--- title: "Building, Physical Plant & Life Safety Guide | WCGTX" description: "Explore building, physical plant, and life-safety guidance for Texas freestanding ERs, with 60 searchable topics and a 60-item fillable PDF checklist." image: "https://wcgtx.com/og-cover-v2.jpg" url: "https://wcgtx.com/facility-resources/building-life-safety/" --- Facility Resources · Building Source Review: September 2026 # Building & Physical Plant *Life Safety Guide* Review the physical environment, life safety, maintenance, and facility readiness in one searchable resource. Browse topics Use readiness checklist Download Fillable PDF Checklist **Educational Resource, Not a Compliance Certification.** Adapted from the supplied departmental guide and blank checklist. The guide states a source review date of September 2026; this is not an independent verification of current requirements. Confirm applicability with current official sources and qualified facility leadership. Checklist selections are self-reported, not an assessment by WCGTX. Start Here ## Your Department’s Working Reference Browse 60 guide topics, review 60 readiness items, or download the fillable PDF checklist for your team. The full guide is available on this page. Read. Review. Follow Through. Search the guide · Review readiness · Save a fillable PDF checklist Review the five readiness questions About This Guide and Its Scope ### A Practical Resource Based on Texas HHSC Architectural Review, Texas FSER Licensing Requirements, and Joint Commission Quality & Life Safety Expectations A Freestanding Emergency Room is not simply a medical office with emergency equipment. The physical environment itself forms part of the clinical safety system. The building must support rapid emergency care while maintaining appropriate: Patient Access • Emergency Egress • Fire Protection • Clinical Space • Infection Prevention • Utilities • Emergency Power • Medical Gas • Security • Equipment Safety • Accessibility • Environmental Safety For Texas Freestanding Emergency Medical Care Facilities, building compliance involves several overlapping authorities and requirements, including: - Texas Health and Human Services Commission - HHSC Architectural Review Unit - 26 Texas Administrative Code Chapter 509 - Local building and fire authorities - Applicable National Fire Protection Association standards - Joint Commission Ambulatory Health Care requirements - Environment of Care - Life Safety - Emergency Management - Infection Prevention and Control Browse the Guide ## Find a Building Topic Search building topics Search the full guidance inside all 60 topics. All Architectural Review & Approvals Access, Fire & Life Safety Clinical Space & Infection Prevention Utilities & Equipment Safety & Environment of Care Construction & Change Management Emergency Management & Quality 60 topics Clear filters Expand all Jump to a Topic Readiness checklist Fillable PDF checklist Reference library 01 Architectural Review & Approvals ### Texas HHSC Architectural Review Unit The HHSC Architectural Review Unit (ARU) reviews and inspects qualifying construction projects involving regulated healthcare facilities, including Freestanding Emergency Medical Care Facilities. Read Guidance The HHSC Architectural Review Unit (ARU) reviews and inspects qualifying construction projects involving regulated healthcare facilities, including Freestanding Emergency Medical Care Facilities. ARU involvement may be required for: - New construction - Conversion of an existing building - Facility relocation - Major remodeling - Renovations - Additions - Alterations - Change in service - Change in building function - Reopening certain facilities - Other construction affecting licensed clinical space HHSC states that ARU inspections and approval must occur before patient and staff use of applicable construction. Source: Building, Physical Plant & Life Safety Compliance Guide for Texas Freestanding Emergency Rooms, Section 1. 02 Architectural Review & Approvals ### Approval before Occupancy For initial FSER licensure, Texas requires architectural approval as part of the licensing process. Read Guidance For initial FSER licensure, Texas requires architectural approval as part of the licensing process. HHSC's FSER application instructions specifically require the facility to: - Obtain Architectural Review Unit approval for occupancy. - Obtain appropriate fire-safety approval. - Complete other required prelicensure processes. A facility should not assume that a municipal Certificate of Occupancy alone satisfies HHSC healthcare architectural requirements. Source: Building, Physical Plant & Life Safety Compliance Guide for Texas Freestanding Emergency Rooms, Section 2. 03 Architectural Review & Approvals ### Construction Should Not Begin before Required Approval Under 26 TAC §509.146, owners or operators may not begin qualifying new construction, additions, renovations, or conversions until final construction documents have been approved by HHSC. Read Guidance Under 26 TAC §509.146, owners or operators may not begin qualifying new construction, additions, renovations, or conversions until final construction documents have been approved by HHSC. Construction documents must be prepared by appropriately registered architects and/or licensed professional engineers. A practical sequence is: Functional Program → Design → Architectural/Engineering Documents → HHSC Review → Deficiency Resolution → Authorization → Construction → Inspection → Correction → Final Approval → Occupancy Source: Building, Physical Plant & Life Safety Compliance Guide for Texas Freestanding Emergency Rooms, Section 3. 04 Architectural Review & Approvals ### Construction Authorization Under 26 TAC §509.147, construction other than minor alterations should not begin until: Read Guidance Under 26 TAC §509.147, construction other than minor alterations should not begin until: - Final plan review deficiencies have been satisfactorily resolved. - Applicable fees have been addressed. - HHSC has issued authorization to begin construction. The architect of record or facility owner/operator must also notify HHSC when construction begins. Source: Building, Physical Plant & Life Safety Compliance Guide for Texas Freestanding Emergency Rooms, Section 4. 05 Architectural Review & Approvals ### New Facility Requirements The principal Texas construction rule for a new FSER is: Read Guidance The principal Texas construction rule for a new FSER is: #### 26 TAC §509.143 — Construction Requirements for a New Facility Texas requires new FSER construction to provide an environment protecting the: - Health - Safety - Welfare of patients, staff, and the public. Where construction standards differ, Texas specifies that the more stringent requirement applies. Source: Building, Physical Plant & Life Safety Compliance Guide for Texas Freestanding Emergency Rooms, Section 5. 06 Architectural Review & Approvals ### Existing and Pre-Existing Facilities Existing facilities may be governed differently depending upon: Read Guidance Existing facilities may be governed differently depending upon: - Original construction date - Original licensing status - Previous approved design - Scope of subsequent renovation Major remodeling, additions, alterations, or renovations can trigger new-construction requirements for the affected portion. Texas addresses these distinctions through: #### §509.141 — Pre-Existing Facilities and §509.142 — Existing Facilities / Construction Completed After September 1, 2010 Facilities should therefore verify their approved architectural baseline before altering existing clinical space. Source: Building, Physical Plant & Life Safety Compliance Guide for Texas Freestanding Emergency Rooms, Section 6. 