Texas Administrative Code
Title 25 - HEALTH SERVICES
Part 1 - DEPARTMENT OF STATE HEALTH SERVICES
Chapter 117 - END STAGE RENAL DISEASE FACILITIES
Subchapter H - PHYSICAL PLANT AND CONSTRUCTION REQUIREMENTS
Section 117.105 - Construction, Inspections, and Approval of Project
Universal Citation: 25 TX Admin Code ยง 117.105
Current through Reg. 49, No. 38; September 20, 2024
(a) Construction.
(1) Construction, other than minor
alterations, shall not commence until the final plan review deficiencies have
been satisfactorily resolved, the appropriate licensing fee has been paid, and
the department has issued a letter granting approval to begin construction.
Such authorization does not constitute release from the requirements contained
in this chapter. If the construction takes place in or near occupied areas,
adequate provision shall be made for the safety and comfort of
occupants.
(2) The architect of
record or the ESRD facility owner or operator shall provide written
notification to the department when construction will commence. The department
shall be notified in writing of any change in the completion
schedules.
(3) Construction shall
be completed in compliance with the construction documents including all
addenda or modifications approved for the project.
(b) All ESRD facilities, including those which maintain certification under Title XVIII of the Social Security Act (42 United States Code, §§1395 et seq.), are subject to construction inspections.
(1) A minimum of
two construction inspections of the project is generally required for the
purpose of verifying compliance with subchapters G and H of this chapter and
the approved plans and specifications. The final plan approval letter shall
inform the architect of record and the owner as to the minimum number of
inspections required for the project.
(2) The architect of record or the ESRD
facility owner or operator shall request an inspection by submitting, at least
three weeks in advance of the requested inspection date, an application for
inspection for each intermediate inspection, final inspection, and reinspection
requested. Inspection requests by contractors shall not be honored.
(A) The architect of record or the ESRD
facility owner or operator shall request an intermediate construction
inspection to occur at approximately 80% completion. All major work above the
ceiling shall be completed at the time of the intermediate inspection, however,
ceilings shall not be installed.
(B) The architect of record or the ESRD
facility owner or operator shall request a final construction inspection at
100% completion. One hundred percent completion means that the project is
completed to the extent that all equipment is operating in accordance with
specifications, all necessary furnishings are in place, and patients could be
admitted and treated in all areas of the project.
(3) Depending upon the number and nature of
the deficiencies cited during the final inspection, the inspector may require
that a reinspection be conducted to confirm correction of all deficiencies
cited. The inspector may also require a reinspection, if he determines that the
project was not sufficiently complete to warrant a final inspection. The
request for reinspection shall be submitted in accordance with paragraph (2) of
this subsection.
(c) Patients and staff shall not occupy a new structure or remodeled or renovated space until approval has been received from the local building and fire authorities and the department.
(1) The ESRD
facility owner or operator shall submit the following documents to the
department before the project will be approved:
(A) written approval of the project by the
fire authority;
(B) a certificate
of occupancy for the project issued by the local building authority;
(C) a copy of a letter or certification from
a professional engineer (P.E.) licensed in the State of Texas indicating the
fire sprinkler working plans, hydraulic calculation, the testing, and field
inspection of the installation of the new or modified sprinkler system is in
compliance with the requirements of NFPA 13, Standard for the Installation of
Sprinkler Systems, 2002 Edition, if applicable. A copy of a letter or
certification of changes in existing fire sprinkler system is not required,
when relocation of not more than twenty sprinkler heads and hydraulic
calculation is not involved;
(D)
fire alarm system certification (form FML-009A of the State Fire Marshal's
Office), if applicable;
(E) a copy
of the test and a letter from the electrical contractor certifying that the
electrical system was tested and complies with the standards of NFPA 99, Health
Care Facilities, 2002 Edition, §4.3.2.2.8 (Special Grounding) and
§4.3.3.1 (Grounding System Testing), if applicable to the
project;
(F) a copy of
documentation indicating the flame spread rating and the smoke development
rating of any wall covering installed in this project. A signed letter or
statement corroborating the installation of the product in the project shall be
provided;
(G) a copy of
documentation indicating that draperies, curtains (including cubicle curtains),
and other similar loosely hanging furnishings and decorations are
flame-resistant as demonstrated by passing both the small and large-scale tests
of NFPA 701, Standard Methods of Fire Tests for Flame-Resistant Textiles and
Films, 1999 Edition, as required by NFPA 101, §20-7.5, and a signed letter
or statement corroborating the installation of the product in the
project;
(H) a written plan of
correction signed by the ESRD facility owner or operator for any deficiencies
noted during the final inspection; and
(I) any other documentation or information
required or requested due to the type of the project.
(2) Architectural approval.
(A) If, during the final inspection, the
inspector finds only a few minor deficiencies that do not jeopardize patient
health, safety and welfare, the inspector may grant architectural approval
contingent upon the documents listed in paragraph (1)(A) - (D) of this
subsection being provided to and approved by the inspector at the time of the
final inspection.
(B) Architectural
approval allows the ESRD facility owner or operator to proceed with licensing.
Patients may not be admitted nor patient services provided until a license or
modified license has been issued to the facility by the department. However,
the ESRD facility owner or operator shall submit the documents required in
paragraph (1)(E) -
(I) of this subsection
before the project receives final approval.
(3) Upon its receipt and acceptance of the
documents required in paragraph (1) of this subsection and receipt of an
acceptable Plan of Correction of the final inspection report, the department
shall issue written final approval of the project.
Disclaimer: These regulations may not be the most recent version. Texas may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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