Ministry of the
Solicitor General

OFM - TG-02-1999: Fire Safety Planning for Institutional Facilities

OFM Guideline

Office of the Fire Marshal

OFM logo



August 1999

The reproduction of this guideline for non-commercial purposes is permitted and encouraged. Permission to reproduce the guideline for commercial purposes must be obtained from the Office of the Fire Marshal, Ontario.




1.0 Definitions

2.0 Background

3.0 Developing The Fire Safety Plan
3.1 Fire Safety Planning
3.2 Fire Safety Responsibilities
3.3 Auditing Your Building
3.4 Contents Of The Fire Safety Plan
3.5 Submission Procedures

4.0 Supervisory Staff
4.1 Appointment And Organization Of Supervisory Staff
4.2 Responsibilities Of Supervisory Staff In Fire Safety
4.3 General Fire Procedures For All Staff
4.4 Sample Responsibilities Of Staff Members During A Fire Emergency

5.0 Control Of Fire Hazards

6.0 Maintenance Of Building Facilities And Fire Protection Equipment
6.1 Instructions On The Use Of Fire Safety Systems Provided In The Building
6.2 Alternate Measures For Temporary Shutdown Of Fire Protection Equipment Or Systems

7.0 Other Features
7.1 Fire Drills
7.2 Stairwell And Floor Identification
7.3 Signage
7.4 Fire Safety Committee

8.0 Fire Safety Plan Distribution/Implementation


Appendix A:Sample Building Audit Forms

Appendix B:Sample Building Human Resources Audit Form

Appendix C:Sample Fire Drill Log

Appendix D:Sample Staff Training Log

Appendix E:Sample Emergency Instruction Signs for Patients/Residents and Visitors

Appendix F:Sample Schematic Drawing



July, 1999
OFM Section: Fire Safety Standards at (416) 325-3100

The reproduction of this guideline for non-commercial purposes is permitted and encouraged. Permission to reproduce the guideline for commercial purposes must be obtained from the Office of the Fire Marshal, Ontario.


This guideline is intended to assist owners, managers and staff of institutional facilities to develop and implement effective Fire Safety Plans. Examples of fire safety responsibilities and procedures are provided for owners and staff for use in creating their own Fire Safety Plans. A discussion of the maintenance and use of building safety features and fire protection equipment and fire drills is also provided.

Additional Appendix material is also provided to illustrate examples of Fire Safety Plans, audit forms, fire drill logs, training logs, signage and schematic drawings.


Except for headings, the words and terms used in this guideline that are in lower case bold lettering have the meanings noted below. With the exception of institutional occupancy, single stage fire alarm system and two stage fire alarm system, these meanings are consistent with the definitions found in the 1997 Fire Code.

Alarm Signal: an audible signal transmitted throughout a zone or zones or throughout a building to advise occupants that a fire emergency exists.

Alert Signal: an audible signal to advise designated persons of a fire emergency.

Approved: means approved by the Chief Fire Official.

Check: means visual observation to ensure the device or system is in place and is not obviously damaged or obstructed.

Chief Fire Official: the assistant to the Fire Marshal who is the Municipal Fire Chief or a member or members of the fire department appointed by the Municipal Fire Chief under Subsection 1.1.8. (of the Ontario Fire Code) or a person appointed by the Fire Marshal under Subsection 1.1.8.

Inspect: means physical examination to determine that the device or system will apparently perform in accordance with its intended function.

Institutional Facility: a building or part thereof used by persons who require supervisory care, medical care or medical treatment. Examples are hospitals, nursing homes and homes for the aged that are licensed by the province of Ontario. (NOTE: For the purposes of this guideline, institutional facilities are limited to Group B, Division 2 occupancies, which are referred to as "care and treatment occupancies" in the 1997 Ontario Building Code.)

Owner: any person, firm or corporation having control over any portion of the building or property under consideration and includes the persons in the building or property.

Single Stage Fire Alarm System: a fire alarm system designed so that activation of any alarm initiating device (i.e. manual pull station, smoke or heat detector, etc.) will cause a general evacuation alarm signal to sound on all audible signal appliances throughout the building.

Supervisory Staff: those occupants of a building who have some delegated responsibility for the fire safety of other occupants under the Fire Safety Plan and may include the fire department where the fire department agrees to accept these responsibilities.

Test: means the operation of a device or system to ensure that it will perform in accordance with its intended operation or function.

Two Stage Fire Alarm System: a fire alarm system designed so that the activation of any alarm initiating device (i.e. manual pull station, smoke or heat detector, etc.) will cause an alert signal to sound to alert supervisory staff on duty about the fire emergency. Activation of a key switch in a manual pull station at the fire alarm control panel or at the central alarm and control facility will cause an alarm signal to sound throughout a zone, zones or throughout the building. (NOTE: A modified two stage fire alarm system may operate in a different manner than above. For example, upon activation of any alarm initiating device, an alarm signal will sound throughout the zone or zones in which the initiating device is situated. Simultaneously, an alert signal will sound in other predetermined areas or throughout the remainder of the building.)