07 Access, Fire & Life Safety ### Site Access A new FSER should be readily accessible to: Read Guidance A new FSER should be readily accessible to: - Patients - Ambulances - Fire apparatus - Delivery vehicles - Emergency services Texas specifically requires proposed facilities to be accessible to the community and service/emergency vehicles. Access routes should remain unobstructed. Source: Building, Physical Plant & Life Safety Compliance Guide for Texas Freestanding Emergency Rooms, Section 7. 08 Access, Fire & Life Safety ### Patient Entrance Texas requirements address the primary public entrance and patient accessibility. Read Guidance Texas requirements address the primary public entrance and patient accessibility. For new facilities, the primary entrance must be located at grade level and be accessible to individuals with disabilities. Texas also requires weather protection at the passenger loading/unloading area through an appropriate canopy. Source: Building, Physical Plant & Life Safety Compliance Guide for Texas Freestanding Emergency Rooms, Section 8. 09 Access, Fire & Life Safety ### Ambulance Access The ambulance entrance should support rapid and safe patient transfer. Read Guidance The ambulance entrance should support rapid and safe patient transfer. Important considerations include: - Grade-level access - Adequate illumination - Clear route - Appropriate door width - Stretcher maneuverability - Weather protection where applicable - Separation from routine pedestrian traffic when practical Texas specifically requires appropriate emergency/ambulance entrance provisions. Source: Building, Physical Plant & Life Safety Compliance Guide for Texas Freestanding Emergency Rooms, Section 9. 10 Access, Fire & Life Safety ### Exits and Means of Egress New Texas FSER facilities must have at least two remotely located exits in accordance with applicable Life Safety Code requirements. Read Guidance New Texas FSER facilities must have at least two remotely located exits in accordance with applicable Life Safety Code requirements. Exit routes must remain: - Unobstructed - Accessible - Clearly identifiable - Appropriately illuminated Joint Commission similarly emphasizes that means of egress must remain functional so patients, visitors, and staff can reach safety during a fire or other emergency. Source: Building, Physical Plant & Life Safety Compliance Guide for Texas Freestanding Emergency Rooms, Section 10. 11 Access, Fire & Life Safety ### Life Safety Code Texas Chapter 509 incorporates Life Safety Code requirements into FSER construction. Read Guidance Texas Chapter 509 incorporates Life Safety Code requirements into FSER construction. For new facilities, Texas references NFPA 101, Chapter 20 — New Ambulatory Health Care Occupancies, within the applicable Texas licensing framework. Joint Commission ambulatory organizations also have a dedicated Life Safety framework. Its current guidance generally references: - NFPA 101-2012 - NFPA 99-2012 where those editions apply through Joint Commission/CMS requirements. Because code editions can differ among authorities, the organization and design team should identify all controlling codes at the start of the project. Source: Building, Physical Plant & Life Safety Compliance Guide for Texas Freestanding Emergency Rooms, Section 11. 12 Access, Fire & Life Safety ### Fire-Rated Construction Fire-rated assemblies should remain intact throughout the life of the facility. Read Guidance Fire-rated assemblies should remain intact throughout the life of the facility. Areas to monitor include: - Fire barriers - Smoke barriers - Fire-rated doors - Door closers - Penetrations - Electrical penetrations - Cable penetrations - Above-ceiling work - Fire stopping Joint Commission specifically identifies compromised fire barriers, doors, and penetrations as common Life Safety concerns because defects can allow smoke, fire, and heat to spread. Source: Building, Physical Plant & Life Safety Compliance Guide for Texas Freestanding Emergency Rooms, Section 12. 13 Access, Fire & Life Safety ### Fire Protection Systems Texas requires facilities to maintain applicable fire-safety systems. Read Guidance Texas requires facilities to maintain applicable fire-safety systems. Depending on the building, these may include: - Fire alarm - Fire sprinklers - Fire pumps - Standpipes - Fire department connections - Portable extinguishers - Smoke detection - Emergency notification systems Inspection, testing, and maintenance must occur according to applicable requirements. Source: Building, Physical Plant & Life Safety Compliance Guide for Texas Freestanding Emergency Rooms, Section 13. 14 Access, Fire & Life Safety ### Local Fire Authority The facility must comply with applicable local fire codes. Read Guidance The facility must comply with applicable local fire codes. Texas also requires FSERs to obtain an annual fire-safety inspection from the local fire authority for continued licensure. Keep current: Fire Inspection → Deficiencies → Corrections → Reinspection/Closure Source: Building, Physical Plant & Life Safety Compliance Guide for Texas Freestanding Emergency Rooms, Section 14. 15 Access, Fire & Life Safety ### Fire Drills Texas FSER rules require regular fire drills. Read Guidance Texas FSER rules require regular fire drills. Under §509.121, the facility conducts: One fire drill per shift per quarter. Staff must understand their roles in the facility fire protection and evacuation plan. Fire drill documentation should identify: - Date/time - Shift - Scenario - Staff response - Problems identified - Corrective action - Follow-up Source: Building, Physical Plant & Life Safety Compliance Guide for Texas Freestanding Emergency Rooms, Section 15. 16 Access, Fire & Life Safety ### Evacuation Plan Texas requires a patient fire-protection and evacuation plan. Read Guidance Texas requires a patient fire-protection and evacuation plan. Evacuation floor plans should be conspicuously posted in public areas readily visible to: - Patients - Employees - Visitors The plan should account for patients who may be: - On stretchers - Receiving oxygen - Connected to monitors - Sedated - Unable to independently evacuate Source: Building, Physical Plant & Life Safety Compliance Guide for Texas Freestanding Emergency Rooms, Section 16. 17 Clinical Space & Infection Prevention ### Main Lobby and Waiting Area For new FSER construction, Texas requires a main lobby located at the primary entrance. Read Guidance For new FSER construction, Texas requires a main lobby located at the primary entrance. Applicable required/supporting elements include: - Reception/information area - Waiting space - Private interview area or appropriate alternative - Public toilets - Drinking water availability - Wheelchair storage The lobby should also support: - Observation - Security - Infection prevention - Patient privacy - Safe circulation Source: Building, Physical Plant & Life Safety Compliance Guide for Texas Freestanding Emergency Rooms, Section 17. 18 Clinical Space & Infection Prevention ### Nurse / Control Station Texas places significant functional importance on the FSER control station. Read Guidance Texas places significant functional importance on the FSER control station. The nurse/control station must be positioned to permit staff observation and control of access to: - Treatment rooms - Examination rooms - Pedestrian entrance - Ambulance entrance - Public waiting areas Video monitoring can be used for some entrance/waiting-area observation under the new-facility provision. Source: Building, Physical Plant & Life Safety Compliance Guide for Texas Freestanding Emergency Rooms, Section 18. 19 Clinical Space & Infection Prevention ### Hand-Washing at the Nurse Station For new facilities, the nurse station must include a hand-washing fixture with hands-free operable controls. Read Guidance For new facilities, the nurse station must include a hand-washing fixture with hands-free operable controls. Hand-hygiene infrastructure should be evaluated whenever workflow or cabinetry changes are proposed. Source: Building, Physical Plant & Life Safety Compliance Guide for Texas Freestanding Emergency Rooms, Section 19. 