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RULE §135.41Fire Prevention and Protection

(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, §§ through

  (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, §

(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.

Source Note: The provisions of this §135.41 adopted to be effective June 18, 2009, 34 TexReg 3948

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