Fire Watch in Hospitals and Nursing Homes: CMS Requirements, Policy and Log

Why a health care fire watch is different

Most buildings answer to the local fire code official. Hospitals and nursing homes in Medicare and Medicaid also answer to CMS, which requires them to meet the Life Safety Code: 42 CFR 482.41 for hospitals and 42 CFR 483.90 for long-term care both incorporate NFPA 101, 2012 edition. The Iowa State Fire Marshal's fire watch guidance for health care is written "in accordance with the 2012 Life Safety Code & the Centers for Medicaid and Medicare Services (CMS)."

So a facility answers to at least two authorities: the fire code official, and the state survey agency that inspects for CMS. Minnesota's Department of Health says CMS requires a written procedure for fire alarm and sprinkler outages, and "Lack of an acceptable procedure is a citable deficiency."

When a fire watch is required

Nursing homes follow the same rule: 42 CFR 483.90(a)(8) uses the same words for "the LTC facility." Local codes can be stricter, and under the fire code the call to the fire department is immediate. Confirm the triggers, and how they're cited, with your fire code official and state survey agency.

For alarms, "out of service" means a significant part of the system, not one device. Minnesota, citing the NFPA 101 annex, gives the example of "an entire initiating device, signaling or notification appliance circuit," not a single detector.

How often to tour, and who walks

Health care guidance asks for tighter rounds: every 30 minutes, not every hour.

The NFPA 101 annex, quoted by West Virginia's fire marshal, describes a fire watch as "some special action beyond normal staffing, such as assigning an additional security guard(s) to walk the areas affected." A nurse or aide on their normal assignment isn't a fire watch.

Minnesota also asks for trained staff, reasonable rest breaks, and more than one person where one can't reach every area within 30 minutes.

What to check on each tour

Minnesota's tour list, written for health care:

• Fire, visible smoke, or a strong smell of smoke or other unwanted odors, reported at once.
• Portable fire extinguishers in place, unobstructed and working.
• Corridors and exits free of storage and other obstructions.
• Exit and stairwell doors clear and fully working.
• EXIT signs visible and lit.
• Fire doors, smoke barrier doors and hazardous area doors closed and latched, not tied, wedged or blocked open.
• Oxygen cylinders and containers not in use stored properly.
• Electrical hazards reported and fixed.
• No smoking, cutting, welding or flammable liquids in use, unless the work was preauthorized in a properly fire-separated area.
• Trash and other unneeded combustibles removed from the building.

While the system is down

Minnesota lists measures to start as soon as you learn a system is out, and keep until it's restored:

• Tell all staff, and the monitoring company, that the system is out of service.
• If the alarm's sounders don't work, set up another way to warn staff: bells, whistles, bullhorns or similar.
• If the fire alarm is out, close all smoke and fire doors, and unlock locked exit doors so people can get out at once.

Iowa's notification list adds the local fire department, the Department of Health, the Fire Marshal and the insurance company. Tag the system at each fire department connection, control valve, fire alarm control unit and annunciator, and when it's restored, tell the same people and remove the tags.

Documentation and how long to keep it

In Minnesota's words, "Almost as important as conducting fire watch tours is documenting the fact that they occurred." For each outage, record:

• Which system was out, when it went out and when it was restored.
• Who was notified, and when.
• Every tour: the time, who walked it, the areas checked, and what was found and done.

Iowa says keep the documentation for one year. Minnesota recommends at least three years, and that at least two people know where the logs are kept, for inspections. Keep them for the longer period unless you're told otherwise.

A fire watch policy outline

Minnesota suggests two written policies, one for a fire alarm outage and one for a sprinkler outage, each tailored to the building. It warns that "using a generic or 'boiler plate' policy could result in a federal deficiency." Each policy should answer:

1. 01

   When it applies

   Which systems, and which triggers: 4 hours for the alarm, 10 hours for sprinklers, or sooner if your authorities say so.

2. 02

   Who's in charge

   The impairment coordinator by role, with a backup for nights and weekends.

3. 03

   Who's notified

   The fire department, state agencies, the insurer, the monitoring company and staff: who makes each call, with the numbers.

4. 04

   Who walks

   Trained staff or contracted security with no other duties, how many, and how they're relieved for breaks.

5. 05

   The route and interval

   Every affected area, each checked at least every 30 minutes.

6. 06

   What's checked

   The tour list above, plus the extra measures while the system is down.

7. 07

   The log

   What's recorded, who reviews it, where it's kept and for how long.

8. 08

   Back in service

   Testing, notifications, removing the tags and ending the watch.

Using PatrolBadges for a health care fire watch

Set up a route with a round every 30 minutes around the clock, and a QR code or NFC tag in each area the tour must reach: each wing or smoke compartment, stairwells, the kitchen, laundry, oxygen storage and mechanical rooms. Name checkpoints by area, never by resident, and keep resident details out of notes and photos.

Add tour items as checklist questions, such as "Fire doors closed and latched?", answered OK or Problem. A Problem needs a note and opens an incident. Staff or contracted guards scan with their phone's camera, with no app or account, giving their name or PIN once a shift. You're emailed if a round ends with an area unscanned or hasn't started a few minutes in.

Each day's report prints as the fire watch log, exports to CSV, has a private link, and can be emailed to the administrator each morning. If your authority wants proof that every room was entered, as Iowa's wording suggests, ask whether area checkpoints satisfy them, or put a code on more doors: Pro is $9 a month for 10 checkpoints, and $39 for 40.

This guide is general information, not legal advice. Rules vary by state and code edition: your fire code official and state survey agency have the final word. For fire watch rules outside health care, see fire watch requirements.