20 Clinical Space & Infection Prevention ### Triage When a dedicated triage room or space is provided in a new facility, Texas requires a counter and a hand-washing fixture with hands-free controls. Read Guidance When a dedicated triage room or space is provided in a new facility, Texas requires a counter and a hand-washing fixture with hands-free controls. The triage design should support: - Patient privacy - Rapid assessment - Infection prevention - Staff safety - Visual access to patient flow Source: Building, Physical Plant & Life Safety Compliance Guide for Texas Freestanding Emergency Rooms, Section 20. 21 Clinical Space & Infection Prevention ### Emergency Treatment Room Texas requires at least one emergency treatment room. Read Guidance Texas requires at least one emergency treatment room. For a new facility, a single-patient emergency treatment room must provide at least: #### 120 Square Feet of Clear Floor Area exclusive of fixed and movable cabinets and shelves. The minimum clear room dimension is 10 feet. The room must also include: - Cabinets - Work counter - Examination light - Hands-free hand-washing fixture Source: Building, Physical Plant & Life Safety Compliance Guide for Texas Freestanding Emergency Rooms, Section 21. 22 Clinical Space & Infection Prevention ### Multiple-Bed Treatment Rooms Where multiple treatment positions are used, Texas specifies minimum clearances between: Read Guidance Where multiple treatment positions are used, Texas specifies minimum clearances between: - Bed and wall - Adjacent beds - Foot of bed/gurney - Traffic areas Each bed location also requires appropriate access to hand washing. Do not allow equipment, storage, or cabinetry to erode required clinical clearances. Source: Building, Physical Plant & Life Safety Compliance Guide for Texas Freestanding Emergency Rooms, Section 22. 23 Clinical Space & Infection Prevention ### Examination Room Texas requires at least one examination room. Read Guidance Texas requires at least one examination room. The applicable design includes appropriate: - Work surfaces - Cabinets - Examination lighting - Hand-washing facilities Facilities with multiple examination rooms should preserve the approved function of each space. Source: Building, Physical Plant & Life Safety Compliance Guide for Texas Freestanding Emergency Rooms, Section 23. 24 Clinical Space & Infection Prevention ### Crash Cart Space Texas requires an area or alcove for emergency crash-cart storage that is: Read Guidance Texas requires an area or alcove for emergency crash-cart storage that is: - Convenient to treatment/exam rooms - Outside the normal path of traffic A crash cart parked in a required corridor width can create both clinical and Life Safety deficiencies. Source: Building, Physical Plant & Life Safety Compliance Guide for Texas Freestanding Emergency Rooms, Section 24. 25 Clinical Space & Infection Prevention ### Stretcher and Wheelchair Storage Texas requires designated stretcher/wheelchair storage outside the line of traffic. Read Guidance Texas requires designated stretcher/wheelchair storage outside the line of traffic. Avoid using: - Corridors - Exit routes - Electrical rooms - Fire-protection spaces for temporary equipment storage. Source: Building, Physical Plant & Life Safety Compliance Guide for Texas Freestanding Emergency Rooms, Section 25. 26 Clinical Space & Infection Prevention ### Medical Supply Storage Storage must be sufficient for emergency-care supplies and equipment. Read Guidance Storage must be sufficient for emergency-care supplies and equipment. Texas specifically expects controlled storage for general emergency medical/surgical supplies and room for equipment such as: - Ventilator - Defibrillator - Monitors - Splints - Emergency treatment trays The facility should prevent storage creep into corridors and clinical clearances. Source: Building, Physical Plant & Life Safety Compliance Guide for Texas Freestanding Emergency Rooms, Section 26. 27 Clinical Space & Infection Prevention ### Clean and Soiled Workflow Physical design should maintain appropriate separation of: Read Guidance Physical design should maintain appropriate separation of: Clean → Patient Care → Contaminated/Soiled Storage, utility areas, cleaning supplies, waste, and clinical equipment should be arranged to reduce contamination risk. Texas requires facilities to actively maintain a safe, functional, comfortable, and sanitary environment that minimizes infection transmission. Source: Building, Physical Plant & Life Safety Compliance Guide for Texas Freestanding Emergency Rooms, Section 27. 28 Clinical Space & Infection Prevention ### Hand-Hygiene Infrastructure Hand-washing locations should remain: Read Guidance Hand-washing locations should remain: - Accessible - Functional - Appropriately supplied - Unobstructed Avoid locating furniture, equipment, boxes, or clinical supplies so they block required hand-washing fixtures. Source: Building, Physical Plant & Life Safety Compliance Guide for Texas Freestanding Emergency Rooms, Section 28. 29 Clinical Space & Infection Prevention ### Environmental Cleanability Healthcare finishes should support cleaning and infection prevention. Read Guidance Healthcare finishes should support cleaning and infection prevention. Pay particular attention to: - Damaged flooring - Cracked surfaces - Water-damaged ceilings - Porous materials - Damaged cabinetry - Failed sealants - Broken wall protection Physical deterioration can become both an infection-control and Environment of Care concern. Source: Building, Physical Plant & Life Safety Compliance Guide for Texas Freestanding Emergency Rooms, Section 29. 30 Utilities & Equipment ### HVAC and Ventilation Texas Chapter 509 contains specific ventilation requirements for FSER spaces. Read Guidance Texas Chapter 509 contains specific ventilation requirements for FSER spaces. §509.148 Table 1 addresses ventilation requirements, and Table 2 addresses filtration efficiencies. Facility leadership should maintain current records for applicable: - Air changes - Pressure relationships - Filtration - HVAC maintenance - Temperature/humidity - Corrective work Changes to room function should be reviewed before assuming the existing HVAC design remains appropriate. Source: Building, Physical Plant & Life Safety Compliance Guide for Texas Freestanding Emergency Rooms, Section 30. 31 Utilities & Equipment ### Medical Gas and Vacuum Texas Chapter 509 includes medical gas/vacuum requirements and a specific Table 3 addressing required station outlets for: Read Guidance Texas Chapter 509 includes medical gas/vacuum requirements and a specific Table 3 addressing required station outlets for: - Oxygen - Vacuum - Medical air The facility should maintain documentation for: - Installation - Certification - Inspection - Preventive maintenance - Alarm testing - Zone valves - Shutoff identification Source: Building, Physical Plant & Life Safety Compliance Guide for Texas Freestanding Emergency Rooms, Section 31. 32 Utilities & Equipment ### Gas Cylinder Storage Compressed gas cylinders should be: Read Guidance Compressed gas cylinders should be: - Properly secured - Separated as required - Protected from damage - Stored in appropriate locations Texas separately regulates handling and storage of gases, anesthetics, and flammable materials under §509.123. Source: Building, Physical Plant & Life Safety Compliance Guide for Texas Freestanding Emergency Rooms, Section 32. 33 Utilities & Equipment ### Emergency Power Texas requires an emergency contingency plan for continuity of essential building systems. Read Guidance Texas requires an emergency contingency plan for continuity of essential building systems. One option specified in Texas rules involves an onsite emergency generator with an essential electrical distribution system. Emergency power planning should address: - Clinical equipment - Emergency lighting - Medication refrigeration - Laboratory - Imaging - Communications - IT systems - Medical gas support equipment - Other essential utilities Source: Building, Physical Plant & Life Safety Compliance Guide for Texas Freestanding Emergency Rooms, Section 33. 