The Wisconsin F 60953 form is a comprehensive document crafted by the Department of Health Services in the state of Wisconsin, particularly by the Division of Quality Assurance. It serves as a vital resource for the Adult Family Home Fire Safety Guide, tailored to ensure the safety and compliance of adult family homes with the fire safety standards outlined in Wis. Admin. Code ch. DHS 88. Although its use is not mandatory, this form plays a crucial role in assisting applicants, licensees, and surveyors in evaluating compliance with fire safety requirements. The form encompasses a series of questions spanning various safety aspects, such as hazard-free environments, multiple means of exit, the specific needs of residents with mobility challenges, written and practiced fire evacuation plans, and the presence and maintenance of smoke detectors and fire extinguishers. Moreover, it addresses the condition and code compliance of electrical systems, heating equipment, and chimney inspections to prevent fire-related incidents. The Wisconsin F 60953 form, last revised in December 2015, not only prioritizes the immediate safety concerns but also encourages ongoing review and improvements by including assessments and documentation requirements for fire safety protocols. Its detailed sections on smoke detection system criteria and fire extinguisher specifications reflect the state's commitment to resident safety in adult family homes.
| Question | Answer |
|---|---|
| Form Name | Wisconsin Form F 60953 |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | F60953 adult family home forms |
DEPARTMENT OF HEALTH SERVICES |
STATE OF WISCONSIN |
Division of Quality Assurance |
Wis. Admin. Code ch. DHS 88 |
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ADULT FAMILY HOME FIRE SAFETY GUIDE |
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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 |
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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
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.]
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YES |
NO |
FIRE SAFETY |
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21. Has the licensee evaluated the new resident using the DQA form,
22. Has the licensee evaluated each resident annually for evacuation time using DQA form,
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?
YES |
NO |
SMOKE DETECTION SYSTEM |
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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.]
YES |
NO |
FIRE EXTINGUISHER |
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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)]