Revision 16-2

 

§92.61 Introduction and Application

  1. Classification of facilities.
    1. A small facility is a building or buildings consisting of one or more floors providing sleeping accommodations for 16 or fewer residents exclusive of "live-in" houseparents, family or staff.
    2. A large facility is a building or buildings consisting of one or more floors providing sleeping accommodations for 17 or more residents exclusive of "live-in" staff.
    3. New construction is any construction work that began on or after January 6, 2014. Converting an unlicensed building or unlicensed portion of a building to an assisted living facility must meet the new construction requirements for the proposed new use referenced in the Life Safety Code.
    4. An existing facility is one that operated with a license as an assisted living facility before January 6, 2014 and has not subsequently become unlicensed.
  2. Applicability of requirements for construction and life safety.
    1. All buildings or structures, new or existing, used as a licensed assisted living facility must comply with these standards. Any exceptions are specifically mentioned.
    2. Existing buildings and structures that are converted to assisted living occupancy, must not admit assisted living residents until all standards are met and DADS grants approval for occupancy.
    3. A licensed nursing facility or licensed hospital that meets the requirements of Chapter 18, New Health Care Occupancies, or Chapter 19, Existing Health Care Occupancies, of National Fire Protection Association 101 (NFPA 101), may be considered as an assisted living occupancy without implementing additional fire safety features as may be specified in this subchapter.
    4. Buildings and structures must comply with the 2000 edition of NFPA 101, as published by the National Fire Protection Association, Inc., as follows. For new construction, DADS may authorize an assisted living facility to comply with later editions of the code, in their entirety, when required by local building authorities.
      1. All new Type A facilities and small Type B facilities must comply with Chapter 32, New Residential Board and Care Occupancies.
      2. All existing Type A facilities and small Type B facilities must comply with Chapter 33, Existing Residential Board and Care Occupancies.
      3. All new Type B large facilities must comply with Chapter 18. The requirements of limited care, as defined by the NFPA 101, may be used.
      4. All existing Type B large facilities must comply with Chapter 19. The requirements of limited care, as defined by the NFPA 101, may be used.
      5. All assisted living facilities must comply with other chapters, sections, subsections, or paragraphs of the NFPA 101, including Chapter 1, Administration; Chapter 2, Mandatory References; Chapter 3, Definitions; Chapter 4, General; Chapter 5, Performance-Based Option; Chapter 6, Classification of Occupancy and Hazard of Contents; Chapter 7, Means of Egress; Chapter 8, Features of Fire Protection; Chapter 9, Building Service and Fire Protection Equipment; and Chapter 10, Interior Finish, Contents, and Furnishings, as they relate to Chapters 18, 19, 30, New Apartment Buildings, 31, Existing Apartment Buildings, 32, and 33.
      6. All assisted living facilities with buildings that contain living units with independent cooking and bathroom facilities must comply with NFPA 101, Chapters 30, 31, 32, and 33.
    5. New construction is subject to local codes. The description of the occupancy may vary with local codes. In the absence of a local code, DADS requires compliance with the fundamentals of the following codes:
      1. the International Building Code, 2000 edition or later by the International Code Council, relating to "I-1" Occupancy for Type A facilities and "I-2" for Type B facilities;
      2. the International Plumbing Code, 2000 edition by the International Code council or the Uniform Plumbing Code, 2000 Edition;
      3. the National Electrical Code as specified under NFPA 101; and
      4. illumination systems must be designed and installed in accordance with the Lighting Handbook of the Illuminatory Engineering Society (IES) of North America, except as may be modified in this subchapter.
    6. An existing building either occupied as an assisted living facility at the time of initial inspection by DADS or converted to occupancy as an assisted living facility must meet all local requirements pertaining to that building for that occupancy. DADS will require the facility sponsor or licensee to submit evidence that local requirements are satisfied. When local laws, codes or ordinances are more stringent than these standards for assisted living, the more stringent requirements will govern.
    7. Buildings must be structurally sound with regard to actual or expected dead, live, and wind loads according to applicable building codes.
    8. The facility must comply with the accessibility requirements for individuals with disabilities as referenced in the revised regulations for Title II and III (2010 ADA Standards for Accessible Design) of the Americans with Disabilities Act of 1990 at Title 42, United States Code, Chapter 126; federal regulations at Title 28, Code of Federal Regulations, Part 35 and Part 36; Texas Accessibility Standards (TAS) at Texas Government Code, Chapter 469; and Texas Department of Licensing and Regulation (TDLR) rules at Title 16, Texas Administrative Code, Chapter 68. A subject facility must register plans for new construction, substantial renovations, modifications, and alterations with TDLR (Attn: Elimination of Architectural Barriers Program) and comply with TAS.

 

§92.62 General Requirements

  1. General. The concept of the National Fire Protection Association (NFPA) 101 Life Safety Code requirements for fire safety with regard to the residents, is based on evacuation capability. In accordance with NFPA 101, Chapters 32 and 33, Type A facilities are classified as "slow" evacuation capability and Type B facilities are classified as "impractical" evacuation capability.
  2. Evacuation procedures. A resident in a Type A facility must be able to demonstrate to the Texas Department of Aging and Disability Services (DADS) that the resident can travel from the resident's living unit to a centralized space, such as lobby, living or dining room on the level of discharge within a 13-minute period without continuous staff assistance. Elevators cannot be used as an evacuation route.
  3. Operational features.
    1. A fire causing damage to the facility or equipment must be reported to DADS within 72 hours after the fire is extinguished. A fire causing injury or death to a resident must be reported immediately. A telephone report must be followed by a written report on a form that DADS supplies.
    2. Fire drills must be conducted quarterly on each shift and with at least one drill conducted each month. The drills may be announced in advance to the residents. The drills must involve the participation of the staff in accordance with the emergency plan. Residents must be informed of evacuation procedures and locations of exits. All fire drills must be documented on a form provided by DADS. In large Type B facilities, the drill must include the activation of the fire alarm signal, except between 9:00 p.m. and 6:00 a.m.
    3. Smoking regulations must be established, and smoking areas must be designated for residents and staff. Ashtrays of noncombustible material and safe design must be provided in smoking areas.
    4. All facilities, except small, one-story facilities, must post an emergency evacuation floor plan.
    5. An assisted living facility must have in effect and available to all supervisory personnel written copies of an evacuation plan for the protection of all persons in the facility in the event of fire. The plan must address sheltering in place, evacuation to an area of refuge, and evacuation from the building when necessary. The plan must include special staff actions including fire protection procedures needed to ensure the safety of any resident. The plan must be amended or revised when needed. All employees must be periodically instructed and informed of their duties and responsibilities under the plan. A copy of the plan must be readily available at all times within the facility. The plan must reflect the current evacuation capabilities of the residents.
  4. Safety operations. The facility must have a written emergency preparedness and response plan. The facility must attach to the plan the procedures the staff must follow. The plan must address, at a minimum, the eight core functions of emergency management, which are: direction and control; warning (how the facility will be notified of emergencies and who they will notify); communication (with whom and by what mechanism); sheltering arrangements; evacuation (destinations, routes); transportation; health and medical needs; and resource management (supplies, staffing, emergency equipment, records). Plans must be coordinated with the local emergency management coordinator and should address those natural, technological and man-made emergencies that could affect the facility. Information about the local emergency management coordinator may be obtained from the office of the local mayor or county judge.
