(a) Scope. The requirements of this section are applicable to both new and existing facilities unless stated otherwise.
(b) Purpose.
  (1) The concept of requirements for fire safety with regard to the residents is based on evacuation capability as published in NFPA 101. These standards are written with the premise that the residents will be capable of self-evacuation without continuous staff assistance. Residents that are not normally capable of self-evacuation nor capable of negotiating stairs unassisted must not be housed above or below the floor of exit discharge unless the facility meets the construction requirements of NFPA 101, Chapter 18, New Health Care Occupancies, or Chapter 19, Existing Health Care Occupancies, for large facilities, or the "impractical" requirements for small facilities as found in NFPA 101, Chapter 32, New Residential Board and Care Occupancies, or Chapter 33, Existing Residential Board and Care Occupancies. Examples of residents who may not be capable of self-evacuation are as follows:
    (A) a person with a physical disability of a nature that he or she is not capable of maneuvering in a wheelchair, walker, or other assistive device unaided;
    (B) a person with an intellectual disability who will not take or cannot understand instructions from a staff member; or
    (C) a person that is taking medication before bedtime which will make it difficult for a staff member to arouse the person quickly.
  (2) The method of determining the evacuation capability of residents under NFPA 101, Chapter 32, New Residential Board and Care Occupancies or Chapter 33, Existing Residential Board and Care Occupancies, is by rating each resident and each staff member to determine an evacuation difficulty score (E-score). If the E-score is 1.5 or less, the evacuation capability of the facility is prompt, greater than 1.5 to five is slow, greater than five is impractical. The worksheets to be completed are located in NFPA 101A, Chapter 6, Evacuation Capability Determination for Board and Care Occupancies. Facilities with capacity for 16 residents or less must meet the evacuation requirement for their designated Chapter 32, New Residential Board and Care Occupancies or Chapter 33, Existing Residential Board and Care Occupancies rating. The ratings and their requirements are:
    (A) Impractical rating.
      (i) The facility must have one fire drill per shift each calendar quarter (minimum of 12 drills per year).
      (ii) The facility must actually evacuate residents once a year on each shift.
      (iii) All facility staff, including relief and substitute staff, must participate in drills as soon as possible after beginning employment on their shift.
      (iv) E-scores are not required for certification under this rating.
    (B) Slow rating.
      (i) The facility must have one fire drill per shift each calendar quarter (minimum of 12 drills per year).
      (ii) The facility must actually evacuate residents during all drills.
      (iii) Staff on each shift must participate in drills.
      (iv) New, relief, and substitute staff must participate in a drill within ten days of employment on their assigned shift.
      (v) E-scores must be calculated as soon as possible, but within ten calendar days of admission.
      (vi) Initial E-scores are based on four drills, as follows:
        (I) two conducted during the daytime; and
        (II) two conducted during the nighttime, after the first 30 minutes and within the first three hours of sleep.
      (vii) After the initial E-scores are obtained, a worksheet for rating residents must be completed for all newly admitted residents to obtain an E-score. The evacuation capability is calculated as described in clause (vi) of this subparagraph.
      (viii) E-scores must be updated annually or sooner if significant changes occur in any resident's evacuation capability. These updated scores are based on the group's overall performance during fire drills as they are conducted throughout the year. Scores do not have to be calculated in accordance with the drills required for newly admitted residents based on the requirements stated in clause (vi) of this subparagraph.
    (C) Prompt rating.
      (i) The facility must have one fire drill per shift each calendar quarter (minimum of 12 drills per year).
      (ii) The facility must actually evacuate residents during all drills.
      (iii) Staff on each shift must participate in drills.
      (iv) New, relief, and substitute staff must participate in a drill within ten days of employment on their assigned shift.
      (v) E-scores must be calculated as soon as possible, but within ten calendar days of admission.
      (vi) Initial E-scores are based on four drills, as follows:
        (I) two conducted during the daytime; and
        (II) two conducted during the nighttime, after the first 30 minutes and within the first three hours of sleep.
      (vii) After the initial E-scores are obtained, a worksheet for rating residents must be completed for all newly admitted residents to obtain an E-score. The evacuation capability is calculated as described in clause (vi) of this subparagraph.
      (viii) E-scores must be updated annually or sooner if significant changes occur that would affect a resident's evacuation capability. These updated scores are based on the group's overall performance during fire drills as they are conducted throughout the year. Scores do not have to be calculated in accordance with the drills required for newly admitted residents based on the requirements stated in clause (vi) of this subparagraph.
  (3) The "E" score will determine which NFPA 101 features are to be installed and maintained in the facility. These features include construction, fire alarm systems, smoke detector systems, interior finish, sprinkler systems, separation of bedrooms, and egress from the building.
(c) Construction.
  (1) New construction is any construction work that began on or after July 5, 2016. The provisions of NFPA 101, Chapter 18, New Health Care Occupancies are applicable for large facilities, and Chapter 32, New Residential Board and Care Occupancies for small facilities.
  (2) An existing facility is one that was operating with a license as a facility for persons with an intellectual disability or related conditions before November 1, 2016, and has not subsequently become unlicensed. The provisions of NFPA 101, Chapter 19, Existing Health Care Occupancies are applicable for large facilities, and Chapter 33, Existing Residential Board and Care Occupancies for small facilities.
  (3) Alterations or new installations of building services equipment, such as mechanical and electrical systems, generators, fire alarm, and detection systems must be accomplished in conformance with the requirements for new construction as required by NFPA 101.
  (4) Site approval, as required by the local health officer, building department, or fire marshal having jurisdiction, must be obtained. Any conditions considered to be a fire, safety, or health hazard will be grounds for disapproval of the site by the Texas Health and Human Services Commission (HHSC) unless applied in an arbitrary or discriminating manner.
  (5) Facilities that renovate must provide documentation for the flame spread rate of any new materials applied as an interior finish.
  (6) Life safety features and equipment that have been installed in existing buildings and are now in excess of that required by NFPA 101 must continue to be maintained or must be removed at the direction of HHSC.
  (7) When an existing licensed facility plans building additions or remodeling, which includes construction of additional resident beds, then the ratio of bathing units must be reevaluated to meet minimum standards and the square footage of dining and living areas must be reevaluated by HHSC. Conversion of existing living, dining, or activity areas to resident bedrooms must not reduce these functions to an area less than required by minimum standards.
  (8) Buildings must be of recognized permanent type construction. They must be structurally sound with regard to actual or expected dead, live, and wind loads according to applicable building codes.
  (9) Each building must be classified as to the building construction type for fire resistance rating purposes in accordance with NFPA 220 and NFPA 101.
Cont'd...