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Location:  Publications > Guidelines > Fire Safety Planning for Institutional Facilities

Office of the Fire Marshal	OFM-TG-02-1999
FIRE SAFETY PLANNING FOR INSTITUTIONAL FACILITIES	O F M GUIDELINE
August 1999

SECTION   

abstract

1.0 Definitions

2.0 Background

3.0 Developing The Fire Safety Plan
3.1 Fire Safety Planning
3.2 Fire Safety Responsibilities
3.3 Auditing Your Building
3.4 Contents Of The Fire Safety Plan
3.5 Submission Procedures

4.0 Supervisory Staff
4.1 Appointment And Organization Of Supervisory Staff
4.2 Responsibilities Of Supervisory Staff In Fire Safety
4.3 General Fire Procedures For All Staff
4.4 Sample Responsibilities Of Staff Members During A Fire Emergency

5.0 Control Of Fire Hazards

6.0 Maintenance Of Building Facilities And Fire Protection Equipment
6.1 Instructions On The Use Of Fire Safety Systems Provided In The Building
6.2 Alternate Measures For Temporary Shutdown Of Fire Protection Equipment Or Systems

7.0 Other Features
7.1 Fire Drills
7.2 Stairwell And Floor Identification
7.3 Signage
7.4 Fire Safety Committee

8.0 Fire Safety Plan Distribution/Implementation

Appendices

Appendix A:Sample Building Audit Forms (HTML - PDF)

Appendix B:Sample Building Human Resources Audit Form (HTML - PDF)

Appendix C:Sample Fire Drill Log (HTML - PDF)

Appendix D:Sample Staff Training Log (HTML - PDF)

Appendix E:Sample Emergency Instruction Signs for Patients/Residents and Visitors (HTML - PDF)

Appendix F:Sample Schematic Drawing (HTML - PDF)

July, 1999
OFM Section: Fire Safety Standards at (416) 325-3100

The reproduction of this guideline for non-commercial purposes is permitted and encouraged. Permission to reproduce the guideline for commercial purposes must be obtained from the Office of the Fire Marshal, Ontario.

Additional Appendix material is also provided to illustrate examples of Fire Safety Plans, audit forms, fire drill logs, training logs, signage and schematic drawings.
 

1.0   DEFINITIONS

Except for headings, the words and terms used in this guideline that are in lower case bold lettering have the meanings noted below. With the exception of institutional occupancy, single stage fire alarm system and two stage fire alarm system, these meanings are consistent with the definitions found in the 1997 Fire Code.

This guideline has been prepared by the Office of the Ontario Fire Marshal with the assistance of the Ontario Association of Fire Chiefs, Ontario Municipal Fire Prevention Officers Association and the Ontario Nursing Home Association. It is intended to assist owners, managers and staff to develop and implement effective Fire Safety Plans for institutional facilities.

Fire safety is an important responsibility for everyone. However, the consequences of inadequate fire safety planning are especially serious for anyone involved in a group setting for persons receiving institutional care who may be vulnerable due to illness or infirmity. Patients/residents depend on the knowledge, skills and training of the supervisory staff in providing and maintaining a fire safe environment.

Procedures contained in a Fire Safety Plan must be designed specifically for each building. In a fire emergency, if followed properly, the procedures should reduce the risk to life safety for all patients/residents, visitors and staff in the building. To be effective however, a Fire Safety Plan requires the following:

• commitment by management and supervisory staff to fire safety,
• a willingness by management to promote fire safety,
• knowledge of the building,
• knowledge of the fire safety protection equipment,
• a clear understanding of the procedures and how to implement them properly,
• co-operation of supervisory staff to enhance the fire safety of patients/residents.

All institutional facility owners, managers and administrators should have a copy of the Fire Code, Ontario Regulation 388/97, as amended, and the Fire Protection and Prevention Act, 1997. Copies of these documents are available at Publications Ontario, 880 Bay Street, Toronto, M7A 1N8, 1-800-668-9938.

