SECTION 133.161. Requirements for Buildings in Which Existing Licensed Hospitals Are Located

(a) Compliance. All buildings in which existing hospitals licensed by the Department of State Health Services (department) are located shall comply with this subsection.

(1) Minimum fire safety and construction requirements.

(A) Existing licensed hospitals shall meet the requirements for health care occupancies contained in the 1967, 1973, 1981, 1985, 1991, 1997, 2000, or 2003 editions of the National Fire Protection Association 101, Life Safety Code, (NFPA 101), the Hospital Licensing Standards/Rules (1969, 1985, or 1998 editions as amended), and the hospital licensing rules under which the buildings or sections of buildings were constructed. 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, P.O. Box 9101, Quincy, MA 02269-9101 or [phone].

(B) Existing hospitals or portions of existing hospitals constructed prior to the adoption of any of the editions of NFPA 101, the Hospital Licensing Standards, and the hospital licensing rules listed in subparagraph (A) of this paragraph, shall comply with this section and Chapter 19, NFPA 101, 2003 edition.

(C) Compliance with the requirements of Chapter 4 of the National Fire Protection Association 101A, Alternative Approaches to Life Safety, 2001 edition, (relating to Fire Safety Evaluation System for Health Care Occupancies) will be acceptable in lieu of complying with the requirements of Chapter 19, NFPA 101, 2003 edition.

(2) Remodeling of existing facilities. All requirements listed in this chapter relating to new construction are applicable to renovations, additions and alterations unless stated otherwise.

(A) Alteration or installation of new equipment. Any alteration or any installation of new equipment shall be accomplished as nearly as practicable with the requirements for new construction, except that when existing conditions make changes impractical to accomplish, minor deviations from functional requirements may be permitted if the intent of the requirements is met and if the care and safety of patients will not be jeopardized.

(B) Installation, alteration, or extension approval. No new system of mechanical, electrical, plumbing, fire protection, or piped medical gas system may be installed or any such existing system may be replaced, materially altered or extended in an existing building licensed as a hospital, until complete plans and specifications for the replacement, installation, alteration, or extension have been submitted to the department, reviewed and approved in accordance with §133.167 of this title (relating to Preparation, Submittal, Review and Approval of Plans, and Retention of Records).

(C) Minor remodeling or alterations. All remodeling or alterations which do not involve alterations to load bearing members or partitions, change functional operation, affect fire safety (e.g. modifications to the fire, smoke, and corridor walls), add or subtract beds or services for which the hospital is licensed, and do not involve changes listed in subparagraph (B) of this paragraph, shall be submitted for approval without submitting contract documents. Such approval shall be requested in writing with a brief description of the proposed changes in accordance with §133.167(f)(3) of this title.

(D) Major remodeling or alterations. Plans shall be submitted in accordance with §133.167 of this title for all major remodeling or alterations. All remodeling or alterations which involve alterations to load bearing members or partitions, change functional operation, affect fire safety (e.g. modifications to the fire, smoke, and corridor walls), or add beds or services over those for which the hospital is licensed are considered as major remodeling and alterations.

(E) Phasing of construction in existing facilities.

(i) Projects involving alterations of and additions to existing buildings shall be programmed and phased so that on-site construction will minimize disruptions of existing functions.

(ii) Access, exit access, and fire protection shall be maintained so that the safety of the occupants will not be jeopardized during construction.

(iii) A noncombustible or limited combustible dust and vapor barrier shall be provided to separate areas undergoing demolition and construction from occupied areas. When a fire retardant plastic material is used for temporary daily usage, it shall be removed at the end of each day.

(iv) The air inside the construction area shall be protected by mechanical filtration that recirculates inside the space or is exhausted directly to the exterior.

(v) The area shall be properly ventilated and maintained. The area under construction shall have a negative air pressure differential to the adjoining areas and shall continue to operate as long as construction dust and odors are present.

(vi) Temporary sound barriers shall be provided where intense prolonged construction noises will disturb patients or staff in the occupied portions of the building.

(F) Nonconforming conditions. When doing renovation work, if it is found to be infeasible to correct all of the nonconforming conditions in the existing hospital in accordance with these rules, a conditional approval may be granted by the department if the operation of the hospital, necessary access by the handicapped, and safety of the patients are not jeopardized by the nonconforming condition.

(b) Previously licensed hospitals. Buildings which have been licensed previously as hospitals but have been vacated or used for purposes other than as hospitals and which are not in compliance with the 1967, 1973, 1981, 1985, 1991, 1997, 2000, or 2003 editions of the NFPA 101, the Hospital Licensing Standards/Rules (1969, 1985, or 1998 editions as amended), and hospital licensing rules under which the building or sections of buildings were constructed shall comply with the requirements of §133.162 of this title (relating to New Construction Requirements), §133.163 of this title (relating to Spatial Requirements for New Construction), §133.165 of this title (relating to Building with Multiple Occupancies), §133.167 of this title, and §133.168 of this title (relating to Construction, Inspections, and Approval of Project).

Source Note: The provisions of this §133.161 adopted to be effective June 21, 2007, 32 TexReg 3587