10A NCAC 13F .0309       fire safety and emergency preparedness plans

(a)  Each facility shall have a written fire evacuation plan that includes a diagram of the facility floor plan including evacuation routes. The plan shall have the written approval of the local fire code enforcement official. The approved diagram shall be legible and be posted on each floor of the facility in a location visible to staff, residents, and visitors. The fire evacuation plan and diagram shall be reviewed with each resident upon admission and shall be included in the orientation for all new staff.

(b)  There shall be unannounced fire drills of the fire plan conducted quarterly on each shift in accordance with the requirement of the local fire prevention code enforcement official and the 2018 North Carolina Building Code: Fire Prevention Code, which is hereby incorporated by reference and includes all subsequent editions, available at https://codes.iccsafe.org/content/NCFC2018.

(c)  Documentation of fire drills shall be maintained by the administrator or their designee in the facility and be made available upon request to the Division of Health Service Regulation, county department of social services, and local officials. The records shall include the date and time of the drills, the shift, staff members present, and a short description of the drill.

(d)  Each facility shall develop and implement an emergency preparedness plan to ensure resident health and safety and continuity of care and services during an emergency. The emergency preparedness plan shall include the following:

(1)           Procedures to address the following threats and hazards that may create an emergency for the facility:

(A)          weather events including hurricanes, tornadoes, ice storms, and extreme heat or cold;

(B)          fires;

(C)          utility failures, to include power, water, and gas;

(D)          equipment failures, to include fire alarm, automatic sprinkler systems, HVAC systems;

(E)           interruptions in communication including phone service and the internet;

(F)           unforeseen widespread communicable public health and emerging infectious diseases;

(G)          intruders and active assailants; and

(H)          other potential threats to the health and safety of residents as identified by the facility or the local emergency management agency.

(2)           The procedures outlined in Subparagraph (d)(1) shall address the following:

(A)          provisions for the care of all residents in the facility before, during, and after an emergency such as required emergency supplies including water, food, resident care items, medical supplies, medical records, medications, medication records, emergency power, and emergency equipment;

(B)          provisions for the care of all residents when evacuated from the facility during an emergency, such as evacuation procedures, procedures for the identification of residents, evacuation transportation arrangements, and sheltering options that are safe and suitable for the resident population served;

(C)          identification of residents with Alzheimer's disease and related dementias, residents with mobility limitations, and any other residents who may have specialized needs such as dialysis, oxygen, tracheostomy, and gastrostomy feeding tubes, special medical equipment, or accommodations either at the facility or in case of evacuation;

(D)          strategies for staffing to meet the needs of the residents during an emergency and for addressing potential staffing issues; and

(E)           procedures for coordinating and communicating with the local emergency management agency and local law enforcement.

(3)           The emergency preparedness plan shall include contact information for State and local resources for emergency response, local law enforcement, facility staff, residents and responsible parties, vendors, contractors, utility companies, and local building officials such as the fire marshal and local health department.

(e)  The facility shall maintain documentation that the emergency preparedness plan has written approval of or documentation that the plan has been submitted to the local emergency management agency and the local agency designated to coordinate and plan for the provision of access to functional needs support services in shelters during disasters.

(f)  The facility's emergency preparedness plan shall be reviewed at least annually and updated as needed by the administrator and shall be submitted to the local emergency management agency and the local agency designated to coordinate and plan for the provision of access to functional needs support services in shelters during disasters. Any changes to the plan shall be submitted to the local emergency management agency and the local agency designated to coordinate and plan for the provision of access to functional needs support services in shelters during disasters within 60 days of the change. For the purpose of this Rule, correction of grammatical or spelling errors do not constitute a change. Documentation of submissions shall be maintained at the facility and made available for review upon request to the Division of Health Service Regulation and county department of social services.

(g)  The emergency preparedness plan outlined in Paragraph (d) of this Rule shall be maintained in the facility and be accessible to staff working in the facility.

