Section 117.91 - Fire Prevention, Protection, and Emergency Contingency Plan(a) An end stage renal disease (ESRD) facility shall comply with the provisions of this section with respect to fire prevention and protection.(1) The facility shall comply with local fire codes.(2) The facility shall report all incidents of fire to the local fire authority and to Texas Health and Human Services Commission Complaint and Incident Intake as soon as possible, but not later than 10 calendar days following the incident. Any fire incident causing injury to a person shall be reported within one business day.(3) The facility shall adopt, implement, and enforce a written smoking policy.(b) The facility shall adopt, implement, and enforce a written policy for periodic inspection, testing, and maintenance of fire fighting equipment, portable fire extinguishers, and when installed sprinkler systems. If installed, fire sprinkler systems shall comply with National Fire Protection Association 13, Standard for the Installation of Sprinkler Systems, 2002 Edition (NFPA 13).(1) 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) Every portable fire extinguisher located in or upon the facility's property shall be installed, tagged, and maintained in accordance with National Fire Protection Association 10, Standard for Portable Fire Extinguishers, 2002 Edition.(c) 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, §21.7.1.1. Copies of the plan shall be available to all staff.(1) An evacuation floor plan shall be prominently and conspicuously posted for display throughout the facility in public areas that are readily visible to patients, employees, and visitors.(2) 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.(3) The facility shall conduct one fire drill per shift per quarter, which shall include the transmission of the fire alarm signal and simulation of the emergency fire condition, simulation of evacuation of patients and other occupants, and use of fire-fighting equipment. Written reports shall be maintained to include evidence of patient and staff participation. Fire exit drills shall incorporate the minimum requirements of NFPA 101, §§21.7.1.2 - 21.7.2.3.(4) All staff shall be familiar with the locations of fire fighting equipment. Fire fighting equipment shall be located so that a person shall not have to travel more than 75 feet from any point to reach the equipment.(d) A fire alarm system shall be installed, maintained, and tested, in accordance with National Fire Protection Association 72, National Fire Alarm Code, 2002 Edition (NFPA 72) and NFPA 101, §21.3.4.(e) 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, §21.3.4.4.(f) As an aid to fire department services, every ESRD facility shall provide the following: (1) The facility shall maintain driveways, free from all obstructions, to main buildings for fire department apparatus use.(2) Upon request, the facility shall submit a copy of the floor plans of the building to the local fire department officials.(3) 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.(g) When the 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.(h) In this subsection, unless the context clearly indicates otherwise, "emergency" means an incident likely to threaten the health, welfare, or safety of a facility's patients, facility staff, or the public, including a fire, equipment failure, power outage, flood, interruption in utility service, medical emergency, or natural or other disaster. (1) In accordance with Texas Health and Safety Code § 251.017, the facility shall adopt an emergency contingency plan for the continuity of emergency essential building systems that meets the requirements described by paragraph (2), (3), or (4) of this subsection.(2) The facility shall have an onsite permanent emergency generator affixed to a generator pad with a Type 2 essential electrical distribution system in accordance with National Fire Protection Association (NFPA) 99: Health Care Facilities Code, 2002 Edition, §4.5, and NFPA 110: Standard for Emergency and Standby Power Systems, 2002 Edition.(A) The emergency generator shall require an onsite fuel source and enough fuel capacity in the tank for a period of 24 hours or more, as determined by the electrical load demand on the emergency generator for that period. When a vapor liquefied petroleum gas (LPG) (natural gas) system is used, the 24 -hour fuel capacity on site is not required. The vapor liquified petroleum gas system shall require a dedicated fuel supply.(B) The facility shall install, test, and maintain the onsite emergency generator in accordance with NFPA 99: Health Care Facilities Code, 2002 Edition, §4.5.4, and NFPA 110 Standard for Emergency and Standby Power Systems.(C) The facility shall always keep the emergency generator not less than 10 feet from any electrical transformer.(D) The facility shall maintain on-site a sufficient quantity of potable water supply for the operation of the water treatment system for at least 24 hours.(E) The facility shall provide and maintain a water valve connection that allows an outside vendor to provide potable water to operate the facility's water treatment system.(3) The facility shall: (A) maintain sufficient resources to provide on demand or to execute a contract with an outside supplier or vendor to provide on demand:(i) a portable emergency generator that:(I) has an electrical transfer switch with a plug-in device sized to provide emergency power for patient care areas and complies with NFPA 99: Health Care Facilities Code, 2002 Edition, §4.5.2.2.2; and(II) has a water valve connection that allows for the use of potable water to operate the facility's water treatment system; and(ii) an alternate power source for light, including battery-powered light, that:(I) is separate and independent from the normal electrical power source;(II) can provide light for at least one-and-a-half hours;(III) can provide enough light to allow for safe evacuation of the building; and(IV) is maintained and tested at least four times each year; and(B) implement the emergency contingency plan when the facility loses of electrical power due to a natural or man-made event during which the electrical power may not be restored within 24 hours; and(C) contact the outside supplier or vendor with which the facility contracts under subparagraph (A) of this subsection, if applicable, within 36 hours after the facility loses electrical power.(4) The facility shall execute a contract with another licensed ESRD facility located within a 100-mile radius of the facility stipulating that the other ESRD facility will provide emergency contingency care to the facility's patients. The other ESRD facility with which the facility contracts must have an alternate power source for light, including battery-powered light, that: (A) is separate and independent from the normal electric power source;(B) can provide light for at least one-and-a-half hours;(C) can provide enough light to allow for safe evacuation of the building; and(D) is maintained and tested at least four times each year.25 Tex. Admin. Code § 117.91
The provisions of this §117.91 adopted to be effective July 6, 2010, 35 TexReg 5835; Amended by Texas Register, Volume 48, Number 07, February 17, 2023, TexReg 0895, eff. 2/21/2023