| (a) Local fire marshal inspection.
(1) An assisted living facility must obtain an inspection
at least once every 12 months, by the local fire marshal, or the Texas
State Fire Marshal's Office in locations where there is no local fire
marshal, and must correct any items cited by the local fire marshal,
or the Texas State Fire Marshal's Office, to the satisfaction of those
authorities.
(2) An assisted living facility must maintain documentation
at the facility reflecting the outcome of the most recent annual inspection.
(b) Emergency evacuation floor plan. An assisted living
facility, other than a one-story small Type A or a one-story small
Type B assisted living facility, must post an emergency evacuation
floor plan in a location visible to residents.
(c) Fire safety plan. An assisted living facility must
establish a fire safety plan for the protection of all persons in
the facility in the event of fire.
(1) An assisted living facility must ensure the fire
safety plan is in effect at all times.
(2) An assisted living facility must make written copies
of the fire safety plan are available to all supervisory personnel.
(3) An assisted living facility must ensure the fire
safety plan addresses:
(A) evacuation to an area of refuge;
(B) evacuation from the building when necessary; and
(C) special staff actions, including fire protection
procedures necessary to ensure the safety of any resident.
(4) If the facility is a large Type B assisted living
facility:
(A) An existing large Type B assisted living facility
must ensure the fire safety plan includes the provisions described
in 19.7.2, Procedure in Case of Fire, in NFPA 101, Chapter 19, Existing
Health Care Occupancies.
(B) A new large Type B assisted living facility must
ensure the fire safety plan includes the provisions described in 18.7.2,
Procedure in Case of Fire, in NFPA 101, Chapter 18, New Health Care
Occupancies.
(5) An assisted living facility must ensure the fire
safety plan is reviewed at least annually and revised, as needed,
to address the changing needs of residents.
(6) An assisted living facility must instruct and inform
all employees of their duties and responsibilities under the fire
safety plan at least annually, and when the fire safety plan is revised.
(7) An assisted living facility must keep a copy of
the fire safety plan readily available at all times within the facility.
(8) An assisted living facility must ensure the fire
safety plan reflects the current evacuation capabilities of the residents.
(d) Fire drills. An assisted living facility must conduct
at least one quarterly fire drill on each shift with at least one
drill each month. Each drill must meet these requirements:
(1) An assisted living facility must ensure staff take
part in fire drills according to the assisted living facility's fire
safety plan.
(2) An assisted living facility must inform residents
of evacuation procedures and locations of exits.
(3) An assisted living facility must document every
fire drill using the most current version of the required Texas Health
and Human Services (HHSC) form titled "Fire Drill Report" available
on the HHSC website.
(4) A large Type B assisted living facility must activate
the fire alarm signal during a fire drill conducted between 6:00 a.m.
and 9:00 p.m.
(5) An assisted living facility may announce a fire
drill to residents in advance.
(e) Reporting fires.
(1) An assisted living facility must immediately report
a fire causing injury or death to a resident.
(2) An assisted living facility must report a fire
causing damage to the facility or facility equipment to HHSC within
72 hours after the fire is extinguished.
(3) After making a report by telephone or email, an
assisted living facility must file a written report using the most
current version of the required HHSC form titled "Fire Report for
Long Term Care Facilities" available on the HHSC website.
(f) Smoking policies. An assisted living facility must
establish and enforce policies regarding smoking, even if the policy
is that smoking will not be permitted. The policy must also address
the use of e-cigarettes and vaping devices. If smoking will be permitted,
the smoking policies must:
(1) designate smoking areas for residents and staff;
and
(2) provide ashtrays of noncombustible material and
safe design in smoking areas.
(g) Fire alarm system. An assisted living facility
must establish a program to inspect, test, and maintain the fire alarm
system according to the requirements of NFPA 72, and according to
the requirements of NFPA 720 where carbon monoxide detection is provided,
and must execute the program at least once every six months.
(1) An assisted living facility must contract with
a company that holds an Alarm Certificate of Registration from the
State Fire Marshal's Office to execute the program.
(2) An assisted living facility must ensure a company
that performs a service under the contract required under paragraph
(1) of this subsection completes, signs, and dates an inspection form
like the inspection and testing form in NFPA 72 for a service provided
under the contract.
(3) If a task required by NFPA 72 or NFPA 720 must
occur at intervals other than during the contracted visits in this
subsection, an assisted living facility must ensure the task is performed
and documented by a knowledgeable individual.
(4) An assisted living facility must ensure:
(A) a fire alarm system component that requires visual
inspection is visually inspected in accordance with NFPA 72;
(B) a fire alarm system component that requires testing
is tested in accordance with NFPA 72; and
(C) a fire alarm system component that requires maintenance
is maintained in accordance with NFPA 72.
(5) An assisted living facility that provides carbon
monoxide detection must ensure:
(A) a carbon monoxide detection component that requires
visual inspection is visually inspected in accordance with NFPA 720;
(B) a carbon monoxide detection component that requires
testing is tested in accordance with NFPA 720;
(C) a carbon monoxide detection component that requires
maintenance is maintained in accordance with NFPA 720; and
(D) a facility with a carbon monoxide detection component
installed before August 31, 2021, must perform visual inspection,
testing, and maintenance of that component beginning no later than
August 31, 2022.
