This federal Condition of Participation requires outpatient physical therapy clinics, rehabilitation agencies, and public health agencies to include fire safety provisions in their emergency preparedness plans, specifically addressing the location and use of alarm systems and fire containment methods. Operators must document procedures aligned with NFPA guidelines and be prepared to demonstrate these to surveyors. This regulation governs physical therapy and speech-language pathology outpatient organizations, not behavioral health facilities.
View official sourceE-0010 (Rev. 204, Issued: 04-16-21; Effective: 04-16-21, Implementation: 04-16-21) §485.727(a)(4) Condition for Participation: [(a) Emergency Plan. The Clinics, Rehabilitation Agencies, and Public Health Agencies as Providers of Outpatient Physical Therapy and Speech-Language Pathology Services (“Organizations”) must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (4) Address the location and use of alarm systems and signals; and methods of containing fire. Interpretive Guidelines for §485.727(a)(4). The Organizations’ emergency plan must address the location and use of alarm systems and signals. The plan must also include the methods used for containing fires, such as fire extinguishers, sprinkler systems and other current methods used. The National Fire Protection Association (NFPA) at section A.20.1.1.1.6, recognizes that certain functions necessary for the life safety of building occupants, such as the closing of corridor doors, the operation of manual fire alarm devices, and the removal of patients from the room of fire origin, require the intervention of facility staff. Therefore, the plan should follow guidelines set forth by the NFPA. Survey Procedures • Ask facility leadership to show the section of the plan which addresses location(s) and use of fire alarms. • Ask facility staff to describe the facility’s current procedure for containing fires.