34 Utilities & Equipment ### Generator Testing and Maintenance The generator should have documented: Read Guidance The generator should have documented: - Routine inspection - Preventive maintenance - Testing - Load testing when applicable - Fuel management - Transfer-switch testing - Corrective actions Generator failure is an operational and patient-safety issue, not merely an engineering issue. Source: Building, Physical Plant & Life Safety Compliance Guide for Texas Freestanding Emergency Rooms, Section 34. 35 Utilities & Equipment ### Electrical Safety Electrical systems should be maintained to reduce: Read Guidance Electrical systems should be maintained to reduce: - Shock - Fire - Overload - Equipment failure Watch for: - Extension cords used as permanent wiring - Daisy-chained power strips - Damaged receptacles - Improper equipment connections - Blocked electrical panels Source: Building, Physical Plant & Life Safety Compliance Guide for Texas Freestanding Emergency Rooms, Section 35. 36 Utilities & Equipment ### Utility Systems Joint Commission identifies utility systems as an important Environment of Care domain. Read Guidance Joint Commission identifies utility systems as an important Environment of Care domain. Ambulatory organizations are expected to maintain an organized approach to managing utilities and environmental risks. Utilities can include: - Electrical - Emergency electrical - HVAC - Water - Medical gas - Vacuum - Communication systems - Other building systems supporting patient care Source: Building, Physical Plant & Life Safety Compliance Guide for Texas Freestanding Emergency Rooms, Section 36. 37 Utilities & Equipment ### Water Management Healthcare facility water systems should be managed to minimize environmental hazards. Read Guidance Healthcare facility water systems should be managed to minimize environmental hazards. The facility should consider: - Stagnant water - Unused fixtures - Water intrusion - Leaks - Temperature problems - Mold/moisture - Waterborne pathogen risk Any significant water event affecting clinical areas should receive documented assessment and remediation. Source: Building, Physical Plant & Life Safety Compliance Guide for Texas Freestanding Emergency Rooms, Section 37. 38 Utilities & Equipment ### Medical Equipment Building planning should provide adequate: Read Guidance Building planning should provide adequate: - Electrical service - Space - Clearances - Cooling - Access - Maintenance pathways for major equipment. Joint Commission includes medical equipment management among the environmental risk areas subject to ongoing oversight. Source: Building, Physical Plant & Life Safety Compliance Guide for Texas Freestanding Emergency Rooms, Section 38. 39 Utilities & Equipment ### Mechanical and Electrical Rooms Texas requires sufficient space in mechanical/electrical rooms for: Read Guidance Texas requires sufficient space in mechanical/electrical rooms for: - Maintenance - Removal - Replacement of equipment. These rooms should not become storage closets. Source: Building, Physical Plant & Life Safety Compliance Guide for Texas Freestanding Emergency Rooms, Section 39. 40 Safety & Environment of Care ### Security Joint Commission requires ambulatory organizations to address security based on the organization's circumstances and risks. Read Guidance Joint Commission requires ambulatory organizations to address security based on the organization's circumstances and risks. For an FSER, consider: - Public entrance - Ambulance entrance - Medication areas - Staff-only areas - Behavioral-health risks - Workplace violence - Parking - Exterior lighting - Cameras - Panic/duress systems Source: Building, Physical Plant & Life Safety Compliance Guide for Texas Freestanding Emergency Rooms, Section 40. 41 Safety & Environment of Care ### Environment of Care Management For Joint Commission Ambulatory Health Care, environmental risk management encompasses: Read Guidance For Joint Commission Ambulatory Health Care, environmental risk management encompasses: - Safety - Security - Hazardous materials and waste - Fire safety - Medical equipment - Utility systems Joint Commission requires these areas to be evaluated systematically and periodically. Source: Building, Physical Plant & Life Safety Compliance Guide for Texas Freestanding Emergency Rooms, Section 41. 42 Safety & Environment of Care ### Annual Environmental Evaluation Joint Commission guidance calls for annual evaluation of applicable Environment of Care management plans. Read Guidance Joint Commission guidance calls for annual evaluation of applicable Environment of Care management plans. The review should consider: - Effectiveness - Previous objectives - New programs/services - New hazards - Fire drill critiques - Incident reports - Improvement priorities Source: Building, Physical Plant & Life Safety Compliance Guide for Texas Freestanding Emergency Rooms, Section 42. 43 Safety & Environment of Care ### Safety Officer Texas requires the governing body to appoint a Safety Officer knowledgeable in healthcare safety practices. Read Guidance Texas requires the governing body to appoint a Safety Officer knowledgeable in healthcare safety practices. The safety program must include: - Incident reporting - Incident evaluation - Corrective action - Safety policies - New employee orientation - Continuing safety education Source: Building, Physical Plant & Life Safety Compliance Guide for Texas Freestanding Emergency Rooms, Section 43. 44 Safety & Environment of Care ### Environmental Rounds Joint Commission does not specifically require an Environment of Care Committee or a particular rounding methodology. Read Guidance Joint Commission does not specifically require an Environment of Care Committee or a particular rounding methodology. However, routine environmental rounds remain an effective way to identify: - Blocked exits - Damaged fire doors - Corridor storage - Expired inspections - Ceiling damage - Electrical hazards - Medical gas problems - Infection-control concerns - Security risks The facility should select a monitoring process appropriate to its risks. Source: Building, Physical Plant & Life Safety Compliance Guide for Texas Freestanding Emergency Rooms, Section 44. 45 Construction & Change Management ### Construction in an Operating Facility If renovations occur while the FSER remains operational, patient and staff safety must be protected. Read Guidance If renovations occur while the FSER remains operational, patient and staff safety must be protected. Texas §509.147 specifically requires adequate provisions for occupant safety and comfort when construction occurs in or near occupied areas. Facilities should address: - Dust - Noise - Construction barriers - Infection prevention - Egress - Fire systems - Utility interruption - Contractor access - Patient privacy - Temporary routes Source: Building, Physical Plant & Life Safety Compliance Guide for Texas Freestanding Emergency Rooms, Section 45. 46 Construction & Change Management ### Infection Control Risk during Construction Before construction begins in occupied clinical areas, evaluate potential risks involving: Read Guidance Before construction begins in occupied clinical areas, evaluate potential risks involving: - Dust - Water - Airflow - Ceiling access - Construction debris - Patient movement - Infection-control barriers The infection prevention team should participate where construction could affect patient-care areas. Source: Building, Physical Plant & Life Safety Compliance Guide for Texas Freestanding Emergency Rooms, Section 46. 