical shock, which is liable to damage the cylinder, valve, or safety device;
    2. (2) Oxygen cylinders shall not be stored near elevators or gangways or in locations where heavy moving objects will strike them or fall on them;
    3. (3) Cylinders shall be protected from tampering by unauthorized individuals;
    4. (4) Cylinders or cylinder valves shall not be repaired, painted, or altered;
    5. (5) Safety relief devices in valves or cylinders shall not be tampered with;
    6. (6) Valve outlets clogged with ice shall be thawed with warm, not boiling water;
    7. (7) A torch flame shall not be permitted, under any circumstances, to come in contact with a cylinder, cylinder valve, or safety device;
    8. (8) Sparks and flame shall be kept away from cylinders;
    9. (9) Even if they are considered to be empty, cylinders shall not be used as rollers, supports, or for any purpose other than that for which the supplier intended them;
    10. (10) Large cylinders, exceeding size E, and containers larger than 45 kg or 100 lbs weight shall be transported on a proper hand truck or cart complying with NFPA 99, section 11.4.3.1;
    11. (11) Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart; and
    12. (12) Cylinders shall not be supported by radiators, steam pipes, or heat ducts.

20. (t) Cylinders and their contents shall be handled with care, which shall include the following specific procedures:

    1. (1) Oxygen fittings, valves, pressure reducing regulators, or gauges shall not be used for any service other than that of oxygen;
    2. (2) Gases of any type shall not be mixed in an oxygen cylinder or any other cylinder;
    3. (3) Oxygen shall always be dispensed from a cylinder through a pressure reducing regulator;
    4. (4) The cylinder valve shall be opened slowly, with the face of the indicator on the pressure reducing regulator pointed away from all persons;
    5. (5) Oxygen shall be referred to by its proper name, oxygen, not air, and liquid oxygen shall be referred to by its proper name, not liquid air;
    6. (6) Oxygen shall not be used as a substitute for compressed air;
    7. (7) The markings stamped on cylinders shall not be tampered with, in compliance with federal law;
    8. (8) Markings used for the identification of contents of cylinders shall not be defaced or removed, including decals, tags, and stenciled marks, except those labels or tags used for indicating cylinder status, for example, full, in use, or empty;
    9. (9) The owner of the cylinder shall be notified if any condition has occurred that might allow any foreign substance to enter a cylinder or valve, giving details and the cylinder number;
    10. (10) Neither cylinders nor containers shall be placed in the proximity of radiators, steam pipes, or heat ducts; and
    11. (11) Very cold cylinders or containers shall be handled with care to avoid injury.

Source. #12985, eff 1-29-20; ss by #14206, eff 2-28-25 (formerly He-P 811.26)