construction section update - wild apricot · 2015-03-19 · 3/17/2015 1 construction section...
TRANSCRIPT
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Construction Section Update
NCHEA 2015 Spring SeminarMarch 13, 2015
Today’s Presenters
Marjorie AckerAssistant Chief
Jeff HarmsEngineering Supervisor
Additional DHSR Staff is present in the audience.
*Please hold your questions until the end of the session.*
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Hidden Slide ‐MA• Who we are
• Mission
• Construction Section Organization
• Agenda• Presenters / topics• Additional staff present• Hold questions to the end
• Web address for DHSR• Rules for Licensure• Construction Section
• Web address for Construction Section• Construction Project Information• Submittal and Review Guide• Color Code Standard• Fees• When is a review required• To come: Plan Submittal Review Guide
• Help Desk
North Carolina
Department of Health and
Human Services (DHHS)
Division of Health Service Regulation (DHSR)
Construction Section
Steven C. Lewis Section Chief, Construction Section
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Mission
To ensure that the construction and operation of buildings regulated
by the Division provide a safe, healthy and suitable environment for residents,
patients, and inmates using those facilities.
Construction SectionOrganization
State LicensurePlan Review
and Inspection
State LicensureBiennial Institutional
Survey Group
Federal LifeSafety Survey Group
Jails andDetention Group
State LicensureBiennial Residential
Survey Group
Assistant Section ChiefMarjorie Acker
Section ChiefSteven Lewis
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http://www.ncdhhs.gov/dhsr/
Rules and Regulations
Construction Section
http://www.ncdhhs.gov/dhsr/
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http://www.ncdhhs.gov/dhsr/
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http://www.ncdhhs.gov/dhsr/const/project.html
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http://www.ncdhhs.gov/dhsr/const/project.html
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http://www.ncdhhs.gov/dhsr/const/project.html
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http://www.ncdhhs.gov/dhsr/const/project.html
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Help Desk
For projects under review or inspection
Contact the Architect or Engineer assigned to the project. Ex: HL-9999-MLA/AJH
Contact the Help Desk at 919-855-3893.
For all other questions
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Introduction of DHSR Staff
C O N S T R U C T I O N S E C T I O N
NCHEA Questions
DHSR RESPONSES TO NCHEA QUESTIONSJeff Harms, Engineering Supervisor
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Q: Mixed Occupancy ‐ Can a Separate Outpatient Clinic Be CreatedWithin a Hospital?
OutpatientClinic
Hospital
NFPA 101 Ch. 18Healthcare
2 Hr. Fire Barrier
A: Yes, If Separated by 2 Hr. Const. and Not More Than 3 Inpatients,Incapable of Self Preservation, Are Simultaneously Served.
NOTE: **DHSR Requires That The Total Number of Simultaneously Treated Inpatients Must Include Those Receiving Treatment Plus Any Waiting For Or Recovering From the Treatment.**
If more than 3 inpatientsIncapable of self‐preservation are served, Healthcare Occupancy requirements must be met.
NFPA 101 [2000] 18.1.2.2NFPA 101 [2012] 18.1.3.4.1
What Occupancy Type Would the Outpatient Clinic Be?
• If Providing Service to Outpatients, No More Than 3 of Whom Are Incapable of Self‐Preservation, NFPA 101 Ch. 38 – Business Would Apply.
• If Providing Service Simultaneously to 4 or More Outpatients Who Are Incapable of Self‐Preservation, NFPA 101 Ch. 20 – Ambulatory Healthcare Would Apply.
• If Providing Service to More Than 3 Inpatients Incapable of Self‐Preservation, NFPA 101 Ch. 18 Healthcare Would Apply.
NFPA 101 [2000 & 2012] Ch. 38 and/or Ch. 20Plus
Relevant sections of NCBC Incl. 422 Ambulatory Healthcare (sprinklers required)
Construction type and means of egress through non‐healthcare spaces addressed elsewhere in Ch. 18
OutpatientClinic
Hospital
NFPA 101 Ch. 18Healthcare
2 Hr. Fire Barrier
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What Hospital Licensure Rules Would Apply to the Outpatient Clinic?
