SECTION 133.141. Fire Prevention and Protection

(a) Fire inspections.

(1) Annual inspection. Approval of the fire protection of a hospital by the local fire department 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 head of the local fire department.

(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 as soon as possible but not later than 10 calendar days following the occurrence.

(c) Fire protection. Fire protection shall be provided in accordance with the requirements of National Fire Protection Association 101, Life Safety Code, 2003 edition (NFPA 101), §18.7, and §133.161(a)(1) of this title (relating to Requirements for Buildings in Which Existing Licensed Hospitals are Located), and §133.162(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, 2001 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 [phone].

(d) Smoking rules. Each hospital 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 hospital.

(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, 2002 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, 2001 edition.

(3) Portable fire extinguishers. Every portable fire extinguisher located in a hospital or upon hospital property shall be installed, tagged, and maintained in accordance with National Fire Protection Association 10, Standard for Portable Fire Extinguishers, 2002 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 hospital in public areas that are readily visible to patients, residents, employees, and visitors.

(2) Annual training. Each hospital 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 hospital 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 hospital 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 §133.161(a)(1)(A) of this title for existing hospitals, and §133.162(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 hospital shall provide the following.

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

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

(3) Outside identification. The hospital 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 hospital 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 §133.141 adopted to be effective June 21, 2007, 32 TexReg 3587