48th Medical Group Risk Assessment for Interim Life Safety Measures

• Site conducted

  Select

• 48th Medical Group Risk Assessment for Interim Life Safety Measures

• Conducted on

  Date

• Prepared by

Location

• Building / Facility

  Select B922 - Hospital Administration Building B932 - Main Hospital Tower B935 - Hospital Annex B944 - Dental Clinic B955 - Early Childhood Intervention Services B830 (RAFM) - Flight Medicine Clinic (Mildenhall) Other - see comments

  • B922 - Hospital Administration Building
  • B932 - Main Hospital Tower
  • B935 - Hospital Annex
  • B944 - Dental Clinic
  • B955 - Early Childhood Intervention Services
  • B830 (RAFM) - Flight Medicine Clinic (Mildenhall)
  • Other - see comments

• Floor

  Select Basement/Undercroft Ground First Second Third Attic/Loft Other - see comments

  • Basement/Undercroft
  • Ground
  • First
  • Second
  • Third
  • Attic/Loft
  • Other - see comments

• Area

  Select Patient Care Non Patient Care Exit corridor Exit doors Exam room Patient room Soiled utility Other - see comments

  • Patient Care
  • Non Patient Care
  • Exit corridor
  • Exit doors
  • Exam room
  • Patient room
  • Soiled utility
  • Other - see comments

• Comments

Code Deficiencies Greater than 24 Hours

• Code Deficiencies Greater than 24 Hours

  Yes

  No

  N/A

• Criteria

  Select Obstructed means of egress. Fire exit stairs discharge improperly. Excessive travel distance to an approved exit. Lack of two remote exits. Improperly protected vertical openings. Large penetrations in fire or smoke barriers. Corridor Walls do not extend to the structure. Hazardous areas not properly protected. Rerouting of vehicle traffic. Other - see comments.

  • Obstructed means of egress.
  • Fire exit stairs discharge improperly.
  • Excessive travel distance to an approved exit.
  • Lack of two remote exits.
  • Improperly protected vertical openings.
  • Large penetrations in fire or smoke barriers.
  • Corridor Walls do not extend to the structure.
  • Hazardous areas not properly protected.
  • Rerouting of vehicle traffic.
  • Other - see comments.

• Comments

Construction Related Issues Greater than 24 Hours

• Construction Related Issues Greater than 24 Hours

  Yes

  No

  N/A

• Criteria

  Select Major renovation of an occupied floor. Significant modifications to smoke or fire walls. Adding an addition to an existing structure. Build-out of a shell floor in an existing building. Removal of ceiling in areas protected by automatic fire alarm and sprinkler systems. Other - see comments

  • Major renovation of an occupied floor.
  • Significant modifications to smoke or fire walls.
  • Adding an addition to an existing structure.
  • Build-out of a shell floor in an existing building.
  • Removal of ceiling in areas protected by automatic fire alarm and sprinkler systems.
  • Other - see comments

• Comments

Fire Detection and Suppression System Issues

• Fire Detection and Suppression System Issues

  Yes

  No

  N/A

• Criteria

  Select Taking a fire alarm system out-of-service (<4 hrs in 24 hr period) For Patient Care Areas. Taking a fire alarm system out-of-service (>4 hrs in 24 hr period) For Patient Care Areas Taking a suppression system out-of-service (<4 hrs in 24 hr period) Taking a suppression system out-of-service (>4 hrs in 24 hr period) Disconnecting alarm devices (<4 hrs in 24 hr period) Disconnecting alarm devices (>4 hrs in 24 hr period) Other - see comments

  • Taking a fire alarm system out-of-service (<4 hrs in 24 hr period) For Patient Care Areas.
  • Taking a fire alarm system out-of-service (>4 hrs in 24 hr period) For Patient Care Areas
  • Taking a suppression system out-of-service (<4 hrs in 24 hr period)
  • Taking a suppression system out-of-service (>4 hrs in 24 hr period)
  • Disconnecting alarm devices (<4 hrs in 24 hr period)
  • Disconnecting alarm devices (>4 hrs in 24 hr period)
  • Other - see comments

• Comments

Comments

• Comments

Risk Assessment

• Risk Assessment

  Yes

  No

  N/A

• Criteria

  Select Findings do not significantly impact the fire safety of the area. Egress - significantly compromises exit access, exiting, or exit discharge building elements Compartmentation - significantly compromises fire/smoke walls, floor/ceiling assemblies, corridors, use area doors, or other defend in place elements Detection/Suppression - significantly compromises systems(s) Other - see comments

  • Findings do not significantly impact the fire safety of the area.
  • Egress - significantly compromises exit access, exiting, or exit discharge building elements
  • Compartmentation - significantly compromises fire/smoke walls, floor/ceiling assemblies, corridors, use area doors, or other defend in place elements
  • Detection/Suppression - significantly compromises systems(s)
  • Other - see comments

• Protective Measures

  Select Alternative exits available. Area has operational fire detection system. Area is sprinklered. Facility is designated as "non smoking". Staff receive annual fire safety education.

  • Alternative exits available.
  • Area has operational fire detection system.
  • Area is sprinklered.
  • Facility is designated as "non smoking".
  • Staff receive annual fire safety education.

Interim Life Safety Measures

• Interim Life Safety Measures

  Yes

  No

  N/A

• Life Safety Assessment - Interim Measures

  Select Inspect exits in affected areas on a daily basis. Provide temporary but equivalent fire alarm and detection systems for use when a fire system is impaired. Provide additional firefighting equipment. Use temporary construction partitions that are smoketight, or made of noncombustible or limitedcombustible material that will not contribute to the development or spread of fire. Increase surveillance of buildings, grounds, and equipment, giving special attention to construction areas and storage, excavation, and field offices. Enforce storage, housekeeping, and debrisremoval practices that reduce the building’s flammable and combustible fire load to the lowest feasible level. Provide additional training to those who work in the hospital on the use of firefighting equipment. Conduct one additional fire drill per shift per quarter. Inspect and test temporary systems monthly. The completion date of the tests is documented. Conduct education to promote awareness of building deficiencies, construction hazards, and temporary measures implemented to maintain fire safety. Train those who work in the hospital to compensate for impaired structural or compartmental fire safety features. Other - see comments.

  • Inspect exits in affected areas on a daily basis.
  • Provide temporary but equivalent fire alarm and detection systems for use when a fire system is impaired.
  • Provide additional firefighting equipment.
  • Use temporary construction partitions that are smoketight, or made of noncombustible or limitedcombustible material that will not contribute to the development or spread of fire.
  • Increase surveillance of buildings, grounds, and equipment, giving special attention to construction areas and storage, excavation, and field offices.
  • Enforce storage, housekeeping, and debrisremoval practices that reduce the building’s flammable and combustible fire load to the lowest feasible level.
  • Provide additional training to those who work in the hospital on the use of firefighting equipment.
  • Conduct one additional fire drill per shift per quarter.
  • Inspect and test temporary systems monthly. The completion date of the tests is documented.
  • Conduct education to promote awareness of building deficiencies, construction hazards, and temporary measures implemented to maintain fire safety.
  • Train those who work in the hospital to compensate for impaired structural or compartmental fire safety features.
  • Other - see comments.

Notification

• Notification

  Select Medical Equipment Repair Center Occupational Safety and Health / Hospital Safety Facility Management Security Manager Facility Maintenance Services Chief Hospital Administrator Environment of Care Committee

  • Medical Equipment Repair Center
  • Occupational Safety and Health / Hospital Safety
  • Facility Management
  • Security Manager
  • Facility Maintenance Services
  • Chief Hospital Administrator
  • Environment of Care Committee

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