The Fire Code is a provincial regulation made under Part IV of the Fire Protection and Prevention Act, 1997. The Fire Code states that the owner is responsible for carrying out "all provisions of the Code".

In a court of law, the definition of "owner" could be interpreted to mean the person whose name is on title, executive officer of a corporation owning the building, an administrator, a night supervisor/manager or even a maintenance supervisor/manager. Penalties for non-compliance by an individual can be as high as $25,000 per conviction and/or imprisonment for up to one year in jail. Penalties for corporations are a maximum of $50,000 per offence.

Owners, managers, administrators and supervisors of institutional facilities should be intimately familiar with their responsibilities under the Fire Code since contravention of any provision can result in a penalty as listed above.

As required by Section 2.8 of the Fire Code, the owner of an institutional facility is responsible for the preparation of a Fire Safety Plan. In most cases, the Fire Safety Plan can be prepared by an experienced building or maintenance supervisor/manager in conjunction with the manager of the facility. Buildings with elaborate emergency systems may require the assistance of a fire protection consultant. After the plan has been prepared, it must be submitted to the Chief Fire Official for approval.

Once approved, the owner is responsible for implementing the Fire Safety Plan and training all staff in their respective duties. It is also the owner's responsibility to ensure that all visitors and staff are informed of what to do in case of fire or when the fire alarm sounds. During a fire emergency, a copy of the approved Fire Safety Plan shall be available for responding fire department. This may be delivered by hand or, provided in a location approved by the Chief Fire Official, such as a security lock box at the main entrance to the building. This lock box, if approved, shall contain the Fire Safety Plan, master keys and schematic diagrams for the building.

 

Your Fire Safety Plan is a unique document that must be prepared specifically for your building. All of the procedures in the plan must provide staff with the guidance necessary to ensure the safe evacuation of the patients/residents and visitors from the building.

3.0   DEVELOPING THE FIRE SAFETY PLAN

3.1   Fire Safety Planning

Sentences 2.8.1.1.(1) and 2.8.2.1.(2) of the Fire Code require that an approved Fire Safety Plan be prepared and implemented in all institutional facilities across Ontario. This plan must be approved by the Chief Fire Official in the municipality. To assist the Chief Fire Official in assessing your plan, you need to prepare an audit of all systems and equipment within your facility. The human resources that are available to respond to emergencies are also important to include as part of the planning information. These resources may include nursing staff, food service staff, maintenance staff, housekeeping staff, security staff and others if applicable.

NOTE: When preparing your Fire Safety Plan and assigning staff responsibilities, it is important to note that the presence of any private duty nurses does not qualify as on-site staff.

The plan for your building is a unique document. The preparation and implementation of an approved Fire Safety Plan will ensure the optimum use of all life safety features installed in your building. The complete plan must reflect the various functions within your building and the resources available to your patients/residents. An approved Fire Safety Plan must identify the essential components to ensure an orderly and safe emergency evacuation of all patients, residents and staff under emergency conditions.

In a fire emergency, the prime consideration of any Fire Safety Plan is to ensure that the patients/residents are safe. This often means moving the patients/residents in the immediate fire area to an alternate zone. If the fire cannot be quickly brought under control, patients/residents may have to be moved to an alternate floor or even relocated to another building. The extent of fire development, building layout, weather conditions, the state of health of the patients/residents and other factors will dictate the need to relocate patients/residents, some almost immediately.

Relocation arrangements for patients/residents must become a set of established, pre-planned options, especially when it becomes necessary to evacuate a building due to fire or other emergency. The relocation arrangements for the patients/residents need to address the length of time that alternate accommodation may be required. This may vary from as little as a few hours to as long as several months.

In addition to alternate accommodation, it is important for the plan to identify the means of transportation that will be used and the agency that will be providing it. Always ensure that there is sufficient transportation available. When considering the arrangements for the transportation of patients/residents, it is important to recognize that in most situations it will be required on extremely short notice. Most municipal transit authorities will assist with emergency transportation.

3.2   Fire Safety Responsibilities

There are many institutional facility owner responsibilities. Most importantly, an owner must ensure that the following items are addressed in the Fire Safety Plan and are implemented.

