See III. above.
Fire protection and life safety systems, equipment, and components are inspected, tested and maintained on schedules in compliance with the highest/most stringent requirements of either the equipment manufacturer recommendations or requirements of state, local and/or accreditation and licensing agencies.

These schedules vary by campus, depending on the specific systems and equipment at the campus. The campus-specific schedules are maintained, implemented and documented by the Maintenance Dept. at that campus.

 
All battery powered emergency lights required for egress are tested for at least 30 seconds at least every 30 days. At least annually, these lights are tested for at least 90 minutes. (EC.7.40)

All fire and smoke dampers are operated at least every four years, with fusible links removed if applicable, to verify that they fully close.1

1. Smoke/fire/heat detection and alarm systems are inspected, tested and cleaned by an outside contractor at least every 12 months. However, alarms are pulled and communications with Berkshire Communicators are checked during each fire drill, which are conducted for each shift and each campus building.
2. At the residential campuses, student dormitories, and some other buildings at campuses are protected by automatic sprinkler systems which are inspected and tested by an outside contractor at least quarterly. Housatonic Academy is not equipped with automatic sprinkler systems.
3. Fire safety and emergency response training is provided to all new employees as part of New Staff Orientation and on a quarterly basis thereafter.
4. Fire Drills – Floor plans are posted in every dormitory common area, and other activity areas. The plans indicate the evacuation route(s) to be followed to exit the building.

Each residential and overnight shift performs a fire drill quarterly in the dorm buildings. The academic shift conducts monthly fire drills in all areas used as classrooms. All drills are recorded on the HEC Fire Drill or Activity Report form (see section D.). The supervisor in charge of running the drill must vary the drill conditions to require students and staff to react to potentially dangerous situations, such as blocked hallways or heavy smoke.

Per recommendation of Lenox, Great Barrington, and Pittsfield Fire Departments, 911 will be called for any alarm activity, excluding drills.

All personnel on all shifts are trained to perform assigned tasks during drills, first during the orientation period, then quarterly thereafter. The training includes the use of firefighting equipment.

A Fire Drill Report is completed after every scheduled and unscheduled fire drill. (See below for Fire Drill Report Retention Policy.)
The supervisor prepares the report and comments on the effectiveness of the drill. Where deficiencies are noted, the supervisor must run a follow-up training session and document such training.

Special care is taken to ensure that students understand the nature of such drills. Drill practices, without the use of the school alarm system, are utilized when necessary for additional training.

Students whose mobility is temporarily or situationally impaired are carried if necessary, to the designated safe area. Students should not be carried or escorted against their will during a drill of any kind. However, during a genuine emergency, unwilling students will be moved or carried as carefully as possible in order to insure their safety.

The program keeps a written log of all evacuation drills in the Administrator’s office. Included in the log is date and time of drill, the affected building, elapsed time, numbers of staff and students involved and comments or recommendations on the drill.

5. Fire extinguishers are inspected at least monthly, and they are maintained and tagged by an outside contractor at least every twelve months. Fire extinguishers are recharged and/or replaced as necessary and as indicated.
6. All campuses are equipped with hard wired, battery backup emergency lights that are tested monthly by maintenance staff and quarterly by the local Fire Department. Residential campuses also have emergency lights that are hard wired into the generator power supply and that are used during power failures. These lights are tested monthly as part of School Dude preventive maintenance when the power generators are tested.

All of the following persons and groups are authorized by the Hillcrest administration to take necessary action to protect life and property and to insure that the Fire Safety Management Plan is properly and fully implemented.
1. At the Agency level
At the agency level, fire safety management is the responsibility of the agency Director of Facilities, the Facility Coordinator, and the Director of Quality Assurance, in addition to the Hillcrest Management Team.
2. At the Campus level
At the campus/program level, fire safety management is the responsibility of the program directors, managers and their delegates (e.g., direct care Supervisors), and campus Environment of Care Committees.

