Attachment C- Fire Plan Template.docx

Attachment C

VETERAN HEALTH INDIANA (VHI) - Emergency Operating Plan (Annex A)

VETERAN HEALTH INDIANA (VHI)

Emergency Operating Plan

Fire Plan Reviewed 01 Sep 2020 Reviewed/updated 5 January 2023

1. Purpose. To establish policy, procedures, and responsibilities for fire regulations and to establish a medical center fire plan.

2. Summary of Contents: This document describes the methods the Veterans Health Indiana (VHI) will utilize in the event of a known or suspected fire or fire hazard.

3. Policy. In the event of a fire, every employee must display and demonstrate knowledge of the Medical Center Fire Plan (see MCM 001AS-06) and assist in protection of lives and property.

4. Implementation.

4.1. Fire Plan: When a fire is discovered, the Medical Center Fire Plan is to be followed. This plan consists of 4 steps forming the acronym

R-A-C-E. These steps are:

Rescue.

Move patients away from immediate danger.

Alert other employees in the area.

If in immediate danger, evacuate to an area beyond smoke doors or down the stairs as conditions require. DO NOT USE ELEVATORS.

Alarm.

Go to the nearest fire alarm pull box and activate the alarm. This signal is automatically transmitted to the telephone operator, chiller plant operator, IVAMC VHI Police Dispatch, and Indianapolis Fire Department.

Go to the nearest telephone and dial 911 or 8-2200 and inform the operator of the fire location, room number, etc. The operator will announce over the public address system "Code RED" and give the location (example: Code RED, 5 South). The operator will slowly repeat this announcement three times. NOTE: Both steps are necessary to assure prompt and proper response to a fire.

Confine. Close all doors and windows.

Evacuate. If the fire is located in the immediate vicinity or adjacent area, evacuate the area and await the arrival of assistance.

First order of evacuation is horizontal by traveling away from the fire’s location and passing through main corridor fire doors, the double doors which are normally open due to magnetic holds but automatically close when the fire system is engaged.

If horizontal evacuation is not possible because the fire danger is present on the floor or an adjacent floor, the second order of evacuation is vertical. Proceed to the nearest stairwell and evacuate the building to the designated meeting location of respective Service/work unit.

4.2. Fire Drills:

4.2.1. Fire drills are scheduled, conducted, and documented in accordance with applicable The Joint Commission (TJC), National Fire Protection Association (NFPA) and VHA guidelines. Current guidelines require that fire drills be conducted at a minimum of one per shift per quarter for all patient occupied buildings. Fire drills will also be conducted, at a minimum, on an annual basis in all non-patient care buildings. Interim life safety measures (ILSM's) associated with construction activities may require additional fire drills per JC guidelines. Most fire drills will be unannounced and will involve the entire Medical Center.

4.2.2. Employees involved in a fire drill are critiqued on their knowledge of the fire plan and implementation process. The Safety Service maintains documentation of fire drills and submits a quarterly summation of fire drill activities to the Safety and Health Leadership Committee for review.

4.3. Reports:

4.3.1. Supervisors in charge of the area affected by fire will report the incident to the Safety Service at 84203 immediately.

4.3.2. The Safety Officer or designee will investigate all fires.

4.3.3. Actual fire incidents are to be reported via the HEFP web based on-line form in accordance with VHA Directive 7711 Fire Incident Reporting by the Safety Officer or designee.

4.4. Training:

4.4.1. Fire safety training is provided as part of New Employee Orientation, Department Operational Instructional Training Guide (Do It Guide), annually via the Talent Management System (TMS) or during staff in-services training provided by the Safety Service.

4.4.2. Documentation of training provided is required and will be reviewed annually by the Annual Workplace Evaluation and/or the Safety and Health Leadership Committee.

4.4.3. The Safety Office will:

4.4.3.1. Conduct or designate to the Education Service to include documentation of fire safety orientation training to new employees and the provisions of this policy, and

4.4.3.2. Provide refresher training to Medical Center employees at staff meetings, etc.

4.4.4. Service Chiefs will:

4.4.4.1. Ensure that all new employees attend new employee orientation within 30 days of date of hire and that all employees receive the required refresher training annually.

4.4.4.2. Ensure that proper documentation is maintained for service-level training that is provided.

4.4.4.3. Designate a meeting location outside the building to meet in the event of a building evacuation.

4.4.4.4. Develop and maintain a roster of staff in order account for staff in the event of an evacuation.

4.4.4.5. Develop and communicate to staff exit route assignments, i.e. primary, secondary and tertiary exit routes.

4.4.4.6. If applicable, develop procedures for staff to remain and operate critical operations unless impacted by fire or other significant safety hazards.

4.4.4.7. Ensure that each department has a completed unit specific fire plan using the “Fire Plan Unit Specific Template” found on the Safety Share Point Site; maintains the plan with @ Safety SharePoint Site and send a copy to Safety at INDSafety@va.gov or to Laura Totten at Laura.Totten@va.gov

4.4.5. Special Areas:

4.4.5.1. Cold Springs Road (CSR). In the event of a fire at VA-occupied spaces at the CSR facility, the following plan will be implemented:

4.4.5.2. The Community Based Outpatient Clinics (CBOCs), Domiciliary, Vet Center and other Auxiliary Facilities that house patients or employees must have written fire safety plans and documented fire drills. Documentation of such drills will be provided to the Safety Service Chief for review and filing.