  5. Construction.
    1. An assisted living facility must be separated from other occupancies. A common wall between an assisted living facility and another occupancy must be not less than a two-hour fire-rated partition. The partition must be constructed as required by National Fire Protection Association Standards. A licensed nursing facility or licensed hospital is not considered another occupancy for this purpose. An exception occurs when an occupancy not subject to DADS licensing standards is located in the same building or structure and is so intermingled that a two hour fire rated partition is impracticable. The means of egress, construction, protection and other safeguards for that location must comply with the National Fire Protection Association (NFPA) 101 requirements of the licensed occupancy.
    2. Interior wall and ceiling surfaces must have as the finished surface or as substrate or sheathing a fire resistance of not less than that provided by 3/8" gypsum board (20 minute fire rating), unless approved otherwise by DADS. A sprinkler system will not substitute for the minimum construction requirements. Exceptions are existing Type B large facilities must meet the construction requirements of NFPA 101, Chapter 19.1.6 and new Type B large facilities must meet NFPA 101, Chapter 18.1.6.
    3. An assisted living facility must meet flame spread rate requirements as specified in Chapters 18, 19, 32, and 33 of NFPA 101.
    4. Doors between resident rooms and corridors or public spaces must be not less than 1-3/4" thick solid core wood construction or 20-minute fire-rated, self-closing or automatic-closing, and latch in their frames. Exceptions are as follows.
      1. Small Type A facilities may have smoke resisting doors, with self-closing or automatic closing devices, if the interior finish is Class 'B' or better and there are two remote exit routes.
      2. Small Type A facilities that have 20-minute fire-rated doors or 1-3/4" solid core wood, Class 'B' or better interior finish, and two remote exit routes are not required to have self-closing or automatic-closing doors.
      3. In a small or large Type A facility protected throughout by an approved automatic sprinkler system, doors to resident bedrooms are not required to be self-closing or automatic-closing, except for a three story or larger building that does not meet construction requirements of NFPA 101, Chapter 18.
      4. In a small or a large Type B facility protected throughout by an approved automatic sprinkler system, the facility may have smoke resisting doors. Door-closing devices are not required.
    5. Upper floors of an assisted living facility must have at least two separate approved stairs. Each stair must be arranged and located so that it is not necessary to go through another room, including a bedroom or bathroom, to reach the stair. All stairs must be provided with handrails and with normal lighting. Refer to NFPA 101 for Class 'A' stair details. DADS may exempt an existing facility with 16 beds or less from meeting this requirement. In the facility, at least one main stair may be Class 'B' and constructed of wood.
    6. All hazardous areas, as defined in NFPA 101, Chapter 18, 19, 32, or 33, must have a one-hour fire-separated barrier or have sprinkler protection, or both, if considered severe. Gasoline, volatile materials, oil base paint, charcoal lighter fluid, or similar products must not be stored in the building housing residents.
    7. Exit signs, with emergency power, must be provided in all large facilities and installed in accordance with NFPA 101, §7.10.
    8. Emergency lighting must be provided in all buildings with 25 or more rooms; in apartment buildings with 12 or more living units or that are three or more stories high; and in all large facilities that are designed for Type B. The system must be installed in accordance with NFPA 101, §7.9.
    9. Emergency motor generators, if required or provided, must be installed in accordance with NFPA 37 or NFPA 110 or other applicable NFPA code or standard.
  6. Fire alarm and sprinkler systems.
    1. Fire alarm and smoke detection system. An assisted living facility must install an underwriter's laboratory (U.L.) listed manual fire alarm initiating system, with an interconnected automatic smoke detection and alarm initiation system, that complies with the NFPA 101, §9.6. The operation of any alarm initiating device must activate an audible or visual alarm at the site.
      1. Smoke detectors must be installed in resident bedrooms, corridors, hallways, living rooms, dining rooms, offices, and public or common areas. Kitchens, laundries, and attached garages used for car parking may have heat detectors in lieu of smoke detectors. Exceptions are as follows.
        1. A large facility with apartment units may use listed smoke detectors with an alarm device and separate heat detector contacts in the living area. The smoke detector must emit an audible signal within the apartment, and annunciate at the main staff station or location. The heat detector contacts must be connected into the fire alarm system and provide a general alarm when activated.
        2. A facility constructed to meet the requirements of NFPA 101, Chapter 18, must meet §18.3.4.5.3 for smoke detector locations.
        3. A facility constructed to meet the requirements of NFPA 101, Chapter 19, must meet §19.3.4.5.1 for smoke detector locations.
      2. The fire alarm control panel must be visible to staff at or near the staff area that is attended 24 hours a day. An exception to this requirement is a fire alarm control panel that is monitored by a device carried by the staff.
      3. The primary power source for the complete fire alarm system must be commercial electric and permanently wired for power on a dedicated circuit in accordance with the National Electrical Code.
      4. An emergency power source must be from approved storage batteries or on-site engine-driven generator set.
      5. The facility must have a written contract with a fire alarm firm which has been issued an Alarm Certificate of Registration (ACR) number from the Texas State Fire Marshal's Office to perform the inspection, test and maintenance requirements of NFPA 72 semiannually. Inspections stipulated in the contract must be performed. The person performing the semiannual service must have an individual fire alarm license from the Texas State Fire Marshal's Office. All other NFPA 72 requirements must be performed and documented by a knowledgeable individual.
      6. Smoke detector sensitivity must be checked within one year after installation and every alternate year thereafter in accordance with NFPA 72. Documentation, including as-built installation drawings, operation and maintenance manuals, and a written sequence of operation, must be available for examination by DADS.
      7. In large facilities, the fire alarm panel must indicate as a separate zone, each floor and smoke compartment as applicable. Each zone must have an alarm and trouble indication. Identification by zone is not required where all alarm initiating devices are addressable and the status of each device is identified on the fire alarm panel.
      8. In large Type B facilities the fire alarm must automatically notify the fire department in accordance with NFPA 101, §9.6.4.
    2. Sprinkler systems. When installed or required, sprinkler systems must be inspected, tested, and maintained in accordance with NFPA 25. The facility must have a written contract with a fire protection sprinkler firm that has been issued a Sprinkler Certificate of Registration number (SCR) from the Texas State Fire Marshal's Office to perform the required services semiannually. The facility must have documentation available to show that all the requirements of NFPA 25 have been met including the annual inspection, test, and maintenance by the registered fire sprinkler firm. The facility must retain one set of the fire sprinkler system plans and hydraulic calculations on the property in accordance with NFPA 25.
      1. An existing small Type A facility housing 16 or fewer residents may have a system that meets NFPA 13, 13D, or 13R requirements.
      2. A new small Type A facility housing 16 or fewer residents must have a system that meets NFPA 13, 13D, or 13R requirements, installed in accordance with §32.2.3.5.2.
