Alarm Systems, Emergency Signals, and Fire Containment

Purpose

This policy establishes the required procedures for the use of alarm systems, emergency signals, and fire‑containment methods at LifeCare Therapy Services. The goal is to ensure rapid detection, notification, and containment of fire or smoke events to protect patients, staff, visitors, and facility assets. This policy supports compliance with:

• QUAD A Standards Section 5 – In Case of an Emergency

• CMS Emergency Preparedness Rule

• Florida Fire Prevention Code (FFPC)

• Local Broward County and City of Tamarac fire safety regulations

Scope

This policy applies to all personnel working at LifeCare Therapy Services, as well as any individuals present in the clinic during operating hours.

Policy  

LifeCare Therapy Services maintains functional alarm systems, emergency signals, and fire‑containment equipment to ensure immediate detection and response to fire emergencies. All personnel must understand alarm types, respond appropriately to signals, and follow established fire‑containment procedures.

 

4.1 Alarm System Requirements

LifeCare Therapy Services maintains a fire alarm system that:

• Detects smoke, heat, or manual activation

• Provides audible and visual alerts throughout the clinic

• Is monitored by a licensed fire alarm monitoring service

• Meets all local and state fire code requirements

The system is inspected, tested, and maintained annually by a certified vendor, with documentation retained for regulatory review.

4.2 Types of Alarms and Signals

a. Fire Alarm (Primary Emergency Signal)

• Audible: Continuous loud alarm tone

• Visual: Flashing strobe lights

• Meaning: Immediate evacuation required

b. Manual Pull Stations

• Located near exits and clearly marked

• Used when smoke or fire is observed before automatic detection

c. Secondary Alerts

Used by staff to communicate internally during an emergency:

• Verbal announcements (if safe to do so)

• Portable/mobile phones for staff coordination

• Text alerts if evacuation is complete and communication is needed

4.3 Staff Response to Alarm Activation

Upon hearing or seeing an alarm:

1. Stop all patient care activities immediately

2. Direct patients toward the nearest safe exit

3. Assist individuals with mobility or cognitive limitations

4. Close doors behind you to slow fire spread

5. Evacuate to the designated assembly area

6. Do not re-enter the building until cleared by fire officials

Staff also have the following responsibilities:

• Front Office Staff is to take the Visitor / Patient Log

• Management is to check restrooms and private treatment rooms

• Meeting location is in the parking area in front of the Center

• If shelter is needed, Tamarac Elementary School is the designated shelter.

5. Fire Containment Methods

5.1 RACE Protocol

All staff must follow the nationally recognized RACE method:

• R – Rescue: Remove anyone in immediate danger

• A – Alarm: Activate the fire alarm and call 911

• C – Contain: Close doors, windows, and fire barriers

• E – Extinguish/Evacuate: Use a fire extinguisher only if safe; otherwise evacuate

5.2 Fire Extinguishers

LifeCare Therapy Services maintains portable fire extinguishers that:

• Are inspected monthly by designated staff

• Receive annual inspection and certification by a licensed vendor

• Are located in visible, accessible areas

• Are appropriate for common fire types (Class A, B, C)

Staff Use of Extinguishers (PASS Method)

• P – Pull the pin

• A – Aim at the base of the fire

• S – Squeeze the handle

• S – Sweep side to side

Staff may attempt extinguishment only if:

• The fire is small and contained

• They have a clear exit path

• They have been trained in extinguisher use

5.4 HVAC and Electrical Safety

To reduce fire spread:

• HVAC systems may be shut down during fire events if directed by emergency personnel

• Staff must report electrical hazards immediately

• Extension cords and power strips must comply with safety standards

6. Training and Drills

 

All personnel receive training at the time of hire and annually thereafter.  Training for in-clinic staff includes: 

• Alarm recognition

• Evacuation routes

• RACE and PASS procedures

• Fire extinguisher use

• Fire‑containment responsibilities

6.2 Fire Drills

Fire drills will be conducted at least once annually, or more frequently if required by QUAD A or local regulations.  Fire drills are documented 

• Documented with date, time, participants, and improvement opportunities

• Reviewed by leadership to enhance preparedness

7. Maintenance and Documentation

LifeCare Therapy Services maintains:

• Alarm system inspection reports

• Fire extinguisher logs

• Fire drill records

• Staff training documentation

• Maintenance and repair records

All records are retained according to regulatory requirements.

 

In the event of an actual emergency (not a drill), re-entry to the building will not be permitted until the local fire or policy authority gives clearance. If this occurs, staff are responsible for coordinating transportation for patients and clients. Staff will remain on-site until the disposition of patients, clients, or visitors is completed.