This guideline has been prepared by the Office of the Ontario Fire Marshal with the assistance of the Ontario Association of Fire Chiefs, Ontario Municipal Fire Prevention Officers Association and the Ontario Nursing Home Association. It is intended to assist owners, managers and staff to develop and implement effective Fire Safety Plans for institutional facilities.

Fire safety is an important responsibility for everyone. However, the consequences of inadequate fire safety planning are especially serious for anyone involved in a group setting for persons receiving institutional care who may be vulnerable due to illness or infirmity. Patients/residents depend on the knowledge, skills and training of the supervisory staff in providing and maintaining a fire safe environment.

Procedures contained in a Fire Safety Plan must be designed specifically for each building. In a fire emergency, if followed properly, the procedures should reduce the risk to life safety for all patients/residents, visitors and staff in the building. To be effective however, a Fire Safety Plan requires the following:

  • commitment by management and supervisory staff to fire safety,
  • a willingness by management to promote fire safety,
  • knowledge of the building,
  • knowledge of the fire safety protection equipment,
  • a clear understanding of the procedures and how to implement them properly,
  • co-operation of supervisory staff to enhance the fire safety of patients/residents.

All institutional facility owners, managers and administrators should have a copy of the Fire Code, Ontario Regulation 388/97, as amended, and the Fire Protection and Prevention Act, 1997. Copies of these documents are available at Publications Ontario, 880 Bay Street, Toronto, M7A 1N8, 1-800-668-9938.

The Fire Code is a provincial regulation made under Part IV of the Fire Protection and Prevention Act, 1997. The Fire Code states that the owner is responsible for carrying out "all provisions of the Code".

In a court of law, the definition of "owner" could be interpreted to mean the person whose name is on title, executive officer of a corporation owning the building, an administrator, a night supervisor/manager or even a maintenance supervisor/manager. Penalties for non-compliance by an individual can be as high as $25,000 per conviction and/or imprisonment for up to one year in jail. Penalties for corporations are a maximum of $50,000 per offence.

Owners, managers, administrators and supervisors of institutional facilities should be intimately familiar with their responsibilities under the Fire Code since contravention of any provision can result in a penalty as listed above.

As required by Section 2.8 of the Fire Code, the owner of an institutional facility is responsible for the preparation of a Fire Safety Plan. In most cases, the Fire Safety Plan can be prepared by an experienced building or maintenance supervisor/manager in conjunction with the manager of the facility. Buildings with elaborate emergency systems may require the assistance of a fire protection consultant. After the plan has been prepared, it must be submitted to the Chief Fire Official for approval.

Once approved, the owner is responsible for implementing the Fire Safety Plan and training all staff in their respective duties. It is also the owner's responsibility to ensure that all visitors and staff are informed of what to do in case of fire or when the fire alarm sounds. During a fire emergency, a copy of the approved Fire Safety Plan shall be available for responding fire department. This may be delivered by hand or, provided in a location approved by the Chief Fire Official, such as a security lock box at the main entrance to the building. This lock box, if approved, shall contain the Fire Safety Plan, master keys and schematic diagrams for the building.

Your Fire Safety Plan is a unique document that must be prepared specifically for your building. All of the procedures in the plan must provide staff with the guidance necessary to ensure the safe evacuation of the patients/residents and visitors from the building.


3.1   Fire Safety Planning

Sentences and of the Fire Code require that an approved Fire Safety Plan be prepared and implemented in all institutional facilities across Ontario. This plan must be approved by the Chief Fire Official in the municipality. To assist the Chief Fire Official in assessing your plan, you need to prepare an audit of all systems and equipment within your facility. The human resources that are available to respond to emergencies are also important to include as part of the planning information. These resources may include nursing staff, food service staff, maintenance staff, housekeeping staff, security staff and others if applicable.

NOTE: When preparing your Fire Safety Plan and assigning staff responsibilities, it is important to note that the presence of any private duty nurses does not qualify as on-site staff.

The plan for your building is a unique document. The preparation and implementation of an approved Fire Safety Plan will ensure the optimum use of all life safety features installed in your building. The complete plan must reflect the various functions within your building and the resources available to your patients/residents. An approved Fire Safety Plan must identify the essential components to ensure an orderly and safe emergency evacuation of all patients, residents and staff under emergency conditions.

In a fire emergency, the prime consideration of any Fire Safety Plan is to ensure that the patients/residents are safe. This often means moving the patients/residents in the immediate fire area to an alternate zone. If the fire cannot be quickly brought under control, patients/residents may have to be moved to an alternate floor or even relocated to another building. The extent of fire development, building layout, weather conditions, the state of health of the patients/residents and other factors will dictate the need to relocate patients/residents, some almost immediately.