      3. An existing small Type B facility housing 16 or fewer residents must be protected by a sprinkler system that meets the requirements of NFPA 13, 13D, or 13R with additional requirements for coverage in all habitable areas and closets as specified by NFPA 101, §33.2.3.5.2.
      4. A new small Type B facility housing 16 or fewer residents must be protected by a sprinkler system that meets the requirement of NFPA 13, NFPA 13R, or NFPA 13D, with additional requirements for coverage in all habitable areas and closets as specified by NFPA 101, §32.2.3.5.2.
      5. A new and an existing large Type B facility must have a complete sprinkler system that meets the requirements of the NFPA 13.
      6. An existing large Type A facility may have an NFPA 13 system. In a building not more than four stories high an NFPA 13R system may be permitted.
      7. A new large Type A facility must have an NFPA 13 system, however a building not more than four stories high may have an NFPA 13R system.
  7. Site and location.
    1. The facility must be serviced by a paid or volunteer firefighting unit. Water supply for firefighting purposes must be as required and approved by the firefighting unit.
    2. The facility must correct any site or building conditions determined by DADS to be a fire, health, or physical hazard.
    3. The facility must provide or arrange for nearby parking spaces for private vehicles of residents and visitors. A minimum of one space must be provided for each four beds or fraction thereof, or per local code, whichever is more stringent.
    4. The facility must ensure that ramps, walks, and steps are of slip-resistive texture and uniform, without irregularities. Ramps must not exceed 1:12 slope, and must meet Texas Accessibility Standards for width. Guardrails, fences, or handrails must be provided where grades make an abrupt change in level.
    5. The facility must ensure that all outside areas, grounds, and adjacent buildings are maintained in good condition and kept free of rubbish, garbage, untended growth that may constitute a fire or health hazard. Site grades must provide for water drainage away from the structure to prevent ponding or standing water at or near the building.
  8. Sanitation and housekeeping.
    1. Wastewater and sewage must be discharged into an approved sewerage system or an onsite sewerage facility approved by the Texas Commission on Environmental Quality or its authorized agent.
    2. The water supply must be of safe, sanitary quality, suitable for use, and adequate in quantity and pressure, and obtained from a water supply system. The location, construction, and operation of the water supply system must be approved by DADS.
    3. Waste, trash, and garbage must be disposed of from the premises at regular intervals in accordance with state and local requirements. Excessive accumulations are not permitted. The facility must comply with 25 TAC §§1.131-1.137 (relating to Definition, Treatment, and Disposition of Special Waste from Health Care Related Facilities).
    4. Operable windows must be insect screened.
    5. An ongoing pest control program must be provided by facility staff or by contract with a licensed pest control company. The least toxic and least flammable effective chemicals must be used.
    6. Bathrooms, toilet rooms, and other odor-producing rooms or areas for soiled and unsanitary operations must be ventilated with operable windows. Bathrooms without operable windows must have powered exhaust vented to the exterior for odor control. An exception is granted for small facilities that vent into an attic in accordance with the International Building Code or local building code.
    7. In kitchens and in laundries, there must be procedures utilized by facility staff to avoid cross-contamination between clean and soiled utensils and linens.
    8. The facility must be kept free of accumulations of dirt, rubbish, dust, and hazards. Floors must be maintained in good condition and cleaned regularly. Walls and ceilings must be structurally maintained, repaired, and repainted or cleaned as needed. Storage areas and cellars must be kept in an organized manner. No storage will be permitted in the attic spaces.
    9. The facility must be ventilated through the use of windows, mechanical ventilation, or a combination of both. Interior areas designated for smoking within the building must have mechanical ventilation directed to the exterior to remove smoke at the rate of 10 air changes per hour.
    10. In addition to a janitor closet required in specific departments of large facilities, other janitor closets must be provided throughout the facility to maintain a clean and sanitary environment. Each janitor closet must have a service sink and forced air ventilation ducted to the outside.
    11. A large facility with 60 beds or less must provide a toilet, including a commode and lavatory, for use by the public and facility staff. A facility that has more than 60 beds must have separate public and staff toilets in addition to the staff toilets required for the dietary staff. Toilets must comply with accessibility standards.
    12. If the facility provides linens to the residents, the quantity of available linen must meet the sanitary and cleanliness needs of the residents. Clean linens must be stored in a clean area.
  9. General safety features.
    1. The facility must have an annual inspection by the local fire marshal.
    2. The building must be kept in good repair. Electrical, heating, and cooling systems must be maintained in a safe manner. DADS may require the facility sponsor or licensee to submit evidence to this effect, consisting of a report from the fire marshal, city or county building official having jurisdiction over the location of the facility, licensed electrician, or a registered professional engineer. Use of electrical appliances, devices, and lamps must not overload circuits or cause excessive lengths of extension cords.
    3. Existing furnace and water heater installations may be continued in service, subject to approval by DADS.
    4. In a large Type B facility, all draperies and other window coverings in public or common areas, bedrooms, and living units must be flame resistant. In a large Type A facility, draperies must be flame resistant, where smoking is permitted.
    5. In an existing large facility, all new floor carpet installed in public or common spaces after DADS performs the initial inspection must be classified as Class I or II based on the "Critical Radiant Flux" ratings as required by NFPA 101, §10.2.7. The facility must provide proper documentation by the carpet manufacturer.
    6. Open flame heating devices are prohibited. All fuel burning heating devices must be vented. Working fireplaces are acceptable if of safe design and construction and if screened or otherwise enclosed.
    7. There must be at least one telephone in the facility available to both staff and residents for use in case of an emergency. Emergency telephone numbers, including fire, police, ambulance, EMS, and poison control center, must be posted conspicuously at or near the telephone.
    8. An initial pressure test of facility gas lines from the gas meter must be provided. Additional pressure tests will be required when the facility has major renovations or additions where the gas service is interrupted. All gas heating systems must be checked prior to the heating season for proper operation and safety by persons who are licensed or approved by the State of Texas to inspect the equipment. A record of the testing of the gas heating system must be maintained by the facility. The facility must correct unsatisfactory conditions promptly.
    9. Exterior and interior stairs must have handrails that are firmly secured to prevent falls.
    10. Cooling and heating must be provided for resident comfort. Air conditioning systems must be capable of maintaining the comfort ranges of 68 degrees Fahrenheit to 82 degrees Fahrenheit in resident-use areas. A facility constructed or licensed after August 1, 2004, must have a central air conditioning system, or a substantially similar air conditioning system, that is capable of maintaining a temperature suitable for resident comfort within areas used by residents. Heating, ventilating, and air conditioning (HVAC) equipment must comply with the requirements of NFPA 90A or 90B, as applicable. NFPA 90A requires automatic shut down upon activation of the fire alarm in HVAC systems of over 2,000 cubic feet per minute (cfm) capacity.
