CBRF Fire Protection Systems

Applicable Codes Relating to Fire Protection Systems to Meet the January 1, 2002 Deadline

Date: January 18, 2002 DSL-BQA Memo 02-001

To: Community Based Residential Facilities CBRF 01

From: La Vern Woodford, Chief, Resident Care Review Section

Via: Susan Schroeder, Director, Bureau of Quality Assurance

Introduction

This is the fifth in a series of BQA Memos that have been sent since 1996 regarding fire protection systems. (Previous memos: DSL-BQA Memo 00-036; DSL-BQA Memo 99-032; DSL-BQA Memo 96-044) By January 1, 2002, all Community Based Residential Facilities (CBRFs) must have an approved, fully interconnected, or radio-transmitting, fire protection system in all required locations.

This memorandum outlines fire protection system requirements for CBRFs that must be in place by January 1, 2002. Because these requirements are based on Wisconsin Statutes (exit DHFS), Section 50.035, and on Wisconsin Administrative Code, Section HFS 83.43 (exit DHFS), no waivers or variances will be provided. CBRFs must be in compliance with the smoke detection, heat detection, and plan review submission described below by January 1, 2002. (Please note that the Chapter HFS 83 code references pertaining to these requirements have been in effect since November 1996.)

Smoke Detectors

1. Section HFS 83.43(4)(b)1. and 2. All CBRFs shall have at least one smoke detector in each of the following locations:

At the head of every open stairway.
On the hallway side of every enclosed stairway on each floor level.
In every corridor, spaced not more than 30 feet apart and not further than 15 feet from any wall or in accordance with the manufacturer’s separation specifications.
In each common use room, including a living room, dining room, family room, lounge and recreation room, but not including a kitchen, bathroom or laundry room.
In or near the living room of an apartment.
In all bedrooms.
In each room of the staff living quarters, including the staff office, but not including the kitchen or bathroom.
In the basement or in each room in the basement, except a furnace room or laundry room.
In adjoining rooms where the shared openings have a minimum lintel depth of eight inches from the ceiling.
In each compartment of any room if the openings between compartments have a minimum lintel depth of at least eight inches from the ceiling.

2. Effective January 1, 1997, facilities were allowed a five-year extension to comply with the fire alarm system requirements.

3. All CBRFs of nine or more beds are required to have an interconnected (hard-wired) detection system. CBRFs of eight or fewer beds are required to have an interconnected or radio-transmitting detection system per Wisconsin Statute, Section 50.035(2)(a)2.

Note: There is no statutory authority for facilities having nine or more beds to install a radio-transmitting smoke detection system that is designed for larger facilities.

Heat Detectors

1) Section HFS 83.43(5)(a). All CBRFs shall have at least one heat detector integrated with the smoke detection system at all of the following locations, or in accordance with the heat detector manufacturer’s separation specifications:

The kitchen, when it is a separate enclosed room, or when it has a shared opening with a minimum lintel depth of at least eight inches from the ceiling separating it from any adjoining room.
In any attached garage.
In the attic or in each enclosed compartment of the attic.
In an enclosed furnace room.
In an enclosed laundry room.

2) Section HFS 83.43(5)(b). CBRFs licensed before January 1, 1997, shall meet the requirements under par. (a) within five years after January, 1997, or when any smoke detector of the smoke detector system in the facility on January 1, 1997 needs replacement and new smoke detectors compatible with the smoke detection system currently in the CBRF are not available and a new smoke detection system needs to be installed, whichever comes first.

Interdepartmental Code

Please be advised that the Department of Health and Family Services, Wisconsin Administrative Code, Section HFS 83.42 and the Department of Commerce, Commercial Building Code COMM 51.24 [updated to COMM 14], both have requirements concerning fire alarm system design, construction, inspection, testing, and maintenance referenced in the National Fire Protection Association (NFPA), Standard 72.

Plan Review

Section HFS 83.56(2). Plan Review. All construction plans for new CBRFs of any size and any additions to existing buildings shall be reviewed and approved by the Department before construction.

The Bureau considers the installation of new parts of the fire protection system to be an addition to the facility.

Any changes to the fire protection system require plan submittal and approval. For plan review assistance, please call (608) 267-1442 and reference forms DSL-2333 for CBRFs attached to health care facilities or DSL-2496 for freestanding CBRFs, or department web site at:
http://www.dhs.state.wi.us/rl_DSL/PlanReview/index.htm [address updated]

Follow Sections HFS 83.56(2) and (3) for plan review submission and fee requirements.

Compliance with This Requirement

The department expects all CBRFs to have an approved, fully interconnected, or radio-transmitting, fire protection system in all required locations by January 1, 2002. Any facility found not to be in compliance will be cited and issued a statement of deficiency. In accordance with Wis. Stat., sec. 50.03(5g)(c)1, a daily forfeiture will be assessed from January 1, 2002, until the facility is in compliance. Forfeitures will range from $10 per day (facilities that are making good faith efforts to get into compliance) to $50 per day (facilities that have not done anything to get into compliance).

If you have questions, please contact the appropriate Regional Field Operations Director listed below [via Regional Offices, ask for Assisted Living Supervisor]

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DHS

Wisconsin Department of Health Services

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