1. (1) All facilities shall be safe and suitable for the comfort and care of the patient. Facilities shall be maintained in a state of good repair and sanitation.

   1. (i) A facility maintenance plan, including provision for routine inspections of the physical plant, shall be developed, maintained, and shall be immediately available for office review upon request.
   2. (ii) A process must be established and implemented at all facilities by which staff can notify administration of any unsafe conditions. Facility staff must routinely be made aware of such process.

2. (2) Patient areas for children must be separate and distinct from patient areas for adults.

   (b) Code compliance.

   Facilities shall be and remain in compliance with applicable State and local building codes and regulations.

3. (1) Prior to construction or renovation of a facility, a building permit from the applicable local authority must be obtained, and proof of same must be made available to the office upon request.

4. (2) A current and effective copy of a Certificate of Occupancy at a facility must be maintained at each facility location.

   (c) Construction standards.

5. (1) Facilities shall be and remain in compliance with the provisions of the appropriate section(s) of the current recognized edition of the National Fire Prevention Association-101 Life Safety Code (LSC).
6. (2) Facilities shall be and remain in compliance with applicable sections of the current recognized edition of the Guidelines for Design and Construction of Health Care Facilities published by the American Institute of Architects (AIA), provided, however, that this provision shall apply only to facilities constructed, or which have undertaken major renovations, on or after April 1, 2010, or the effective date of this paragraph, whichever is later. Facilities constructed, or which have completed major renovations, prior to that date in accordance with Part 77 of this Title, shall be deemed to be in compliance with this paragraph.

7. (3) Facilities shall be and remain in compliance with applicable sections of the The Americans with Disabilities Act of 1990 (ADA) and implementing regulations (28 CFR parts 35 and 36).

   (d) Provisions for unplanned events.

8. (1) Facility administration must evaluate the potential for specific unplanned events including but not limited to: power outages, heat loss, water shortages, extreme temperatures, floods, earthquakes, winds, fires and explosions.

9. (2) Facilities shall have policies and procedures in place which establish a reaction plan with respect to management of the facility in the event of unplanned events and potential disasters.

   1. (i) Such policies and procedures shall include provisions designed to ensure staff are made aware of, and are familiar with, the reaction plan.

   2. (ii) The reaction plan shall be periodically reviewed and updated as needed.

      (e) Fire safety.

10. (1) Training. Facilities shall provide fire safety training to all staff. Fire safety training shall address topics including, but not limited to:

    1. (i) fire prevention;
    2. (ii) discovering a fire;
    3. (iii) operating the fire alarm system;
    4. (iv) use of firefighting equipment; and
    5. (v) building evacuation, including fire drill protocols that identify staff roles and locations where patients must assemble (i.e., assembly points).

11. (2) Fire drills. On a quarterly basis, facilities shall conduct fire drills in each building that houses patients. At least 50 percent of such drills must be unannounced.

    1. (i) For each quarter, each such building must have a minimum of one practice fire drill per shift.
    2. (ii) Facilities must direct all staff members on all shifts to participate in fire drills.
    3. (iii) Drills must be scheduled at varying times during a shift.
    4. (iv) Use of alternative exits must be practiced during fire drills.
    5. (v) Whenever practicable, drills shall involve the actual evacuation of patients to an assembly point as specified in the fire drill protocols. Consistent with Life Safety Code standards, in larger facilities that are subdivided into separate smoke compartments to limit the spread of fire and smoke and move patients without leaving the building or changing floors, evacuation may include relocation of patients to such compartments.
    6. (vi) Properly documented actual or false alarms may be used for up to 50 percent of required drills for each shift, if all elements of the facility’s fire plan were implemented.
    7. (vii) Facilities must document and maintain records regarding fire drill performance which include an evaluation of the results of the fire drill, any corrective action that may be required, and completion of steps taken to achieve such corrective action.

12. (3) Tests and inspections. Facilities must routinely test and inspect all fire safety equipment according to applicable codes, regulations and manufacturer’s recommendations.

    1. (i) All tests and inspections, and the dates conducted, shall be documented.
    2. (ii) Facilities shall immediately correct, and document correction of, any deficiency noted during inspection and testing.

13. (4) Prohibited items.

    1. (i) The following items are prohibited from use within any buildings on the grounds of the facility:

       1. (a) devices for heating, cooking, or lighting which use kerosene, gasoline, wood, or alcohol;
       2. (b) portable electric hot plates; and
       3. (c) barbeque grills, which may only be used outside the building if located further than 30 feet away of any building structure, including overhangs, canopies or awnings.

    2. (ii) The use of portable space heating devices is prohibited in patient sleeping and treatment areas of the facility, as well as in facility administrative offices. Use of a portable space heating device in any other building on the grounds of a facility shall be in accordance with guidelines of the office, provided that:

       1. (a) the unit has an Underwriters Laboratories (UL) certification mark;
       2. (b) the unit is thermostat-controlled and has a tip-over cutoff device;
       3. (c) the unit is plugged directly into a wall receptacle (no extension cords);
       4. (d) combustible materials are not stored around or near the unit;
       5. (e) at least a three-foot clearance around the unit is maintained; and
       6. (f) the unit is not placed underneath a desk, furniture or other combustible items.

14. (5) Smoking. Facilities must not permit smoking within any buildings on the grounds of the facility. If smoking is permitted on the grounds of the facility, it shall be contained to a specific location(s) equipped with an approved non-combustible ash receptacle. Smoking shall not be permitted within 30 feet of any building structure, including overhangs, canopies or awnings.

    (f) Electroconvulsive therapy (ECT).

15. (1) Facilities administering ECT must have a treatment room and recovery space that is specifically dedicated for this service and which meets applicable Federal and State safety and health standards and applicable standards of practice.
16. (2) Facilities administering ECT shall remain current with standards of practice supported by the American Psychiatric Association related to treatment and administration of this service consistent with such standards.

(a) Safety.