    11. The Illumination Engineering Society of North America recommendations must be followed to achieve proper illumination characteristics and lighting levels throughout the facility. Minimum illumination must be 10 footcandles in resident rooms during the day and 20 footcandles in corridors, staff stations, dining rooms, lobbies, toilets, bathing facilities, laundries, stairways and elevators during the day. Illumination requirements for these areas apply to lighting throughout the space and should be measured at approximately 30 inches above the floor anywhere in the room. Minimum illumination for medication preparation or storage areas, kitchens, and staff station desks must be 50 footcandles during the day. Illumination requirements for these areas apply to the task performed and should be measured on the tasks.
    12. All buildings three stories or higher and facilities that provide services, treatment, or social activities on floors above or below the level of discharge and house mobility impaired residents must have a passenger elevator. The lowest level of discharge will be the first floor for determining floor level.
    13. Floor, ceiling, and wall finish materials must be complete and in place to provide a sanitary and structurally safe environment.
    14. All equipment requiring periodic maintenance, testing, and servicing must be reasonably accessible. Necessary equipment to conduct maintenance, testing, and servicing, including ladders, specific tools, and keys, must be readily available on site. Access panels (20" x 20" minimum) must be provided for building maintenance and must be located for reasonable access to equipment or barriers installed in the attic or other concealed spaces.
    15. The facility must implement procedures that comply with the standards and recommendations of the Compressed Gas Association to assure safe and sanitary use and storage of oxygen. Liquid oxygen containers must be certified by Underwriters Laboratory (UL) or other approved testing laboratories for compliance with NFPA 50 requirements. The facility is responsible for defining all potential hazards both graphically and verbally to all persons involved in the use of liquid oxygen and ensuring the liquid oxygen provider does also.
  10. Portable fire extinguishers. Portable fire extinguishers must be provided and maintained to comply with the provisions of NFPA 10. For extinguisher types (A, B, C, and K), the facility must comply with location, spacing, mounting heights, monthly inspections by staff, yearly inspections by a licensed agent, including any necessary servicing, and hydrostatic testing as recommended by the manufacturer.
    1. Extinguishers in resident corridors must be spaced so that travel distance is not more than 75 feet. The minimum size of extinguishers must be either 1-A for water type or 2-A 5-BC type. Actual sizes must meet NFPA 10 requirements for maximum floor area per unit covered. In large facilities, at least one portable Underwriters Laboratory (U.L.) or factory mutual (F.M.)-approved 20-B:C dry chemical fire extinguisher, rechargeable type, is required in each laundry, kitchen and walk-in mechanical room.
    2. Extinguishers must be installed on supplied hangers or brackets or be mounted in cabinets approved by DADS.
    3. Extinguishers must be surface wall-mounted or recessed in cabinets where they are not subject to physical damage or dislodgement.
    4. Extinguishers having a gross weight not exceeding 40 pounds must be installed so that the top of the extinguisher is not more than five feet above the floor. Extinguishers with a gross weight greater than 40 pounds must be installed so the top of the extinguisher is not more than 3½ feet above the floor. The clearance between the bottom of the extinguisher and the floor must not be less than four inches.
    5. Portable extinguishers provided in hazardous rooms must be located as close as possible to the exit door opening and on the latch or knob side.
    6. Staff must be appropriately trained in the use of each type of extinguisher in the facility.
    7. Regular monthly inspections or "quick checks" must be made by facility representatives to assure that extinguishers are in the proper location, condition, and working order. Annual maintenance or "thorough checks" must be accomplished in accordance with NFPA 10 by competent personnel licensed or certified to perform servicing by the State Fire Marshal. Unserviceable extinguishers must be replaced.
  11. Waste and storage containers.
    1. Metal waste baskets of substantial gauge or any U.L. or F.M. approved containers must be provided in facilities in all areas where smoking is permitted.
    2. Garbage, waste, or trash containers provided for kitchens, janitor closets, laundries, mechanical or boiler rooms, general storage, and similar places must be made of metal or any U.L. or F.M. approved material with a close fitting cover. Disposable plastic liners may be used in these containers for sanitation.
  12. Accessibility provisions. The physical plant of facilities housing residents with physical disabilities or mobility impairments must comply with applicable federal, state and local requirements for persons with disabilities.
  13. Resident accommodations.
    1. Resident bedrooms.
      1. Bedroom usable floor space for Type A facilities must not be less than 80 square feet for a one-bed room and not less than 60 square feet per bed for a multiple bed room. A bedroom must be not less than eight feet in the smallest dimension, unless specifically approved otherwise by DADS. A bedroom for a person with a physical disability or mobility impairment must meet accessibility standards for access around the bed or beds, which is a minimum of 3'-0" clear width for access aisles.
      2. Bedroom usable floor space for Type B facilities must be not less than 100 square feet per bed for a single-bed room and not less than 80 square feet per bed for a multiple-bed room. A bedroom for a person with a physical disability or mobility impairment must meet accessibility standards for access around the bed or beds, which is a minimum of 3'-0" clear width for access aisles. A bedroom must not be less than ten feet in the smallest dimension unless specifically approved by DADS.
      3. In facilities that have living units consisting of separate living spaces, dining spaces, and bedrooms, 10% of the required bedroom square footage may be included as part of the living and dining space.
      4. A facility must have no more than 50 percent of its beds in bedrooms of three or more beds. A bedroom must have no more than four beds.
      5. Each bedroom must have at least one operable window with outside exposure. The window sill must be no higher than 44" from the floor and must be at or above grade level. The window must be operable from the inside, without the use of tools or special devices, and provide an operable section with a clear opening of not less than 5.7 square feet with a minimum width of 20" x 41.2" high and minimum height of 24" x 34.2" wide. Windows required for evacuation must not be blocked by bars, shrubs, or any obstacle that would impede evacuation. Exceptions are as follows.
        1. In large Type B facilities and other facilities protected throughout by an approved automatic sprinkler system, the window opening size may be smaller than the minimum size listed in this subparagraph but must permit the venting of products of combustion in compliance with the Life Safety Code for Healthcare Occupancy. The total window area in a bedroom must not be less than 8 percent of the required bedroom size.
        2. In existing buildings, if the window is not required for the secondary means of escape, the window size and sill height requirements do not apply if the windows meet the requirements of the local building code.
      6. In the event the resident does not provide his or her own furnishings, the facility must provide for each resident a bed with mattress, chair, table or dresser, and enclosed closet space for clothing and personal belongings. Drawer space must be provided. Furnishings provided by the facility must be maintained in good repair.
      7. All resident rooms must open upon an exit, corridor, living area, or public area and must be arranged for convenient resident access to dining and recreation areas.
      8. A staff or attendant area must be provided on each floor or in each separate building. The area must consist of a desk or writing surface and telephone. An exception is that Type A facilities, two-story or less in height, with separate buildings grouped together, and connected by covered walks, need not have staff or attendant areas on each floor or in each building, provided that the areas are not more than 200 feet walking distance from the furthest resident living unit. The areas must have a communication system and fire alarm annunciation indicating the units served.
      9. Facilities which consist of two or more floors or separate buildings must have a communication system from each resident living unit to a central staff location. This communication system may be a direct telephone, nurse call, or intercom.
