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TITLE 25HEALTH SERVICES
PART 1DEPARTMENT OF STATE HEALTH SERVICES
CHAPTER 117END STAGE RENAL DISEASE FACILITIES
SUBCHAPTER GFIRE PREVENTION AND SAFETY REQUIREMENTS
RULE §117.91Fire Prevention, Protection, and Emergency Contingency Plan

(a) An ESRD facility shall comply with the provisions of this section with respect to fire prevention and protection.

  (1) An ESRD 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 Facility Licensing Group, Regulatory Licensing Unit, Department of State Health Services, Mail Code 2835, P.O. Box 149347, Austin, TX 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) An ESRD facility shall adopt, implement, and enforce a written smoking policy.

(b) An ESRD 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 an ESRD facility or upon ESRD 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 ESRD facility in public areas that are readily visible to patients, employees, and visitors.

  (2) Each ESRD 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 ESRD 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 ESRD facility shall maintain driveways, free from all obstructions, to main buildings for fire department apparatus use.

  (2) Upon request, the ESRD facility shall submit a copy of the floor plans of the building to the local fire department officials.

  (3) The ESRD 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 an ESRD 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 ESRD 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 three options as described as follows.

  (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) 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. When a vapor liquefied petroleum gas (LPG) (natural gas) system is used, the twenty-four hour fuel capacity on site is not required. The vapor withdrawal LPG system shall require a dedicated fuel supply. The fuel tank capacity shall be sized by the electrical load demand on the emergency generator for a period of twenty-four hours.

    (B) 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.

    (C) When the emergency generator(s) and electrical transformer(s) are located within the same area, they shall be located at least 10 feet apart.

    (D) Sufficient quantity of potable water supply shall be on site for the operation of the water treatment system for at least twenty-four hours. A water valve connection shall be provided to allow hook-up for potable water from an outside vendor to supply the water treatment system.

  (2) An executed contract with an outside supplier/vendor that will provide a portable emergency generator(s) and potable water on demand.

    (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) A water valve connection to allow hook-up for potable water from an outside vendor to supply the water treatment system.

    (C) 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 1-1/2 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.

    (D) 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.

  (3) An executed contract with another licensed ESRD facility within a 100 mile radius to provide emergency contingency care for the patient(s).

    (A) The accepting licensed ESRD facility shall meet the requirements of paragraph (1) of this subsection.

    (B) An alternate source of power shall be provided separate and independent from the normal electrical power source that will be effective for a minimum of 1-1/2 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.


Source Note: The provisions of this §117.91 adopted to be effective July 6, 2010, 35 TexReg 5835

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