The primary objectives of the Fire Safety Management Plan are to:
1. Understand and apply the latest life safety codes of the National Fire Protection Association and all applicable local, state, and federal regulatory and accreditation standards.
2. Develop corrective action plans for fire safety deficiencies when necessary.
3. Maintain a level of safety (i.e., interim Life Safety) during all levels of renovation or construction.
4. Test and practice staff compliance and knowledge through participation in fire drills.
5. Maintain the Statement of Conditions as a working document.
6. Train staff in the RACE (Rescue, Alarm, Confine, Evacuate or Extinguish) and “PASS” (Pull, Aim, Squeeze, Sweep) protocol for fire extinguisher use.
7. Hillcrest will accomplish these objectives in a manner compliant with regulations promulgated by the Mass. Dept. of Early Education and Care (DEEC), Mass. Department of Elementary and Secondary Education (DESE), standards established by the Joint Commission (JC), and all other applicable laws, regulations and standards.

PURPOSE
The Fire Safety Management Plan is developed and implemented in order to establish and maintain a fire safe environment of care for Hillcrest students and staff.

This Plan shall be reviewed and evaluated each year for its effectiveness, scope, performance and objectives. A work group typically consisting of the Director of Quality Assurance, the Director of Facilities, and the Chairpersons of 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 and the Senior Management Team for their review and approval. Barring unforeseen and unavoidable delays, this revised Plan shall be implemented each July at the beginning of the new Program Year.

The maintenance and supervision of all grounds and equipment is the ultimate, joint responsibility of the Maintenance Department and the campus Program Director. Others, as noted above, share this responsibility.

Hillcrest Educational Centers:
• Operates 24 hours per day, 365 days per year.
• Has multiple residential and non-residential sites.
• Primarily serves children and adolescents who have severe psychiatric and behavior disorders and who sometimes act in a manner that is dangerous to themselves or others.
• Holds the safety and security of students, clients and staff as our highest priority.

Given these conditions and priorities, it is necessary to have numerous people at the agency and campus levels who are authorized to intervene whenever conditions pose an immediate threat to life or health (such as a chemical spill, gas leak) or threaten damage to buildings or equipment (such as water leaks, electrical power system malfunction). Additionally, the agency clearly communicates by word and deed that there is a preference and an expectation for authorized persons to act proactively, preventively, and decisively in high risk situations.

The following people are authorized and expected to intervene in such cases.
1. Agency level
The Director of Quality Assurance
Any member of the Senior Management Team (i.e., Senior Managers and department heads)
The Director of Facilities
2. Campus level
Program Director
Any campus administrator/department head
Direct care Supervisors (who run all shifts each day)
Any member of the campus Environment of Care Committee.

Finally, as noted above, Hillcrest considers safety management to be an interactive process involving all staff members. Each staff member, regardless of position or role, is trained and expected to be vigilant and proactive with regard to safety and security in order to maximize the therapeutic and protective nature of the Hillcrest environment for students and clients.

While all Hillcrest employees are expected to attend to matters of safety and security, and while the Board of Directors and the President/CEO are ultimately responsible for safety at Hillcrest, the following persons and groups are responsible for the implementation and monitoring of the Safety Management Plan.
1. Agency level
At the agency level, safety management is the responsibility of the agency Director of Quality Assurance and the Hillcrest Senior Management Team, which is comprised of Senior Managers, Program Directors and department heads.
2. Campus/program level
At the campus/program level, safety management is the responsibility of the campus Program Director, and their delegates (including other campus administrators and the direct care Supervisors who run shifts each day), and campus Environment of Care Committees. Campus Environment of Care Committees are multi-disciplinary groups that meet at least six times each year with a focus on safety and security in the environment of care. The campus Environment of Care Committee reports to the campus’ IOP Committee, which is comprised of the campus’ multidisciplinary leadership and which is focused on systematically improving care, treatment and general operations, including environment of care. The Environment of Care Committee regularly reports to the IOP Committee, which in turn reports quarterly and annually to the Senior Management and the Board of Directors on performance issues, including safety and security.

Hillcrest Policies and Procedures are available in all departments at all times. However, policies and procedures related to safety are distributed to all departments for purposes of review and revision as needed, and the Safety Management Plan is reviewed annually, and revised as needed, as noted in section XII. below.

New staff are oriented to Safety policies and procedures during New Staff Orientation, and training in procedures related to safety, security and emergency management and response is provided on a quarterly basis.

As noted, HEC conducts an Infection Control Program and has a Continuity of Operations Plan (COOP), as required by the state of Massachusetts.

Each Hillcrest site has one or more Automated External Defibrillator, and staff are trained in proper AED utilization.