    2. Resident toilet and bathing facilities.
      1. All bedrooms must be served by separate private, connecting, or general toilet rooms for each sex if the facility houses both sexes. General toilet room or bathing room must be accessible from a corridor or public space. A lavatory must be readily accessible to each water closet. At least one water closet, lavatory, and bathing unit must be provided on each sleeping floor accessible to residents of that floor.
      2. One water closet and one lavatory for each six occupants or fraction thereof including a portion less than six is required. One tub or shower for each ten occupants or fraction thereof is required.
      3. Privacy partitions or curtains must be provided at water closets and bathing units in rooms for multi-resident use.
      4. Tubs and showers must have non-slip bottoms or floor surfaces, either built-in or applied to the surface.
      5. Resident-use hot water for lavatories and bathing units will be maintained between 100 degrees Fahrenheit and 120 degrees Fahrenheit.
      6. Towels, soap, and toilet tissue must be available at all times for individual resident use.
    3. Resident living areas.
      1. Social-diversional spaces must be provided and have appropriate furniture. Examples of social-diversional spaces include living rooms, day rooms, lounges, dens, game rooms, and sunrooms. A minimum of 120 square feet must be provided in at least one space regardless of number of residents. This space must have exterior windows providing a view of the outside.
      2. The total space requirement for social-diversional areas must be provided on a sliding scale as follows:
No. of Beds Area Per Bed Minimum
4-16 15 sq. feet (min. 120 sq. ft.)
17-39 13 sq. feet
40-59 12 sq. feet
60+ 10 sq. feet
  1. For calculation purposes, DADS deducts a pathway equal to the corridor width when a corridor is required through a living or dining area to access an exit. The exit pathways must be kept clear of obstructions.
  1. Resident dining areas.
    1. A dining area must be provided and have appropriate furnishings. A minimum of 120 square feet must be provided in at least one space, regardless of number of residents. This space must have exterior windows providing a view of the outside.
    2. Access to a dining area from the resident living units or bedrooms must be covered.
    3. The total space requirement for a dining area must be provided on a sliding scale as follows:
No. of Beds Area Per Bed Minimum
4-16 15 sq. feet (min. 120 sq. ft.)
17-39 13 sq. feet
40-59 12 sq. feet
60+ 10 sq. feet
  1. The total living and dining area may be a single or interconnecting space with a minimum of 240 square feet of area.
  1. Storage areas. The facility must provide sufficient separate storage spaces or areas for the following:
    1. administration for records and office supplies;
    2. locked areas for medications and medical supplies. Poisons must be stored in a locked area and separate from all medications and preparation;
    3. equipment supplied by the facility for resident needs including wheelchairs, walkers, beds, and mattresses;
    4. cleaning supplies including janitorial needs;
    5. food storage;
    6. clean linens and towels if furnished by the facility;
    7. lawn and maintenance equipment, if needed;
    8. janitor closets with deep sink and hot and cold water for large facilities; and
    9. soiled linen storage or holding room if the facility furnishes linen.
  2. Kitchen.
    1. The facility must have a kitchen or dietary area to meet the general food service needs of the residents. It must include provisions for the storage, refrigeration, preparation, and serving of food, dish and utensil cleaning, and refuse storage and removal. Exception: Food may be prepared off-site or in a separate building provided that the food is served at the proper temperature and transported in a sanitary manner.
    2. Kitchens for facilities serving 16 or fewer non-employees per meal on a routine basis that have residential ranges may have residential range hoods, if the range hoods meet the requirements of the local building code.
    3. Kitchens for facilities serving 17 or more non-employees per meal on a routine basis must be designed as follows:
      1. Kitchens are evaluated on the basis of their performance in the sanitary and efficient preparation and serving of meals to residents and compliance with requirements for dietary service in §92.41(m)(18) of this chapter (relating to Standards for Type A and Type B Assisted Living Facilities).
        1. A facility must consider the type of meals served, the overall building design, the food service equipment, arrangement, and the work flow involved in the preparation and delivery of food.
        2. Plans must include a detailed kitchen layout designed by a registered or licensed dietitian or architect with knowledge of the design of food service operations.
      2. Kitchens must be designed so that room temperature, at peak load or in the summer, must not exceed 85 degrees Fahrenheit measured over the room at the five foot level. The amount of supply air must take into account the large quantities of air that may be exhausted at the range hood and dishwashing area.
      3. Facilities for washing and sanitizing dishes and cooking utensils must be provided. The kitchen must contain a multi-compartment pot sink large enough to immerse pots and pans, and a mechanical dishwasher for washing and sanitizing dishes. Separation of soiled and clean dish areas must be maintained, including air flow.
      4. A food preparation sink must be provided. It must be separate from the pot and hand sinks.
      5. A supply of hot and cold water must be provided. Hot water for sanitizing purposes must be 180 degrees Fahrenheit or the manufacturer's suggested temperature for chemical sanitizers.
      6. The kitchen must be provided with a hand-washing lavatory in the food preparation area with hot and cold water, soap, towel dispenser, and waste receptacle. The dish room area must have ready access to a hand washing lavatory.
      7. Staff restroom facilities with lavatory must be directly accessible to kitchen staff without traversing resident use areas. The rest room must not open directly into the kitchen, but must open into a vestibule. An exception may exist in an existing facility if the staff restroom is located outside of the kitchen area.
      8. Janitorial facilities must be provided exclusively for the kitchen and must be located in the kitchen area. An exception may occur if a janitorial closet in an existing facility is located outside of the kitchen and if sanitary procedures are used to reduce the possibility of cross-contamination.
      9. Non-absorbent smooth finishes or surfaces must be used on kitchen floors, walls and ceilings. Surfaces must be capable of being routinely cleaned and sanitized to maintain a healthful environment. Counter and cabinet surfaces, inside and outside, must also have smooth, cleanable, non-porous finishes.
      10. Doors between kitchen and dining or serving areas must have ¼-inch fixed safety glass or a fire related glazing view panel mounted in a steel frame.
      11. A garbage can or cart washing area with drain and hot water must be provided either on the interior or exterior of the facility.
      12. Floor drains must be provided in the kitchen and dishwashing areas. Exception: Floor drains are not required in existing facilities provided the floors are kept clean.
      13. A commercial range must be provided and equipped with a commercial range hood and exhaust designed and installed in accordance with NFPA 96.
      14. Grease traps must be provided as required by local authorities.
    4. Food storage areas for large facilities must be as follows.
      1. Food storage areas must provide for storage of a four-day minimum supply of non-perishable foods at all times.
      2. Shelves must be adjustable wire type. An exception may occur if an existing facility uses wood shelves and keeps the shelves sealed and clean.
      3. Walls and floors must have a non-absorbent finish to provide a cleanable surface.
      4. Food must not be stored on the floor. Dollies, racks, pallets, or wheeled containers may be used to elevate foods not stored on shelving.
      5. Dry foods storage must have an effective venting system to provide for positive air circulation.
      6. The maximum room temperature for food storage must not exceed 85 degrees Fahrenheit at any time. The measurement must be taken at the highest food storage level, but not less than five feet from the floor.
      7. Food storage areas may be located away from the food preparation area as long as there is space adjacent to the kitchen for necessary daily usage.