• If the clinic is operated under the Hospital’s Medicare Provider Number, the services that are to be rendered would determine which HL rules would apply.
• This is true for outpatient clinics located in the hospital or stand alone licensed facilities owned and operated by the hospital.
• 10A NCAC Chapter 13 Subchapter B
EXAMPLES FOLLOW…
Ex. #1 ‐ The Hospital Based Outpatient Clinic Contains8 Oncology Infusion Stations.
Typical Hospital Rule Requirements That Would Apply:.6223 Details and Finishes.6225 (5) Ventilation for Treatment Room – 6 ACH.6225 (7) Filter Efficiencies for Treatment Areas – 25/90%
.6226 (g) Table 4 Med Gas for Exam and Treatment – 1/O, 1/V
.6227 (g) (2) Nurse Call at Patient Use Toilet Sink Per Acute Care Licensure Clinical RequirementsAt Least 90 Min. Emergency Lighting if B‐Occupancy
Additional Functional Issues Must Be Addressed Case‐By‐Case Based On The Function of the Outpatient Clinic and Policies and Procedures
• In This Clinic the Infusion Treatments Do Not Render the Patients Incapable of Self‐Preservation
NFPA 101 [2000 & 2012] Ch.38 Business if No More Than 3 Rendered Incapable.Ch. 20 Ambulatory Healthcare if 4 or More Rendered Incapable…Plus…Relevant Sections of NCBC
HospitalNFPA 101 Ch. 18
Healthcare
2 Hr. Fire Barrier
Outpatient Infusion Clinic
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FYI ‐ Large Diagnostic Equipment and Self ‐Evacuation• It is DHSR’s position that certain large diagnostic and treatment equipment can render patients incapable of self‐evacuation (self‐preservation), even in an outpatient facility.
• MRI and CT may require physical restraint of the patient, contrast via injector, etc. to produce a successful scan.
• Linac and HDR (Brachytherapy) treatments are given in procedure rooms that patients must be assisted by staff in order to leave.
Sedation – Information Is Needed From Facility• Depending on when minimal, moderate, or deep sedation is administered, as defined by NFPA 99 [2012] Section 3.3.6.3, for a scan or procedure, a patient otherwise ambulatory, is rendered incapable of self‐preservation.
• If sedation is administered before the scan, and wears off afterwards, the result may be at least three patients unable to self‐evacuate in the outpatient facility at the same time. Other combinations may occur.
• This may affect the Occupancy Type.
**Since new techniques and equipment continually evolve, owners must evaluate their procedures and clinical practices periodically to see if the categories of patient self‐preservation have changed for their facility.**
Pre – Sedation Given? Procedure – Sedation or Restraint? Post – Sedation Wearing Off?
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What Is theOccupancyType of the Clinic?
2 Hr. Fire Barrier
Ex. #2 ‐ This Hospital Based Outpatient ClinicContains 1 MRI and 4 Exam/Consult Rooms.
• No Sedation Will Be Used Prior to the Scan.
Could be Business if no more than 3 unable to self evacuate…. Might be Ambulatory Health if the 3 hospital inpatients and 1 other patient (all unable to self‐preserve) are treated simultaneously.
OutpatientMRI Clinic
MRIExam
Exam
See next slide for applicable HL Rules…
Hospital
What HL Rules Apply to the MRI Clinic?• 10 NCAC 13B .6219 (4) MRI Imaging Services(a) Procedure and Support room for equipment(b) Control Room(c) Patient Holding Area(d) Patient toilet within 50 ft. of Procedure Rm. (e) At Least 1 Emergency Light(f) Hand Washing Sink Adjacent to MRI Rm.
• .6223 Details and Finishes
• .6225 (5) Table 1 ventilation for X‐Ray (Diagnostic and Treatment) 6 ACH (same in ASHRAE 170).
