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TITLE 40SOCIAL SERVICES AND ASSISTANCE
PART 1DEPARTMENT OF AGING AND DISABILITY SERVICES
CHAPTER 19NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION
SUBCHAPTER DFACILITY CONSTRUCTION
DIVISION 3PROVISIONS APPLICABLE TO ALL FACILITIES
RULE §19.326Safety Operations

(a) The facility must have a program to inspect, test, and maintain the fire alarm system and must execute the program at least once every three months.

  (1) The facility must contract with a company that is registered by the State Fire Marshal's Office to execute the program.

  (2) A person who performs a service under the contract must be licensed by the State Fire Marshal's Office to perform the service and must complete, sign and date an inspection form similar to the inspection and testing form in NFPA 72 for a service provided under the contract.

  (3) The facility must ensure fire alarm system components that require visual inspection are visually inspected in accordance with NFPA 72.

  (4) The facility must ensure fire alarm system components that require testing are tested in accordance with NFPA 72.

  (5) The facility must ensure fire alarm system components that require maintenance are maintained in accordance with NFPA 72.

  (6) The facility must ensure smoke dampers are inspected and tested in accordance with NFPA 101.

  (7) The facility must maintain onsite documentation of compliance with this subsection.

(b) A facility must have a program to inspect, test and maintain the sprinkler system and must execute the program at least once every three months.

  (1) The facility must contract with a company that is registered by the State Fire Marshal's Office to execute the program.

  (2) The person who performs a service under the contract must be licensed by the State Fire Marshal's Office to perform the service and must complete, sign and date an inspection form similar to the inspection and testing form in NFPA 25 for a service provided under the contract.

  (3) The facility must ensure sprinkler system components that require visual inspection are visually inspected in accordance with NFPA 13 and 25.

  (4) The facility must ensure sprinkler system components that require testing are tested in accordance with the NFPA 13 and 25.

  (5) The facility must ensure sprinkler system components that require maintenance are maintained in accordance with NFPA 13 and 25.

  (6) The facility must ensure that individual sprinkler heads are inspected and maintained in accordance with NFPA 13 and 25.

  (7) The facility must maintain onsite documentation of compliance with this subsection.

(c) If facility staff verify or suspect a malfunction of the fire alarm, emergency electrical, or sprinkler system, the facility must immediately investigate and correct the condition. In addition, the facility must immediately report the failure of the fire alarm, emergency electrical, or sprinkler system to all facility staff and the local fire authority.

(d) If emergency generators are required or provided, a facility must have a program to maintain, operate, and test all emergency generators, including all appurtenant components, and must execute the program at least once every week.

  (1) The facility must use a properly instructed person to oversee and execute the program.

  (2) The facility must ensure generator components are inspected, tested, and maintained in accordance with NFPA 37, 70, 99, and 110.

  (3) The facility must ensure all generators are operated, under load, for at least 30 minutes each week.

  (4) The person who executes the program must maintain a signed and dated record or log of inspections, tests and maintenance performed.

  (5) For each required operation of the generator under the program, the record or log must include the information necessary to verify:

    (A) the total time taken to transfer the load to emergency power;

    (B) the total time the generator operated under load;

    (C) the total time the facility's emergency system remained on generator power after restoration of normal utility power; and

    (D) the total time the generator operated without load after the facility's return to normal utility power.

  (6) The facility must ensure the condition and proper operation of all emergency lighting is inspected and tested at least once every week.

  (7) The facility must maintain onsite documentation of compliance with this subsection.

(e) Duplex receptacles powered through the emergency electrical system must be installed at each resident bed location where resident-care-related electrical appliances are in use, unless a facility can demonstrate that it can provide the diagnostic, therapeutic, or monitoring benefits of the resident-care-related electrical appliances through acceptable alternative means in the event of a power outage.

(f) A facility must conduct a functional test on every required battery emergency lighting system at 30-day intervals for a minimum of 30 seconds. The facility must also conduct an annual test for a minimum of 1 1/2 hours. The lighting system must be fully operational for the duration of the testing. The facility must maintain an onsite written record of all tests performed and make those records available to the authority having jurisdiction during an inspection.

(g) A facility must ensure that a person licensed by the State Fire Marshal's Office inspects and services automatic fixed fire extinguishment systems mounted in kitchen range hoods at least once every six months in accordance with NFPA 96. The facility must maintain, onsite, a written and signed report of the inspection and service performed. The facility must keep the hood, exhaust ducts, and filters clean and free of accumulated grease.

(h) A facility must inspect and maintain portable fire extinguishers.

  (1) Facility staff must visually inspect portable fire extinguishers monthly. Facility staff conducting the monthly visual inspection must ensure portable extinguishers are protected from damage, kept on their mounting brackets or in cabinets at all times, and kept in the proper condition and working order.

  (2) A facility must ensure that a person licensed by the State Fire Marshal's Office inspects and maintains portable fire extinguishers at least once every 12 months in accordance with NFPA 10.

