HospitalInspections.org

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Based on observation the facility failed to provide
self-closing devices that allowed the door to latch
into the frame at smoke and fire barriers.

The inspector observed, while accompanied by
the Facility Director on 10/11/22 from 9:00am to
11:30am that door closers needed to be installed
or adjusted at smoke or fire barriers.
The Maintenance Manager stated on 10/11/22 at
10:55am that the facility would make required
revisions.
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During the survey on 10/11/22 with the Maintenance Manager, it was observed several rooms were being used for services not originally intended and have not been modified to properly provide current services. Please obtain an ARU Application Form for newer projects that need State Inspections at https://hhs.texas.gov/doing-business-hhs/provider-portals/health-care-facilities-regulation/architectural-review. Please complete the for for all revised uses as a Minor Project and email to AskARU@hhs.texas.gov to allow review and determination if an ARU Inspection is warranted.

When new projects arise, please be reminded of the requirements of Department of State Health Services Facility Licensing Group, Title 25, Texas Administrative Code, Chapter 133, Hospital Licensing State Regulations, Effective June 21, 2007, including:

(d) Building design and construction requirements. Every building and every portion thereof shall be designed and constructed to sustain all dead and live loads in accordance with accepted engineering practices and standards and the local governing building codes. Where there is no local governing building code, the hospital shall be constructed in accordance with the International Building Code, 2003 edition, published by the International Code Council, 5203 Leesburg Pike, Falls Church, VA 22041, telephone (800) 786-4452.
(1) General architectural requirements. All new construction, including conversion of an existing building to a hospital, and establishing a separately licensed hospital in a building with an existing licensed hospital, shall comply with Chapter 18 of the National Fire Protection Association 101, Life Safety Code, 2003 edition (NFPA 101), and Subchapters H and I of this chapter (relating to Fire Prevention and Safety Requirements, and Physical Plant and Construction Requirements, respectively). Construction documents shall be submitted to the department in accordance with §133.167 of this title (relating to Preparation, Submittal, Review and Approval of Plans, and Retention of Records).
(A) Physical environment. A physical environment that protects the health and safety of patients, personnel, and the public shall be provided in each hospital. The physical premises of the hospital and those areas of the hospital's physical structure that are used by the patients (including all stairwells, corridors, and passageways) shall meet the local building and fire safety codes and Subchapters H and I of this chapter.
(B) Construction type. A hospital may occupy an entire building or a portion of a building, provided the hospital portion of the building is separated from the rest of the building in accordance with subparagraph (C) of this paragraph and the entire building or the hospital portion of the building complies with new construction requirements (type of construction permitted for hospitals by NFPA 101, §18.1.6.2), and the entire building is protected with a fire sprinkler system conforming with requirements of National Fire Protection Association 13, Standard for the Installation of Sprinkler Systems, 2002 Edition (NFPA 13).
(C) Separate buildings. Portions of a building divided horizontally with two-hour fire rated walls which are continuous (without offsets) from the foundation to above the roof shall be considered as a separate building. Communicating openings in the two-hour wall shall be limited to public spaces such as lobbies and corridors. All such openings shall be protected with self-closing one and one-half hour, Class B fire door assemblies.
(D) Design for the handicapped. Special considerations benefiting handicapped staff, visitors, and patients shall be provided. Each hospital shall comply with the Americans with Disabilities Act (ADA) of 1990, Public Law 101-336, 42 United States Code, Chapter 126, and Title 36 Code of Federal Regulations, Part 1191, Appendix A, Accessibility Guidelines for Buildings and Facilities, or Title 16 TAC, Chapter 68, Texas Accessibility Standards (TAS), April 1, 1994 edition, issued by the Texas Department of Licensing and Regulation, under the Texas Architectural Barriers Act, Texas Government Code, Chapter 469.
(E) Patient safety. In developing construction documents for submission to the department in accordance with §133.167 of this title, the owner shall comply with the requirements of Health and Safety Code, Chapter 256, Safe Patient Handling and Movement Practices. Section 256.002(b)(8) requires a hospital's governing body to consider the feasibility of incorporating patient handling equipment or the physical space and construction design needed to incorporate that equipment at a later date.
(F) Other regulations. The more stringent standard, code or requirement shall apply when a difference in requirements for construction exists.
(G) Exceeding minimum requirements. Nothing in this subchapter shall be construed to prohibit a better type of building construction, more exits, or otherwise safer conditions than the minimum requirements specified in this subchapter.
(H) Equivalency. Nothing in this subchapter is intended to prevent the use of systems, methods, or devices of equivalent or superior quality, strength, fire resistance, effectiveness, durability, and safety to those prescribed by this subchapter, providing technical documentation which demonstrates equivalency is submitted to the department for approval.
(I) Freestanding buildings (not for patient use). Separate freestanding buildings for nonpatient use such as the heating plant, boiler plant, laundry, repair workshops, or general storage may be of unprotected noncombustible construction, protected noncombustible construction, or fire-resistive construction and be designed in accordance with other occupancy classifications requirements listed in NFPA 101.
(J) Freestanding buildings (for patient use other than sleeping). Buildings containing areas for patient use which do not contain patient sleeping areas and in which care or treatment is rendered to ambulatory inpatients who are capable of judgment and appropriate physical action for self-preservation under emergency conditions, may be classified as business or ambulatory care occupancies as listed in NFPA 101, Chapters 20 and 38, respectively, instead of hospital occupancy.
(K) Energy conservation. In new construction and in major alterations and additions to existing buildings and in new buildings, electrical and mechanical components shall be selected for efficient utilization of energy. Hospital construction shall be in accordance with the provisions of the Texas Building Energy Performance Standards, Health and Safety Code, Chapter 388.
(L) Heliports. Heliports located on hospital buildings or land used or intended to be used for landing and take off of helicopters shall comply with National Fire Protection Association 418, Standard for Heliports, and 2001 edition.

