Texas Administrative Code
Title 26 - HEALTH AND HUMAN SERVICES
Part 1 - HEALTH AND HUMAN SERVICES COMMISSION
Chapter 554 - NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION
Subchapter D - FACILITY CONSTRUCTION
Division 3 - PROVISIONS APPLICABLE TO ALL FACILITIES
Section 554.326 - Safety Operations

(a) The facility must have a program to inspect, test, and maintain the fire alarm system and must execute the program at least once every three months.

(b) A facility must have a program to inspect, test and maintain the sprinkler system and must execute the program at least once every three months.

(c) If facility staff verify or suspect a malfunction of the fire alarm, emergency electrical, or sprinkler system, the facility must immediately investigate and correct the condition. In addition, the facility must immediately report the failure of the fire alarm, emergency electrical, or sprinkler system to all facility staff and the local fire authority.

(d) If emergency generators are required or provided, a facility must have a program to maintain, operate, and test all emergency generators, including all appurtenant components, and must execute the program at least once every week.

(e) Duplex receptacles powered through the emergency electrical system must be installed at each resident bed location where resident-care-related electrical appliances are in use, unless a facility can demonstrate that it can provide the diagnostic, therapeutic, or monitoring benefits of the resident-care-related electrical appliances through acceptable alternative means in the event of a power outage.

(f) A facility must conduct a functional test on every required battery emergency lighting system at 30-day intervals for a minimum of 30 seconds. The facility must also conduct an annual test for a minimum of 1 1/2 hours. The lighting system must be fully operational for the duration of the testing. The facility must maintain an onsite written record of all tests performed and make those records available to the authority having jurisdiction during an inspection.

(g) A facility must ensure that a person licensed by the State Fire Marshal's Office inspects and services automatic fixed fire extinguishment systems mounted in kitchen range hoods at least once every six months in accordance with NFPA 96. The facility must maintain, onsite, a written and signed report of the inspection and service performed. The facility must keep the hood, exhaust ducts, and filters clean and free of accumulated grease.

(h) A facility must inspect and maintain portable fire extinguishers.

(i) A facility using gas must have the gas piping lines between the meter and appliances tested for leaks annually by a person licensed by the State Board of Plumbing Examiners. The facility must maintain, onsite, a written and signed report of these tests. The facility must note and correct any unsatisfactory conditions immediately.

(j) A facility must formulate, adopt, and enforce policies regarding smoking, smoking areas, and smoking safety that also take into account non-smoking residents.

(k) A facility must not allow storage of combustible products in facility rooms with gas-fired equipment.

(l) A facility must not allow storage of volatile or flammable liquids or materials anywhere within the facility building.

(m) A facility may install alcohol-based hand rub dispensers if the dispensers are:

(n) A facility must not store or leave unattended medical equipment, carts, wheelchairs, tables, furniture, dispensing machines, or similar physical objects in corridors or other ways of egress, except as permitted by NFPA 101.

(o) A facility must keep smoke doors, fire doors, and doors to hazardous rooms in the facility closed and not prop or wedge a door open. The facility may use only approved devices to hold open a door, such as alarm-activated electromagnetic hold-open devices, as permitted by NFPA 101.

(p) The facility must post building evacuation routes at prominent locations throughout the facility.

(q) A facility must provide approved electrical receptacles in quantity and location for the normal use of appliances in the facility.

(r) A facility must not use electrical extension cords or multi-receptacle plug-in adaptors as a substitute for approved wiring methods in the facility.

(s) A facility may use a listed and approved surge-protection device for equipment for which the manufacturer recommends surge protection, but in no case may the facility use a surge-protection device to increase the number of existing electrical outlets in a room.

(t) A facility must remove all abandoned utilities, such as electrical wiring, ducts, and pipes, from the facility when no longer in use. The facility may, however, leave an existing damper that is no longer required by NFPA 101 in-place and inoperable, if the damper is in a duct penetration of a smoke barrier in a fully ducted heating, ventilating, and air conditioning system; the damper is permanently secured in the open position; and quick-response sprinklers have been provided for the smoke compartments on both sides of the smoke barrier.

(u) In operations where there is a chance of cross-contamination, clean and soiled operations must be separated to lessen the chance of cross-contamination by facility employees, residents, and others. This separation must be in relation to traffic flow, air currents, air exhaust, water flow, vapors, and other conditions.

(v) A facility must have and implement as necessary a fire safety plan that:

(w) Floors, walls, and ceilings.

(x) All gas heating systems must be checked annually for proper operation and safety by persons who are licensed or approved by the State of Texas to inspect such equipment. A record of this service must be maintained by the facility. Any unsatisfactory condition must be corrected promptly.

(y) A facility must have an annual inspection by the local fire marshal and maintain documentation of such an inspection at the facility.