VHA Directive 7717 D 2023-06-13.pdf

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Department of Veterans Affairs VHA DIRECTIVE 7717 Veterans Health Administration Transmittal Sheet Washington, DC 20420 June 13, 2023

PLANNING FOR FIRE RESPONSE

1. SUMMARY OF MAJOR CHANGES:

a. Modifies responsibilities of the Under Secretary for Health, Veterans Integrated Services Network Director and Department of Veterans Affairs (VA) medical facility Director in paragraph 2.

b. Adds responsibilities for the Assistant Under Secretary for Health for Support;

Assistant Under Secretary for Health for Operations; Executive Director, Healthcare Environment and Facilities Program; and Director, Occupational Safety and Health in paragraph 2.

c. Removes responsibilities for the Deputy Under Secretary for Health for Operations and Management; Assistant Deputy Under Secretary for Health for Administrative Operations and Director; Office of Occupational Safety, Health and Green Environmental Management Systems Programs.

d. Relocates fire response procedures to Appendix A.

e. Relocates fire evacuation and relocation response, sprinkler-protected smoke zone risk assessment to Appendix B.

2. RELATED ISSUES: VHA Directive 7711, Fire Incident Reporting, dated March 23, 2023, and VHA Directive 7701, Comprehensive Occupational Safety and Health Program, dated December 12, 2022.

3. POLICY OWNER: The Assistant Under Secretary for Health for Support (19) is responsible for the contents of this directive. Questions related to this directive may be directed to the Director, Occupational Safety and Health, Office of Healthcare Environment and Facilities Program at VHAOccSafetyandHealthAction@va.gov.

4. RESCISSIONS: VHA Directive 7717, Planning for Fire Response, dated January 2, 2018, is rescinded.

5. RECERTIFICATION: This Veterans Health Administration (VHA) directive is scheduled for recertification on or before the last working day of June 2028. This VHA directive will continue to serve as national VHA policy until it is recertified or rescinded.

6. IMPLEMENTATION SCHEDULE: This directive is effective upon publication.

mailto:VHAOccSafetyandHealthAction@va.gov

June 13, 2023 VHA DIRECTIVE 7717

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BY DIRECTION OF THE OFFICE OF THE

UNDER SECRETARY FOR HEALTH:

/s/ Alfred A. Montoya Jr., MHA, FACHE Acting Assistant Under Secretary for Health for Support

NOTE: All references herein to VA and VHA documents incorporate by reference subsequent VA and VHA documents on the same or similar subject matter.

DISTRIBUTION: Emailed to the VHA Publications Distribution List on June 15, 2023.

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CONTENTS

PLANNING FOR FIRE RESPONSE

1. POLICY

2. RESPONSIBILITIES

3. TRAINING

4. RECORDS MANAGEMENT

5. BACKGROUND

6. DEFINITIONS

7. REFERENCES

APPENDIX A

FIRE RESPONSE PROCEDURES ..............................................................................A-1

APPENDIX B

FIRE EVACUATION AND RELOCATION RESPONSE, SPRINKLER-PROTECTED

SMOKE ZONE RISK ASSESSMENT ...........................................................................B-1

PLANNING FOR FIRE RESPONSE

1. POLICY

It is Veterans Health Administration (VHA) policy that each VA medical facility in the Department of Veterans Affairs (VA) must have plans, procedures, sufficient equipment and adequate staff to appropriately respond to any fire emergency in buildings providing patient care. AUTHORITY: 38 U.S.C. § 7301(b).

2. RESPONSIBILITIES

a. Under Secretary for Health. The Under Secretary for Health is responsible for ensuring overall VHA compliance with this directive.

b. Assistant Under Secretary for Health for Support. The Assistant Under Secretary for Health for Support is responsible for establishing policy and providing guidance and oversight as necessary to ensure the timely and successful implementation of this directive.

c. Assistant Under Secretary for Health for Operations. The Assistant Under Secretary for Health for Operations is responsible for:

(1) Communicating the contents of this directive to each of the Veterans Integrated Services Networks (VISNs).

(2) Assisting VISN Directors to resolve implementation and compliance challenges in all VA medical facilities within that VISN.

(3) Providing oversight of VISNs to ensure compliance with this directive and its effectiveness.

d. Executive Director, Healthcare Environment and Facilities Program. The Executive Director, Healthcare Environment and Facilities Program is responsible for:

(1) Periodically assessing the VHA fire response program for continued need, currency and effectiveness.

(2) Coordinating with the Assistant Under Secretary for Health for Operations, VISN Directors and VA medical facility Directors to ensure all necessary action is taken and funding is obtained to address fire response planning in a manner that meets the requirements of Federal, State and local statutes and regulations; applicable Executive Orders; and VA and VHA directives.

e. Director, Office of Occupational Safety and Health. The Director, Office of Occupational Safety and Health is responsible for monitoring changes in The Joint Commission standards and National Fire Protection Association (NFPA) Life Safety Code (NFPA 101) requirements and ensuring that changes from The Joint Commission standards and NFPA 101 requirements related to this directive are conveyed to VA medical facilities.

f. Veterans Integrated Services Network Director. The VISN Director is responsible for ensuring that all VA medical facilities within the VISN comply with this directive and informing leadership when barriers to compliance are identified.

g. VA Medical Facility Director. The VA medical facility Director is responsible for:

(1) Ensuring overall VA medical facility compliance with this directive and appropriate corrective action is taken if non-compliance is identified.

