|(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/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 Hospital Licensing Director, Health Facility Licensing and
Compliance Division, Texas Department of Health, 1100 West 49th Street,
Austin, Texas 78756, 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/location;
(B) amount of damage;
(C) were patients or employees/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;
(I) has the fire area/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 marshall incident report shall
be provided if the fire marshall 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 §134.121(a)(1) of this
title (relating to Requirements for Buildings in which Existing Licensed
Facilities are Located), and §134.122(a)(1) and (d) of this title
(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.
All documents published by 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, Post Office Box 9101, Quincy, MA 02269-9101 or (800) 344-3555.
(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
(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,
(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
(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
§134.121(a)(1)(A) of this title for existing facilities, and
§134.122(d)(5)(N) of this title 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, §18-18.104.22.168.
(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
(2) Floor plans. Upon request, the facility shall
submit a copy of the floor plans of the building to the local fire
(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.