The Wisconsin F 60953 form is a fire safety guide designed to help adult family homes ensure compliance with fire safety requirements set forth in Wisconsin Administrative Code Chapter DHS 88. This form assists applicants, licensees, and surveyors in evaluating the safety measures implemented within the home. While completing this form is not mandatory, it serves as a valuable tool for maintaining a safe living environment.
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The Wisconsin F 60953 form serves as a crucial tool for ensuring fire safety in adult family homes. This guide assists applicants, licensees, and surveyors in evaluating compliance with fire safety requirements outlined in Wisconsin Administrative Code Chapter DHS 88. While the use of this form is not mandatory, it provides a structured approach to assess various safety measures. Key areas covered include the presence of hazards, evacuation plans, and the functionality of smoke detectors and fire extinguishers. The form prompts users to verify that homes are free from dangerous substances and that residents can easily exit in an emergency. It also emphasizes the importance of regular inspections and maintenance of heating systems and smoke detection equipment. By following the guidelines set forth in this form, adult family homes can enhance the safety and well-being of their residents, ensuring a secure living environment.
What is the purpose of the Wisconsin F 60953 form?
The Wisconsin F 60953 form serves as a guide to help adult family home applicants, licensees, and surveyors ensure compliance with fire safety requirements as outlined in the Wisconsin Administrative Code, Chapter DHS 88. Although using this form is not mandatory, it provides a structured way to assess fire safety measures within the home.
Who should complete the F 60953 form?
The form should be completed by the licensee or an authorized representative of the adult family home. This may include someone responsible for overseeing the facility's operations or safety compliance. It is important that the individual completing the form is familiar with the fire safety requirements and the specific layout of the home.
What are the key fire safety requirements listed in the form?
The form outlines several critical fire safety requirements, including:
Are there specific requirements for smoke detectors?
Yes, the form specifies that smoke detectors must be installed on each floor, in habitable rooms (excluding kitchens and bathrooms), at stairway entrances, and in basements. Additionally, each smoke detector must be maintained in working condition, and monthly testing should be documented to ensure functionality.
What should be done if a fire occurs in the home?
If a fire occurs that requires the assistance of the fire department, the licensee must inform the licensing agency within 72 hours. This ensures that the incident is documented and that any necessary follow-up actions can be taken to improve safety measures.
How often should fire extinguishers be inspected?
Fire extinguishers should be inspected annually by an authorized dealer or the local fire department. Each extinguisher must have a tag attached that indicates the date of the last inspection. Regular maintenance ensures that the extinguishers are in good working condition and ready for use in case of an emergency.
What happens if a resident cannot evacuate without assistance?
For residents who cannot evacuate on their own, the licensee must have a plan in place. This includes evaluating the resident's evacuation time and ensuring that a staff member is present in the home at all times to assist them. The licensee must also communicate any special needs related to evacuation to all service providers working on the premises.
Is there a requirement for maintaining the home’s electrical system?
Yes, the home's electrical system must meet local building codes. This is crucial for ensuring the safety of all residents, as a compliant electrical system minimizes the risk of electrical fires and other hazards.
The Wisconsin F 60953 form is a helpful guide for ensuring fire safety in adult family homes.
Completing the form is not mandatory, but it can assist applicants, licensees, and surveyors in meeting safety requirements.
Make sure to provide accurate information, including the facility name, address, and the person completing the form.
Review all fire safety questions carefully. They cover essential areas such as evacuation plans, smoke detectors, and fire extinguishers.
Document any fire drills conducted and keep records of evacuation times for residents.
Ensure that smoke detectors are installed on every floor and in key areas like bedrooms and living rooms.
Fire extinguishers should be accessible on each floor and inspected annually to ensure they are in working condition.
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DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Quality Assurance
Wis. Admin. Code ch. DHS 88
F-60953 (12/2015)
Page 1 of 2
ADULT FAMILY HOME FIRE SAFETY GUIDE
This guide can be used to assist the applicant, licensee, and surveyor to determine compliance with the fire safety requirements of Wis. Admin. Code ch. DHS 88. This form is not mandatory.
Name – Facility
Address
City
State
Zip Code
Name – Licensee
County
Name – Person Completing This Form
Date Completed (MM/dd/yyyy)
YES
NO
FIRE SAFETY
1. Is the home free from hazards and kept uncluttered and free of dangerous substances? [DHS 88.05(3)(b)]
2. Does the home have at least two means of exiting that provide unobstructed travel to the outside? [DHS 88.05(4)(c)1.]
3. Does the home have exits ramped to grade, with a hard surfaced pathway with handrails, if a resident is not able to walk at all, or able to walk only with difficulty, or only with the assistance of crutches, a cane, or walker, or is unable to easily negotiate stairs without assistance? [DHS 88.05(2)(a) and (a)1.]
4. Does the licensee have a written plan for the immediate and safe evacuation of all occupants of the home in the event of a fire? [DHS 88.05(4)(d)1.]