• .6225 Table 2 Filter Efficiencies 25/90% (All areas for inpatient care, treatment, and diagnosis…)Note – ASHRAE 170 Table 6‐1 also says MERV 7/14 for ambulatory diagnostic and therapeutic rad.
• .6226 (c)(1 and 2) Hands free trim on sinks and faucet 5” above flood level rim.
• .6226 (g) Table 4 Med Gas Exam and Treatment 1‐O/1‐V
• .6227 (g)(2)Nurse Call at patient use toilet
• Good Clinical Practice will get a sink in the exam rooms
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• Whether in the hospital or remote from the main facility, for hospital licensed outpatient facilities, the applicable portions of hospital rules are required to be observed for the clinical services rendered.
What Rules Apply If The Clinic Is Not In The Hospital?
Johns HopkinsOutpatient Clinic
John’s Clinic
When associated with the name of a trusted hospital, the users expect a certain level of care.
BetterCall Saul?
Feeling MuchBetterNow
What If An Outpatient Clinic is Further Than 30’ From The Hospital?• Does it qualify as a House Bill 1297 project and exempt from review by DHSR?
• In general, if the Hospital owned outpatient facility is located further than 30’ away and does not treat more than 3 outpatients incapable of self preservation, does not provide any surgical procedure, and is classified as a Business Occupancy under NFPA 101 [2000], it will not be reviewed or licensed by DHSR.
• It shall be certified per CMS requirements (if B‐Occupancy Per 101) and Medicare/Medicaid reimbursement is provided.
• If the owner wishes to design the occupancy to Ambulatory Healthcare or Healthcare for future growth, DHSR would review upon request. This would be treated as a consultation and not licensed. To be licensed at a future time, bldg. would still have to meet the current Licensure and NCBC req’mts. then in effect.
**The most important issue with project submittals is receiving a thorough scope description or narrative so DHSR will know whether to review or what occupancy to review it as.**
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Project Description
Please include a complete narrative of the project including any phases so we will know:
• Whether to Review• What Occupancy to Review It Under• Which Reviewers to Assign it To.
Submit This Project to DHSR or Not?
• Greater than 30’ of separation and has at least 4 outpatients rendered incapable of self‐preservation. Thus, ambulatory healthcare.
• Does notmeet the B Occupancy exemption requirement of NFPA 101 [2000] and House Bill 1297 so must be submitted for review.
• Hospital rules would apply for the services rendered in the outpatient facility.
Suite #1 Suite #2
MRI CT HBOTHBOT
Hospital receives Medicare Facility Fee for Suites #1 and 2. [It is CMS certified but not necessarily licensed.]
Further than 30’ from hospital.
Hospital
Outpatient Facility Ownedand Operated by Hospital
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Submit This Project to DHSR or Not?
• Greater than 30’ of separation.
• If the hospital owned section does not treat more than 3 outpatients incapable of self‐preservation, tenant #1 could be a business occupancy and not be reviewed by DHSR.
• A 1‐hr tenant separation must be maintained between tenant #1 and 2.
• The hospital may wish to design the space for tenant #1 as ambulatory healthcare (or healthcare) for maximum future flexibility. Then DHSR would review if requested.
• If hospital acquires tenant #2 then overall provides service to 4 or more outpatients incapable of self‐preservation, the facility would need to meet ambulatory healthcare requirements. The 1‐hr fire barrier may no longer be required.
Tenant #1 Tenant #2
8 outpatient oncology infusion stations
HBOTHBOTFurther than 30’ from hospital.
Hospital
Owned and operated by hospital.
Operated by private practitioner
Not licensed under hospital
1‐Hr. Tenant Separation
What Types of Projects Must Be Submitted to DHSR for Review?• The real answer is projects are case‐by‐case and you should contact the office (919 855‐3893) to discuss every project in a heath care facility that is not obvious to submit.
• Paint and paper finish projects? Not usually unless patients need to be moved about and interim life safety measures need to be put in place.