Relocation arrangements for patients/residents must become a set of established, pre-planned options, especially when it becomes necessary to evacuate a building due to fire or other emergency. The relocation arrangements for the patients/residents need to address the length of time that alternate accommodation may be required. This may vary from as little as a few hours to as long as several months.

In addition to alternate accommodation, it is important for the plan to identify the means of transportation that will be used and the agency that will be providing it. Always ensure that there is sufficient transportation available. When considering the arrangements for the transportation of patients/residents, it is important to recognize that in most situations it will be required on extremely short notice. Most municipal transit authorities will assist with emergency transportation.

3.2   Fire Safety Responsibilities

There are many institutional facility owner responsibilities. Most importantly, an owner must ensure that the following items are addressed in the Fire Safety Plan and are implemented.

  • Establishing and posting the fire emergency procedures on each floor.
  • Appointing, organizing and training supervisory staff to carry out fire safety duties and emergency procedures.
  • Scheduling and co-ordinating regular fire drills.
  • Ensuring that fire hazards throughout the building are identified and eliminated or controlled.
  • Providing alternate measures for fire safety during the temporary shutdown of fire protection equipment or systems.
  • Completing the necessary checks, tests, inspections and maintenance of fire protection equipment as required by the Fire Code.
  • Keeping records of all tests and corrective measures of the above for a period of two years after they are made. When the test frequency is longer than two years, records must be kept for the period of the test interval plus one year. The records shall be available upon request by the Chief Fire Official.
  • Keeping adequate records of all training and fire safety education delivered to patients/residents and staff.

3.3   Auditing Your Building

An audit of the fire safety systems, equipment and resources in your facility must include information on the following features:

  • fire alarm system,
  • exit locations,
  • fire department access,
  • portable fire extinguishers,
  • standpipe and hose systems,
  • automatic sprinkler systems,
  • automatic fire pumps,
  • emergency power & lighting,
  • voice communication systems,
  • smoke control measures,
  • automatic extinguishing systems,
  • firefighters' elevators,
  • water supplies such as private and public hydrants,
  • gas shut-off valves,
  • main power disconnect.

The audit should also include the following additional information:

  • description of building construction (combustible, non-combustible, etc.),
  • building size by area,
  • number of storeys,
  • number of patient/resident rooms,
  • critical care units, surgery rooms and other areas where evacuation may be difficult to initiate without delay,
  • bed capacity,
  • location of corridor smoke barrier doors (zone separations),
  • supervisory staff on each shift by position,
  • names and telephone numbers (including off-duty phone numbers) of the building owner, manager, alternate contact personnel and fire protection equipment service companies.

Compiling this information will ensure that many of the critical elements required to carry out the emergency procedures are accounted for in the plan. Remember to identify the building owner, manager and other alternate contact personnel and the methods to contact them in an emergency (See Appendix A "Sample Building Audit Forms" and Appendix B "Sample Building Human Resources Audit Form").

3.4   Contents of the Fire Safety Plan

Your Fire Safety Plan must include the following information:

  1. Emergency procedures to be used in case of fire including: sounding the alarm; notifying the fire department; provisions for access for fire fighting; evacuating patients/residents; and confining, controlling and extinguishing the fire.  
  2. The appointment and organization of designated supervisory staff by position, with related duties and responsibilities during an emergency. This includes the actions to be taken by supervisory staff in initiating any smoke control or other emergency fire protection systems prior to the arrival of the fire department where applicable.  
  3. The method of training supervisory staff for fire emergencies.  
  4. The method and frequency of conducting fire drills.  
  5. The control of fire hazards throughout the building.  
  6. Detailed maintenance procedures for fire protection systems and building facilities.  
  7. The identification of alternate fire safety measures in case of a temporary shutdown of fire protection equipment or systems so that occupant safety can be assured.  
  8. Floor plans that feature the type, location and operation of fire protection systems, access for fire fighting and all exit facilities.  
  9. Detailed instructions for supervisory staff on the use of any emergency equipment such as the voice communication system, the fire alarm system, smoke control system or emergency power system.  
  10. Procedures for the use of elevators and the evacuation of patients/residents requiring special assistance.  
  11. Established procedures for assisting the fire department in accessing the building, locating the fire and activating or operating smoke control systems and fire protection systems upon request. For large facilities it is recommended that floor plans showing exit locations be posted on each floor.

3.5   Approval Requirements

Once the Fire Safety Plan has been prepared, the facility owner must submit at least one copy of the plan to the Chief Fire Official for review and approval. Additional copies may be submitted in the event that the fire department wishes to retain a copy.

The approval process may require an on-site inspection of the facility by the Chief Fire Official, a designate and/or a pre-fire planning visit by the fire department from the nearest fire station.

After the Fire Safety Plan is approved by the Chief Fire Official, the approval will be noted and the Fire Safety Plan will be returned to the facility owner. A second copy, if provided, may be retained by the fire department for their records.