5. Responsibilities:

5.1. Supervisor-in-Charge. The supervisor or designated employee in the area that a fire is found will:

5.1.1. Take charge and ensure that all steps of the fire plan are implemented.

5.1.2. After assessing the situation, the supervisor may make an additional call to extension 911 for additional assistance as needed.

5.1.3. Make use of all available employees to evacuate (as necessary) or use of employees to assist with sheltering in place by closing all doors and maintaining vigilance of deteriorating conditions. Nursing personnel and others trained in lifting and carrying patients should be assigned to work with others who may not be trained.

5.1.4. Remain in charge to minimize confusion and duplication of effort until properly relieved by hospital management or until firefighters arrive.

5.1.5. When Indianapolis Fire Department (IFD) personnel arrive, IFD will assume control of all firefighting activities (in an actual fire only).

NOTE: In the event there is oxygen in use, only designated personnel responsible for that area can turn the oxygen off in case of fire or other emergency.

5.2. Medical Center Staff will:

5.2.1. Follow the RACE fire plan in a calm and collaborative manner.

5.3. If the danger is NOT in the immediate vicinity, exercise sheltering in place by closing all doors and windows and maintaining constant communication with other staff (staff are not to respond to fires not in their immediate area).

5.3.1. If the fire is in the immediate area staff shall evacuate patients, visitors and all staff with a minimum ratio of one responder per four non-ambulatory patients in the immediate area. Staff shall practice continuous two-way direct communication amongst other staff and patients. If feasible, the initial evacuation will be in the horizontal direction via exiting the current fire zone to the adjacent one (1) or two (2) hour fire zone (or egress from building if residing on the first floor or basement). If the dangerous conditions persist or worsen, evacuation will be horizontal via stairwells then egressing from the building and meet at their Service/work unit’s designated meeting place.

5.4. The Telephone Operator will:

5.4.1. Announce over the public address speaker system the exact location of the fire. The words "CODE RED" will be used instead of "fire". Slowly repeat the announcement three times. For any fire situation, an example of the announcement would be: “Code RED, 8 South….. Code RED, 8 South….. Code RED, 8 South…..”

5.4.2. Announce any requests for additional assistance in the same manner as the initial call. (Example: “Code RED, 8 South, assistance needed.”)

5.4.3. During other than regular duty hours call the following (for actual fire only):

5.5. The Police Office will notify:

5.5.1. Nursing Supervisor

5.5.2. Medical Administrative Assistant (MAA)

5.6. The MAA/Nursing Supervisor will coordinate, with the telephone operator on duty, the notification of the following (actual fire during other than regular duty hours):

5.6.1. Chief of Safety Service

5.6.2. Director

5.6.3. Chief of Staff

5.6.4. Associate Director

5.6.5. AD/Patient Care Services

5.6.6. Chief, Engineering Service

5.6.7. Chief of the affected Service

5.7. Engineering Service personnel will:

5.7.1. Respond to identified location to assist in locating/resolving the situation, and

5.7.2. Reset fire alarm system after "ALL CLEAR" has been announced.

5.7.3. Contact the fire alarm monitoring station during a fire alarm.

5.8. Police Service will:

5.8.1. Give first priority to Extension 911 when it rings.

5.8.2. By using either internal Police staff or manpower pool, provide traffic control and guide the fire department to the fire scene.

5.8.3. Once the fire scene has been declared safe by competent authority, the VA Police will treat as a crime scene and secure the area until an investigation is complete.

5.9. Office of the Director will:

5.9.1. Determine if situation dictates stand up the Emergency Operations Center (EOC).

5.9.2. Relieve the affected area’s Supervisor-in-Charge as the incident leader when the situation allows.

5.9.3. Provide leadership, guidance, and resources for mitigating actions.

6. Fire Protection Features:

6.1. Building #1 is a fully NFPA compliant fire sprinkler building.

6.2. The Medical Center is compartmentalized with 2-hour fire protection between each floor and one (1) or two (2) hour fire protection zones for each floor separated by main corridor double doors which are held open except during fire incidents by magnetic holders. All main egress stairwells have a 2-hour fire protection rating.

6.3. Pull stations are tied into the automated fire detection and alarm system which when engaged automatically contacts the Indianapolis Fire Department (IFD) and alarms the building with the location of the fire.

6.4. Over four hundred fire extinguishers are located throughout the Medical Center. The fire extinguishers are intended for assisting staff in egress/evacuation. Medical Center staff are not required to use fire extinguishers.

7. References:

MCM: 001AS-06 Fire Plan Reviewed/updated 20 December 2018, Geldar Jeanbaptiste Reviewed/updated 1 September 2020, Geldar Jeanbaptiste (changes in Red) Reviewed/updated 11 January 2021, Tammy Mann (changes is blue) Reviewed/updated 26 April 2022, Laura M. Totten (changes is blue) Reviewed/updated 05 January 2023, Laura M. Totten (no changes)

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