Tha Maintenance Manager stated that the Architectural Review Group will be notified of all revised spaces and proper application forms will be submitted on 10/11/22.
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Based on observation the facility failed to provide
a fully exhaust system throughout the facility, as
required by:
Department of State Health Services, Facility
Licensing Group, Title 25, Texas Administrative
Code, Chapter 133, Hospital Licensing State
Regulations
§133.162. New Construction Requirements.
(d)(3)(D) Heating, ventilating and air conditioning
(HVAC) systems. All HVAC systems shall comply
with and shall be installed in accordance with the
requirements of National Fire Protection
Association 90A, Standard for the Installation of
Air Conditioning and Ventilating Systems, 2002
edition, (NFPA 90A), NFPA 99, Chapter 6, the
requirements contained in this subparagraph, and
the specific requirements for a particular unit in
accordance with §133.163 of this title.
(i) General ventilation requirements. All rooms
and areas in the hospital listed in Table 3 of
§133.169(c) of this title shall have provision for
positive ventilation. Fans serving exhaust
systems shall be located at the discharge end
and shall be conveniently accessible for service.
Exhaust systems may be combined, unless
otherwise noted, for efficient use of recovery
devices required for energy conservation. The
ventilation rates shown in Table 3 of §133.169(c)
of this title shall be used only as minimum
requirements since they do not preclude the use
of higher rates that may be appropriate. Supply
air to the building and exhaust air from the
building shall be regulated to provide a positive
pressure within the building with respect to the
exterior.
(VII) Areas requiring fully ducted systems. Fully
ducted supply, return and exhaust air for HVAC
systems shall be provided for all critical care
areas, sensitive care areas, all patient care areas,
all areas requiring a sterile regimen, storage
rooms, food preparation areas, and where
required for fire safety purposes. Combination
systems, utilizing both ducts and plenums for
movement of air in these areas shall not be
permitted.
(I) If the toilet is for patient use, an additional
hand washing fixture shall be provided in each
room at the entrance of the room. If the modular
toilet/hand washing unit is for patient use,
provision shall be made for patient privacy and
odor control. The toilet room exhaust shall be in
accordance with Table 3 of §133.169(c) of this
title.
(C) The isolation room exhaust shall be a
dedicated system which exhausts all air
continuously to the exterior in accordance with
Table 3 of §133.169(c) of this title. Multiple
isolation rooms may be interconnected to the
same exhaust system.
(viii) The isolation exhaust system shall be
connected to the emergency essential electrical
system.

The inspector observed, while accompanied by
the Maintenance Manager on 10/11/22 from
9:00am to 11:30am that the negative air at the
exhaust grille would not hold a tissue in place
when tested at several required locations.
The Facility Director stated on 10/11/22 at
10:10am that the facility would make required
revisions.