It is important to remember that the owner is required to notify the Chief Fire Official when changes are necessary to an approved Fire Safety Plan. Some examples of revisions that must be included in an updated plan are:

  • change in facility ownership,
  • the addition of new fire safety equipment,
  • facility renovations, and
  • staffing level changes.


4.1   Appointment and Organization of Supervisory Staff

The effectiveness of a Fire Safety Plan depends upon a number of factors. The most important are the number and mobility of patients/residents and the number of trained staff to respond to the emergency. Other determining factors include fire safety features of the building, combustible loading within the building, and the size and layout of the building.

Individuals preparing the Fire Safety Plan must be familiar with the strategy behind a co-ordinated evacuation. For example, during the early stages of a fire emergency, supervisory staff must conduct certain essential activities including: notifying the fire department, providing access for fire department and co-ordinating the evacuation of endangered occupants. The need to relocate patients/residents to other facilities, if required, will be dictated by the extent of the emergency, the state of health of the patients/residents, the weather conditions and other factors.

Relocation arrangements for patients/residents must become a set of established, pre-planned options with sufficient staff assigned for each option. Staffing arrangements for relocated patients/residents should address the length of time that alternate accommodation may be required. This may vary from as little as a few hours to as long as several months.

Since patients/residents generally have special needs, supervisory staff must be trained in various "lifts and carries techniques" that could be utilized to evacuate patients/residents. In addition, supervisory staff must be familiar with the use of portable fire extinguishers and other equipment that could be utilized in an emergency.

The organization of supervisory staff must be well planned in order to reduce the risks to patients/residents and to the supervisory staff themselves. This is especially true for institutional facilities that provide treatment or care for patients/residents who rely on others to assist them to evacuate. In this type of environment, the efforts of supervisory staff must be well co-ordinated and practised in order to be most effective.

When the fire alarm activates, supervisory staff with defined duties should carry them out immediately. Supervisory staff trained to assist in the evacuation of patients/residents should respond to the area of fire alarm origin. When they arrive, circumstances will dictate their appropriate response. Co-ordinated efforts are necessary to evacuate patients/residents from the immediate fire area to smoke-free floor zones. Where necessary, efforts should also be made to confine and control the fire. This may involve simply closing the door to the room of fire origin and ensuring doors in the floor zone fire separation remain closed until the fire department responds and extinguishes the fire. Further evacuation of patients/residents to lower floors or to the exterior should be co-ordinated with the fire department and other emergency response groups.

It is essential that every organization have supervisory staff trained to respond to a fire emergency in a prompt, positive and effective manner. It is important that every institutional facility have a nucleus of key supervisory staff. This supervisory staff must be prepared through effective training to ensure patient/resident safety is maintained during an emergency.

The need for complete co-operation and understanding between management and staff of the fire safety responsibilities during this emergency is vital. It is the owner's responsibility to ensure that all staff members are trained and familiar with the information in the Fire Safety Plan.

NOTE: An Office of the Fire Marshal guideline OFM-TG-01-98, "Staffing Levels for the Emergency Evacuation of Care and Treatment Facilities" is available to assist with establishing staffing levels for emergency evacuation of care and treatment facilities.

4.2   Responsibilities of Supervisory Staff in Fire Safety

An effective Fire Safety Plan will depend upon the knowledge, experience and commitment of management personnel. Every supervisor/manager must have a clearly defined role and the authority to respond appropriately. All new staff MUST receive training in the Fire Safety Plan before responsibilities can be delegated. Training for all staff members must be organized and should be conducted at least annually (see Appendix D "Sample Staff Training Log").


Owner/Manager Responsibilities in Fire Safety

  • Ensure a Fire Safety Plan is developed, approved and fully implemented. Ensure that the Fire Safety Plan is maintained updated.
  • Ensure a sufficient number of alternates are designated and trained to act in a supervisory capacity in the event that the appointed supervisor/manager is absent from the building.
  • Ensure that all staff receive appropriate training in the use of existing fire protection equipment and actions to take when responding to a fire emergency.
  • Ensure that fire drills involving all staff are held at least monthly. It is advantageous to have these drills activated in various locations at different times. A sufficient number of fire drills must be held to ensure all shift workers participate.
  • Adequate records of all staff training and fire drills must be kept for future reference.


Nursing Manager/Supervisor Responsibilities in Fire Safety

  • Identify and establish a plan for patients/residents who require assistance to evacuate due to physical or mental disabilities.
  • Ensure all hallways and stairwells are kept clear of storage, debris and equipment (such as medication carts, wheel chairs and appliances and tools used by housekeeping and maintenance).
  • Ensure stairwell doors and doors in other fire separations are kept closed except where approved hold-open devices are provided. Do not allow anyone to interfere with the self-closing device on any door.