(2) Ensuring the creation of written local VA medical facility fire response procedures with specific staff accountability and responsibilities in accordance with Appendix A.

(3) Ensuring a multidisciplinary team including clinical, engineering and safety staff is established to perform the risk assessment when required by Appendix B.

3. TRAINING

There are no formal training requirements associated with this directive.

4. RECORDS MANAGEMENT

All records regardless of format (e.g., paper, electronic, electronic systems) created by this directive shall be managed as required by the National Archives and Records Administration (NARA) approved records schedules found in VHA Records Control Schedule 10-1. Questions regarding any aspect of records management should be addressed to the appropriate Records Officer.

5. BACKGROUND

a. This directive provides guidance on meeting the requirements for the minimum number of staff responders to assist with patient safety based on the ambulatory capability of patients in a smoke compartment, the size of the smoke compartment and whether the building is fully sprinkler protected. This directive also provides requirements to mitigate the severity of smoke and water damage.

b. To be in compliance with NFPA 101, VA patient care facilities must have a fire safety plan and procedures in effect to ensure adequate preparedness.

c. The Joint Commission Environment of Care Standards, in EC.02.03.03, require health care organizations to conduct fire drills and have an adequate fire response, including follow-up evaluations on the effectiveness of the fire safety plan and response.

6. DEFINITIONS

a. Non-Ambulatory Patients. For the purposes of this directive, non-ambulatory patients include individuals with physical, cognitive or behavioral impairments who need assistance when relocating to an adjacent smoke zone.

b. Patients. For the purposes of this directive, patients include residents of Community Living Centers, Residential Board and Care Occupancies, as well as patients in Health Care Occupancies and Ambulatory Health Care Occupancies.

7. REFERENCES

a. 38 U.S.C. § 7301(b).

b. Department of Veterans Affairs, Fire Safety Guidebook, available at:

http://vaww.hefp.va.gov/guidebooks. NOTE: This is an internal VA website that is not available to the public.

c. National Fire Protection Association. Life Safety Code (NFPA 101).

d. The Joint Commission Standards. EC.02.03.03.

http://vaww.hefp.va.gov/guidebooks

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APPENDIX A

FIRE RESPONSE PROCEDURES

At a minimum, the fire response procedures must include the following:

a. For occupancies that are required by National Fire Protection Association (NFPA) 101 to be subdivided by smoke barriers, there must be an adequate number of staff, including clinical staff, to immediately respond to the fire area regardless of the day of the week or time of day, to assist in patient relocation to the next smoke zone or another safe area should it become necessary. The number of responders needed is dependent on the number of patients in the impacted smoke zone, the mobility of patients and the acuity level of the patients. Based on past fire events, the minimum staff response (not including fire department personnel) must meet the requirements outlined in paragraphs a.(1) and a.(2) below. NOTE: For occupancies where the written Department of Veterans Affairs (VA) medical facility fire safety plan requires general evacuation (rather than defend-in-place), the requirements of paragraph a. do not apply.

(1) For buildings that are not fully sprinkler-protected, there must be one responder for every two non-ambulatory patients. If this response ratio cannot be met, a plan must be in place and operational to provide adequate response. Options for compliance include, but are not limited to:

(a) Installing sprinkler protection,

(b) Modifying the number (mix) of non-ambulatory to ambulatory patients in the smoke zone,

(c) Reducing the size of the smoke zone(s), or

(d) A combination of these actions.

(2) For buildings that are fully sprinkler-protected, there must be one responder for every four non-ambulatory patients. If this response ratio cannot be met, a risk assessment in accordance with Appendix B must be conducted to determine that an appropriate level of safety is being provided. This risk assessment must not be used to reduce the number of responders in the VA medical facility’s fire safety plan, if the 1:4 ratio is currently being met.

b. A requirement to telephone the fire department, in compliance with NFPA 101.

c. Identification of qualified individual(s) who are responsible for turning off the room or zone oxygen shut-off control valve(s) in each area should it become necessary.

NOTE: This is especially important in acute medicine, surgery and Intensive Care Unit areas. These qualified individuals must be knowledgeable of the needs of the patients in the areas served by the valves.

APPENDIX A

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d. Identification of qualified individuals who must respond to each fire incident with special keys, equipment and tools as needed, to:

(1) Control the operation of utility systems (e.g., sprinkler, fire pump, fire alarm, Heating, Ventilation and Air Conditioning (HVAC), electrical).

(2) Open locked doors and windows (e.g., mental health units, mechanical spaces, IT areas).

(3) Consult with fire department personnel, as necessary.

