Are the residential care facilities in your response district up to code? If so, are they safe? As we all know, a myriad of codes—determined by the type of residence and the level of care it provides—apply to these structures. In some cases, the requirements differ even though the residents within the facilities covered share many of the same symptoms and characteristics.

of facilities. Working within the realities of the current situation, however, we at NeuroCare, a system of rehabilitation centers that provide post acute care for individuals who have suffered head injuries, have committed ourselves to promoting safety for our

Ideally, sprinklers and operable smoke detectors for all hidden voids should be incorporated in these types brain-injured clients (and our staff) in a practical manner. We have taken an approach that is consistent with our objective of preparing our clients to develop the level of life skills that will enable them to become reintegrated into the community.

A head injury is a tremendous insult to the brain, and its presence is not always obvious, as is the case when there is an open wound. An individual in an automobile accident who is wearing a seat belt, for example, can suffer an impact injury: The brain of an individual traveling in a car going 55 mph can slam into the front of the skull when the car is forcibly jolted. Impairments in speech, vision, hearing, memory, concentration, emotions, and other functions may not be immediately evident to rescue teams at the accident scene. Individuals who have suffered this type of injury sometimes are referred to as the “walking wounded,” and they constitute the population at our NeuroCare center and similar facilities.

We found that the code requirements governing this type of facility— although helpful —have little practical safety value for these individuals. We also noted that the impaired thinking processes of our clients could increase the potential for fatalities in emergencies that create high carbon monoxide releases (which cause confusion even for populations who do not have thinking impairments) and generate significant levels of toxins, such as those generated by today’s building materials and home furnishings.

NeuroCare, consequently, made a commitment to a practical and realistic fire and life safety program that could improve the safety of those at the facility. We chose policies and procedures that conform to code and licensing requirements and set out to back them with practical and meaningful activities that ultimately would translate into improved safety for all at the facility. We instituted a weekly “survival skills” therapy group in which clients were taught how to participate in “home” safety checks, emergency procedure plans, and emergency supply checks and to prepare for events such as fires and earthquakes.


Some of the components of our life safety program are listed below:

  • A staff member on each shift is designated as the “point person” during an emergency. This individual — usually the receptionist during the day shift and a life skills trainer on other shifts, since the switchboard is closed during the niglit — is in charge of emergency operations. The point person also has the following responsibilities: to call 911, to sound the house alarm, to take a head count of the clients and staff members, and to safeguard medical records—removing the records with the client if possible. When sufficient staff members are present, the point person assigns one member to a position in front of the building to await emergency responders and brief them on the conditions. The responsibilities are printed on a laminated card the size of a credit card and carried at all times by the designated point person on duty.
  • An evacuation center has been designated so that when evacuation becomes necessary, all clients and staff members will assemble at one location in a controlled area; this system also reduces the possibility of clients wandering off.
  • A designated emergency supply station is now housed in a structure not connected to the main building. (This center is housed in a lightweight structure such as a shed or garage so that it would be easy to remove debris and gain access to the supplies should the structure collapse during an earthquake.) The supply station is stocked with enough food, water, and basic medical and personal-hygiene items to last 14 days. Several fire extinguishers also are kept at this center in case the fire department is not available in the event of a major earthquake or other catastrophe.
  • A direction appropriate evacuation map is posted in every client’s room and throughout the facility. The map usually found posted in these facilities has “north” designated at the top regardless of whether it is hanging on a wall facing east, south, or west, creating orientation problems for clients and even more confusion during an emergency. The floor plans now posted have designated on top the same direction that the wall is facing. (The next time you are in a facility that has an evacuation map displayed, try to figure it out—especially if “north” is printed at the top and the map is hanging on a wall that is not facing north.)
  • Safety procedures are discussed with clients within 72 hours of admission. Many of them are also physically handicapped due to their injuries and therefore must be shown how to crawl in a fire situation while remaining close to the floor. We have had to be very creative in developing various crawling systems geared to clients’ abilities: We have devised the side crawl, the fanny crawl, and the backward butt pull —all executed while the clients keep their heads 12 to 18 inches off the floor so that they can avoid the heavier-than-air deadly gasses as they evacuate.
  • To compensate for the fact that smoke rises and may render invisible the exit signs posted at ceiling level, reflective red arrows indicating the direction of the exit have been placed on baseboards. Flashlights also arclocated at baseboard level so that the clients can use them as guides as they crawl to safety during an emergency.
  • Since many new phone systems (including ours) are totally dependent on electricity and have a limited capacity even with a power backup, we installed a phone jack before the point at which the lines enter the system. An older-style, nonpower-dependent phone is kept next to the jack and can be hooked up for use
  • should the power fail.
  • We have established a safety committee that includes clients, who are encouraged to engage in therapeutic problem-solving and memory-training exercises focused on safety issues that hopefully will help them retain the information. These exercises also serve as reviews for staff members.
  • Smoking is prohibited in all buildings.
  • Staff and clients conduct monthly safety inspections.
  • Fire and earthquake drills that incorporate meeting at the designated evacuation point for clients and staff are held monthly. These exercises paid off recently when an earthquake drill held in the morning was followed by the real Upland earthquake in the afternoon. We evacuated the buildings, did a safety check, and then reentered without incident.


The use of forms and posted signs help us to monitor safety conditions and reinforce procedures. The following serve as practical reminders to help ensure that the safety program will continue and that clients and staff will remember their roles:

  • Fire and earthquake drill report forms that provide space for evaluations and critiques.
  • Room-by-room fire and safety checklists.
  • Safety corrective action request forms that are used when safety hazards are found; correcting these hazards are “priority 1” tasks for the maintenance crew.
  • Shut-off maps for gas, water, and electricity are displayed (a wrench is chained to the gas shut-off valve).
  • Monthly checklists for the testing of smoke detectors in clients’ rooms and extinguishers.
  • Checklists that cover emergency food supplies (checked monthly), nonfood supplies (batteries, hygiene items, blankets, tools, etc.), first-aid supplies for the large emergency kit, and items that must be replaced every six months or every year.
  • The RACE poster indicates the steps to be taken in case of a fire: remove the occupants, activate the alarm, confine the fire, extinguish the fire if possible.
  • The “In Case of Earthquake” poster lists the following steps: find shelter; evacuate to designated location; conduct head count; turn off gas, water, and electricity if warranted; check for injuries; do not return to building until it is deemed safe.

In addition, clients ready to be discharged are given a safety reminder sheet to post at home. Those who go home for weekends are assigned the tasks of making a safety check in the home and performing an EDITH exercise with other family members.

Fire and earthquake safety also are part of the agenda for family-support group meetings that are held twice a month.

By stressing practical and realistic safetyprocedures and making them a regular and integral part of our rehabilitative program. NeuroCare is promoting safety not only at its facilities but also in the homes of its present and former clients.

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