Food Service Supervisor/Manager Responsibilities in Fire Safety

  • Ensure that cooking equipment and appliances are maintained in good working order.
  • Ensure that all grease filters in hoods and duct systems serving cooking appliances are cleaned regularly.
  • Ensure that the fixed automatic extinguishing systems are maintained and tested in accordance with Part 6 of the Fire Code.

Laundry Supervisor/Manager Responsibilities in Fire Safety

  • Ensure that commercial laundry equipment is maintained in good working order.
  • Ensure that all duct systems and dryer drums are cleaned of lint and combustible residue regularly.
  • Ensure that there is no lint accumulation in the laundry room.
  • Ensure that flammable or combustible liquid saturated rags are only cleaned off-site.
  • Ensure that laundry chemicals are safely stored.
  • Ensure that laundry staff know how to shut down the drying equipment safely in order to prevent foam rubber products from spontaneously heating.

Housekeeping Supervisor/Manager Responsibilities in Fire Safety

  • Ensure that commercial housekeeping equipment is maintained in good working order.
  • Ensure that cleaning chemicals and materials are safely stored.

Maintenance Supervisor/Manager Responsibilities in Fire Safety

  • Ensure that all fire protection equipment and building features such as fire separations, emergency lighting, fire alarm systems, sprinkler systems, standpipe systems, fire extinguishers, fixed extinguishing systems and voice communication systems are checked, tested, inspected and maintained in accordance with Parts 2, 6 and 7 of the Fire Code and all applicable standards referenced therein.
  • Ensure that magnetic locking devices, if installed on exit and access to exit doors, release upon activation of the fire alarm and adjacent manual pull stations.
  • Maintain permanent records of all fire equipment inspections, tests and maintenance as set out in Subsection 1.1.2. of the Fire Code.
  • Access roadways, fire routes, hydrants and pumper connections are accessible to the fire department and are clear of all obstructions (e.g. snow, parked vehicles and shrubs).

NOTE:    Although the responsibilities mentioned above have been assigned to specific positions, the plan needs to be flexible enough so that these responsibilities may be assigned to other staff members based on the size and complexities of your facility.

All supervisory staff must ensure that:

  • They are aware of their responsibilities upon discovery of a fire, or upon hearing the fire alarm.
  • Stairway doors are kept in the closed and latched position at all times.
  • Doors that separate floors into fire safety zones are kept closed and latched at all times, unless designed to close automatically upon activation of the fire alarm.
  • Self-closing devices attached to doors are not disengaged or rendered inoperable.
  • Doors on hold-open devices in fire separations close automatically upon activation of the fire alarm.
  • Stairways, landings, hallways, passageways and exits are kept clear of any storage or other obstructions.
  • Combustible waste and debris accumulations are restricted to designated storage areas within the building.
  • They understand what each type of fire alarm signal means and how to initiate the fire alarm from anywhere in the facility. This also includes activation of the second stage evacuation signal of the fire alarm where provided.
  • Where applicable, they understand the conditions under which they may silence the fire evacuation signal and the procedure by which they may silence and reset the fire alarm system.

4.3   General Fire Procedures for All Staff

If You Discover a Fire or Smoke

Many care and treatment facilities are using the acronym "REACT" to assist staff in following the correct emergency procedures (see next page for details).

The sequence of the steps in the acronym will vary depending upon the circumstances of the fire and the abilities of the responding individuals. For example, activation of the fire alarm could be the initial step upon discovery of smoke or fire, to alert other staff of the danger.


Remove persons in immediate danger if possible
nsure the door(s) is closed to confine the fire and smoke
ctivate the fire alarm system using the nearest pull station
all the fire department and/or notify switchboard
ry to extinguish the fire or concentrate on further evacuation


If You Hear a Fire Alarm Alert Signal

  • Check your floor to make sure the fire is not in your area. If fire in your area, see "REACT" above.
  • Prepare for the assembly and relocation of patients/residents. Ensure that all of the patients/residents who require special assistance are prepared for relocation.
  • Await further instructions.
  • If assigned, assist with the relocation of endangered patients/residents.
  • If assigned, meet arriving fire department and provide them with any necessary information (e.g. location of the fire if known, patients/residents needing assistance to relocate, etc.).


If You Hear a Fire Alarm Evacuation Signal

  • Relocate all patients/residents who are in danger.
  • Co-ordinate the assembly and relocation of all patients/residents.
  • Await further instructions if floor area is in no immediate danger.


4.4   Sample Responsibilities of Staff Members During a Fire Emergency

Owner/Manager Responsibilities During a Fire Emergency

  • Ensure that the fire department has been called.
  • Co-ordinate the evacuation, assembly and relocation of all patients/residents to safe areas of the building.
  • Meet fire department and ensure that they have access to the building and are provided with master keys.
  • Direct fire department to fire alarm panel and central control system and assist them with the operation of these systems.
  • Co-ordinate the transportation of all patients/residents and their personal and medical records to other facilities, if needed.


