Current through Reg. 50, No. 13; March 28, 2025
(a) Fire
inspections.
(1) Annual inspection. Approval
of the fire protection of a facility by the local fire department or State Fire
Marshall's Office shall be a prerequisite for licensure.
(2) Purpose of inspection. The purpose of
these inspections shall be to ascertain and to cause to be corrected any
conditions liable to cause fire or violations of any of the provisions or
intent of these rules, or of any other applicable ordinances, which affect fire
safety in any way.
(3) Hazardous or
dangerous conditions or materials. Whenever any of the officers, members, or
inspectors of the fire department or bureau of fire prevention find in any
building or upon any premises dangerous or hazardous conditions or materials,
removal or remedy of dangerous conditions or materials shall be carried out in
a manner specified by the inspector or officer.
(4) Access for inspection. At all reasonable
hours, the chief of the fire department, the chief of the bureau of fire
prevention, or any of the fire inspectors may enter any building or premises
for the purpose of making an inspection or investigation which may be deemed
necessary under the provisions of these rules.
(b) Fire reporting. All occurrences of fire
shall be reported to the local fire authority and shall be reported in writing
to the Texas Health and Human Services Commission, as soon as possible but not
later than 10 calendar days following the occurrence.
(1) The fire incident report shall indicate
as a minimum the following information:
(A)
the fire origin and area or location;
(C) were patients or employees or staff
injured;
(D) was the fire
department notified and did they respond;
(E) how was the fire detected;
(F) how was the fire extinguished;
(G) what caused the fire;
(H) was there a general evacuation or just
area evacuation; and
(I) has the
fire area or location been reoccupied.
(2) The fire incident report shall be
provided on facility letterhead and signed by hospital
administration.
(3) A copy of the
fire marshal incident report shall be provided if the fire marshal wrote an
incident report.
(c) Fire
protection. Fire protection shall be provided in accordance with the
requirements of National Fire Protection Association 101, Code for Safety to
Life from Fire in Buildings and Structures, 2000 edition (NFPA 101),
§18-7, and §
510.121(a)(1) of
this chapter (relating to Requirements for Buildings in which Existing Licensed
Facilities are Located), and §
510.122(a)(1) and
(d) of this chapter (relating to New
Construction Requirements). When required or installed, sprinkler systems for
exterior fire exposures shall comply with National Fire Protection Association
80A, Recommended Practice for Protection of Buildings from Exterior Fire
Exposures, 1999 edition.
(d)
Smoking rules. Each facility shall adopt, implement, and enforce a smoking
policy. The policy shall include the minimal provisions of NFPA 101
§18-7.4.
(e) Fire
extinguishing systems. Inspection, testing, and maintenance of fire-fighting
equipment shall be conducted by each facility.
(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, 1995 edition.
(2) Range hood extinguishers. Fire
extinguishing systems for commercial cooking equipment, such as at range hoods,
shall be inspected and maintained in accordance with National Fire Protection
Association 96, Standard for Ventilation Control and Fire Protection of Cooking
Operations, 1998 edition.
(3)
Portable fire extinguishers. 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, 1998 edition.
(f) 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
§18-7. 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
facility in public areas that are readily visible to patients, residents,
employees, and visitors.
(2) Annual
training. 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.
(g) Fire drills. The facility shall conduct
at least one fire drill per shift per quarter, which shall include
communication of alarms, simulation of evacuation of patients and other
occupants, and use of fire-fighting equipment. Documentation of the drills
shall be maintained for a period of not less than one year.
(h) Fire alarm system. Every facility and
building used for patient care shall have an approved fire alarm system. Each
fire alarm system shall be installed and tested in accordance with §
510.121(a)(1)(A)
of this chapter for existing facilities, and §
510.122(d)(5)(M)
of this chapter for new construction.
(i) 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
§18-3.4.3.2.
(j) Fire
department access. As an aid to fire department services, every facility shall
provide the following.
(1) Driveways. The
facility shall maintain driveways, free from all obstructions, to main
buildings for fire department apparatus use.
(2) Floor plans. Upon request, the facility
shall submit a copy of the floor plans of the building to the local fire
department officials.
(3) Outside
identification. 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.
(k) Fire department protection.
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.