(6) A large assisted living facility containing smoke
compartments must ensure each required smoke damper is inspected and
tested in accordance with NFPA 101.
(7) An assisted living facility must ensure smoke detector
sensitivity is checked within one year after installation and every
two years thereafter in accordance with test methods in NFPA 72.
(8) An assisted living facility must maintain onsite
documentation of compliance with this subsection and must maintain
record copies of documents regarding the installation of a fire alarm
system, including as-built installation drawings, operation and maintenance
manuals, the installation certificate for the system, and written
sequences for its operation.
(9) An assisted living facility must make documentation
described in paragraph (8) of this subsection available to HHSC on
request.
(h) Fire sprinkler system. An assisted living facility
that is equipped with a fire sprinkler system, including a fire sprinkler
system meeting NFPA 13D, must establish a program to inspect, test,
and maintain the fire sprinkler system according to the requirements
of NFPA 25, and must execute the program at least once every six months.
(1) An assisted living facility must contract with
a company that holds an appropriate Sprinkler Certificate of Registration
from the State Fire Marshal's Office to execute the program.
(2) An assisted living facility must ensure a company
that performs a service under the contract required under paragraph
(1) of this subsection completes, signs, and dates an inspection form
like the inspection and testing form in NFPA 25 for a service provided
under the contract.
(3) If a task required by NFPA 25 must occur at intervals
other than during the contracted visits in this subsection, an assisted
living facility must ensure the task is performed and documented by
knowledgeable individuals.
(4) An assisted living facility must ensure that a
sprinkler system component that requires visual inspection is visually
inspected in accordance with NFPA 25.
(5) An assisted living facility must ensure that a
sprinkler system component that requires testing is tested in accordance
with NFPA 25.
(6) An assisted living facility must ensure that a
sprinkler system component that requires maintenance is maintained
in accordance with NFPA 25.
(7) An assisted living facility must ensure that an
individual sprinkler head is inspected and maintained in accordance
with NFPA 25.
(8) An assisted living facility must maintain onsite
documentation of compliance with this subsection and must maintain
record copies of documents regarding the installation of a fire sprinkler
system, including as-built installation drawings, hydraulic calculations,
proof of adequate fire sprinkler water supply, and installation certificates
for the system.
(9) An assisted living facility must make documentation
described in paragraph (8) of this subsection available to HHSC on
request.
(i) Portable fire extinguishers.
(1) An assisted living facility must ensure staff are
appropriately trained in the use of each type of extinguisher in the
facility.
(2) An assisted living facility must inspect and maintain
portable fire extinguishers and:
(A) ensure that its staff perform regular monthly inspections
or "quick checks" to ensure extinguishers are located in the designated
place, extinguisher locations are not obstructed to access or visibility,
and the pressure gauge reading or indicator on the extinguisher is
in the operable range or position;
(B) ensure annual maintenance and inspection or "thorough
checks" are performed according to NFPA 10 by an individual employed
by a company holding an appropriate Extinguisher Certificate of Registration
from the State Fire Marshal's Office to perform inspection, testing,
and maintenance of portable fire extinguishers;
(C) maintain onsite, a record of all fire extinguisher
inspections and maintenance performed; and
(D) replace unserviceable fire extinguishers.
(j) General facility condition and safety features.
(1) An assisted living facility must ensure staff utilize
procedures to avoid cross-contamination between clean and soiled processes,
including the handling of linens and cooking utensils.
(2) An assisted living facility must keep all buildings
in good repair.
(A) An assisted living facility must maintain electrical,
heating, and cooling systems so these systems operate in a safe manner.
As evidence that these systems operate in a safe manner, HHSC may
require the facility to submit a report prepared by one of the following:
(i) the fire marshal;
(ii) the city or county building official having jurisdiction
over the location of the facility;
(iii) a licensed electrician; or
(iv) a registered professional engineer.
(B) An assisted living facility must ensure electrical
appliances, devices, and lamps do not overload circuits or use extension
cords of excessive length.
(3) An assisted living facility must keep all buildings
free of accumulations of dirt, rubbish, dust, and hazards.
(4) An assisted living facility must maintain floors
in good condition and clean floors regularly.
(5) An assisted living facility must structurally maintain
walls and ceilings and must repair, repaint, or clean walls and ceilings
whenever needed.
(6) An assisted living facility must keep storage areas
and cellars organized and free from obstructions.
(7) An assisted living facility must not store any
items in attic spaces.
(8) An assisted living facility must ensure all equipment
requiring periodic maintenance, testing, and servicing is accessible.
(A) An assisted living facility must ensure equipment
that is necessary to conduct maintenance, testing, and services, including
ladders, specific tools, and keys, is readily available to staff or
maintenance personnel on site.
(B) An assisted living facility must provide access
panels, at least 20 inches wide by 20 inches long, for building maintenance
and must ensure access panels are located for reasonable access to
equipment and fire or smoke barrier walls installed in the attic or
other concealed spaces.
(k) Waste and storage containers.
Cont'd... |
