Evacuation Drills for ICFs/IID Certified Under the Life Safety

2142 – Evacuation Drills for ICFs/IID Certified Under the Life Safety Code NFPA 101, 2000 Edition (Rev. 91, Issued: 09-27-13, Effective: 09-27-13, Implementation: 09-27-13) • Self-evacuation during an emergency. Clients residing in ICFs/IID certified under Chapter 32/33 of the Life Safety Code NFPA 101, 2000 Edition (LSC) are expected to be capable of self-evacuation during an emergency. • Full evacuation drills- All drills under this Chapter must be full evacuation drills unless the facility is designated as evacuation capability, “impractical.” • Exceptions to full evacuation drills- With a designation of evacuation capability “impractical” the facility must meet the requirements of Chapter 18/19 of the LSC as regards to evacuation drills. ICF/IID facilities that are certified under Section 32.7.3 or Section 33.7.3 of the LSC must conduct emergency drills no less than six (6) times per year on a bi-monthly basis. These drills must all be full evacuation drills and all clients residing in the facility must participate in each drill. At least two of these drills must take place during sleeping hours. This requirement is consistent with the requirements of 42CFR 483.470(i)(2)(i) which require actual evacuation of clients during at least one emergency drill each year on each shift. ICF/IID facilities certified under Section 32.7.3 or Section 33.7.3 of the LSC with a capability classification of “impractical” must meet the emergency drill requirements found at Section 18.7 or Section 19.7 of the LSC. These sections require that the facility conduct fire drills which simulate emergency fire conditions on a quarterly basis. Since these drills are conducted to train staff rather the clients, the Code does not require full evacuation. However, the facility must also meet the ICF/IID regulations at 42CFR 483.470(i)(2)(i) which do require the actual evacuation of clients during at least one emergency drill each year on each shift. These drills are conducted primarily to prepare and train staff and it is critical that the staff from each shift participate in these drills. The facility may not elect to conduct night shift drills during another shift. The LSC requires that the facility make the determination of “impractical” utilizing the criteria of the Code found in Sections 32/33.2.1.2.2 concerning the characteristics of the client population. The LSC surveyor verifies that the determination was correctly made at the time of the annual survey. The requirements of full evacuation during a drill is not intended to address the requirements for frequency of evacuation drills. The regulation at §483.470 (i) requires that evacuation/fire drills be conducted at all ICF/IID facilities on a quarterly basis on each shift. This requirement supersedes the number of evacuation drills required by the LSC under Chapters 32/33 it does not impact the requirements for full evacuation during such drills.