BACKGROUND & INTRODUCTION
In developing this plan the following factors were taken into account.
• Hillcrest residential and non-residential sites are located in suburban and semi-rural areas that have relatively low crime rates.
• Hillcrest students come from multiple states. Therefore the general flow of visitors from the community to Hillcrest sites; visitors to students and the security issues that accompany student visitation; and the possibility of student abduction, disturbance or other event performed by a family member or non-family visitor, are minimized and within controllable limits.
• Hillcrest staff to student ratios are comparatively high, including awake overnight staff. There are many staff, almost all of whom know one another, present throughout all hours of the day, and supervisors at each site periodically patrol the campus. This high staff and supervisor ratio help to minimize the possibility of student elopement and the undetected presence of unauthorized or unaffiliated visitors or intruders on site.
• Hillcrest utilizes video security cameras that are strategically located on campuses for supervision and security purposes.
• All Hillcrest staff are trained and authorized to take responsibility for maintaining a safe, secure environment of care.

1. Fire Watch
The National Fire Protection Association (NFPA) 101 Life Safety Code®, ed. 2006 (sections 3.3.91, 9.6.1.6, and A9.6.1.6) and Joint Commission standards require that, when a fire alarm and/or sprinkler system in an occupied building is out of service for any reason for a specified period of time:
a) the building must be evacuated, or
b) a Fire Watch must be provided continuously until the fire alarm and/or sprinkler system has been returned to service.

Whenever a fire alarm or automatic sprinkler system is out of service in an occupied building for more than 4 hours within a 24 hour period, Hillcrest provides a fire watch.
Depending on conditions, the agency may consider initiating a fire watch before the 4 hour mark is reached. However, if and when the 4/24 mark is reached in an occupied building, a fire watch will be provided

2. Definition
Providing a Fire Watch means designating a trained staff person whose sole responsibility is to look for and prevent fires within a designated area, typically one occupied building, as authorized by a program supervisor, administrator or maintenance supervisor. Fire Watch duties are not to be added to a staff’s normal duties; the person assigned to Fire Watch cannot be engaged in any activities beyond fire prevention and safety.

Maintenance managers and program supervisors are responsible for overseeing the activities of the individual(s) assigned to conduct the Fire Watch.

3. Rationale
In most cases, the evacuation of an occupied building on a Hillcrest campus is not practical and could be disruptive.

All HEC program staff are periodically trained in Rescue, Alarm, Contain, and Extinguish/ Evacuate (RACE) and the implementation of a facility-wide fire watch. The Fire Watch is a short-term alternative that safely allows continued occupancy of facilities. Therefore, all HEC program sites will utilize the following procedure for providing a fire watch.

Conditions and Procedures
a) Immediately following the deactivation of a fire alarm system in an occupied building, the Supervisor or a designee will:
1. contact the on-call maintenance staff;
2. notify the local fire department of the outage;
3. communicate the need for heightened awareness and vigilance to all staff on duty.

b) If more than one occupied building is affected by outages, the Maintenance on call person and the Supervisor or Administrator will decide how many staff will be assigned to Fire Watch, and their areas of responsibility, in order to insure safe conditions.

c) Fire Watch activities include:
(1) Monitoring the unprotected area(s) to detect conditions likely to cause and spread fires.
(2) Promptly notifying the fire department if a fire occurs.

d) The staff serving as Fire Watch will tour the building or buildings for which the Fire Watch staff is responsible, looking through all rooms and areas in the building for possible signs of fire or potentially dangerous conditions.

e) The person assigned to Fire Watch will not engage in any other program or campus related activities or events. At an Administrator’s discretion, additional staff may be called to the program if necessary to insure Fire Watch and safe conditions.

Cancellation of the Fire Watch

A Fire Watch will be cancelled only by the local Fire Department, based on an assessment that the fire alarm and/or sprinkler system is operating properly. Neither agency managers nor the person conducting the Fire Watch have the authority to cancel the Fire Watch without the approval of the local fire department.

Hillcrest maintains policies pertaining to the use of interim life safety measures (ILSM) as part of Hillcrest Policies and Procedures. These include written criteria to evaluate deficiencies and construction hazards for determining when and to what extent one or more of the following measures are applicable:
1. Ensuring free and unobstructed exits. Staff receive additional training when alternative exits are designated. Buildings or areas under construction must maintain escape routes for construction workers at all times, and the means of exiting construction areas are inspected daily.

2. Ensuring free and unobstructed access to emergency services and for fire, police, and other emergency forces.

3. Ensuring that fire alarm, detection, and suppression systems are in good working order. A temporary but equivalent system is provided when any fire system is impaired. If used, temporary systems are inspected and tested monthly.

4. Ensuring that temporary construction partitions are smoke tight and built of noncombustible or limited combustible materials that will not contribute to the development or spread of fire.

5. As required by the Life Safety Code®, NFPA 101, 1997 edition, Hillcrest immediately notifies the local fire department of any alarm system power disruption. As detailed below, Hillcrest provides a fire watch, whenever a fire alarm or automatic sprinkler system is out of service in an occupied building.

6. Providing additional fire-fighting equipment and training staff in its use.

7. Prohibiting smoking at all HEC sites.

8. Developing and enforcing storage, housekeeping, and debris-removal practices that reduce the building’s flammable and combustible fire load to the lowest feasible level.

9. Conducting fire drills on a quarterly basis on each residential and overnight shift in the dorm buildings, and monthly on the academic shift in all areas used as classrooms.

