Current through Reg. 50, No. 13; March 28, 2025
(a)
Compliance. An ambulatory surgical center (ASC) shall comply with the
provisions of this section with respect to fire prevention and protection.
(1) Fire inspections. An ASC shall comply
with local fire codes.
(2) Fire
reporting. Except as required under § 135.43(b)(6) of this title (relating
to Handling and Storage of Gases, Anesthetics, and Flammable Liquids), an ASC
shall report all occurrences of fire to the local fire authority and in writing
to the department's facility licensing group manager as soon as possible but
not later than 10 calendar days following the occurrence. Any fire occurrence
causing injury to a person shall be reported no later than the next business
day to the facility licensing group manager by fax, (512) 834-4514, or
overnight mail to Department of State Health Services, Facility Licensing Group
Manager, Post Office Box 149347, Austin, Texas 78714-9347.
(3) Smoking policy. An ASC shall adopt,
implement and enforce a written smoking policy. The policy shall include the
minimum provisions of National Fire Protection Association 101, Life Safety
Code, 2003 Edition (NFPA 101), §20.7.4. 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.
(b) Fire extinguishing systems. An ASC 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) Water-based fire protection systems. 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) Portable fire extinguishers. Every
portable fire extinguisher located in an ASC or upon ASC property shall be
installed, tagged, and maintained in accordance with National Fire Protection
Association 10, Standard for Portable Fire Extinguishers, 2002
Edition.
(c) Fire
protection and evacuation plan. 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, §20.7. Copies of the plan shall be
available to all staff.
(1) Posting
requirements. An evacuation floor plan shall be prominently and conspicuously
posted for display throughout the ASC in public areas that are readily visible
to patients, employees, and visitors.
(2) Annual training. Each ASC 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) Fire drills. The ASC shall conduct at
least one fire drill per shift, per quarter. Each drill shall include the use
of communication of alarms, use of fire-fighting equipment, simulation of
evacuation of patients, discussion with patients, visitors, other occupants,
employees and staff about the evacuation plan. Written reports shall be
maintained to include evidence of staff and patient participation. Fire exit
drills shall incorporate the minimum requirements of NFPA 101,
§§20.7.1.2 through 20.7.2.3.
(4) Fire-fighting equipment. 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) Fire alarm system. 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, §20.3.4.
(e) System
for communicating an alarm of fire. 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, §20.3.4.4.
(f) Fire
department access. As an aid to fire department services, every ASC shall
provide the following.
(1) Driveways. The ASC
shall maintain driveways, free from all obstructions, to main buildings for
fire department apparatus use.
(2)
Submission of plans. Upon request, the ASC shall submit a copy of the floor
plans of the building to the local fire department officials.
(3) Outside identification. The ASC 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)
Fire department protection. When an ASC 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) Physical environment. A facility shall
provide a physical environment that protects the health, welfare, and safety of
patients, personnel and the public. The physical premises of the facility and
those areas of the facility's surrounding physical structure that are used by
the patients (including all stairwells, corridors and passageways) must meet
the local building and fire safety codes as they relate to safe access and
patient privacy.
