(a) If flammable germicides, including alcohol-based products, are used for surgical skin preparation, the facility must:
  (1) use only self-contained, single-use, pre-measured applicators to apply the surgical skin preparations;
  (2) follow all manufacturer product safety warnings and guidelines;
  (3) develop, implement and enforce written policies and procedures outlining the safety precautions required related to the use of the products, which, at a minimum, must include minimum drying times, prevention and management of product pooling, parameters related to draping and the use of ignition sources, staff responsibilities related to ensuring safe use of the product, and documentation requirements sufficient to evaluate compliance with the written policies and procedures;
  (4) ensure that all staff working in the surgical environment where flammable surgical skin preparation products are in use have received training on product safety and the facility policies and procedures related to the use of the product;
  (5) develop, implement and enforce an interdisciplinary team process for the investigation and analysis of all flammable germicides fires and alleged violations of the policies; and
  (6) report all occurrences of flammable germicide fires to the department in care of the Facility Licensing Group not later than the second business day after the fire, and complete an investigation of the occurrence and develop and implement a corrective action plan not later than the 30th day after the fire.
(b) Alcohol-based hand rubs (ABHRs) are considered flammable. When used, the ABHRs shall meet the following requirements.
  (1) The dispensers may be installed in a corridor so long as the corridor width is six feet or greater. The dispensers shall be installed at least four feet apart.
  (2) The maximum individual dispenser fluid capacity is 1.2 liters for dispensers in rooms, corridors, and areas open to corridors, and 2.0 liters for dispensers in suites of rooms.
  (3) The dispensers shall not be installed over or directly adjacent to electrical outlets and switches.
  (4) Dispensers installed directly over carpeted surfaces shall be permitted only in sprinklered smoke compartments.
  (5) Each smoke compartment may contain a maximum aggregate of 10 gallons of ABHR solution in dispensers and a maximum of five gallons in storage.
(c) An facility shall comply with the requirements of this section for handling and storage of gas and flammable liquids. Flammability of liquids and gases shall be determined by National Fire Protection Association 329, Handling Releases of Flammable and Combustible Liquids and Gases, 2002 Edition.
  (1) Nonflammable gases, including but not limited to oxygen and nitrous oxide, shall be stored and distributed in accordance with Chapter 5 of the National Fire Protection Association 99, Standard for Health Care Facilities, 2002 edition (NFPA 99). 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. NFPA documents are also available for public inspection during regular working hours at the offices of Architectural Review Group, Texas Department of State Health Services, 1100 West 49th Street, Austin, Texas 78756-3199.
    (A) Medical gases and liquefied medical gases shall be handled in accordance with the requirements of NFPA 99, Chapter 9.
    (B) Oxygen shall be administered in accordance with NFPA 99, §9.6.
    (C) When inhalation anesthetic agents are used, the ventilation requirements shall be in accordance with the requirements of NFPA 99, §13.4.1.2.
  (2) Piped flammable gas systems intended for use in laboratories and piping systems for fuel gases shall comply with requirements of NFPA 99, §11.11.
  (3) Flammable gases shall be stored in accordance with NFPA 99, §11.10.
  (4) Flammable and combustible liquids used in laboratories shall be handled and stored in accordance with NFPA 99, §11.7, and National Fire Protection Association 101, Life Safety Code, 2003 edition, §18.3.2.2.
  (5) Other flammable agents shall be stored in accordance with NFPA 99, Chapter 7.
(d) No motor vehicles including gasoline powered standby generators or any amount of gasoline shall be located within the facility building. Other devices which may cause or communicate fire, and which are not necessary for patient treatment or care, shall not be stored within the facility building. All such devices and materials when necessary shall be used within the building only with precautions ensuring a reasonable degree of safety from fire.
(e) The installation, use, and maintenance of gas fired appliances and gas piping installations shall comply with the National Fire Protection Association 54, National Fuel Gas Code, 2002 Edition. The use of portable gas heaters and unvented open flame heaters is specifically prohibited.

Source Note: The provisions of this §131.123 adopted to be effective June 1, 2010, 35 TexReg 4400