47 Construction & Change Management ### Above-Ceiling Work After contractors perform above-ceiling work, verify: Read Guidance After contractors perform above-ceiling work, verify: - Fire stopping - Barrier integrity - Dampers - Cabling - Pipes - Ceiling tiles - Infection-control integrity Incomplete repair after contractor work is a common source of Life Safety defects. Source: Building, Physical Plant & Life Safety Compliance Guide for Texas Freestanding Emergency Rooms, Section 47. 48 Construction & Change Management ### Change of Room Function Do not convert rooms informally. Read Guidance Do not convert rooms informally. Examples: Office → Exam Room Storage → Lab Exam Room → Observation Room Clinical Room → Pharmacy may have implications for: - Square footage - Hand washing - HVAC - Medical gas - Fire protection - Accessibility - Electrical systems - HHSC architectural approval Changes in function may require ARU review. Source: Building, Physical Plant & Life Safety Compliance Guide for Texas Freestanding Emergency Rooms, Section 48. 49 Construction & Change Management ### Building Drawings Facilities should maintain accurate: Read Guidance Facilities should maintain accurate: - Architectural plans - Life Safety information - Utility drawings - Medical gas drawings - Fire-system documentation Joint Commission requires applicable organizations to maintain accurate building information, particularly where Life Safety occupancy requirements apply. Source: Building, Physical Plant & Life Safety Compliance Guide for Texas Freestanding Emergency Rooms, Section 49. 50 Construction & Change Management ### Leased Buildings Leasing space does not transfer healthcare compliance responsibility to the landlord. Read Guidance Leasing space does not transfer healthcare compliance responsibility to the landlord. Joint Commission states that its physical-environment requirements apply to facilities where patients are seen or treated, including applicable leased facilities. Leases should support access to building-system inspection and maintenance documentation necessary to demonstrate compliance. Source: Building, Physical Plant & Life Safety Compliance Guide for Texas Freestanding Emergency Rooms, Section 50. 51 Utilities & Equipment ### Elevators If patient services are located above or below the main entrance level, Texas contains specific elevator requirements. Read Guidance If patient services are located above or below the main entrance level, Texas contains specific elevator requirements. Elevators must support patient and public access with appropriate capacity and performance. Elevator inspection certificates and maintenance records should remain current. Source: Building, Physical Plant & Life Safety Compliance Guide for Texas Freestanding Emergency Rooms, Section 51. 52 Safety & Environment of Care ### Hazardous Materials and Waste Building operations should support safe management of: Read Guidance Building operations should support safe management of: - Biohazardous waste - Sharps - Chemicals - Cleaning agents - Laboratory materials - Compressed gases - Other hazardous substances Storage rooms should remain appropriate to the hazards present. Source: Building, Physical Plant & Life Safety Compliance Guide for Texas Freestanding Emergency Rooms, Section 52. 53 Emergency Management & Quality ### Emergency Management The Joint Commission Ambulatory Health Care Emergency Management framework addresses preparedness for hazards capable of disrupting healthcare services. Read Guidance The Joint Commission Ambulatory Health Care Emergency Management framework addresses preparedness for hazards capable of disrupting healthcare services. The physical plant should support the facility's Emergency Operations Plan, including: - Power loss - Water interruption - HVAC failure - Fire - Severe weather - Security events - Utility failure - Evacuation - Shelter-in-place Source: Building, Physical Plant & Life Safety Compliance Guide for Texas Freestanding Emergency Rooms, Section 53. 54 Emergency Management & Quality ### Hazard Vulnerability Building risks should be incorporated into the organization's Hazard Vulnerability Analysis. Read Guidance Building risks should be incorporated into the organization's Hazard Vulnerability Analysis. For a Texas FSER, examples may include: - Tornado - Severe storm - Extended power failure - Water outage - Extreme heat - Fire - HVAC outage - Medical gas failure - Active threat - IT outage The building's infrastructure and contingency plans should reflect identified risks. Source: Building, Physical Plant & Life Safety Compliance Guide for Texas Freestanding Emergency Rooms, Section 54. 55 Emergency Management & Quality ### Environmental Incident Reporting Physical-environment events should enter the facility safety system when clinically significant. Read Guidance Physical-environment events should enter the facility safety system when clinically significant. Examples: - Electrical outage - Water intrusion - Fire - Medical gas failure - Patient injury from equipment/building defect - Security failure - Temperature excursion - Major HVAC failure Texas requires the Safety Officer's incident-reporting system to include evaluation, follow-up, and corrective action. Source: Building, Physical Plant & Life Safety Compliance Guide for Texas Freestanding Emergency Rooms, Section 55. 56 Emergency Management & Quality ### Building Quality Dashboard A practical monthly FSER Building / Environment of Care dashboard may include: Read Guidance A practical monthly FSER Building / Environment of Care dashboard may include: #### Fire & Life Safety - Fire drill completion - Fire-alarm deficiencies - Sprinkler deficiencies - Fire-door deficiencies - Barrier penetrations - Blocked-exit findings #### Facility - Maintenance work orders - Overdue PM - Water leaks - Ceiling/floor/wall defects - Temperature/humidity events #### Utilities - Generator tests - Electrical interruptions - HVAC outages - Medical-gas alarms - Plumbing interruptions #### Security - Security incidents - Door/access failures - Workplace-violence events #### Safety - Environmental injuries - Hazardous-material incidents - Construction-related issues #### Regulatory - ARU deficiencies - Fire inspection deficiencies - Open corrective actions Source: Building, Physical Plant & Life Safety Compliance Guide for Texas Freestanding Emergency Rooms, Section 56. 57 Emergency Management & Quality ### Monthly Building / Environment of Care Review A monthly facility review should answer: Read Guidance A monthly facility review should answer: #### Architectural Have any renovations, additions, alterations, or room-function changes occurred? #### Fire Safety Are exits, doors, barriers, alarms, sprinklers, and extinguishers compliant? #### Utilities Are emergency power, HVAC, medical gas, electrical, and water systems reliable? #### Environment Are clinical spaces safe, clean, intact, and functional? #### Security Are identified security risks appropriately controlled? #### Emergency Management Can essential building systems continue during an emergency? #### Corrective Action Have previous environmental findings been corrected and effectiveness verified? Source: Building, Physical Plant & Life Safety Compliance Guide for Texas Freestanding Emergency Rooms, Section 57. 58 Emergency Management & Quality ### Building QAPI Model A practical environmental-performance model is: Read Guidance A practical environmental-performance model is: IDENTIFY → RISK-RANK → CORRECT → VERIFY → MONITOR → CLOSE Example: Finding: Fire door fails to positively latch. Risk: Smoke/fire compartmentation may be impaired. Immediate Action: Door evaluated and area monitored as appropriate. Corrective Action: Repair door hardware. Verification: Facilities manager confirms successful latching. Sustainability: Included in subsequent environmental rounds. Status: Closed. Source: Building, Physical Plant & Life Safety Compliance Guide for Texas Freestanding Emergency Rooms, Section 58. 