(4) Limit smoke and water damage to the building immediately after the fire is declared to be extinguished. To limit water damage, response staff must understand the information displayed by the fire alarm system (i.e., control unit, annunciator and printout), must specifically be able to identify which water flow switch is in alarm and must know the location of each control valve associated with each water flow switch in order to stop the flow of water without delay. NOTE: Damage control can be accomplished by evacuating smoke, shutting off the fire pump, closing sprinkler control valves and containing sprinkler and fire hose discharge water. Water damage may be limited through the use of plugs specifically designed to seal open fire sprinklers and absorbent “pigs” to dike water on the floor to keep it from spreading. It should be noted that a single sprinkler can discharge 55 or more gallons of water per minute. Smoke spread may be limited by opening windows, stopping the HVAC environmental air re-circulation and by using dedicated portable exhaust fans.

e. For fires resulting in serious injury, death or damages exceeding $10,000, VA Police secure the fire scene after the event and before clean-up to permit an investigation to be conducted by qualified individuals. Qualified individuals might include the local fire marshal, qualified VA medical facility staff or other individuals as appropriate based on the event. The purpose of this investigation is to determine fire origin and cause and assess the effectiveness of both active (e.g., suppression and detection) and passive (e.g., smoke and fire barriers) fire protection systems. See the Fire Safety Guidebook at http://vaww.hefp.va.gov/guidebooks for more information regarding investigations. NOTE: This is an internal VA website that is not available to the public.

http://vaww.hefp.va.gov/guidebooks

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APPENDIX B

FIRE EVACUATION AND RELOCATION RESPONSE, SPRINKLER-PROTECTED

SMOKE ZONE RISK ASSESSMENT

1. INTRODUCTION

a. Factors outlined in paragraph 2 below must be considered when assessing the adequacy of the Department of Veterans Affairs (VA) medical facility fire response for sprinkler-protected smoke zones and the ratio of responders to non-ambulatory patients.

b. A responder may be any individual who can respond within 8 minutes and is trained in the VA medical facility fire safety plan or participates in the fire drills (fire department personnel must not be counted since their primary efforts may be in suppression activities).

c. For the purposes of this risk assessment, the number of non-ambulatory patients present in a smoke zone must be the “most likely worst-case” scenario and is determined by the greatest number of non-ambulatory patients simultaneously present in the smoke zone over the past 36 months. NOTE: The “most likely worst-case” scenario is intended to be used where the use of the space within a smoke compartment has not changed for the past 36 months or more (e.g., the space in the smoke compartment has continuously been used as a nursing ward). Where the use of the space within a smoke compartment has changed within the past 36 months, the “most likely worst case” scenario does not have to consider the number of non-ambulatory patients in the space during the time when the space had a different use.

d. This risk assessment must not be used to reduce the number of responders in the VA medical facility fire safety plan if the 1:4 ratio is currently being met.

2. FACTORS

a. Private Rooms. If the smoke zone is comprised of private rooms, there is a greater likelihood that a fire and its products of combustion (smoke) will be contained to the room of fire origin, as VA medical facility staff will not need to re-enter the room to rescue additional patients (award one point).

b. Room Separation. If the walls between the patient sleeping room and adjacent rooms, as well as the walls between the patient sleeping room and the corridor, extend from floor slab to floor slab and are without penetrations, there is a greater likelihood that patients in rooms adjacent to the room of fire origin will not have to be relocated (award two points).

c. Fast Response Sprinklers. A fast response sprinkler has a response time index (RTI) of 50 (meters-second)1/2 or less. Faster sprinkler response will significantly reduce the heat and products of combustion generated by the fire. Fast response sprinklers, such as quick response and residential type, will be expected to activate faster than

APPENDIX B

B-2 standard response sprinklers. In order to take credit for fast response sprinklers, the sprinklers must not be concealed (award three points).

d. Smoke Detection. Properly installed and maintained smoke detectors will provide early detection of a fire and will give additional time for staff response (maximum of two points permitted from paragraphs 2.d.(1) through 2.d.(4)).

(1) System smoke detectors throughout all areas of the smoke zone (award two points).

(2) System smoke detectors in patient sleeping rooms and throughout the corridor (award one and a half points).

(3) Single station smoke alarms in all patient sleeping rooms (award one point).

(4) System smoke detectors provided only throughout the corridors (award half a point).

e. Heating, Ventilation and Air Conditioning Systems Fully Ducted. An environmental air system that is fully ducted will aid in containing the products of combustion from a fire (award one point).

f. Oxygen Not Present. The presence of medical oxygen in the patient sleeping rooms (piped, cylinder or concentrator) can increase how rapidly a fire will spread (award one point).

3. NUMBER OF REQUIRED RESPONDERS BASED ON RISK ASSESSMENT

Number of Points from paragraphs 2a – 2f

Minimum Ratio, Responders to Non- Ambulatory Patients

≤ 3 (see 1.d.) 1:4

>3 and ≤ 8 1:5

> 8 1:6