• Routine maintenance jobs do not need to become submitted projects unless they result in changing a piece of equipment or a required life safety system is affected.
• True “like‐for‐like” replacements – maybe. HOWEVER, must be exact wire‐for‐wire replacements of other than required life safety equipment.
• Replacing parts in med gas outlets on the wall that do not require a third party verifier –likely not. Just don’t stretch it.
• Replacing a nurse call system or fire alarm, even if the same type, must be submitted.
• DHSR will work with the owner when emergency conditions occur.
• Bottom Line : Projects are case‐by‐case. Call to discuss before deciding not to submit.
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Has DHSR Adopted FGI For Use As Part of Hospital Licensure Rules?
• The State of North Carolina has not adopted any edition of FGI.
• We use FGI as a reference for design and construction practices of healthcare facilities (one of many references DHSR uses).
• In the future, North Carolina may adopt FGI standards, but all stakeholders will be involved in deciding whether to adopt the FGI or revise the current licensure rules.
How Does DHSR Handle Intermediate Care Projects?
• Since 10 NCAC 13B Licensure Rules does not have a distinct category for Intermediate Care, owners must define what is to be done in this space to see if it is equivalent to current licensure requirements for Special Care.
• Any electrical, med gas, or mechanical requirements would be based on an explanation of what level of care is clinically being provided.
Step Down from Critical Care
To Intermediate Care
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Why Isolated Power?• HL Licensure Rule .6227 (6) requires inhalation anesthetizing locations and other areas where patients are intended to have a direct electrical path to the heart muscle shall be equipped with an isolated power system…
• This has been in the licensure rules since 1976 when described as a monitored electrical source essential to patient safety….(T10 03C .1705).
• OR’s, Trauma Rooms, Recovery, PACU, ICU, CCU, NICU, and Cath Labs, among other areas, will care for electrically sensitive patients with electrical apparatus or conductive pathways to the heart.
• It has been DHSR’s long standing expectation to have isolated power in these areas.
• NC Elect. Code 517.80 commentary – “One of the major objectives of Article 517 is to minimize patients’ exposure to any level of current that could compromise their well being.”
• Isolated power systems provide detection of current leakage in circuit conductors, early warning for accumulating hazard current without tripping circuits to critical equipment, reduction of shock hazard to patients, etc.
Why Isolated Power…continued…• While the hospital declares clinical areas where electrically sensitive patients will be located, taking the stance: “We will not have such patients” or “We will transport those patients to another facility” is not viable.
• All OR’s must have isolated power. While there is no formula or ratio, it is best to have some PACU bays and certainly ICU equipped to handle patients with pacing leads or other electrically conductive paths to the heart in order to maintain the best patient care safety.
• NEC Article 210.8 commentary – “No statistics are available for the actual number of lives saved or injuries prevented by GFCI devices, but most safety experts agree…a substantial number have been saved”. The same deduction could be made for isolated power.
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Relative Humidity
• On Feb. 20, 2015 CMS issued a Memorandum describing the findings of the AAMI (Assoc. for Advancement of Medical Instrumentation) that some sterile supplies and electro‐medical equip used in OR’s may be adversely affected by RH lower than 30%.
• Although the LSC Categorical Waiver for hospitals to use OR relative humidity as low as 20% can be issued, hospitals are expected to ensure equipment and supply manufacturers’ humidity requirements are met.
• However, at this time, DHSR has put granting RH equivalency requests on hold. Please contact Construction Section Chief, Steve Lewis for any equivalency requests in the immediate future.
What Storage Rooms Have To Be Rated?• NCBC Table 508.2.5 requires Group I‐2 Storage Rooms larger than 100 sq. ft. to be 1‐hr rated with no reductions allowed. Clarification of the definition of “storage” is not given however 311.3 Low Hazard Storage, describes noncombustible material and products that have a negligible amount of plastic trim.
• NFPA 101 [2000] describes low hazard contents as those of such low combustibility that self propagating fire cannot occur (6.2.2.2). Per 101, most occupancies are considered to have ordinary hazard contents.