Switchboard Responsibilities During a Fire Emergency

  • Notify the fire department. Do not depend on the outside fire alarm or security agency to contact fire officials.
  • Provide voice communication messages as instructed by the Fire Safety Plan, management and the fire department.
  • Activate procedures to summon off-site staff to the facility (using "Fan-out List" where implemented). Assist with the evacuation, assembly and relocation of patients/residents, including arranging for alternate accommodation and transportation.


Nursing Manager/Night Supervisor Responsibilities During a Fire Emergency

  • Undertake owner/manager responsibilities if they are not on-site.
  • Supervise and direct the evacuation, assembly and relocation of all visitors and patients/residents.
  • Inform arriving fire department of any patients/residents, visitors or staff who require assistance or rescue.


Maintenance Supervisor/Manager Responsibilities During a Fire Emergency

  • Meet arriving fire department.
  • Upon request, provide fire department with master keys for all areas and rooms in the building.
  • In large facilities, provide floor plans that show the locations of exits and all fire protection equipment.
  • Upon request, direct fire department to the location of the fire alarm and voice communication systems, sprinkler system control valves, natural gas shut-off valves and Hydro disconnects.
  • At the direction of the fire department, initiate any smoke control system, emergency power systems and firefighters' elevators.
  • At the direction of the fire department, transmit special instructions to patients/residents, visitors and staff via the voice communication system.
  • Be available to assist the fire department.


Food Service Supervisor/Manager and Kitchen/Dietary Staff Responsibilities During a Fire Emergency

  • Assist anyone in immediate danger to evacuate the kitchen area.
  • Manually activate the automatic extinguishing system, if required.
  • Shut off electrical and gas equipment, cooking equipment, coffee-pots, etc. in a safe manner.
  • Close doors to the kitchen to confine the smoke and fire.
  • Activate the fire alarm system.
  • Notify the switchboard or fire department of the fire condition.
  • Assist in the assembly and relocation of patients/residents and visitors.


Laundry Supervisor/Manager and Staff Responsibilities During a Fire Emergency

  • Shut off electrical and gas laundry cleaning and drying equipment in a safe manner.
  • Ensure that all doors are closed when evacuating the laundry room.
  • Assist in the assembly and relocation of patients/residents and visitors.


The Fire Safety Plan must contain information on the control of fire hazards. For example, everyone must be aware of the potential fire hazards that can exist throughout the facility. Therefore, it is recommended that a designated staff member perform a weekly walk-through of the entire facility. The walk-through should include at least the common areas, stairwells, storage, electrical and furnace rooms of the building.

Check the following to ensure that potential fire hazards are being controlled:

  • Smoking in institutional facilities should be closely monitored. Smoking by staff, visitors and patients/residents should be restricted to designated areas.
  • Smoking materials, such as cigarette butts and the contents of ashtrays should be disposed of with caution and never into combustible containers.
  • Restrict ignition sources in areas where oxygen is in use.
  • Never dispose of flammable liquids or aerosol cans in garbage chutes.
  • Avoid unsafe cooking practices in kitchen areas, such as deep fat frying and/or unattended stoves.
  • Always keep storage, laundry, furnace and electrical rooms clear of combustible materials.
  • Avoid washing clothing or rags saturated with flammable or combustible liquids in laundry facilities.
  • Do not store any materials or equipment in exit stairwells.
  • All personal electrical appliances used by patients/residents must be closely monitored and must meet CSA Standards.
  • Do not wedge open any fire doors or disengage the self-closing device installed on them.

NOTE: Ensure that visitors to the facility are familiar with the fire safety rules. Where practical, it is recommended that a guest register be used to record visitors received by the patients/residents. The guest register will help to keep track of visitors at all times. The register will also be a valuable source of information during an emergency.


The building owner/manager must:

  • Ensure that all fire protection features and equipment, such as fire separations, smoke control equipment, emergency lighting, fire alarm systems, automatic sprinkler systems, standpipe systems, fire extinguishers, fixed extinguishing systems, voice communication systems, firefighters' elevators and emergency generators are checked, tested, inspected and maintained in accordance with the frequencies specified in Parts 2, 6 and 7 of the Fire Code and all applicable standards referenced in the Fire Code.
  • Maintain records of all fire equipment tests and maintenance as set out in Subsection 1.1.2. of the Fire Code.

The Fire Safety Plan must contain a detailed schedule or list of required checks, inspections and tests of all fire safety systems and features provided in the building.

6.1   Instructions on the Use of Fire Safety Systems provided in the Building

The Fire Safety Plan must contain detailed instructions on the use of:

  • firefighters' elevators,
  • the voice communication system,
  • the fire alarm system,
  • smoke control equipment (if applicable),
  • emergency power system (including the manual operation of the transfer switches if applicable).

6.2   Alternate Measures for Temporary Shutdown of Fire Protection Equipment or Systems

Supervisory staff shall be notified when the fire alarm or voice communication systems are shut down or temporarily out of service.