• Establishing and posting the fire emergency procedures on each floor.
• Appointing, organizing and training supervisory staff to carry out fire safety duties and emergency procedures.
• Scheduling and co-ordinating regular fire drills.
• Ensuring that fire hazards throughout the building are identified and eliminated or controlled.
• Providing alternate measures for fire safety during the temporary shutdown of fire protection equipment or systems.
• Completing the necessary checks, tests, inspections and maintenance of fire protection equipment as required by the Fire Code.
• Keeping records of all tests and corrective measures of the above for a period of two years after they are made. When the test frequency is longer than two years, records must be kept for the period of the test interval plus one year. The records shall be available upon request by the Chief Fire Official.
• Keeping adequate records of all training and fire safety education delivered to patients/residents and staff.

3.3   Auditing Your Building

An audit of the fire safety systems, equipment and resources in your facility must include information on the following features:

• fire alarm system,
• exit locations,
• fire department access,
• portable fire extinguishers,
• standpipe and hose systems,
• automatic sprinkler systems,
• automatic fire pumps,
• emergency power & lighting,
• voice communication systems,
• smoke control measures,
• automatic extinguishing systems,
• firefighters' elevators,
• water supplies such as private and public hydrants,
• gas shut-off valves,
• main power disconnect.

The audit should also include the following additional information:

• description of building construction (combustible, non-combustible, etc.),
• building size by area,
• number of storeys,
• number of patient/resident rooms,
• critical care units, surgery rooms and other areas where evacuation may be difficult to initiate without delay,
• bed capacity,
• location of corridor smoke barrier doors (zone separations),
• supervisory staff on each shift by position,
• names and telephone numbers (including off-duty phone numbers) of the building owner, manager, alternate contact personnel and fire protection equipment service companies.

Compiling this information will ensure that many of the critical elements required to carry out the emergency procedures are accounted for in the plan. Remember to identify the building owner, manager and other alternate contact personnel and the methods to contact them in an emergency (See Appendix A "Sample Building Audit Forms" and Appendix B "Sample Building Human Resources Audit Form").

3.4   Contents of the Fire Safety Plan

Your Fire Safety Plan must include the following information:

1. Emergency procedures to be used in case of fire including: sounding the alarm; notifying the fire department; provisions for access for fire fighting; evacuating patients/residents; and confining, controlling and extinguishing the fire.

2. The appointment and organization of designated supervisory staff by position, with related duties and responsibilities during an emergency. This includes the actions to be taken by supervisory staff in initiating any smoke control or other emergency fire protection systems prior to the arrival of the fire department where applicable.

3. The method of training supervisory staff for fire emergencies.

4. The method and frequency of conducting fire drills.

5. The control of fire hazards throughout the building.

6. Detailed maintenance procedures for fire protection systems and building facilities.

7. The identification of alternate fire safety measures in case of a temporary shutdown of fire protection equipment or systems so that occupant safety can be assured.

8. Floor plans that feature the type, location and operation of fire protection systems, access for fire fighting and all exit facilities.

9. Detailed instructions for supervisory staff on the use of any emergency equipment such as the voice communication system, the fire alarm system, smoke control system or emergency power system.

10. Procedures for the use of elevators and the evacuation of patients/residents requiring special assistance.

11. Established procedures for assisting the fire department in accessing the building, locating the fire and activating or operating smoke control systems and fire protection systems upon request. For large facilities it is recommended that floor plans showing exit locations be posted on each floor.

3.5   Approval Requirements

Once the Fire Safety Plan has been prepared, the facility owner must submit at least one copy of the plan to the Chief Fire Official for review and approval. Additional copies may be submitted in the event that the fire department wishes to retain a copy.

The approval process may require an on-site inspection of the facility by the Chief Fire Official, a designate and/or a pre-fire planning visit by the fire department from the nearest fire station.

After the Fire Safety Plan is approved by the Chief Fire Official, the approval will be noted and the Fire Safety Plan will be returned to the facility owner. A second copy, if provided, may be retained by the fire department for their records.