59 Emergency Management & Quality ### Survey-Ready Building Binder A well-organized building compliance binder can include: Read Guidance A well-organized building compliance binder can include: #### Section 1 — HHSC / ARU - Approved plans - ARU approvals - Plan-review correspondence - Final inspection documentation - Architectural deficiency resolutions #### Section 2 — Fire & Life Safety - Local fire inspection - Fire alarm records - Sprinkler inspection - Extinguisher records - Fire drills - Evacuation plans #### Section 3 — Utilities - Generator - ATS - HVAC - Electrical - Water - Medical gas #### Section 4 — Facility Maintenance - Preventive maintenance - Work orders - Repairs - Contractor reports #### Section 5 — Environment of Care - Safety plan - Security plan - Hazardous-material plan - Annual evaluations - Environmental rounds #### Section 6 — Emergency Management - HVA - Emergency Operations Plan - Drills - Utility contingency plans #### Section 7 — Construction - Renovation approvals - Infection-control assessments - Interim safety controls - Contractor documentation #### Section 8 — QAPI - Environmental dashboard - Deficiencies - Corrective actions - Effectiveness verification Source: Building, Physical Plant & Life Safety Compliance Guide for Texas Freestanding Emergency Rooms, Section 59. 60 Emergency Management & Quality ### Five Questions Every FSER Should Be Able to Answer about Its Building 1\. Was the facility constructed and occupied with the required HHSC architectural approvals? Read Guidance 1\. Was the facility constructed and occupied with the required HHSC architectural approvals? 2\. Are our fire, utility, emergency-power, and medical-gas systems maintained and tested? 3\. Does our physical environment support safe emergency patient care today—not just when it originally opened? 4\. How do we identify building and environmental hazards? 5\. How do we prove that identified deficiencies were corrected and stayed corrected? Source: Building, Physical Plant & Life Safety Compliance Guide for Texas Freestanding Emergency Rooms, Section 60. Quick Reference ## Five Questions Every FSER Should Be Able to Answer about Its Building Use these questions to guide a discussion with department leadership. They do not replace the detailed review or applicable requirements. 1. Was the facility constructed and occupied with the required HHSC architectural approvals? 2. Are our fire, utility, emergency-power, and medical-gas systems maintained and tested? 3. Does our physical environment support safe emergency patient care today—not just when it originally opened? 4. How do we identify building and environmental hazards? 5. How do we prove that identified deficiencies were corrected and stayed corrected? Review Your Readiness ## Building Survey Readiness Checklist Review all 60 items from the supplied checklist. The framework labels reproduce the source’s reference columns; they are not independently verified regulatory determinations. **Session-Only Tool.** Selections stay in this page and are not saved or submitted. They reset when you reload or leave. Do not enter patient information. Use the downloadable fillable PDF checklist for facility details, findings, due dates, and sign-off. Search Checklist Items Filter by Status Reset selections 0 of 60 reviewed · 0 marked deficient 60 checklist items shown ### Architectural Review, Physical Plant, Fire & Life Safety Item 01 Current HHSC Architectural Review Unit (ARU) approval/occupancy documentation is available for the licensed facility. Source References: HHSC/ARU · TJC Review Status Item 02 Approved architectural plans accurately reflect the current facility layout and clinical room functions. Source References: HHSC/ARU · TJC Review Status Item 03 Renovations, additions, alterations, conversions, or changes of room function received required HHSC/ARU review before use. Source References: HHSC/ARU · TJC Review Status Item 04 Construction authorization and required HHSC notifications were completed before applicable construction began. Source References: HHSC/ARU Review Status Item 05 Current local Certificate of Occupancy and applicable municipal building approvals are available. Source References: HHSC/ARU · Fire/LS Review Status Item 06 Current annual local fire-safety inspection is available; cited deficiencies are closed or under documented correction. Source References: Fire/LS · TJC Review Status Item 07 Facility maintains at least two remotely located exits as required; exit paths are unobstructed and functional. Source References: HHSC/ARU · Fire/LS · TJC Review Status Item 08 Exit signs and emergency lighting are functional, visible, and tested at required intervals. Source References: Fire/LS · TJC Review Status Item 09 Fire and smoke barriers are intact; penetrations are appropriately fire-stopped. Source References: Fire/LS · TJC Review Status Item 10 Fire-rated and smoke doors close/latch properly and are not wedged or obstructed. Source References: Fire/LS · TJC Review Status Item 11 Fire alarm inspection, testing, maintenance, and deficiency documentation are current. Source References: Fire/LS · TJC Review Status Item 12 Automatic sprinkler system inspection/testing and deficiency documentation are current where applicable. Source References: Fire/LS · TJC Review Status Item 13 Portable fire extinguishers are accessible, inspected, properly mounted, and within service dates. Source References: Fire/LS · TJC Review Status Item 14 Fire drills are completed one per shift per quarter and include critique/corrective action when deficiencies occur. Source References: Fire/LS · TJC Review Status Item 15 Current fire/evacuation plan is available and evacuation diagrams are posted in appropriate public areas. Source References: Fire/LS · TJC Review Status Item 16 Staff can describe fire response, evacuation responsibilities, and relocation of nonambulatory patients. Source References: Fire/LS · TJC Review Status Item 17 Public/patient entrance is accessible, safe, adequately illuminated, and weather protected as applicable. Source References: HHSC/ARU · TJC Review Status Item 18 Ambulance entrance and route support safe stretcher access and remain unobstructed. Source References: HHSC/ARU · Fire/LS · TJC Review Status Item 19 Required accessible parking, routes, entrances, toilets, and patient areas remain compliant and unobstructed. Source References: HHSC/ARU · Fire/LS · TJC Review Status Item 20 Lobby/waiting, reception, privacy, public toilet, drinking-water, and wheelchair-storage functions remain available as approved. Source References: HHSC/ARU · TJC Review Status Item 21 Nurse/control station maintains required visibility/monitoring of treatment areas and entrances. Source References: HHSC/ARU · TJC Review Status Item 22 Required hand-washing fixtures are accessible, functional, supplied, and unobstructed. Source References: HHSC/ARU · TJC Review Status Item 23 Triage space, when provided, maintains approved function, privacy, hand hygiene, and safe patient flow. Source References: HHSC/ARU · TJC Review Status Item 24 Emergency treatment room(s) maintain required minimum clear floor area, dimensions, equipment, work surfaces, and hand washing. Source References: HHSC/ARU · TJC Review Status Item 25 Exam rooms maintain approved dimensions, clinical function, work surfaces, lighting, and hand-washing capability. Source References: HHSC/ARU · TJC Review Status Item 26 Multiple-bed treatment areas maintain required bed-to-wall, bed-to-bed, and foot-of-bed clearances. Source References: HHSC/ARU · Fire/LS · TJC Review Status Item 27 Crash cart storage is convenient to patient-care areas and does not obstruct corridors or required egress. Source References: HHSC/ARU · Fire/LS · TJC Review Status Item 28 Stretcher, wheelchair, and mobile-equipment storage is outside required corridors and lines of traffic. Source References: