(a) Fire inspections.
  (1) Annual inspection. A limited services rural hospital (LSRH) shall obtain approval of the fire protection of the LSRH by an individual certified by the Texas Commission on Fire Protection as a prerequisite for licensure.
  (2) Hazardous or dangerous conditions or materials. Whenever any of the officers, members, or inspectors of the Texas Commission on Fire Protection 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 head of the local fire department.
  (3) Access for inspection. At all reasonable hours, the LSRH shall allow the chief of the fire department, the chief of the bureau of fire prevention, or any of the fire inspectors to enter any LSRH building or premises for the purpose of making an inspection or investigation that may be deemed necessary under the provisions of these rules.
(b) Fire reporting. All occurrences of fire shall be reported, in writing, to the Texas Health and Human Services Commission (HHSC) as soon as possible but not later than 10 calendar days after the occurrence.
(c) Fire protection. Fire protection shall be provided in accordance with the requirements of National Fire Protection Association 101, Life Safety Code, 2012 edition (NFPA 101), §18.7, §511.161(a)(1) of this chapter (relating to Requirements for Buildings in Which Existing Licensed Hospitals are Located), and §511.162(a)(1) and (d) of this chapter (relating to General Construction Requirements). Sprinkler systems for exterior fire exposures shall comply with NFPA 80A, Recommended Practice for Protection of Buildings from Exterior Fire Exposures, 2001 edition.
(d) Smoking rules. Each LSRH 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. An LSRH shall conduct inspection, testing, and maintenance of fire-fighting equipment.
  (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 NFPA 25, Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems, 2011 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 NFPA 96, Standard for Ventilation Control and Fire Protection of Cooking Operations, 2011 edition.
  (3) Portable fire extinguishers. Every portable fire extinguisher located in an LSRH or on LSRH property shall be installed, tagged, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers, 2010 edition.
(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 staff.
  (1) Posting requirements. An evacuation floor plan shall be prominently and conspicuously posted for display throughout the LSRH in public areas that are readily visible to patients, residents, employees, and visitors.
  (2) Annual training. The LSRH shall conduct an annual training program for instruction of all personnel in the LSRH 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. An LSRH shall conduct at least 12 fire drills each year, 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.
(h) Fire alarm system. Every LSRH 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 §511.161(a)(1)(A) of this chapter for existing hospitals, and §511.162(d)(5)(N) of this chapter 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, §18.3.4.3.2.
(j) Fire department access. As an aid to fire department services, an LSRH shall provide the following.
  (1) Driveways. The LSRH shall maintain driveways, free from all obstructions, to main buildings for fire department apparatus use.
  (2) Submission of plans. Upon request, the LSRH shall submit a copy of the floor plans of the building to the local fire department officials.
  (3) Outside identification. The LSRH 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 an LSRH 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.

Source Note: The provisions of this §511.141 adopted to be effective October 5, 2023, 48 TexReg 5668