(a) Fire inspections.

(1) Annual inspection. Approval of the fire protection of a facility by the local fire department or State Fire Marshall's Office shall be a prerequisite for licensure.

(2) Purpose of inspection. The purpose of these inspections shall be to ascertain and to cause to be corrected any conditions liable to cause fire or violations of any of the provisions or intent of these rules, or of any other applicable ordinances, which affect fire safety in any way.

(3) Hazardous or dangerous conditions or materials. Whenever any of the officers, members, or inspectors of the fire department or bureau of fire prevention 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 inspector/officer.

(4) Access for inspection. At all reasonable hours, the chief of the fire department, the chief of the bureau of fire prevention, or any of the fire inspectors may enter any building or premises for the purpose of making an inspection or investigation which may be deemed necessary under the provisions of these rules.

(b) Fire reporting. All occurrences of fire shall be reported to the local fire authority and shall be reported in writing to the Hospital Licensing Director, Health Facility Licensing and Compliance Division, Texas Department of Health, 1100 West 49th Street, Austin, Texas 78756, as soon as possible but not later than 10 calendar days following the occurrence.

(1) The fire incident report shall indicate as a minimum the following information: (A) the fire origin and area/location; (B) amount of damage; (C) were patients or employees/staff injured; (D) was the fire department notified and did they respond; (E) how was the fire detected; (F) how was the fire extinguished; (G) what caused the fire; (H) was there a general evacuation or just area evacuation; and (I) has the fire area/location been reoccupied.

(2) The fire incident report shall be provided on facility letterhead and signed by hospital administration.

(3) A copy of the fire marshall incident report shall be provided if the fire marshall wrote an incident report.

(c) Fire protection. Fire protection shall be provided in accordance with the requirements of National Fire Protection Association 101, Code for Safety to Life from Fire in Buildings and Structures, 2000 edition (NFPA 101), §18-7, and §134.121(a)(1) of this title (relating to Requirements for Buildings in which Existing Licensed Facilities are Located), and §134.122(a)(1) and (d) of this title (relating to New Construction Requirements). When required or installed, sprinkler systems for exterior fire exposures shall comply with National Fire Protection Association 80A, Recommended Practice for Protection of Buildings from Exterior Fire Exposures, 1999 edition. All documents published by 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, Post Office Box 9101, Quincy, MA 02269-9101 or (800) 344-3555.

(d) Smoking rules. Each facility 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. Inspection, testing, and maintenance of fire-fighting equipment shall be conducted by each facility.

(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 National Fire Protection Association 25, Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems, 1995 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 National Fire Protection Association 96, Standard for Ventilation Control and Fire Protection of Cooking Operations, 1998 edition.

(3) Portable fire extinguishers. Every portable fire extinguisher located in a facility or upon facility property shall be installed, tagged, and maintained in accordance with National Fire Protection Association 10, Standard for Portable Fire Extinguishers, 1998 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 facility in public areas that are readily visible to patients, residents, employees, and visitors.

(2) Annual training. Each facility shall conduct an annual training program for instruction of all personnel in the 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. The facility shall conduct at least 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. Documentation of the drills shall be maintained for a period of not less than one year.

(h) Fire alarm system. Every facility 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 §134.121(a)(1)(A) of this title for existing facilities, and §134.122(d)(5)(N) of this title 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, every facility shall provide the following.

(1) Driveways. The facility shall maintain driveways, free from all obstructions, to main buildings for fire department apparatus use.

(2) Floor plans. Upon request, the facility shall submit a copy of the floor plans of the building to the local fire department officials.

(3) Outside identification. The facility 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 a facility 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 §510.101 adopted to be effective January 1, 2004, 28 TexReg 5154; transferred effective June 1, 2019, as published in the Texas Register May 17, 2019, 44 TexReg 2469