Article of the Fire Code requires that the fire department be notified of planned temporary shutdowns of sprinkler protection systems for repairs or alterations and their restoration to service again. This includes the shutdown of sprinkler control valves or fire protection water supplies for more than a 24 hour period. The fire department should also be notified of any other fire protection system impairments.

To ensure that fire safety in the building continues under fire protection impairment conditions, a regular fire safety patrol of the building should be established until such time that the fire equipment or system is repaired and returned to service. Persons conducting the patrol must be provided with a means of communication should an emergency arise.

Each tour of the building by the fire safety patrol must be recorded by time and date. As well, any deficiencies noted and any measures taken to correct the deficiencies must also be recorded.

Supervisors/mangers should always have designated alternates to ensure that an incident is handled adequately in their absence. It will be necessary to appoint someone who is familiar with all of the procedures in the building's Fire Safety Plan.


7.1   Fire Drills

Subsection 2.8.3. of the Fire Code requires that procedures for conducting fire drills be implemented in the Fire Safety Plan and that fire drills be held at least monthly.

The importance of being prepared has been stressed throughout this guideline. Due to the nature of the emergency actions required of the staff in a fire or other emergency situation, fire drill practices must become an integral part of staff preparedness.

The purpose of a fire drill is to ensure that all staff are familiar with the building's overall evacuation procedures. Therefore, the owners and managers of institutional facilities must be aware of the benefits of holding monthly fire drills that involve all staff. To maximize the benefits of these fire drills, they should be scheduled and rotated throughout the year in such a way that the personnel on all three shifts employed in the facility participate.

Fire drills can be used to provide additional training for staff by allowing them to become more familiar with use of the building's fire safety systems. Supervisory staff should practise using the emergency voice communication system and other equipment where applicable during these fire drills to gain experience and confidence.

It is very important that all personnel with specific responsibilities attend a debriefing meeting following every practise fire drill. This meeting is held to review the procedures and reactions of all participants. During the debriefing, problem areas can be identified and, if necessary, solutions to overcome any deficiencies in the facility's Fire Safety Plan can be discussed and corrected. The fire department should be consulted on the development of the fire drill procedures.

The date and time of all fire drills, as well as the names of participating staff, should be recorded in the facility's permanent log book (see Appendix C "Sample Fire Drill Log).

7.2   Stairwell & Floor Identification

To avoid confusion when referring to a particular exit stairway during an emergency, every stairway should be designated with a specific letter or colour code. Throughout the building, every stairway should be clearly identified at each floor level, including the basement.

7.3   Signage

Warning signs indicating the direction of travel should be provided in the stairwell to prevent individuals from trying to evacuate to the roof. Signs cautioning individuals to use an alternate exit stairwell or find refuge in the nearest suite/room if they encounter smoke within the stairwell should also be considered (see Appendix E "Sample Emergency Instruction Signs for Patients/Residents and Visitors").

7.4   Fire Safety Committee

Although it is not a requirement of the Fire Code, operators of institutional occupancies should consider establishing a Fire Safety Committee.

The committee should include representation from management, supervisory staff, volunteers and relatives of patients/residents where appropriate.

The committee can assist management and supervisory staff in promoting the importance of fire safety planning and fire prevention. They can emphasize the need for regular fire drills and be key players in providing assistance to ensure that the facility has a viable and effective Fire Safety Plan. The committee can also help to facilitate the delivery of fire safety education programs to staff and patients/residents.

The principle of getting people involved helps to promote the importance of fire safety as it generates the necessary input from concerned employees, patient/resident relatives and volunteers.


Once approved, the Fire Safety Plan must be implemented and kept in the building in a location acceptable to the fire department.

A copy of the plan must be made available to the following:

  • institutional facility owner and manager,
  • supervisor/manager of administration staff,
  • supervisor/manager of nursing staff,
  • supervisor/manager of dietary staff,
  • supervisor/manager of maintenance staff,
  • supervisor/manager of Housekeeping, and
  • supervisor/manager of Laundry Services.

A copy of the fire emergency procedures and other supervisory staff duties as prescribed in the Fire Safety Plan should be given to all supervisory staff. It may also be appropriate to have sections of the plan posted in staff work areas, lunchrooms and any information bulletin boards provided for visitors and patients/residents.




Appendix A


Building Audit Forms

Sample Building Evaluation Form


Building Name:    


Phone #    



Phone #    


Phone #    


Maximum number of patients/residents:

Total -    

Nonambulatory -   



Under Legal Restraint -    


Relocation Facility


Building Address:    


Phone #    


Emergency Transportation


Company Name:    



Phone #    

Company Name:    

Type of Vehicles:    


This audit is designed to gather and record specific construction information about the building.