    5. Auxiliary serving kitchens that are not contiguous to a food preparation or serving area must be designed as follows.
      1. Where service areas other than the kitchen are used to dispense foods, these areas must be designated as food service areas and contain equipment for maintaining required food temperatures while serving.
      2. Separate food service areas must have hand washing facilities as part of the food service area.
      3. Finishes of all surfaces must be the same as those required for food and nutrition services or comparable areas.
  3. Laundry and linen services.
    1. A large assisted living facility that co-mingles and processes laundry on-site in a central location must comply with the following.
      1. The laundry must be separated and provided with sprinkler protection if the laundry area is located in the main building. Separation must consist of a one-hour fire rated partition carried to the underside of the floor or roof deck above. Access doors must be from the exterior or interior non-resident use areas including a small vestibule or service corridor.
      2. The laundry must be provided with the following physical features:
        1. a soiled linen receiving, holding, and sorting room with a floor drain and forced exhaust to the exterior which must operate at all times when soiled linen is held in this area and may be combined with the washer section;
        2. a general laundry work area that is separated by partitioning a washer section and a dryer section;
        3. a storage area for laundry supplies;
        4. a folding area;
        5. adequate air supply and ventilation for staff comfort without having to rely on opening a door that is part of the fire wall separation; and
        6. provisions to exhaust heat from dryers and to separate dryer make-up air from the habitable work areas of the laundry.
    2. If linen is processed off the site, the following must be provided on the premises:
      1. a soiled linen holding room with adequate forced exhaust ducted to the exterior; and
      2. a clean linen receiving, holding, inspection, sorting or folding, and storage room.
    3. Resident-use laundry, if provided, must utilize residential type washers and dryers. If more than three washers and three dryers are located in one space, the area must be separated by a one-hour fire rated barrier or have sprinkler protection.

 

§92.63 Construction and Initial Survey of Completed Construction

  1. Construction phase.
    1. DADS Regulatory Services Division, Licensing and Credentialing Section must be notified in writing of construction start.
    2. All construction must comply with minimum licensing requirements. It is the sponsor's responsibility to employ qualified personnel to prepare the contract documents for construction of a new facility or remodeling of an existing facility. Contract documents for additions and remodeling and for the construction of an entirely new facility must be prepared by an architect licensed by the Texas Board of Architectural Examiners. Drawings must bear the seal of the architect. Certain parts of contract documents including final plans, designs, and specifications concerning sheets and sections covering structural, electrical, mechanical, sanitary, and civil engineering must bear the seal of a professional engineer licensed by the Texas Board of Professional Engineers to operate in Texas or, the signature of a Responsible Managing Employee or Alarm Planning Superintendent licensed by the State Fire Marshal's Office as authorized by subsection (b)(12) and (15) of this section.
      1. Remodeling is the construction, removal, or relocation of walls and partitions, the construction of foundations, floors, or ceiling-roof assemblies, or the expanding or altering of safety systems including sprinkler, fire alarm, and emergency systems.
      2. General maintenance and repairs of existing material and equipment, repainting, applications of new floor, wall, or ceiling finishes, or similar projects are not included as remodeling, unless as a part of new construction. DADS must be provided flame spread documentation for new materials applied as finishes.
  2. Contract documents.
    1. Site plan documents must include grade contours; streets with names; north arrow; fire hydrants; fire lanes; utilities, public or private; fences; unusual site conditions including ditches, low water levels, other buildings on-site; and indications of buildings five feet or less beyond site property lines.
    2. Foundation plan documents must include general foundation design and details.
    3. Floor plan documents must include room names, numbers, and usages; numbered doors including swing; windows; legend or clarification of wall types; dimensions; fixed equipment; plumbing fixtures; and kitchen basic layout; and identification of all smoke barrier walls from outside wall to outside wall or fire walls.
    4. For both new construction and additions or remodeling to existing buildings, an overall plan of the entire building must be drawn or reduced to fit on an 8½ inch by 11 inch sheet; submit two reduced plans for file record. See subsection (d)(3) of this section.
    5. Schedules must include door materials, widths, types; window materials, sizes, types; room finishes; and special hardware.
    6. Elevations and roof plan must include exterior elevations, including material note indications and any roof top equipment; roof slopes, drains, and gas piping, and interior elevations where needed for special conditions.
    7. Details must include wall sections as needed (especially for special conditions); cabinet and built-in work; cross sections through buildings as needed; and miscellaneous details and enlargements as needed.
    8. Building structure documents must include structural framing layout and details primarily for column, beam, joist, and structural frame building, roof framing layout if the layout cannot be adequately shown on a cross section; cross sections in quantity and detail to show sufficient structural design and structural details as necessary to assure adequate structural design, also calculated design loads.
    9. Electrical documents must include electrical layout, including lights, convenience outlets, equipment outlets, switches, and other electrical outlets and devices; service, circuiting, distribution, and panel diagrams; exit light system with exit signs and emergency egress lighting; emergency electrical provisions including generators and panels; and similar systems including control panels, devices, and alarms; sizes and details sufficient to assure safe and properly operating systems; and a staff communication system.
    10. Plumbing documents must include plumbing layout with pipe sizes and details sufficient to assure safe and properly operating systems, water systems, sanitary systems, gas systems, other systems normally considered under the scope of plumbing, fixtures, and provisions for combustion air supply.
    11. Heating, ventilation, and air-conditioning (HVAC) documents must include sufficient details of HVAC systems and components to assure a safe and properly operating installation including, but not limited to, heating, ventilating, and air-conditioning layout, ducts, protection of duct inlets and outlets, combustion air, piping, exhausts, and duct smoke and/or fire dampers; and equipment types, sizes, and locations.
    12. Fire sprinkler system plans and hydraulic calculations must be designed in accordance with and including all the required information on the plan, specified in NFPA 13, NFPA 13R, or NFPA 13D as applicable and the NFPA documents referenced therein, published by the National Fire Protection Association and signed by a Responsible Managing Employee, licensed by the State Fire Marshal's Office or bear the seal of a licensed professional engineer.
    13. Other layouts, plans, or details as may be necessary for a clear understanding of the design and scope of the project; including plans covering private water or sewer systems must be reviewed by the local health or wastewater authority having jurisdiction. If no local authority, then the plans will be reviewed by DADS.
    14. Specifications must include installation techniques, quality standards and/or manufacturers, references to specific codes and standards, design criteria, special equipment, hardware, painting, and any others as needed to amplify drawings and notes.
    15. Detailed fire detection and alarm system working plans must be designed in accordance with the applicable sections of the National Fire Alarm and Signaling Code (NFPA 72) and the National Electric Code (NFPA 70) and signed by an Alarm Planning Superintendent licensed by the State Fire Marshal's Office or bear the seal of a licensed professional engineer.
  3. Initial survey of completed construction.
    1. Upon completion of construction, including grounds and basic equipment and furnishings, an initial architectural inspection of the facility, including additions or remodeled areas, is required to be performed by DADS prior to occupancy. The completed construction must have the written approval from the local authorities having jurisdiction where the facility is located, including the fire marshal, health department, and building inspector.