It is important to remember that the owner is required to notify the Chief Fire Official when changes are necessary to an approved Fire Safety Plan. Some examples of revisions that must be included in an updated plan are:

• change in facility ownership,
• the addition of new fire safety equipment,
• facility renovations, and
• staffing level changes.
   

4.0   SUPERVISORY STAFF

4.1   Appointment and Organization of Supervisory Staff

The effectiveness of a Fire Safety Plan depends upon a number of factors. The most important are the number and mobility of patients/residents and the number of trained staff to respond to the emergency. Other determining factors include fire safety features of the building, combustible loading within the building, and the size and layout of the building.

Individuals preparing the Fire Safety Plan must be familiar with the strategy behind a co-ordinated evacuation. For example, during the early stages of a fire emergency, supervisory staff must conduct certain essential activities including: notifying the fire department, providing access for fire department and co-ordinating the evacuation of endangered occupants. The need to relocate patients/residents to other facilities, if required, will be dictated by the extent of the emergency, the state of health of the patients/residents, the weather conditions and other factors.

Relocation arrangements for patients/residents must become a set of established, pre-planned options with sufficient staff assigned for each option. Staffing arrangements for relocated patients/residents should address the length of time that alternate accommodation may be required. This may vary from as little as a few hours to as long as several months.

Since patients/residents generally have special needs, supervisory staff must be trained in various "lifts and carries techniques" that could be utilized to evacuate patients/residents. In addition, supervisory staff must be familiar with the use of portable fire extinguishers and other equipment that could be utilized in an emergency.

The organization of supervisory staff must be well planned in order to reduce the risks to patients/residents and to the supervisory staff themselves. This is especially true for institutional facilities that provide treatment or care for patients/residents who rely on others to assist them to evacuate. In this type of environment, the efforts of supervisory staff must be well co-ordinated and practised in order to be most effective.

When the fire alarm activates, supervisory staff with defined duties should carry them out immediately. Supervisory staff trained to assist in the evacuation of patients/residents should respond to the area of fire alarm origin. When they arrive, circumstances will dictate their appropriate response. Co-ordinated efforts are necessary to evacuate patients/residents from the immediate fire area to smoke-free floor zones. Where necessary, efforts should also be made to confine and control the fire. This may involve simply closing the door to the room of fire origin and ensuring doors in the floor zone fire separation remain closed until the fire department responds and extinguishes the fire. Further evacuation of patients/residents to lower floors or to the exterior should be co-ordinated with the fire department and other emergency response groups.

It is essential that every organization have supervisory staff trained to respond to a fire emergency in a prompt, positive and effective manner. It is important that every institutional facility have a nucleus of key supervisory staff. This supervisory staff must be prepared through effective training to ensure patient/resident safety is maintained during an emergency.

The need for complete co-operation and understanding between management and staff of the fire safety responsibilities during this emergency is vital. It is the owner's responsibility to ensure that all staff members are trained and familiar with the information in the Fire Safety Plan.

NOTE: An Office of the Fire Marshal guideline OFM-TG-01-98, "Staffing Levels for the Emergency Evacuation of Care and Treatment Facilities" is available to assist with establishing staffing levels for emergency evacuation of care and treatment facilities.

4.2   Responsibilities of Supervisory Staff in Fire Safety

An effective Fire Safety Plan will depend upon the knowledge, experience and commitment of management personnel. Every supervisor/manager must have a clearly defined role and the authority to respond appropriately. All new staff MUST receive training in the Fire Safety Plan before responsibilities can be delegated. Training for all staff members must be organized and should be conducted at least annually (see Appendix D "Sample Staff Training Log").

 

Owner/Manager Responsibilities in Fire Safety

• Ensure a Fire Safety Plan is developed, approved and fully implemented. Ensure that the Fire Safety Plan is maintained updated.
• Ensure a sufficient number of alternates are designated and trained to act in a supervisory capacity in the event that the appointed supervisor/manager is absent from the building.
• Ensure that all staff receive appropriate training in the use of existing fire protection equipment and actions to take when responding to a fire emergency.
• Ensure that fire drills involving all staff are held at least monthly. It is advantageous to have these drills activated in various locations at different times. A sufficient number of fire drills must be held to ensure all shift workers participate.
• Adequate records of all staff training and fire drills must be kept for future reference.
   

