GuideOne Risk Resources for Health Care
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W. Des Moines, IA 50265-3538



Fire Watch Program

Automatic sprinkler and fire alarm systems are an important safety component to keeping your residents and tenants safe. However, there are periods when these systems are not in operation. These include planned events, such as maintenance and construction, and unplanned events, such as weather or power outages. According to Center for Medicare and Medicaid Services (CMS) and the National Fire Protection Association (NFPA) 101 section, whenever the automatic sprinkler and/or fire alarm systems are inoperable for a time period of four hours or more in a 24-hour time frame, the building shall be evacuated, or an approved fire watch program must be provided for all parties left unprotected by the shutdown until the sprinkler or fire alarm system has been returned to service.

What is a Fire Watch?

A fire watch is a process where dedicated staff regularly and thoroughly check all parts of a building that are affected by the automatic sprinkler and fire alarm impairment. This requires a routine tour of the building noting physical observations and maintaining a Fire Watch Log.

Components of a Fire Watch Program

  • A facility must notify the State Agency, local fire department and the facilities insurance company whenever either system is going to be inoperable for more than four hours in a 24-hour period.

  • For preplanned impairments, the facility must inform the above agencies of the extent and expected duration of the impairment, the areas and buildings involved have been inspected and any increased risks determined.

  • A fire watch should involve at least one additional trained staff beyond normal facility staffing. These individuals are specially trained in fire prevention, occupant and fire department notification and understand fire safety. In addition, these staff members must be dedicated to the fire watch and cannot conduct a watch in addition to their normal duties.

  • Staff members must take tours of the building every 30 minutes and log each tour. Each staff member will have a designated area to tour. The log should include the name of the person conducting the tour, building area, date, time and any unusual events must be noted. The log should be kept and available for inspection.

  • All hallways and rooms on each floor of the building should be toured. If your facility has multiple floors, there should be at least one staff person per floor. Also, any areas that have higher fire exposures, such as boiler rooms, mechanical rooms, laundry and kitchens, must be inspected. No open flames of any type shall be used for any reason.

  • Prohibit all smoking on facility grounds.

  • Signs should be posted on all entrance doors and in other areas of the facility notifying visitors and occupants that the fire watch is taking place.

  • All staff must be trained on their responsibilities during the fire watch.

  • All fire watch staff should be equipped with a signaling device, such as a whistle or two-way radio, to alert occupants that a fire has been found and a full evacuation is needed.

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