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The Pennsylvania Code website reflects the Pennsylvania Code changes effective through 54 Pa.B. 2336 (April 27, 2024).

Pennsylvania Code




569.1.    Principle.
569.2.    Fire safety standards.
569.3.    Policies and procedures.


569.11.    Firefighting service.
569.12.    Fire warning and safety systems.
569.13.    Testing fire warning systems.
569.14.    Internal disaster and fire plans.
569.15.    Safety education program.


569.21.    Fire drills.


569.31.    Emergency power.
569.32.    Fire inspection.
569.33.    Smoking.
569.34.    Electrical safety.
569.35.    General safety precautions.
569.36.    Safety devices.
569.37.    Report of emergencies causing interruption of service.


   The provisions of this Chapter 569 issued under Chapter 8 of the Health Care Facilities Act (35 P. S. § §  448.801a—448.820), specifically sections 448.801a and 448.803; and section 2102(a) and (g) of The Administrative Code of 1929 (71 P. S. §  532(a) and (g)), unless otherwise noted.


   The provisions of this Chapter 569 adopted January 23, 1987, effective March 25, 1987, 17 Pa.B. 376, unless otherwise noted.


§ 569.1. Principle.

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

§ 569.2. Fire safety standards.

 (a)  An ASF shall meet the applicable edition of National Fire Protection Association 101 Life Safety Code, which is currently adopted by the Department.

 (b)  An ASF previously in compliance with prior editions of the Life Safety Code, is deemed in compliance with subsequent Life Safety Codes, except renovation or new construction shall meet the current edition adopted by the Department.


   The provisions of this §  569.2 amended October 22, 1999, effective November 22, 1999, 29 Pa.B. 5583. Immediately preceding text appears at serial page (256594).

Cross References

   This section cited in 28 Pa. Code §  571.2 (relating to modifications to HHS requirements).

§ 569.3. Policies and procedures.

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


§ 569.11. Firefighting service.

 The person in charge of the ASF shall establish a workable plan with the nearest fire department for fire- fighting service. The ASF shall provide the fire department with a current floor plan of the building showing the location of firefighting equipment, exits, patient rooms, storage places of flammable and information that the fire department requires or as may be necessary.


   The provisions of this §  569.11 amended October 22, 1999, effective November 22, 1999, 29 Pa.B. 5583. Immediately preceding text appears at serial page (256594).

§ 569.12. Fire warning and safety systems.

 An ASF shall 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 ordinances.

§ 569.13. 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 ASF personnel at least every 3 months. Records of the inspections shall be kept on file for the licensure period.

§ 569.14. Internal disaster and fire plans.

 The ASF shall have an internal disaster and fire plan incorporating evacuation procedures and the safety of both closed records and the records of those patients being evacuated. These plans shall be made available to personnel and evacuation diagrams shall be posted throughout the ASF.

§ 569.15. Safety education program.

 Employes shall participate in the safety program and perform 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 if electric power is impaired.


§ 569.21. Fire drills.

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

 (b)  The CEO shall:

   (1)  Ensure that all personnel are trained to perform assigned duties.

   (2)  Ensure that all personnel are familiar with the use and operation of the firefighting equipment in the ASF.

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

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

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


   The provisions of this §  569.21 amended October 22, 1999, effective November 22, 1999, 29 Pa.B. 5583. Immediately preceding text appears at serial page (256595).


§ 569.31. 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.

§ 569.32. Fire inspection.

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

§ 569.33. Smoking.

 Smoking is not permitted in an ASF.


   The provisions of this §  569.33 amended October 22, 1999, effective November 22, 1999, 29 Pa.B. 5583. Immediately preceding text appears at serial page (256596).

§ 569.34. Electrical safety.

 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 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.

§ 569.35. General safety precautions.

 The following safety precautions shall be met:

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

   (2)  Doors into patient rooms may not be locked.

   (3)  Exit doors may not be locked from the inside while patients are in the ASF.

   (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.

   (7)  Only nonflammable agents may be present in a surgical suite.


   The provisions of this §  569.35 amended October 22, 1999, effective November 22, 1999, 29 Pa.B. 5583. Immediately preceding text appears at serial page (256596).

§ 569.36. 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.

§ 569.37. Report of emergencies causing interruption of service.

 (a)  The person in charge of the ASF shall make a report of any emergency, such as a strike, fire or natural disaster which significantly interrupts or alters ASF 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 a 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 a deceased patient.

   (4)  Names of patients sent to other facilities and names of the facilities.

   (5)  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 in subsection (b). The written report shall be dated and shall be authenticated by the person in charge.

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