HHSC/ARU · Fire/LS · TJC Review Status Item 29 Clinical supply storage is adequate and does not encroach on patient-care clearances, exits, electrical rooms, or fire systems. Source References: HHSC/ARU · Fire/LS · TJC Review Status Item 30 Clean and soiled workflows are physically separated or operationally controlled to reduce contamination risk. Source References: HHSC/ARU · TJC Review Status Item 31 Walls, floors, ceilings, cabinetry, sealants, and other finishes are intact, cleanable, and free of significant water damage. Source References: HHSC/ARU · TJC Review Status Item 32 HVAC systems are maintained; applicable ventilation, pressure relationships, filtration, temperature, and humidity requirements are monitored. Source References: HHSC/ARU · TJC Review Status Item 33 Medical gas/vacuum outlets, alarms, zone valves, shutoffs, and required certifications/inspections are current and accessible. Source References: HHSC/ARU · Fire/LS · TJC Review Status ### Utilities, Environment of Care, Emergency Management & QAPI Item 34 Compressed gas cylinders are secured, segregated/stored appropriately, and protected from damage. Source References: HHSC/ARU · Fire/LS · TJC Review Status Item 35 Emergency power system supports essential clinical and building functions and is maintained in operable condition. Source References: HHSC/ARU · Fire/LS · TJC Review Status Item 36 Generator inspections, preventive maintenance, transfer-switch testing, load testing, and fuel management records are current. Source References: Fire/LS · TJC Review Status Item 37 Electrical panels are accessible; no unsafe extension-cord, daisy-chain, damaged receptacle, or permanent temporary-wiring conditions are present. Source References: Fire/LS · TJC Review Status Item 38 Utility systems including power, HVAC, water, medical gas, vacuum, and communications have preventive maintenance and contingency plans. Source References: HHSC/ARU · TJC Review Status Item 39 Water-management risks, leaks, water intrusion, stagnation, mold/moisture, and waterborne-pathogen concerns are assessed and corrected. Source References: TJC Review Status Item 40 Mechanical and electrical rooms have required service clearances and are not used for inappropriate storage. Source References: HHSC/ARU · Fire/LS · TJC Review Status Item 41 Medical equipment has adequate space, power, ventilation, access, and preventive maintenance support. Source References: HHSC/ARU · TJC Review Status Item 42 Security controls address public/ambulance entrances, staff-only areas, medication areas, parking, exterior lighting, and identified workplace-violence risks. Source References: TJC Review Status Item 43 Safety Officer designation is current and responsibilities include incident evaluation, corrective action, orientation, and continuing safety education. Source References: HHSC/ARU · TJC Review Status Item 44 Routine Environment of Care/safety rounds identify, risk-rank, assign, and close physical-environment deficiencies. Source References: TJC Review Status Item 45 Hazardous materials, chemicals, biohazard waste, sharps, and cleaning products are stored and managed safely. Source References: HHSC/ARU · Fire/LS · TJC Review Status Item 46 Construction or renovation in occupied areas includes controls for dust, noise, barriers, infection prevention, egress, utilities, and patient safety. Source References: HHSC/ARU · Fire/LS · TJC Review Status Item 47 Above-ceiling work is followed by verification of fire stopping, barrier integrity, cabling, dampers, and ceiling restoration. Source References: Fire/LS · TJC Review Status Item 48 Room use has not been changed informally; any conversion is evaluated for ARU, HVAC, handwashing, medical gas, electrical, fire, and accessibility implications. Source References: HHSC/ARU · TJC Review Status Item 49 Accurate architectural, life-safety, utility, medical-gas, and fire-system drawings are maintained and available. Source References: HHSC/ARU · Fire/LS · TJC Review Status Item 50 Leased-building agreements provide access to landlord fire, utility, maintenance, and inspection documentation needed for compliance. Source References: Fire/LS · TJC Review Status Item 51 Elevator inspection certificates and maintenance records are current where elevators serve patient-access areas. Source References: HHSC/ARU · Fire/LS · TJC Review Status Item 52 Emergency Operations Plan addresses power, water, HVAC, medical gas, fire, severe weather, security, evacuation, and shelter-in-place. Source References: HHSC/ARU · Fire/LS · TJC Review Status Item 53 Hazard Vulnerability Analysis includes relevant building and infrastructure risks and informs mitigation priorities. Source References: TJC Review Status Item 54 Emergency utility failure procedures define escalation, backup operations, patient-safety decisions, and recovery. Source References: HHSC/ARU · Fire/LS · TJC Review Status Item 55 Environmental incidents such as outages, leaks, fire, medical-gas failure, security events, or building-related injuries are reported and investigated. Source References: HHSC/ARU · TJC Review Status Item 56 Monthly building/Environment of Care performance data are reported to the facility Quality/QAPI Committee. Source References: TJC Review Status Item 57 Annual Environment of Care program evaluation is completed as applicable and identifies new risks, objectives, and improvement priorities. Source References: TJC Review Status Item 58 Prior HHSC/ARU, fire authority, Joint Commission, or internal building deficiencies have documented corrective action and closure evidence. Source References: HHSC/ARU · Fire/LS · TJC Review Status Item 59 Corrective actions are re-inspected or re-measured to verify effectiveness and sustained compliance. Source References: HHSC/ARU · Fire/LS · TJC Review Status Item 60 Building/Environment of Care QAPI projects have measurable goals, owners, due dates, outcome measures, and leadership oversight. Source References: TJC Review Status Checklist Scope and Instructions Crosswalk: HHSC/ARU = 26 TAC Chapter 509 / Architectural Review | Fire/LS = applicable fire, life-safety and NFPA requirements | TJC = Joint Commission Ambulatory EC/LS/EM/PI expectations References: Texas HHSC Architectural Review Unit; 26 TAC Chapter 509 including §§509.121-123 and Subchapter G §§509.141-148; applicable local fire/building codes and NFPA requirements; current Joint Commission Ambulatory Health Care Environment of Care, Life Safety, Emergency Management, and Performance Improvement standards. Internal readiness tool only; verify current codes and standards. Last reviewed: September 2026. Monthly Building / Environment of Care Dashboard The indicators and goals below are copied from the supplied worksheet. They are template goals, not independently verified or universal regulatory thresholds. Use the fillable PDF checklist to record current and prior measurements and follow-up actions. | Indicator | Source Worksheet Goal | | --- | --- | | HHSC/ARU approvals current | 100% | | Annual fire inspection current | 100% | | Fire drills completed | 100% | | Open fire/life-safety deficiencies | 0 unresolved | | Blocked egress findings | 0 | | Fire door/barrier deficiencies | 0 unresolved | | Generator/ATS testing completion | 100% | | Medical gas inspection compliance | 100% | | HVAC/utility PM completion | 100% | | Water intrusion events | 0 unresolved | | Environment of Care round closure | 100% | | Security incidents | Trend review | | Utility interruptions | Trend review | | Construction-related deficiencies | 0 unresolved | | Overdue corrective actions | 0 | | Prior survey findings closed | 100% | Corrective Action and Leadership Review Facility: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ | ARU / Project Ref.: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ | Safety Officer: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ | Review