1. (a) All ASC’s 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 to 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 ASC 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 are not limited to, evacuation routes, emergency notification numbers, and emergency instructions and shall be posted in locations accessible to personnel and visitors;

      2. b. The ASC 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. c. Ensuring that the fire safety and evacuation plans are available to all supervisory personnel;
      4. d. Ensuring that all employees receive in-service annual training to clarify their responsibilities in carrying out the emergency plan; and
      5. e. Ensuring that the required plan shall be readily available at all times in the telephone operator’s location or at the security center; and

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

      1. a. Recovery and operating room patients shall not be required to be moved during drills to safety areas or to the exterior of the building; and
      2. b. Drills shall be conducted quarterly on each shift to familiarize ASC personnel with the signals and emergency action required under varied conditions.
4. (d) The emergency plan required by (b)(2) above shall be approved and signed by the local fire chief.
5. (e) The ASC 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. The ASC 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) The ASC shall notify the department when the emergency power has been utilized for 6 or more hours due to power outage.
7. (g) Provisions shall be made for the medical gas(es) used in the facility. Adequate space for supply and storage, including space for serve cylinders, shall be provided. Protection of this area shall meet NFPA 101 and NFPA 99 health care facilities code, as adopted by the state fire code.
8. (h) If piped medical gas is used, the installation, testing, and certification of nonflammable medical gas and air systems shall comply with the requirements of NFPA 99, as adopted by the state fire code.
9. (i) Where the functional program requires, central clinical vacuum system installations shall be in accordance with NFPA 99, as adopted by the state fire code.
10. (j) If there is an incident including, but not limited to, fire, toxic fumes including smoke, flooding, and power outage, which requires the evacuation of the ASC all or in part, the ASC shall immediately notify the department by phone, once the incident has been stabilized. Within 72 hours of the incident, the ASC shall submit a written report which gives further details of the incident and the action taken.

Source. . #12926, eff 11-26-19; ss by #14042, eff 8-6-24 (formerly He-P 812.25)