Section 518.2130  Fire Safety

a)         Buildings and equipment shall be maintained so as to prevent fire and other hazards to personal safety.

b)         Exits, stairways, doors, and corridors shall be kept free of obstructions.

c)         Flammable and combustible liquids shall be labeled, stored, handled and used in compliance with NFPA 30 .

d)         Flammable and non-flammable gases shall be labeled, handled, and used in compliance with NFPA 99.  Separate storage for flammable and oxidizing gases shall be provided.

e)         A master fire plan, developed to suit the needs of the facility, and acceptable to the Department, shall be maintained.

f)         Fire regulations listing the fire stations, procedures and staff emergency duties by title or position shall be posted conspicuously on each floor at appropriate locations, and shall be available in each unit, section and department.

g)         Employees shall be trained in procedures to be followed in the master fire plan.

h)         Fire drills shall be conducted at irregular intervals at least l2 times per year.  A record shall be kept of the staff performance and results, and indicated corrective measures shall be made.

i)          Portable fire extinguishers, provided in accordance with NFPA l0, shall be inspected at least annually, recharged or repaired as needed and labeled with the dates of the last inspection.

j)          Sprinkler systems, fire hoses, fire detection and alarm devices, and other equipment for use in the fire safety program shall be connected and maintained in a fully functional condition at all times.

k)         Fire detection and protection systems shall be inspected no less frequently than twice a year by a recognized, competent authority.  A written report of the inspection shall be kept on file at the FEC for at least three years following the date of inspection.

l)          The FEC shall maintain a procedure for reporting to a designated administrative officer, on a standard form adopted for the purpose, all accidents to patients, employees or visitors. The report shall include all pertinent information and shall be kept on file for no fewer than six years after the occurrence is reported.

m)        The FEC shall maintain a procedure to investigate fires. The FEC shall notify the Department of all fires within 24 hours after the occurrence. A written report of the investigation containing all pertinent information shall be made and a copy forwarded to the Department.  The report shall remain on file for no fewer than six years.

(Source:  Amended at 33 Ill. Reg. 8317, effective June 4, 2009)