5. Does the fire evacuation plan identify an external meeting place? [DHS 88.05(4)(d)1]
6. Does the licensee review the fire safety evacuation plan with each new resident immediately following placement? [DHS 88.05(4)(d)2a.]
7. Does the licensee conduct semi-annual fire drills with all household members with written documentation of the date and evacuation time for each drill maintained by the home? [DHS 88.05(4)(d)2c.]
8. Is the licensee or service provider in the home at all times when a resident who is incapable of self evacuation is present in the home? [DHS 88.05(4)(f)]
9. Does the home have the telephone number for the fire department located on or near each telephone? [DHS 88.05(5)]
10. Are the residents able to easily enter and exit the home? [DHS 88.05(2)]
11. Does any resident who is unable to easily negotiate stairs without assistance have his or her bedroom, toilet and bathing facilities and all common living areas on the first floor? [DHS 88.05(2)(d)]
12. If any resident is not able to walk at all, do exit and interior doors have a clear opening of at least 32 inches? [DHS 88.05(2)(a)2.]
13. If there is any resident in the home who has either manual strength or dexterity limitations, does the home have levered handles on all doors normally used by that resident if these can be replaced and if replacement is readily achievable? [DHS 88.05(2)(c)]
14. Does the home electrical system meet the local building codes? [DHS 88.05(3)(c)]
15. Is there a condition or occurrence relating to the operation of the home that directly threatens the safety of a resident? [DHS 88.03(6)]
16. Has the oil furnace been inspected and serviced every 2 years by a heating contractor? [DHS 88.05(3)(e)2a.]
17. Has the gas furnace been inspected and serviced every 3 years by a heating contractor? [DHS 88.05(3)(e)2b.]
18. Has the chimney been visually inspected by the inspector who inspected the gas or oil furnace? [DHS 88.05(3)e)2c.]
19. If the home has a wood burning stove or fireplace, is there a flue separate from the one used by a gas or oil furnace? [DHS 88.05(3)(e)2d.]
20. If “yes” to number 19, has the flue been cleaned as often as necessary, but not less than two (2) times during each heating season? If this wood burning stove or fireplace is used no more than four days each month of the heating season, has the flue been cleaned at least during each heating season?
[DHS 88.05(3)(e)2d.]
Page 2 of 2
21. Has the licensee evaluated the new resident using the DQA form, F-62372, CBRF Resident Satisfaction Evaluation, to determine whether the resident is able to evacuate the home without any help within two minutes? [DHS 88.05(4)(d)2a.]
22. Has the licensee evaluated each resident annually for evacuation time using DQA form, F-62373, Resident Evacuation Assessment? [DHS 88.05(4)(d)2b.]
23. Has the licensee made all service providers who work on the premises aware of each resident having an evacuation time of more than two minutes? [DHS 88.05(4)9c)2b.]
24. If there was a fire in the home, which required the assistance of the fire department, did the licensee inform the licensing agency within 72 hours of the occurrence? [DHS 88.05(4)(e)]
25. Has the clothes dryer(s) in the home been properly vented in accordance with manufacturers’ recommendations?
SMOKE DETECTION SYSTEM
26. Does the home have one or more single station, battery operated, electrically interconnected or radio signal emitting smoke detectors on each floor level? [DHS 88.05(4)(b)1.]
27. Is there a smoke detector located in each habitable room, except the kitchen and bathroom? [DHS 88.05(4)(b)1.]
28. Is there a smoke detector at the head of each open stairway? [DHS 88.05(4)(b)1.]
29. Is there a smoke detector at the door leading to every enclosed stairway? [DHS 88.05(4)(b)1.]
30. Is there a smoke detector on the ceiling of the living room or family room? [DHS 88.05(4)(b)1.]
31. Is there a smoke detector on the ceiling of every sleeping room? [DHS 88.05(4)(b)1.]
32. Is there a smoke detector in the basement? [DHS 88.05(4)(b)1.]
33. Has the licensee maintained each required smoke detector in working condition? [DHS 88.05(4)(b)2.]
34. Has the licensee documented that each smoke detector was tested monthly to make sure it is operating? If a unit is found to be not operating, the licensee is to immediately replace the battery or have the unit repaired or replaced. [DHS 88.05(4)(b)2.]
FIRE EXTINGUISHER
35. Is there a fire extinguisher on each floor? [DHS 88.05(4)(a)]
36. Does each fire extinguisher have a minimum 2A, 10B – C rating? [DHS 88.05(4)(a)]
37. Is each fire extinguisher mounted? [DHS 88.05(4)(a)]
38. Is there a fire extinguisher at the head of each stairway? [DHS 88.05(4)(a)]
39. Is there a fire extinguisher located in or near the kitchen? A single fire extinguisher in close proximity to the kitchen and the head of a stairway may be used to meet the requirement for an extinguisher at each location. [DHS 88.05(4)(a)]
40. Is the fire extinguisher maintained in readily usable condition? [DHS 88.05(4)(a)]
41. Is the fire extinguisher inspected annually by an authorized dealer or the local fire department with an attached tag showing the date of the last dealer or fire department inspection? [DHS 88.05(f)(a)]