    2. The inspection described in paragraph (1) of this subsection may be obtained on an expedited basis by complying with §92.4(g) of this chapter (relating to License Fees).
    3. After the completed construction has been surveyed by DADS and found acceptable, DADS Life Safety Code staff conveys the survey results to DADS Licensing and Credentialing Section as part of an applicant's license application. In the case of additions or remodeling of existing facilities, the applicant may be required to submit a revision or modification to an existing license. All building, grades, drives, and parking must essentially be 100 percent complete including basic furnishings and operational needs at the time of the initial visit for occupancy approval and licensing. A facility may accept up to three residents after it receives initial approval from DADS Life Safety Code staff but before the license is issued.
    4. The following documents must be available to DADS surveyor at the time of the survey of the completed building:
      1. written approval of local authorities as called for in paragraph (1) of this subsection;
      2. record drawings of the fire detection and alarm system as installed, signed by an Alarm Planning Superintendent licensed by the State Fire Marshal's office or sealed by a licensed professional engineer, including a sequence of operation, the owner's manuals and the manufacturer's published instructions covering all system equipment, a signed copy of the State Fire Marshal's Office Fire Alarm Installation Certificate, and, for software-based systems, a record copy of the site-specific software excluding the system executive software or external programmer software in a non-volatile, non-erasable, non-rewritable memory;
      3. documentation of materials used in the building which are required to have a specific limited fire or flame spread rating including special wall finishes or floor coverings, flame retardant curtains including cubicle curtains and rated ceilings. In the case of carpeting, the documentation must include a signed letter from the installer, verifying that the carpeting installed is named in the laboratory test document;
      4. record drawings of the fire sprinkler system as installed, signed by a Responsible Managing Employee, licensed by the State Fire Marshal's Office or sealed by a licensed professional engineer, including the hydraulic calculations, alarm configuration, aboveground and underground Contractor's Material and Test Certificate, all literature and instructions provided by the manufacturer describing the proper operation and maintenance of all equipment and devices in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems;
      5. service contracts for maintenance and testing of alarm systems and sprinkler systems;
      6. a copy of gas test results of the facility's gas lines from the meter;
      7. a written statement from an architect or engineer stating that, from periodic onsite observation visits, the facility as constructed is, to the best of the architect's or engineer's knowledge and belief, in substantial compliance with the architect's or engineer's construction documents, the Life Safety Code, DADS licensure standards, and local codes; and
      8. the contract documents specified in subsection (b) of this section.
  4. Nonapproval of new construction.
    1. If, during the initial on-site survey of completed construction, the surveyor finds certain basic requirements not met, the surveyor may recommend to DADS Licensing and Credentialing Unit that the facility should not yet be licensed and approved for occupancy. The basic items that may trigger non-approval include:
      1. construction which does not meet minimum code or licensure standards for basic requirements including corridors that are less than the required width, ceilings installed at less than the minimum seven-foot six-inch height, resident bedroom dimensions less than required, and other features which would disrupt or otherwise adversely affect the residents and staff if corrected after occupancy;
      2. lack of written approval by local authorities having jurisdiction, including the fire marshal, health department, and building inspector;
      3. fire protection systems not completely installed or not functioning properly, including, but not limited to, fire alarm systems, emergency power and lighting, and sprinkler systems;
      4. required exits not all usable according to NFPA 101 requirements;
      5. telephone not installed or not properly working;
      6. sufficient basic furnishings, essential appliances, and equipment are not installed or not functioning; and
      7. any other basic operational or safety feature which the surveyor, as the authority having jurisdiction, believes would preclude safe and normal occupancy by residents on that day.
    2. If the surveyor encounters minor deficiencies, the surveyor may recommend approval of the facility's license based on an approved written plan of correction from the facility's administrator.
    3. A facility must submit two copies of reduced size floor plans on an 8 1/2 inch by 11 inch sheet to DADS for DADS record and for the facility's use including an evacuation plan or fire alarm zone identification. The plan must contain basic legible information including scale, room usage names, actual bedroom numbers, doors, windows, and any other pertinent information.

 

§92.64 Plans, Approvals, and Construction Procedures

At the option of the applicant, DADS reviews plans for new buildings, additions, conversion of buildings not licensed by DADS, or remodeling of existing licensed facilities. DADS informs the applicant of the results of the review within 30 days after receipt of the plans. If the plans comply with DADS architectural requirements, DADS may not subsequently change the architectural requirement applicable to the project unless the change is required by federal law or the applicant fails to complete the project within a reasonable time.

  1. Submittal of plans.
    1. For review of plans, before construction is begun, the applicant must submit one copy of contract documents including working drawings and specifications in sufficient detail to interpret compliance with these standards and assure proper construction by the general contractor or builder. Documents must be prepared according to accepted architectural practice and must include general construction, special conditions, and schedules.
    2. Final copies of plans must have a title block showing name of facility, person, or organization preparing the sheet, sheet numbers, facility address, and drawing date. Sheets and sections covering structural, electrical, mechanical, and sanitary engineering final plans, designs, and specifications must bear the seal of a registered professional engineer licensed by the Texas Board of Professional Engineers. Contract documents for additions, remodeling, and construction of an entirely new facility must be prepared by an architect licensed by the Texas Board of Architectural Examiners. Drawings must bear the seal of the architect.
    3. A final plan for a major addition to a facility must include a basic layout to scale of the entire building onto which the addition connects. North direction must be shown. Usually the entire basic layout can be drawn to scale of 1/16 inch per foot or 1/32 inch per foot for very large buildings.
    4. Plans and specifications for conversions or remodeling must be complete for all parts and features involved. DADS review is limited to the plans and specifications for conversions or remodeling as submitted.
    5. The sponsor is responsible for employing qualified personnel to prepare the contract documents for construction. If the contract documents have errors or omissions to the extent that compliance with architectural and DADS licensing standards cannot be reasonably assured or determined by DADS, DADS may request a revised set of documents for review.
    6. The review of plans and specifications by DADS is based on general utility, the minimum licensing standards, and conformance of the Life Safety Code, and is not to be construed as all-inclusive approval of the structural, electrical, or mechanical components, nor does it include a review of building plans for compliance with the Texas Accessibility Standards as administered and enforced by the Texas Department of Licensing and Regulation.
    7. Fees for plan review will be required in accordance with §92.4 of this chapter (relating to License Fees).
  2. Contract documents.
    1. Site plan documents must include grade contours; streets with names; North arrow; fire hydrants, fire lanes, utilities, public or private; fences; and unusual site conditions, including ditches, low water levels, other buildings on-site, and indications of buildings five feet or less beyond site property lines.
    2. Foundation plan documents must include general foundation design and details.
    3. Floor plan documents must include room names, numbers, and usages; numbered doors including swing; windows; legend or clarification of wall types; dimensions; fixed equipment; plumbing fixtures; kitchen basic layout; and identification of all smoke barrier walls from outside wall to outside wall or fire walls.
    4. For both new construction and additions or remodeling to existing buildings, an overall plan of the entire building must be drawn or reduced to fit on an 8 1/2 inch by 11 inch sheet.