Height / Area:



Building Area:    

Building Height:    

Number of Floors    


Type of Construction:










Number of Basement Levels    





Floor Construction:







Roof Construction:






Flat      Gable    




Interior Finishes:







Fire Separation:





Patient/Resident Sleeping Rooms    

Zone Separations

yes __

no __

Date of Construction    

Date of Major Renovations    



The following pages of this Appendix can be used to provide a description of the fire safety equipment installed in the building including:

  • Fire Alarm and Detection Systems
  • Central Station Connection (Fire Alarm System Monitoring)
  • Standpipe Systems
  • Sprinkler Systems
  • Portable Fire Extinguishers
  • Automatic Extinguishing Systems
  • Emergency Lighting
  • Building Emergency Generator
  • Exits from Floor Areas
  • Fire-fighters' Elevators
  • Smoke Control Equipment

To provide information on the location of other building equipment, refer to Appendix F "Sample Schematic Drawing".


Sample Audit of Building Resources

Fire Alarm and Detection System:

Manufacturer:       _______

Model:       _______

Type:            single-stage    _______               two-stage   _______                other       _______    

Primary Power Supply:       _______

Secondary Power Supply:       _______

Location of Main Panel:       _______

Location of Annunciator Panel(s):       _______

Location of Manual Pull Stations:       _______

Location of Second Stage Initiating Devices and Keys:       _______

Location of Alarm Signal Zones (Floors, Wings etc.):       _______

Central Station Connection (Fire Alarm System Monitoring):    

Name of Monitoring Company:       _______
Address:       _______
Telephone:       _______

Standpipe and Hose System:

Provide details on:

• the size and location of fire hose connections        _______

• the size and location of hoses in hose cabinets        _______

• fire department pumper connection(s)        _______

• location of fire protection system isolation valves        _______

Sprinkler System:    

Provide details on:

• sprinkler system type     Wet    _______    Dry    _______

• size of main and risers       _______

• location of main and isolation control valves       _______

• fire department connection       _______

• system coverage Full     _______   Partial        _______

If partial coverage, describe sprinklered areas:       ____________________




Portable Fire Extinguishers:


Floor Location


Pressurized Water









Multi-Purpose Dry Chemical





















Standard Dry Chemical









Carbon Dioxide







Automatic Kitchen Extinguishing System(s):

Name of Company:    
Extinguishing Agent:    
Location of Manual Pull-Handle:   
Type of Fuel for Cooking:    

Automatic Fuel Shut-Off:         Yes    No    

Hood and Duct System:    

Emergency Lighting (Battery Type):





Building Emergency Generator:

Provided Yes     No    
Equipment Fuel    
Make and Model of Emergency Generator    

Is emergency power provided to all elevator cars simultaneously? Yes    No    
Is emergency power provided to firefighters' elevator?  Yes     No    
Is emergency power provided to smoke control pressurization fans? Yes    No    
What other systems are provided with emergency power?    




Exits from all Floor Areas:

Basements -
Number of Exits Available    
Location of Exits and Area Served:

Ground Floor -
Number of Exits Available    
Location of Exits and Area Served:

Typical Floor Above Grade -
Number of Exits Available    
Location of Exits and Area Served:

Underground Garage -
Number of Exits Available    

Mechanical Penthouse -
Number of Exits Available    

Firefighter's Elevators:

Installed:  Yes     No    
Complies with Ontario Building Code (OBC):   Yes    No    
Complies with Ontario Fire Code (OFC):  Yes     No    
Labelled OBC red     or OFC yellow    
Keys are provided at    

Smoke Control System:

Stairwell Pressurized   Yes __ No __
Elevator Shaft Pressurized    Yes __ No __
Smoke Shafts    Yes __ No __

Other Information:    






Appendix B


Building Human Resources
Audit Form


Sample Audit of Human Resources

Appointed Supervisory Staff consist of the following:

Day Shift

Evening Shift

Night Shift










Nursing Staff




Building Maintenance




Dietary Supervisor/Manager




Dietary Staff




Activity Director




Housekeeping Staff




Emergency fire co-ordination will be carried out by the building's administrator. When the administrator is not present in the building, the Emergency Fire Co-ordinator will be one of the following:

Day Shift:

Nursing Staff


Evening Shift:

Nursing Staff


Night Shift:

Nursing Staff


Week-End and Holiday Shifts

Nursing Staff




Appendix C

ctor with patient

Fire Drill Log

Fire Drill



Time: (Start)    


Conducted By:    

Staff Attending







Outside Agency Attending







 Fire Drill Results




Comments / Recommendations
















Appendix D


Staff Training Log























TEST RESULTS (If provided):   




Appendix E

gn post

Instruction Signs For
And Visitors


 exit at roof

No. 1: Recommended sign to be Used throughout exit stairs

 exit beyond this point

No. 2: Recommended sign inside

If you encounter
Go to
Or find refuge in the

No 3: Recommended wording for signs In corridors and/or exit stairs

commended wording for signs In corridors and/or exit stairs



Appendix F

eometry set

Schematic Drawing

ample schematic drawing