Current through Reg. 49, No. 38; September 20, 2024
(a) An end stage renal disease (ESRD)
facility shall comply with the provisions of this section with respect to fire
prevention and protection.
(1) The facility
shall comply with local fire codes.
(2) The facility shall report all incidents
of fire to the local fire authority and to Texas Health and Human Services
Commission Complaint and Incident Intake as soon as possible, but not later
than 10 calendar days following the incident. Any fire incident causing injury
to a person shall be reported within one business day.
(3) The facility shall adopt, implement, and
enforce a written smoking policy.
(b) The facility shall adopt, implement, and
enforce a written policy for periodic inspection, testing, and maintenance of
fire fighting equipment, portable fire extinguishers, and when installed
sprinkler systems. If installed, fire sprinkler systems shall comply with
National Fire Protection Association 13, Standard for the Installation of
Sprinkler Systems, 2002 Edition (NFPA 13).
(1)
All fire sprinkler systems, fire pumps, fire standpipe and hose systems, water
storage tanks, and valves and fire department connections shall be inspected,
tested, and maintained in accordance with National Fire Protection Association
25, Standard for the Inspection, Testing and Maintenance of Water-Based Fire
Protection Systems, 2002 Edition.
(2) Every portable fire extinguisher located
in or upon the facility's property shall be installed, tagged, and maintained
in accordance with National Fire Protection Association 10, Standard for
Portable Fire Extinguishers, 2002 Edition.
(c) A plan for the protection of patients in
the event of fire and their evacuation from the building when necessary shall
be formulated according to NFPA 101, §21.7.1.1. Copies of the plan shall
be available to all staff.
(1) An evacuation
floor plan shall be prominently and conspicuously posted for display throughout
the facility in public areas that are readily visible to patients, employees,
and visitors.
(2) Each facility
shall conduct an annual training program for instruction of all personnel in
the location and use of fire fighting equipment. All employees shall be
instructed regarding their duties under the fire protection and evacuation
plan.
(3) The facility shall
conduct one fire drill per shift per quarter, which shall include the
transmission of the fire alarm signal and simulation of the emergency fire
condition, simulation of evacuation of patients and other occupants, and use of
fire-fighting equipment. Written reports shall be maintained to include
evidence of patient and staff participation. Fire exit drills shall incorporate
the minimum requirements of NFPA 101, §§21.7.1.2 -
21.7.2.3.
(4) All staff shall be
familiar with the locations of fire fighting equipment. Fire fighting equipment
shall be located so that a person shall not have to travel more than 75 feet
from any point to reach the equipment.
(d) A fire alarm system shall be installed,
maintained, and tested, in accordance with National Fire Protection Association
72, National Fire Alarm Code, 2002 Edition (NFPA 72) and NFPA 101,
§21.3.4.
(e) A reliable
communication system shall be provided as a means of reporting a fire to the
fire department. This is in addition to the automatic alarm transmission to the
fire department required by NFPA 101, §21.3.4.4.
(f) As an aid to fire department services,
every ESRD facility shall provide the following:
(1) The facility shall maintain driveways,
free from all obstructions, to main buildings for fire department apparatus
use.
(2) Upon request, the facility
shall submit a copy of the floor plans of the building to the local fire
department officials.
(3) The
facility shall place proper identification on the outside of the main building
showing the locations of siamese connections and standpipes as required by the
local fire department services.
(g) When the facility is located outside of
the service area or range of the public fire protection, arrangements shall be
made to have the nearest fire department respond in case of a fire.
(h) In this subsection, unless the context
clearly indicates otherwise, "emergency" means an incident likely to threaten
the health, welfare, or safety of a facility's patients, facility staff, or the
public, including a fire, equipment failure, power outage, flood, interruption
in utility service, medical emergency, or natural or other disaster.
(1) In accordance with Texas Health and
Safety Code §
251.017, the
facility shall adopt an emergency contingency plan for the continuity of
emergency essential building systems that meets the requirements described by
paragraph (2), (3), or (4) of this subsection.
(2) The facility shall have an onsite
permanent emergency generator affixed to a generator pad with a Type 2
essential electrical distribution system in accordance with National Fire
Protection Association (NFPA) 99: Health Care Facilities Code, 2002 Edition,
§4.5, and NFPA 110: Standard for Emergency and Standby Power Systems, 2002
Edition.
(A) The emergency generator shall
require an onsite fuel source and enough fuel capacity in the tank for a period
of 24 hours or more, as determined by the electrical load demand on the
emergency generator for that period. When a vapor liquefied petroleum gas (LPG)
(natural gas) system is used, the 24 -hour fuel capacity on site is not
required. The vapor liquified petroleum gas system shall require a dedicated
fuel supply.
(B) The facility shall
install, test, and maintain the onsite emergency generator in accordance with
NFPA 99: Health Care Facilities Code, 2002 Edition, §4.5.4, and NFPA 110
Standard for Emergency and Standby Power Systems.
(C) The facility shall always keep the
emergency generator not less than 10 feet from any electrical
transformer.
(D) The facility shall
maintain on-site a sufficient quantity of potable water supply for the
operation of the water treatment system for at least 24 hours.
(E) The facility shall provide and maintain a
water valve connection that allows an outside vendor to provide potable water
to operate the facility's water treatment system.
(3) The facility shall:
(A) maintain sufficient resources to provide
on demand or to execute a contract with an outside supplier or vendor to
provide on demand:
(i) a portable emergency
generator that:
(I) has an electrical transfer
switch with a plug-in device sized to provide emergency power for patient care
areas and complies with NFPA 99: Health Care Facilities Code, 2002 Edition,
§4.5.2.2.2; and
(II) has a
water valve connection that allows for the use of potable water to operate the
facility's water treatment system; and
(ii) an alternate power source for light,
including battery-powered light, that:
(I) is
separate and independent from the normal electrical power source;
(II) can provide light for at least
one-and-a-half hours;
(III) can
provide enough light to allow for safe evacuation of the building;
and
(IV) is maintained and tested
at least four times each year; and
(iii) potable water;
(B) implement the emergency contingency plan
when the facility loses of electrical power due to a natural or man-made event
during which the electrical power may not be restored within 24 hours;
and
(C) contact the outside
supplier or vendor with which the facility contracts under subparagraph (A) of
this subsection, if applicable, within 36 hours after the facility loses
electrical power.
(4) The
facility shall execute a contract with another licensed ESRD facility located
within a 100-mile radius of the facility stipulating that the other ESRD
facility will provide emergency contingency care to the facility's patients.
The other ESRD facility with which the facility contracts must have an
alternate power source for light, including battery-powered light, that:
(A) is separate and independent from the
normal electric power source;
(B)
can provide light for at least one-and-a-half hours;
(C) can provide enough light to allow for
safe evacuation of the building; and
(D) is maintained and tested at least four
times each year.
