Form 5604, HCS Program Provider Request for Life Safety Inspection

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Documents

Effective Date: 4/2014

Instructions

Updated: 4/2014

Purpose

Home and Community-based Services (HCS) program providers complete Form 5604 to request life safety inspections when the local fire safety authority and the Texas State Fire Marshal’s Office are unable or unwilling to perform an inspection for certification of an HCS four-bed home.

Procedure

An HCS program provider completes and submits this form when the local fire safety authority (fire marshal of the municipality, county or emergency services district) and the Texas State Fire Marshal’s Office refuse to inspect the home. The HCS program provider must include documentation to support the assertion that both the local fire authority and State Fire Marshal’s Office have refused.

The program provider submits the completed request form to the Survey Operations Architectural Unit by one of the methods indicated at the bottom of the form.

Detailed Instructions

Date — Enter the date of the request.

Program Provider

Name — Enter the name of program provider.

Mailing Address — Enter the complete current mailing address for the program provider.

Telephone Number — Enter the area code and telephone number for the program provider.

Fax Number — Enter the area code and fax number for the program provider.

Provider Contact

Name — Enter the name of the person who will act as the contact for the program provider.

Telephone Number — Enter the area code and telephone number of the person who will act as the contact for the program provider.

Cell Phone Number — Enter the area code and cell phone number of the person who will act as the contact for the program provider.

Residence to Be Inspected

Street Address/City/ZIP Code — Enter the street address, city and ZIP code of the residence.

Location Code — Enter the program provider-assigned location code for this location.

Type of Inspection Requested — Check the appropriate box, indicating the type of inspection requested.

Initial — Check this box if requesting an initial inspection for a home that is not currently certified as a four-bed home. If checking this box, also check one of the boxes below.

Conversion (3- to 4-bed, or dwelling to 4-bed) — Check this box if the initial inspection is for certification of a four-bed home that is currently certified as a three-bed home or is currently a one- or two-family dwelling.

New Construction — Check this box if the initial inspection is for certification of a newly constructed building that has never been occupied for any purpose.

Annual — Check this box if requesting an inspection for a home that is currently certified as a four-bed home.

Reinspection — Check this box if requesting a reinspection after a home has failed an initial or annual inspection.

Level of Evacuation Capability — When requesting an annual inspection for a four-bed home certified for four beds before Nov. 8, 2012, provide the level of evacuation capability, as determined using the methods outlined in NFPA 101A, Guide on Alternative Approaches to Life Safety, for the current four individuals residing in the home.

Prompt — Check this box when the evacuation capability score (e-score) is less than or equal to 1.5.

Slow — Check this box when the evacuation capability score (e-score) is greater than 1.5 and less than or equal to 5.0.

Impractical — Check this box when the evacuation capability score (e-score) is greater than 5.0.

  • The evacuation capability shall be determined for the individuals residing in a given home who are living as a group and are provided with staff assistance.
  • The method of determining evacuation capability set forth in NFPA 101A has been designed to minimize speculation about how an individual might perform in an actual fire emergency by using ratings based on observed performance. Instead of speculating, raters who are not familiar enough with the individual to provide ratings confidently should consult with staff who have observed the individual on a daily basis.
  • Determining a home’s evacuation capability is not simply a matter of timing a fire drill in the middle of the day. Many variables affect an individual’s capability to evacuate, and these variables must be carefully considered and factored into the evacuation capability determination.
  • Time of Day. An individual’s ability to evacuate might be slowed dramatically when the individual must be awakened. In such a situation, the individual must process the information that evacuation is necessary and then begin evacuating.
  • Medication. Many individuals take medications. Individuals who are medicated might need additional assistance in responding and evacuating.
  • Mobility and Location of Occupants. Once individuals become aware of an emergency and take action, their ability to move through the building must be considered. Individuals using wheelchairs, walkers or canes are further slowed when using stairs or ramps or when opening doors.
  • Staff Assistance. Staffing levels should be considered, especially where high individual-to-staff ratios exist. Given the additional needs mentioned in the three variables above, the staff will be limited in their ability to affect evacuation time where multiple individuals need assistance.
  • The evacuation capability of the population of a home might vary over time. The evacuation capability determination should be reviewed regularly to ensure that it accurately represents the current evacuation capability of the individuals and staff.
  • www.nfpa.org or 1-800-344-3555.

Fire Protection System Status

Home is equipped with fire sprinklers — Check this box if the home is equipped with a fire sprinkler system.

Home is not equipped with fire sprinklers — Check this box if the home is not equipped with a fire sprinkler system.

Attachments — The rules regarding Life Safety Code certification are not intended to allow a program provider to circumvent or override the requirements or decisions made by local fire safety authorities. A program provider may only request a life safety inspection from the Texas Health and Human Services Commission (HHSC) when both the local fire safety authority and the State Fire Marshal’s Office are unable, unwilling or refuse to perform an inspection of a home. Documentation must be provided to support this assertion.

Local fire safety authority refusal to inspect home — Check this box if the local fire safety authority refuses to inspect the home. The program provider must attach documentation that the local fire safety authority has refused to inspect the home.

State Fire Marshal’s Office refusal to inspect home — Check this box of the State Fire Marshal’s Office refuses to inspect the home. The program provider must attach documentation that the State Fire Marshal’s Offices has refused to inspect the home.

  • A program provider requesting a life safety inspection from HHSC as the fire safety authority must submit documentation that both the local fire safety authority, if one exists, and the State Fire Marshal’s Office have refused to inspect the home.
  • Many local fire safety authorities and the State Fire Marshal’s Office charge a fee for inspections. A program provider may not request an inspection from HHSC to avoid paying a fee for the inspection.
  • Fire prevention codes adopted by local fire safety authorities have many and varied requirements based on which code, edition and occupancy classification the local fire safety authority applies. A program provider may not request an inspection from HHSC to avoid complying with the requirements set forth by local fire safety authorities.
  • Even though HHSC will inspect a home using the same code the State Fire Marshal’s Office uses, HHSC may or may not apply the code in the same way as the State Fire Marshal’s Office. A program provider may not request an inspection from HHSC to avoid complying with the requirements of the State Fire Marshal’s Office.
  • HHSC will review documentation submitted by program providers requesting an inspection by HHSC. HHSC will contact the local fire safety authority and the State Fire Marshal’s Office to confirm that those agencies refused to perform an inspection.

  • Documentation supporting the refusal by the local fire safety authority and the State Fire Marshal’s Office may include, but is not limited to, the following documents:

    • Form 5606, Life Safety Code Certification, signed by the entity and indicating refusal to complete the home inspection;
    • an email sent by the entity that indicates refusal to complete the inspection;
    • a letter from the entity that indicates refusal to complete the inspection; or
    • certification from the program provider that includes the name of the contact person for the entity that refused to complete the home inspection and the date that the entity refused to complete the inspection.