(h)  Newly licensed facilities and facilities that have changed ownership shall submit an emergency preparedness plan to the local emergency management agency and the local agency designated to coordinate and plan for the provision of access to functional needs support services in shelters during disasters within 30 days after obtaining the new license. Documentation of submissions shall be maintained at the facility and made available for review upon request to the Division of Health Service Regulation and county department of social services.

(i)  The facility's emergency preparedness plan shall be made available upon request to the Division of Health Service Regulation, county department of social services, and emergency management officials.

(j)  The administrator shall ensure staff are trained on their roles and responsibilities related to emergencies in accordance with the facility's emergency preparedness plan as outlined in Paragraph (d) of this Rule. Staff shall be trained upon employment and annually in accordance with Rule .1211 of this Subchapter.

(k)  The facility shall conduct at least one drill per year to test the facility's emergency preparedness plan. The drill may be conducted as a tabletop exercise. For the purposes of this Rule "tabletop exercise" means a discussion-based session led by the administrator and includes other facility staff as designated by the administrator, that reviews a potential emergency scenario and the roles and responsibilities of staff, based on the facility's emergency preparedness plan and procedures. The facility shall maintain documentation of the annual drill which shall be made available upon request to the Division of Health Service Regulation, county department of social services, and emergency management officials.

(l)  If the facility evacuates residents for any reason, the administrator or their designee shall report the evacuation to the local emergency management agency, the local county department of social services, and the Division of Health Service Regulation Adult Care Licensure Section within four hours or as soon as practicable of the decision to evacuate and shall notify the agencies within four hours of the return of residents to the facility.

(m)  Any damage to the facility or building systems that disrupts the normal care and services provided to residents shall be reported to the Division of Health Service Regulation Construction Section within four hours or as soon as practicable of the incidence occurring.

(n)  If a facility is ordered to evacuate residents by the local emergency management or public health official due to an emergency, the facility shall not re-occupy the building until local building or public health officials have given approval to do so.

(o)  In accordance with G.S. 131D-7, if a facility intends to shelter residents from an evacuating adult care home or desires to temporarily increase the facility's licensed bed capacity, the facility shall request a waiver from the Division of Health Service Regulation prior to accepting the additional residents into the facility or as soon as practicable but no later than 48 hours after the facility has accepted the residents for sheltering. The waiver request form can be found on the Division of Health Service Regulation Adult Care Licensure Section website at https://info.ncdhhs.gov/dhsr/acls/acforms.html#resident.

(p)  If a facility evacuates residents to a public emergency shelter, the facility remains responsible for the care, supervision, and safety of each resident, including providing required staffing and supplies in accordance with the Rules of this Subchapter. Evacuation to a public emergency shelter shall be a last resort, and the decision shall be made in consultation with the local emergency management agency, or the local agency designated to coordinate and plan for the provision of access to functional needs support services in shelters during disasters. If a facility evacuates residents to a public emergency shelter, the facility shall notify the Division of Health Service Regulation Adult Care Licensure Section and the county department of social services within four hours of the decision to evacuate or as soon as practicable.

(q)  Where a fire alarm or automatic sprinkler system is out of service, the facility shall immediately notify the fire department, the fire marshal, and the Division of Health Service Regulation Construction Section and, where required by the fire marshal, a fire watch shall be conducted until the impaired system has been returned to service as approved by the fire marshal. The facility will adhere to the instructions provided by the fire marshal related to the duties of staff performing the fire watch. The facility will maintain documentation of fire watch activities which shall be made available upon request to the DHSR Construction Section and fire marshal. The facility shall notify the DHSR Construction Section when the facility is no longer conducting a fire watch as directed by the fire marshal.

(r)  Notwithstanding the requirements of Rule .0301 of this Section, this Rule shall apply to new and existing facilities.

History Note:        Authority G.S. 131D.2.16; 143B-165;

Eff. January 1, 1977;

Readopted Eff. October 31, 1977;

Amended Eff. April 1, 1987; April 1, 1984;

Recodified from 10A NCAC 13F .0307 Eff. July 1, 2004;

Temporary Amendment Eff. July 1, 2004;

Amended Eff. July 1, 2005;

Readopted Eff. June 1, 2025.