    5. Schedules must include door materials, widths, and types; window materials, sizes, and types; room finishes; and special hardware.
    6. Elevations and roof plan must include exterior elevations, including material note indications and any roof top equipment; roof slopes, drains, gas piping, and interior elevations where needed for special conditions.
    7. Details must include wall sections as needed, especially for special conditions; cabinet and built-in work; cross sections through buildings as needed and miscellaneous details and enlargements as needed.
    8. Building structure documents must include structural framing layout and details primarily for column, beam, joist, and structural building; roof framing layout if the layout cannot be adequately shown on a cross section; and cross sections in quantity and detail to show sufficient structural design and structural details as necessary to assure adequate structural design and calculated design loads.
    9. Electrical documents must include electrical layout, including lights, convenience outlets, equipment outlets, switches, and other electrical outlets and devices; service, circuiting, distribution, and panel diagrams; exit light system including exit signs and emergency egress lighting; emergency electrical provisions including generators and panels; staff communication system; fire alarm and similar systems including control panel, devices, and alarms; and sizes and details sufficient to assure safe and properly operating systems.
    10. Plumbing documents must include plumbing layout with pipe sizes and details sufficient to assure safe and properly operating systems, water systems, sanitary systems, gas systems, and other systems normally considered under the scope of plumbing, fixtures, and provisions for combustion air supply.
    11. Heating, ventilating and air-conditioning systems (HVAC) documents must include sufficient details of HVAC systems and components to assure a safe and properly operating installation including, but not limited to, heating, ventilating, and air-conditioning layout, ducts, protection of duct inlets and outlets, combustion air, piping, exhausts, and duct smoke and/or fire dampers; and equipment types, sizes, and locations.
    12. Sprinkler system documents must include plans and details of NFPA designed systems; plans and details of partial systems provided only for hazardous areas; and electrical devices interconnected to the alarm system.
    13. Specifications must include information about installation techniques; quality standards and manufacturers; references to applicable codes and other standards used for design; design criteria; special equipment; hardware; finishes; and any other information DADS may need to interpret drawings and notes.
    14. Other layout, plans, or details as may be necessary for a clear understanding of the design and scope of the project, including plans covering private water or sewer systems, must be reviewed by local health or wastewater authority having jurisdiction where the facility is located.
  3. Construction phase.
    1. DADS must be notified in writing prior to construction start.
    2. All construction not done to comply with the completed plans and specifications as submitted for review and as modified in accordance with review requirements will require additional drawings if the change is significant.
  4. Initial survey of completed construction.
    1. Upon completion of construction, including grounds and basic equipment and furnishings, a final construction inspection or initial survey of the facility must be performed by DADS prior to the facility admitting residents, unless DADS issues a provisional license. An initial architectural inspection will be scheduled after DADS receives a notarized licensure application, required fee, fire marshal approval, and a letter from an architect or engineer stating that to the best of the architect's or engineer's knowledge that the facility meets the architectural requirements for a license.
    2. After DADS surveys the completed construction and finds it acceptable, DADS forwards the information to the Licensing and Credentialing Unit as part of the applicant's license application. In the case of additions or remodeling of existing facilities, the applicant may be required to submit a revision or modification to an existing license. All buildings, including basic furnishings and operational needs, grades, drives, and parking must be 100 percent complete at the time of the initial visit for occupancy approval and licensing. A facility may admit no more than three residents after it receives initial approval from DADS but before a license is issued, except if DADS issues one of the following licenses the facility may admit more than three residents:
      1. a provisional license in accordance with §92.20 of this chapter (relating to Provisional License); or
      2. an initial license in accordance with §92.21 of this chapter (relating to Initial License for a Type A or Type B Facility for an Applicant in Good Standing).
    3. An applicant must make the following documents available to a DADS surveyor at the time of the survey of the completed building:
      1. written approval of local authorities as required by subparagraph (A) of this paragraph;
      2. record drawings of the fire detection and alarm system as installed, signed by an Alarm Planning Superintendent licensed by the State Fire Marshal's office or bearing the seal of a licensed professional engineer, including a sequence of operation, the owner's manuals, and the manufacturer's published instructions covering all system equipment;
      3. a signed copy of the State Fire Marshal's Office Fire Alarm Installation Certificate;
      4. for software-based fire alarm systems, a record copy of the site-specific software, excluding the system executive software or external programmer software in a non-volatile, non-erasable, non-rewritable memory;
      5. documentation of materials used in the building which have a specific limited fire or flame spread rating, including special wall finishes or floor coverings, flame retardant curtains, including cubicle curtains, and rated ceilings;
      6. a signed letter from the installer of carpeting verifying that the carpeting is named in the laboratory test document;
      7. record drawings of the fire sprinkler system as installed, signed by a Responsible Managing Employee licensed by the State Fire Marshal's Office, or bearing the seal of a licensed professional engineer, including the hydraulic calculations, fire alarm configuration, aboveground and underground Contractor's Material and Test Certificate;
      8. all literature and instructions provided by the sprinkler system manufacturer describing the proper operation and maintenance of all equipment and devices in accordance with NFPA 25;
      9. service contracts for maintenance and testing of alarm systems, sprinkler systems, and other systems;
      10. a copy of a gas test results of the facility's gas lines from the meter;
      11. a written statement from an architect or engineer stating that, from periodic onsite observation visits, the facility as constructed is, to the best of architect or engineer's knowledge and belief, in substantial compliance with the architect or engineer's contract documents, the Life Safety Code, DADS licensure standards, and local codes; and
      12. the contract documents described in paragraph (2) of this section.
  5. Non-approval of new construction.
    1. If, during the initial on-site survey of completed construction, the surveyor finds certain basic requirements not met, DADS may recommend that the facility not be licensed and approved for occupancy. The items that may trigger non-approval include:
      1. substantial changes made during construction that were not submitted to DADS for review and which may require revised "as-built" drawings to cover the changes, including architectural, structural, mechanical, and electrical items specified in paragraph (3)(B) of this section;
      2. construction that does not meet minimum Life Safety Code or DADS licensure standards, including corridors that are less than required width, ceilings installed at less than the minimum seven-foot six-inch height, resident bedroom dimensions less than required, and other features which would disrupt or otherwise adversely affect the residents and staff if corrected after occupancy;
      3. lack of written approval by local authorities;
      4. fire protection systems, including fire alarm systems, emergency power and lighting, and sprinkler systems, not completely installed or not functioning properly;
      5. required exits not all usable according to NFPA 101 requirements;
      6. telephones that are not installed or not properly working;
      7. sufficient basic furnishings, essential appliances, and equipment that are not installed or not functioning; and
      8. any other basic operational or safety feature which would preclude safe and normal occupancy by residents on that day.
    2. If the surveyor encounters only minor deficiencies, licensure may be recommended based on an approved written plan of correction from the facility's administrator.
    3. A facility must submit two copies of reduced size floor plans on an 8 1/2 inch by 11 inch sheet to DADS for DADS records and the facility's use for evacuation plans and fire alarm zone identification. The plan must contain basic legible information including scale, room usage names, actual bedroom numbers, doors, windows, and any other pertinent information.