Month/Year: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Reviewed By: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ | Date: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ | Medical Director: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ | Status Key: ☐ C = Compliant ☐ D = Deficient ☐ N/A IMMEDIATE-ATTENTION FINDINGS: Critical Finding(s): \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Immediate Action: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Owner: \_\_\_\_\_\_\_\_\_\_\_\_\_\_ Due: \_\_\_\_\_\_\_\_\_ Indicator | Current | Goal | Prior | Trend / Action ### Corrective Action & Effectiveness Tracker - Finding - Immediate - Root Cause - Corrective Action - Owner - Due - Effectiveness - Status ### Building / Environment of Care Leadership Review High - What Went Well? \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Low - What Did Not Meet Expectations? \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Blocker - What Is Preventing Compliance or Improvement? \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Decision Needed - What Requires Safety Officer, Administrator, Medical Director, or Governing Body Action? \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ ### Survey-Readiness Status ☐ Survey Ready ☐ Minor Corrective Actions ☐ Corrective Action Required ☐ Immediate Leadership Review ### Sign-Off Safety Officer: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Signature: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Date: \_\_\_\_\_\_\_\_ Facility Administrator: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Signature: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Date: \_\_\_\_\_\_\_\_ Medical Director: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Signature: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Date: \_\_\_\_\_\_\_\_ Quality / Compliance Representative: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Signature: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Date: \_\_\_\_\_\_\_\_ Closing Standard: Finding -> Risk-Rank -> Immediate Correction -> Corrective Action -> Verification -> Monitor -> Closed Use the fillable PDF checklist to record your review and follow-up. Sign-off is an internal review step, not a certification by WCGTX. “Reviewed” means a status has been selected, including Not Applicable. No overall “Survey Ready” or compliance score is generated. Keep a Working Copy ## Download the Fillable PDF Checklist Read the guide on this page. Download the checklist to record and save your facility’s review. Fillable PDF ### Building Survey Readiness Checklist The complete 60-item checklist, with editable review statuses, a monthly quality dashboard, corrective actions, and leadership review fields. [Download Fillable PDF Checklist](https://wcgtx.com/resources/building-survey-readiness-checklist-fillable.pdf) Open in a PDF reader that supports fillable forms and save your completed copy securely. Website selections are not transferred to the PDF. Do not enter patient information. Keep the Source in View ## References & Regulatory Resources These links and reference notes come from the supplied guide. Requirements may depend on the facility’s services, licenses, accreditation, equipment, and current regulations. Confirm current applicability before use. 1. [Environment of Care Resource Center (opens in a new tab)](https://www.jointcommission.org/en-us/knowledge-library/environment-of-care) Source Reference Notes ### Primary Regulatory References ### Texas Health and Human Services Commission — Architectural Review Unit ### HHSC Architectural Review Unit Responsible for architectural review and inspection of qualifying healthcare construction projects, including Freestanding Emergency Medical Care Facilities. HHSC Regulatory Division Health Care Quality Section Architectural Review Unit ARU inspection guidance states that qualifying construction must receive required inspection/approval before patient and staff use. ### Texas HHSC — Freestanding Emergency Medical Care Facilities ### 26 TAC Chapter 509 Major building-related sections include: ### §509.121 — Fire Prevention, Protection, and Emergency Contingency Plan ### §509.122 — General Safety ### §509.123 — Handling and Storage of Gases, Anesthetics, and Flammable Liquids ### Subchapter G — Physical Plant and Construction Requirements ### §509.141 — Construction Requirements for a Pre-Existing Facility ### §509.142 — Construction Requirements for an Existing Facility ### §509.143 — Construction Requirements for a New Facility ### §509.144 — Elevators, Escalators, and Conveyors ### §509.145 — Mobile, Transportable, and Relocatable Units ### §509.146 — Preparation, Submittal, Review and Approval of Plans, and Retention of Records ### §509.147 — Construction, Inspection, and Approval of Project ### §509.148 — Tables Table 1 — Ventilation Requirements Table 2 — Filter Efficiencies Table 3 — Medical Gas and Vacuum Systems Table 4 — Interior Finish Requirements Table 5 — Multiple-Bed Configurations ### Joint Commission References ### Environment of Care Joint Commission's Environment of Care framework addresses risks involving: - Safety - Security - Hazardous materials - Fire safety - Medical equipment - Utility systems Environment of Care Resource Center https://www.jointcommission.org/en-us/knowledge-library/environment-of-care ### Life Safety Joint Commission's Ambulatory Life Safety requirements address building and fire-protection systems, egress, fire barriers, fire doors, protection systems, and other building-safety elements. ### Emergency Management ### R3 Report Issue 39 — Emergency Management Standards for Ambulatory Care Programs Provides the framework for emergency management within Joint Commission-accredited ambulatory organizations. ### 2026 Physical Environment Essentials Joint Commission's 2026 physical-environment reference includes dedicated matrices for: - Ambulatory Environment of Care - Emergency Management - Ambulatory Life Safety ### Important Code-Edition Note Texas FSER licensing rules currently contain references to specific legacy editions of NFPA standards. Joint Commission's applicable ambulatory Life Safety requirements may reference different code editions, including NFPA 101-2012 and NFPA 99-2012 depending on accreditation status and applicability. Local municipalities may also enforce adopted building/fire codes that differ from the state healthcare licensing rule. Therefore, project teams should create a Code Applicability Matrix before design or renovation identifying: HHSC Requirement → Local Building Code → Local Fire Code → NFPA Requirement → Joint Commission Requirement → Most Stringent Applicable Requirement Do not assume compliance with one authority automatically establishes compliance with all authorities. Important Disclaimer IMPORTANT DISCLAIMER This document is intended for: Education • Compliance Planning • Facility Management • Quality Improvement • Survey Preparedness It is not: Architectural advice Engineering advice Legal advice An official HHSC interpretation An official Joint Commission interpretation A substitute for current building, fire, NFPA, accessibility, or municipal requirements Each FSER should verify requirements with: Current HHSC Architectural Review requirements Current 26 TAC Chapter 509 Current local building and fire codes Applicable NFPA requirements Current Joint Commission Ambulatory standards Architect of record Professional engineers Local fire marshal Authority Having Jurisdiction Last reviewed: September 2026 Source: Building, Physical Plant & Life Safety Compliance Guide for Texas Freestanding Emergency Rooms and Texas FSER Building / Environment of Care Survey-Readiness Checklist. Supplied by Wellness & Care Group of Texas. Presented as a searchable reference with the original blank fillable PDF checklist; no independent regulatory certification is implied. 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