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Pennsylvania Code




151.1.    Principle.
151.2.    Policies and procedures.


151.11.    Fire fighting service.
151.12.    Fire warning and safety systems.
151.13.    Testing fire warning systems.
151.14.    Internal disaster and fire plans.
151.15.    Safety education program.


151.21.    Fire drills.
151.22.    Fire drill supervised by the local fire department.
151.23.    Record of fire drills.
151.24.    Evacuation of patients.


151.31.    Written external disaster plan.
151.32.    Rehearsed disaster plan.


151.41.    Emergency power.
151.42.    Fire inspection.
151.43.    Smoking.
151.44.    Hazardous areas.
151.45.    Electrical safety.
151.46.    General safety precautions.
151.47.    Safety devices.
151.48.    Report of emergencies causing interruption of service.

Cross References

   This chapter cited in 28 Pa. Code §  115.33 (relating to entries); 28 Pa. Code §  117.41 (relating to emergency patient care); and 55 Pa. Code §  6100.2 (relating to applicability).


§ 151.1. Principle.

 The hospital shall have an organized fire, safety and disaster program under the direction and supervision of one or more persons qualified to implement the program.

§ 151.2. Policies and procedures.

 Written policies and procedures for use in preventing and responding to fire and disaster shall be available to all personnel.


§ 151.11. Fire fighting service.

 The chief executive officer, or his designee, shall establish a workable plan with the nearest fire department for fire fighting service. The hospital shall provide the fire department with a current floor plan of the building showing the location of fire fighting equipment, exits, patient rooms, storage places of flammable and explosive gases, and other information as the fire department requires or as may be necessary.

§ 151.12. Fire warning and safety systems.

 Every building should have an automatic and manually activated fire alarm system installed to transmit an alarm automatically to the fire department by the most direct and reliable method approved by local regulations.

§ 151.13. Testing fire warning systems.

 Fire safety systems, including automatic fire extinguishing systems, automatic and manual alarms, stand-pipes, and hose reels shall be of an approved type. They shall be kept in good operating condition and inspected by qualified hospital personnel at least every 3 months. Records of these inspections shall be kept on file for 2 years.

§ 151.14. Internal disaster and fire plans.

 The hospital shall have an internal disaster and fire plan incorporating evacuation procedures. These plans shall be made available to all personnel and posted throughout the hospital. These plans should be developed in accordance with the American Hospital Association’s guidelines for disaster planning.

§ 151.15. Safety education program.

 All employes shall participate in the safety program in the duties delegated to them and be instructed in the operation of the fire warning system, the proper use of fire fighting equipment, and the procedure to follow in event that electric power is impaired.


§ 151.21. Fire drills.

 (a)  Fire, internal disaster and evacuation drills shall be held at least quarterly for each shift of hospital personnel and under varied conditions.

 (b)  These drills shall be planned and implemented so as to:

   (1)  Ensure that all personnel on all tours of duty are trained to perform assigned duties.

   (2)  Ensure that all personnel on all tours of duty are familiar with the use and operation of the fire-fighting equipment in the hospital.

   (3)  Enable the chief executive officer to evaluate the effectiveness of the plan.

§ 151.22. Fire drill supervised by the local fire department.

 At least one hospital fire drill each year should be supervised by the local fire department.

§ 151.23. Record of fire drills.

 A written report and evaluation of all drills conducted since the last survey shall be kept on file.

§ 151.24. Evacuation of patients.

 The actual evacuation of patients to safe areas during a drill is optional.


§ 151.31. Written external disaster plan.

 (a)  Each hospital shall have written plans, based on its capabilities, for the proper and timely care of casualties arising from external disasters. These plans should be developed in accordance with the disaster planning guidelines published by the American Hospital Association. The disaster plan should be developed in conjunction with other emergency facilities in the community so that adequate logistical provisions are made for the expansion of the activities of the hospital in coordination with the activities of other facilities.

 (b)  The disaster plan should make provision for the following:

   (1)  The availability of basic utilities and supplies, including gas, water, food and essential medical and supportive materials.

   (2)  An efficient system of notifying and assigning personnel.

   (3)  Unified medical command.

   (4)  Conversion of all usable space into clearly defined areas for efficient triage and for patient observation and for immediate care.

   (5)  Prompt transfer of casualties, when necessary, after preliminary medical or surgical services have been rendered, to the facility most appropriate for administering definitive care.

   (6)  A special disaster medical record which shall accompany the casualty patient as he is moved.

   (7)  The prompt and orderly discharge or transfer of patients already in the hospital who can be safely moved without jeopardy.

   (8)  Maintaining security to keep unauthorized persons out of the triage area.