• NFPA 101 Table 18.3.2.1 calls for rooms > 100 sq. ft. storing combustible material to be 1‐hr separated (sprinklering is required for Ch. 18 occupancies).
• If the room is designated as “Storage” and contains combustible materials as deemed by the AHJ, it must meet the requirements of Table 18.3.2.1 as well as NCBC 508.2.5.
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Drainage Piping and Drain Pans – Options?10A NCAC 13B .6226 (f)(2)
Drainage piping shall be installed to avoid installations in the ceiling directly over operating and delivery rooms, nurseries, food preparation centers, food serving facilities, food storage areas, central services, electronic data processing areas, electrical closets, and other sensitive areas. Where overhead drain piping in these areas is unavoidable, special provisions such as auxiliary drain pans shall be installed to protect the space below from leakage.
• Operating and Procedure Tables• Patient Bed and Bassinet Locations• Pharmacy Prep and Mixing Areas
• Food Prep, Serving and Storage Areas• Electrical Gear• Sterile Supplies
*Don’t Forget About NFPA 99 Ch. 7 TR’s and TER’s.*
• Drain Pans May Not be The Sole Answer• Submit Your Proposal – We Will Consider Your Possibility
DHSR Equivalency for Generator 10+ Sec. Start?
• It is code that calls for emergency power and lighting to be restored within 10 seconds, not 10 NCAC 13B Licensure Rules. DHSR cannot grant an equivalency for code requirements.
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Flexible Medical Gas Hoses Above Ceiling
2/17/2015
Subject: Flexible Medical Gas Hose Concealed Above Ceiling
Question for NFPA: Articulated booms are frequently found in hospital OR's at the operating table. These manufactured assemblies typically contain electrical receptacles and/or medical gas outlets/inlets. The flexible gas tubing runs from within the boom to just above the ceiling where flexible connection is made to a brazed hard‐pipe manifold. Per 5.1.10.11.6.1, if a ceiling access door is provided in the OR hard ceiling near the manifold/flex connection which will allow inspection and maintenance above the ceiling, is the intent of the code met?
CEILING
Med‐Gas Hose Above Ceiling‐NFPA Response
Mr. Harms,
Such an arrangement would not meet the requirement of Section 5.1.10.11.6.1 of NFPA 99 (2012 edition). The requirement states that hose and flexible connectors cannot penetrate walls, floors, ceilings, or partitions. Simply providing access at the point where penetration occurs does not change the fact that the requirement has not been met.
Jonathan Hart, P.E.
Fire Protection Engineer
NFPA
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Use Of Med Air For Endo Scope Blow Down?…No…
• NFPA 99 [2012] 5.1.3.6.2 Uses of Medical AirMedical air sources…shall be used only for air in the application of human respiration and calibration of medical devices for respiratory application.
• CommentaryThe…medical air compressor is not to be used…for other air driven patient therapy devices such as air cushion mattresses, for cleaning or blowing down scopes either before or after use of sterilizers, for laboratory or pneumatic temperature controllers, or for other non patient functions.
• A.5.1.3.6.2It is the intent that the medical air piping distribution system support only the intended need for breathable air for such items as intermittent positive pressure breathing and long‐term respiratory assistance needs, anesthesia machines, and so forth. The system is not intended to be used to provide engineering, maintenance, and equipment needs for general hospital support use.
Med Gas Requirements For Triage
• 10 NCAC 13B .6226 (g) Table 4 Minimum Med Gas Station Outlets:
• Exam and Treatment Rooms….1‐O/1‐V
• Emergency Room….1‐O/1‐V/1‐A
• In Order To Have Uniformity of Gases Within the ED Unit, DHSR requires the same number of outlets/inlets as in an ED Exam and Treatment Room….1‐O/1‐V/1‐A.
• When the ED becomes overloaded, Triage becomes used as an Exam/Treatment Room.
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Questions?Suggestions?
Steven C. Lewis
Section Chief, Construction Section
919‐855‐3893