Current through Reg. 49, No. 38; September 20, 2024
(a) A facility shall comply with the
provisions of this section with respect to fire prevention and protection.
(1) A facility shall comply with local fire
codes.
(2) All incidents of fire
shall be reported to the local fire authority and shall be reported in writing
to the Department of State Health Services, Facility Licensing Group, Mail Code
1979, P.O. Box 149347 Austin, Texas 78714-9347, 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 no later than the next business
day.
(3) A facility shall adopt,
implement, and enforce a written smoking policy.
(b) A 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). All documents published by National
Fire Protection Association (NFPA) as referenced in this section may be
obtained by writing or calling the NFPA at the following address or telephone
number: National Fire Protection Association, 1 Batterymarch Park, Quincy,
Massachusetts 02269-9101 or (800) 344-3555. NFPA documents are also available
for public inspection during regular working hours at the offices of
Architectural Review Group, Texas Department of State Health Services, 1100
West 49th Street, Austin, Texas 78756-3199.
(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 a facility or upon facility 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. The governing body of the facility shall define working
shifts for the facility. Fire drills 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 through 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 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 a 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) The facility shall provide an emergency
contingency plan for the continuity of emergency essential building systems.
The emergency contingency plan shall consist of one of the two options as
described in paragraphs (1) and (2) of this subsection.
(1) An onsite emergency generator shall be
provided with a Type II essential electrical distribution system in accordance
with requirements of NFPA 99, §4.5, and National Fire Protection
Association 110, Standard for Emergency and Standby Power Systems, 2002
Edition.
(A) The minimum electrical load
connection shall be in accordance with NFPA 99 §4.5.2.
(B) An emergency generator standby power
system(s) shall require an onsite fuel source and enough fuel capacity in the
tank for a period of twenty-four hours or more. The facility shall execute
contract(s) with the supplier/vendor(s) for fuel on demand. When a vapor
liquefied petroleum gas (LPG) (natural gas) system is used, the twenty-four
hour fuel capacity onsite is not required. The vapor withdrawal LPG system
shall require a dedicated fuel supply.
(C) The emergency generator shall be
installed, tested and maintained in accordance with the National Fire
Protection Association 99, §4.5.4, and National Fire Protection
Association 110, Standard for Emergency and Standby Power Systems, 2002
Edition.
(2) An executed
contract(s) with an outside supplier/vendor that will provide a portable
emergency generator(s) and fuel.
(A) An
electrical transfer switch with plug-in device sized to provide emergency power
for the patient care areas and the provisions in NFPA 99,
§4.5.2.2.2.
(B) An alternate
source of power (battery power lighting) shall be provided separate and
independent from the normal electrical power source that will be effective for
a minimum of one and one half hours after loss of the electrical power. The
emergency lighting system shall be capable of providing sufficient illumination
to allow safe evacuation from the building. The battery pack systems shall be
maintained and tested quarterly.
(C) The facility shall implement the
emergency contingency plan upon the loss of electrical power following a
natural weather or man-made event when the electrical power may not be restored
within 24 hours. The facility shall exercise the contract(s) with the
supplier/vendor(s) in order to have portable emergency generator(s) and potable
water available within 36 hours after the loss of electrical power.
(i) The facility
premises shall be kept free from accumulations of combustible materials not
necessary for immediate operation of the facility.