• Identify and establish a plan for patients/residents who require assistance to evacuate due to physical or mental disabilities.
• Ensure all hallways and stairwells are kept clear of storage, debris and equipment (such as medication carts, wheel chairs and appliances and tools used by housekeeping and maintenance).
• Ensure stairwell doors and doors in other fire separations are kept closed except where approved hold-open devices are provided. Do not allow anyone to interfere with the self-closing device on any door.
   

• Ensure that cooking equipment and appliances are maintained in good working order.
• Ensure that all grease filters in hoods and duct systems serving cooking appliances are cleaned regularly.

• Ensure that the fixed automatic extinguishing systems are maintained and tested in accordance with Part 6 of the Fire Code.

• Ensure that commercial laundry equipment is maintained in good working order.
• Ensure that all duct systems and dryer drums are cleaned of lint and combustible residue regularly.
• Ensure that there is no lint accumulation in the laundry room.
• Ensure that flammable or combustible liquid saturated rags are only cleaned off-site.
• Ensure that laundry chemicals are safely stored.
• Ensure that laundry staff know how to shut down the drying equipment safely in order to prevent foam rubber products from spontaneously heating.

• Ensure that commercial housekeeping equipment is maintained in good working order.
• Ensure that cleaning chemicals and materials are safely stored.

• Ensure that all fire protection equipment and building features such as fire separations, emergency lighting, fire alarm systems, sprinkler systems, standpipe systems, fire extinguishers, fixed extinguishing systems and voice communication systems are checked, tested, inspected and maintained in accordance with Parts 2, 6 and 7 of the Fire Code and all applicable standards referenced therein.
• Ensure that magnetic locking devices, if installed on exit and access to exit doors, release upon activation of the fire alarm and adjacent manual pull stations.
• Maintain permanent records of all fire equipment inspections, tests and maintenance as set out in Subsection 1.1.2. of the Fire Code.
• Access roadways, fire routes, hydrants and pumper connections are accessible to the fire department and are clear of all obstructions (e.g. snow, parked vehicles and shrubs).

NOTE:    Although the responsibilities mentioned above have been assigned to specific positions, the plan needs to be flexible enough so that these responsibilities may be assigned to other staff members based on the size and complexities of your facility.

All supervisory staff must ensure that:

• They are aware of their responsibilities upon discovery of a fire, or upon hearing the fire alarm.
• Stairway doors are kept in the closed and latched position at all times.
• Doors that separate floors into fire safety zones are kept closed and latched at all times, unless designed to close automatically upon activation of the fire alarm.
• Self-closing devices attached to doors are not disengaged or rendered inoperable.
• Doors on hold-open devices in fire separations close automatically upon activation of the fire alarm.
• Stairways, landings, hallways, passageways and exits are kept clear of any storage or other obstructions.
• Combustible waste and debris accumulations are restricted to designated storage areas within the building.
• They understand what each type of fire alarm signal means and how to initiate the fire alarm from anywhere in the facility. This also includes activation of the second stage evacuation signal of the fire alarm where provided.
• Where applicable, they understand the conditions under which they may silence the fire evacuation signal and the procedure by which they may silence and reset the fire alarm system.

If You Discover a Fire or Smoke

 

Many care and treatment facilities are using the acronym "REACT" to assist staff in following the correct emergency procedures (see next page for details).

The sequence of the steps in the acronym will vary depending upon the circumstances of the fire and the abilities of the responding individuals. For example, activation of the fire alarm could be the initial step upon discovery of smoke or fire, to alert other staff of the danger.