  (3) The facility must maintain, onsite, a record of all fire extinguisher inspections and maintenance performed.

(i) A facility using gas must have the gas piping lines between the meter and appliances tested for leaks annually by a person licensed by the State Board of Plumbing Examiners. The facility must maintain, onsite, a written and signed report of these tests. The facility must note and correct any unsatisfactory conditions immediately.

(j) A facility must formulate, adopt, and enforce policies regarding smoking, smoking areas, and smoking safety that also take into account non-smoking residents.

  (1) The facility's policies must comply with all applicable federal, state, and local laws and regulations.

  (2) The facility is responsible for informing residents, staff, visitors, and other affected parties of smoking policies through the distribution and posting of policies.

  (3) A facility must prohibit smoking in any room, ward, or compartment where flammable liquids, combustible gas, or oxygen are used or stored and in any other hazardous locations. These areas must be posted with "No Smoking" signs.

  (4) A facility must provide ashtrays of noncombustible material and safe design in all areas where smoking is permitted.

  (5) A facility must provide a metal container with a self-closing cover device into which ashtrays can be emptied in all areas where smoking is permitted.

(k) A facility must not allow storage of combustible products in facility rooms with gas-fired equipment.

(l) A facility must not allow storage of volatile or flammable liquids or materials anywhere within the facility building.

(m) A facility may install alcohol-based hand rub dispensers if the dispensers are:

  (1) installed in a manner that:

    (A) does not conflict with any state or local codes that prohibit or otherwise restrict the placement of alcohol-based hand rub dispensers in health care facilities;

    (B) minimizes leaks and spills that could lead to falls;

    (C) adequately protects against access by vulnerable populations; and

    (D) complies with NFPA 101; and

  (2) maintained in accordance with dispenser manufacturer guidelines.

(n) A facility must not store or leave unattended medical equipment, carts, wheelchairs, tables, furniture, dispensing machines, or similar physical objects in corridors or other ways of egress, except as permitted by NFPA 101.

(o) A facility must keep smoke doors, fire doors, and doors to hazardous rooms in the facility closed and not prop or wedge a door open. The facility may use only approved devices to hold open a door, such as alarm-activated electromagnetic hold-open devices, as permitted by NFPA 101.

(p) The facility must post building evacuation routes at prominent locations throughout the facility.

(q) A facility must provide approved electrical receptacles in quantity and location for the normal use of appliances in the facility.

(r) A facility must not use electrical extension cords or multi-receptacle plug-in adaptors as a substitute for approved wiring methods in the facility.

(s) A facility may use a listed and approved surge-protection device for equipment for which the manufacturer recommends surge protection, but in no case may the facility use a surge-protection device to increase the number of existing electrical outlets in a room.

(t) A facility must remove all abandoned utilities, such as electrical wiring, ducts, and pipes, from the facility when no longer in use. The facility may, however, leave an existing damper that is no longer required by NFPA 101 in-place and inoperable, if the damper is in a duct penetration of a smoke barrier in a fully ducted heating, ventilating, and air conditioning system; the damper is permanently secured in the open position; and quick-response sprinklers have been provided for the smoke compartments on both sides of the smoke barrier.

(u) In operations where there is a chance of cross-contamination, clean and soiled operations must be separated to lessen the chance of cross-contamination by facility employees, residents, and others. This separation must be in relation to traffic flow, air currents, air exhaust, water flow, vapors, and other conditions.

(v) A facility must have and implement as necessary a fire safety plan that:

  (1) includes the provisions described in the Operating Features section of NFPA 101, Chapter 18 New Health Care Occupancies and Chapter 19, Existing Health Care Occupancies and concerning:

    (A) use of alarms;

    (B) transmission of alarms to fire department;

    (C) emergency phone call to fire department;

    (D) response to alarms;

    (E) isolation of fire;

    (F) evacuation of immediate area;

    (G) evacuation of smoke compartment;

    (H) preparation of floors and building for evacuation; and

    (I) extinguishment of fire;

  (2) includes procedures for:

    (A) conducting a fire drill on each work shift at least once per quarter with at least one fire drill conducted each month; and

    (B) completing the most current version of the required HHSC form titled "Fire Drill Report" available on the HHSC website for each fire drill conducted.

(w) Floors, walls, and ceilings.

  (1) Floors of the facility must be level, smooth, and free of any irregularities that might affect safety.

  (2) Walls and ceilings not specifically described elsewhere in this chapter must be cleanable, maintained attractively, and in good repair.

  (3) Walls and floors must be kept free of cracks. The joint between the walls and floors is to be maintained so as to be free of spaces that might harbor insects, rodents, or vermin.


Source Note: The provisions of this §19.326 adopted to be effective August 1, 2011, 36 TexReg 4668; amended to be effective March 22, 2018, 43 TexReg 1646

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