10. Increasing hazard surveillance of buildings, grounds, and equipment, with special attention to excavations, construction areas, construction storage, and field offices.

11. Training staff to compensate for impaired structural or compartmentalization features of fire safety.

12. Conducting organization wide safety education programs to promote awareness of life safety building deficiencies, construction hazards, and ILSM.

1. Campus specific fire response needs are determined by the population, staffing and building and/or campus lay out.

On all campuses, however, direct care staff are concerned with managing the safety of students as the highest priority.

2. Area-specific needs and fire evacuation routes are determined on a campus specific and building specific basis.

3. Specific roles and responsibilities of personnel at a fire’s point of origin are determined on a campus specific and building specific basis.

As noted above, however, on all campuses direct care staff are concerned with managing the safety of students as the highest priority.

4. Specific roles and responsibilities of personnel away from a fire’s point of origin are determined on a campus specific and building specific basis.

As noted above, however, on all campuses direct care staff are concerned with managing the safety of students as the highest priority.

5. Specific roles and responsibilities of personnel in preparing for building evacuation are determined on a campus specific and building specific basis.

As noted above, however, on all campuses direct care staff are concerned with managing the safety of students as the highest priority.

When a fire alarm goes off at a program or work site the monitoring company, Berkshire Communicators, performs the following actions in the following order:
1) Dispatches the fire department to the program/work site.
2) Calls the program/work site for more information. (See NOTE 1 below)
3) Calls the HEC maintenance department cell phone, which is carried by the on-call maintenance manager.
4) If #3 is not successful, calls through the call list of designated Maintenance staff until one is reached.
NOTE 1:
The monitoring company will try to reach the program or work site to acquire more information to be sure that no other help is needed, such as an ambulance, police, etc. The staff should also dial 911 as soon as it is safe to do so when any fire alarm is activated, unless it is a drill.
With the exception of a fire drill, whenever a fire alarm is activated – even in the event that, for example, a student activates the alarm — the program should immediately contact 911 emergency services, and NOT Berkshire Communicators.

Monitoring of fire and life safety performance is conducted on an ongoing basis in a number of ways.

1. Staff knowledge and skills
The monitoring of staff knowledge and skills is conducted through regular observation of performance by supervisors, including performance during fire drills; through formal supervision meetings; through annual performance evaluations; and through training and refresher training conducted each year.

2. Level of staff participation
The monitoring of staff participation is conducted through means described above, and particularly during actual fire drills and fire safety training.

3. Monitoring and inspection activities
Hazard/safety surveillance inspections are conducted on each campus at least quarterly. Hazard surveillance inspection reports, fire inspection reports conducted by the local fire inspectors, and investigation findings are reviewed by campus Environment of Care Committees, as they occur or are completed.

4. Emergency and incident reporting
All incident reports, including reports related to fire safety issues and the required Mandatory School Fire Reporting Form are reviewed by supervisors, nursing staff, clinical staff, and program administrators some of whom are members of the campus Environment of Care Committee.

Incidents that are not documented require follow up by supervisors, and incident reports that are not completed correctly or according to procedure, are returned for follow up by the supervisor.

Data on fire safety incident and emergency reports is maintained and is reviewed on a regular basis, as they occur, by program and agency administration and by the campus Environment of Care Committee.

5. Inspection, preventive maintenance and testing of fire safety and life safety equipment.
As noted above, fire safety and life safety systems, equipment, and components are inspected, tested and maintained on schedules in compliance with the highest/most stringent requirements of equipment manufacturer recommendations or requirements of state, local and/or accreditation and licensing agencies.

These schedules vary from campus to campus and are dependent upon the systems and equipment at the specific campus. The campus-specific schedules are maintained, implemented and documented by the Maintenance Dept. at that campus.

An orientation to life safety and emergency response policies and procedures is provided for all new staff during New Staff Orientation, and life safety and emergency response training is provided on a quarterly basis thereafter.

This Plan shall be reviewed and evaluated each year for its effectiveness, scope, performance and objectives. A work group minimally consisting of the Facilities Coordinator, the Director of Facilities, the Director of Quality Assurance, and the Chairpersons from each campus EOC Committee and/or their designee will conduct the review and evaluation between March and May of each year. The results of the review and evaluation, and related recommendations, will be reported sequentially to the campus EOC Committees, the Senior Management Team for review and approval. Barring unforeseen and unavoidable delays, this revised Plan shall be implemented each July at the beginning of the new Program Year.

Virtually all purchasing is done on a campus by campus basis. The campus specific person responsible for purchasing reviews all proposed acquisitions (i.e., bedding, window draperies, and other curtains, furnishings, decorations, wastebaskets, and other equipment) for fire safety issues. If concerns are identified during the review, the purchase of the proposed item will be cancelled or postponed until safety can be clarified or confirmed. Consultation with the local fire department and/or manufacturer on any proposed acquisition will be done if necessary.

Any and all fire protection deficiencies, failures, and user errors are immediately reported to program supervisors or administrators, as well as to the campus Maintenance Dept. Fire protection deficiencies, failures, and user errors are addressed and corrected as soon as possible, with necessary steps (e.g., notifying the local fire dept.; additional staff to conduct fire watch) taken to provide protection during the period of correction.

Any extensive or systemic deficiency, failure, or user error is reported to the Director of Facilities and the on-call Senior Manager as soon as possible after diagnosis or detection.