| (a) An end stage renal disease (ESRD) facility shall
comply with the provisions of this section with respect to fire prevention
and protection.
(1) The facility shall comply with local fire codes.
(2) The facility shall report all incidents of fire
to the local fire authority and to Texas Health and Human Services
Commission Complaint and Incident Intake 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 within one business day.
(3) The facility shall adopt, implement, and enforce
a written smoking policy.
(b) The 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).
(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 or
upon the facility's 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, which 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 - 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 ESRD
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 the 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) In this subsection, unless the context clearly
indicates otherwise, "emergency" means an incident likely to threaten
the health, welfare, or safety of a facility's patients, facility
staff, or the public, including a fire, equipment failure, power outage,
flood, interruption in utility service, medical emergency, or natural
or other disaster.
(1) In accordance with Texas Health and Safety Code §251.017,
the facility shall adopt an emergency contingency plan for the continuity
of emergency essential building systems that meets the requirements
described by paragraph (2), (3), or (4) of this subsection.
(2) The facility shall have an onsite permanent emergency
generator affixed to a generator pad with a Type 2 essential electrical
distribution system in accordance with National Fire Protection Association
(NFPA) 99: Health Care Facilities Code, 2002 Edition, §4.5, and
NFPA 110: Standard for Emergency and Standby Power Systems, 2002 Edition.
(A) The emergency generator shall require an onsite
fuel source and enough fuel capacity in the tank for a period of 24
hours or more, as determined by the electrical load demand on the
emergency generator for that period. When a vapor liquefied petroleum
gas (LPG) (natural gas) system is used, the 24-hour fuel capacity
on site is not required. The vapor liquified petroleum gas system
shall require a dedicated fuel supply.
(B) The facility shall install, test, and maintain
the onsite emergency generator in accordance with NFPA 99: Health
Care Facilities Code, 2002 Edition, §4.5.4, and NFPA 110 Standard
for Emergency and Standby Power Systems.
(C) The facility shall always keep the emergency generator
not less than 10 feet from any electrical transformer.
(D) The facility shall maintain on-site a sufficient
quantity of potable water supply for the operation of the water treatment
system for at least 24 hours.
(E) The facility shall provide and maintain a water
valve connection that allows an outside vendor to provide potable
water to operate the facility's water treatment system.
(3) The facility shall:
(A) maintain sufficient resources to provide on demand
or to execute a contract with an outside supplier or vendor to provide
on demand:
(i) a portable emergency generator that:
(I) has an electrical transfer switch with a plug-in
device sized to provide emergency power for patient care areas and
complies with NFPA 99: Health Care Facilities Code, 2002 Edition, §4.5.2.2.2;
and
(II) has a water valve connection that allows for the
use of potable water to operate the facility's water treatment system;
and
(ii) an alternate power source for light, including
battery-powered light, that:
(I) is separate and independent from the normal electrical
power source;
(II) can provide light for at least one-and-a-half
hours;
(III) can provide enough light to allow for safe evacuation
of the building; and
(IV) is maintained and tested at least four times each
year; and
(iii) potable water;
(B) implement the emergency contingency plan when the
facility loses of electrical power due to a natural or man-made event
during which the electrical power may not be restored within 24 hours;
and
(C) contact the outside supplier or vendor with which
the facility contracts under subparagraph (A) of this subsection,
if applicable, within 36 hours after the facility loses electrical
power.
(4) The facility shall execute a contract with another
licensed ESRD facility located within a 100-mile radius of the facility
stipulating that the other ESRD facility will provide emergency contingency
care to the facility's patients. The other ESRD facility with which
the facility contracts must have an alternate power source for light,
including battery-powered light, that:
(A) is separate and independent from the normal electric
power source;
(B) can provide light for at least one-and-a-half hours;
(C) can provide enough light to allow for safe evacuation
of the building; and
(D) is maintained and tested at least four times each
year.
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