   (9)  Preestablishment of a public information center and assignment of public relations liaison duties to a qualified individual. Advance arrangements should be made with communications media to provide for organized dissemination of information in the event of a disaster.

§ 151.32. Rehearsed disaster plan.

 The external disaster plan shall be rehearsed at least twice a year, preferably as part of a coordinated drill in which other community emergency service agencies participate. The drills shall involve professional, administrative, nursing and other hospital personnel. Actual evacuation of patients during drills is optional. A written report and evaluation of all drills must be maintained for at least 2 years.


§ 151.41. Emergency power.

 The emergency electric power source and associated equipment shall be regularly inspected, tested and maintained in accordance with current NFPA Standards. A written record shall be maintained of inspection, performance, exercising period and repairs of emergency power equipment.

§ 151.42. Fire inspection.

 The hospital shall request an annual inspection by its local fire department.

§ 151.43. Smoking.

 (a)  The governing body shall adopt written rules governing smoking within the hospital which shall be made known to hospital personnel, to patients and to the public.

 (b)  These rules shall include at least the following:

   (1)  Smoking shall be prohibited in any room, ward or compartment where flammable liquid, combustible gas, or oxygen is being used or stored and in any other hazardous area of the hospital. The areas shall be posted with ‘‘NO SMOKING’’ signs.

   (2)  Patients classified as not mentally or physically responsible for their actions shall be prohibited from smoking unless constant supervision is provided.

§ 151.44. Hazardous areas.

 Special safety procedures, including use of special facilities and equipment, shall be provided for areas of the hospital which present an unusual hazard to patients and personnel. Exposed heating pipes and radiators in patient rooms and within reach shall be covered.

§ 151.45. Electrical safety.

 All appliances, instruments and installations shall be tested before use to determine compliance with grounding, current leakage and other device safety requirements to ensure protection of patients and employes. A program of routine maintenance shall be effectively enforced to ensure that all electrical receptacles and plugs, wires and connectors are safe. If an appliance requiring three-wire circuitry for grounding is attached to a two-wire outlet, the adaptor plug pigtail shall be attached to a ground.

§ 151.46. General safety precautions.

 The following safety precautions shall be met:

   (1)  Doorways, corridors and stairwells shall be free of obstructions and properly lighted.

   (2)  Doors into patient rooms shall not be locked when the patient is alone in the room.

   (3)  Exit doors shall never be locked from the inside.

   (4)  Doors opening to shafts shall be equipped with self-closing devices and positive latches.

   (5)  Wastebaskets, cubicle curtains, window shades and drapes shall be rendered flame retardant.

   (6)  Call bells in the shower, tub room or water closet shall be easily accessible to patients while using these facilities.


   The provisions of this §  151.46 issued under section 2102(g) of The Administrative Code of 1929 (71 P. S. §  532(g)); and section 803 of the Health Care Facilities Act (35 P. S. §  448.803).


   The provisions of this §  151.46 amended through December 3, 1982, effective December 4, 1982, 12 Pa.B. 4129. Immediately preceding text appears at serial page (52884).

§ 151.47. Safety devices.

 The following safety devices shall be provided:

   (1)  Grab bars within reaching distance on at least one side of toilets, bathtubs and showers used by patients.

   (2)  Bedside rails on both sides of a bed for use when the condition of the patient warrants.

§ 151.48. Report of emergencies causing interruption of service.

 (a)  The chief executive officer or his designee shall make a report of any emergency, such as a strike, fire or natural disaster, which significantly interrupts or alters hospital services and threatens the health and safety of patients and which requires one of the following:

   (1)  The services of a fire department.

   (2)  The evacuation of any patient.

   (3)  The use of nonmedical emergency equipment.

 (b)  The report made under subsection (a) shall be submitted to the Director of the Division of Hospitals of the Department as soon as possible and shall include the following information:

   (1)  Time, date, cause, location, and nature of emergency.

   (2)  Number of patients evacuated.

   (3)  Loss of life and name of any deceased patient.

   (4)  Name of any patients sent to other facilities and name of the facilities.

   (5)  Any assistance required from the Health Department to protect the health and safety of the patients.

 (c)  Oral reports shall be followed by a complete written report verifying the information listed in this section. The written report shall be dated and shall be authenticated by the chief executive officer or his designee.


   The provisions of this §  151.48 issued under 67 Pa.C.S. § §  6101—6104; and Reorganization Plan No. 2 of 1973 (71 P. S. §  755-2).


   The provisions of this §  151.48 amended September 19, 1980, effective September 20, 1980, 10 Pa.B. 3761. Immediately preceding text appears at serial page (37939).

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