If You Hear a Fire Alarm Alert Signal

• Check your floor to make sure the fire is not in your area. If fire in your area, see "REACT" above.
• Prepare for the assembly and relocation of patients/residents. Ensure that all of the patients/residents who require special assistance are prepared for relocation.
• Await further instructions.
• If assigned, assist with the relocation of endangered patients/residents.
• If assigned, meet arriving fire department and provide them with any necessary information (e.g. location of the fire if known, patients/residents needing assistance to relocate, etc.).

If You Hear a Fire Alarm Evacuation Signal

• Relocate all patients/residents who are in danger.
• Co-ordinate the assembly and relocation of all patients/residents.
• Await further instructions if floor area is in no immediate danger.

• Ensure that the fire department has been called.
• Co-ordinate the evacuation, assembly and relocation of all patients/residents to safe areas of the building.
• Meet fire department and ensure that they have access to the building and are provided with master keys.
• Direct fire department to fire alarm panel and central control system and assist them with the operation of these systems.
• Co-ordinate the transportation of all patients/residents and their personal and medical records to other facilities, if needed.

• Notify the fire department. Do not depend on the outside fire alarm or security agency to contact fire officials.
• Provide voice communication messages as instructed by the Fire Safety Plan, management and the fire department.
• Activate procedures to summon off-site staff to the facility (using "Fan-out List" where implemented). Assist with the evacuation, assembly and relocation of patients/residents, including arranging for alternate accommodation and transportation.

• Undertake owner/manager responsibilities if they are not on-site.
• Supervise and direct the evacuation, assembly and relocation of all visitors and patients/residents.
• Inform arriving fire department of any patients/residents, visitors or staff who require assistance or rescue.

• Meet arriving fire department.
• Upon request, provide fire department with master keys for all areas and rooms in the building.
• In large facilities, provide floor plans that show the locations of exits and all fire protection equipment.
• Upon request, direct fire department to the location of the fire alarm and voice communication systems, sprinkler system control valves, natural gas shut-off valves and Hydro disconnects.
• At the direction of the fire department, initiate any smoke control system, emergency power systems and firefighters' elevators.
• At the direction of the fire department, transmit special instructions to patients/residents, visitors and staff via the voice communication system.
• Be available to assist the fire department.

• Assist anyone in immediate danger to evacuate the kitchen area.
• Manually activate the automatic extinguishing system, if required.
• Shut off electrical and gas equipment, cooking equipment, coffee-pots, etc. in a safe manner.
• Close doors to the kitchen to confine the smoke and fire.
• Activate the fire alarm system.
• Notify the switchboard or fire department of the fire condition.
• Assist in the assembly and relocation of patients/residents and visitors.

• Shut off electrical and gas laundry cleaning and drying equipment in a safe manner.
• Ensure that all doors are closed when evacuating the laundry room.
• Assist in the assembly and relocation of patients/residents and visitors.
   

 5.0   CONTROL OF FIRE HAZARDS

The Fire Safety Plan must contain information on the control of fire hazards. For example, everyone must be aware of the potential fire hazards that can exist throughout the facility. Therefore, it is recommended that a designated staff member perform a weekly walk-through of the entire facility. The walk-through should include at least the common areas, stairwells, storage, electrical and furnace rooms of the building.

Check the following to ensure that potential fire hazards are being controlled:

• Smoking in institutional facilities should be closely monitored. Smoking by staff, visitors and patients/residents should be restricted to designated areas.
• Smoking materials, such as cigarette butts and the contents of ashtrays should be disposed of with caution and never into combustible containers.
• Restrict ignition sources in areas where oxygen is in use.
• Never dispose of flammable liquids or aerosol cans in garbage chutes.
• Avoid unsafe cooking practices in kitchen areas, such as deep fat frying and/or unattended stoves.
• Always keep storage, laundry, furnace and electrical rooms clear of combustible materials.
• Avoid washing clothing or rags saturated with flammable or combustible liquids in laundry facilities.
• Do not store any materials or equipment in exit stairwells.
• All personal electrical appliances used by patients/residents must be closely monitored and must meet CSA Standards.
• Do not wedge open any fire doors or disengage the self-closing device installed on them.