HFES Approval Process with Tips for Success

1. HFES Approval Process (with Tips for Success) Presented By: Jeffrey L. McManus, P.E. & Pier-George Zanoni, P.E., C.I.H. MDCH � Health Facilities Engineering Section March 10, 2011

2. In the January issue of the Lancet How to pay for health care for the poor Continued concerns regarding cancer Dealing with food borne disease outbreaks Ongoing fight with TB From 1911, not 2011 So the issues we deal with haven�t changed

3. MDCH - HFES Health Facilities Engineering Section Address: 3rd Floor, Lewis Cass Bldg 320 S. Walnut Street Lansing, MI 48913 Phone: 517-241-3408 Fax: 517-241-3423 Web address: michigan.gov/hfes

4. Our office:

5. Our Staff

6. Minimum Design Standards - Health Care Facilities ��2007 Design Standards Available Announcement Letter� ��2007 Minimum Design Standards for Health Care Facilities in Michigan� ��1998 Minimum Design Standards for Health Care Facilities� Interpretive Bulletins ��01-2006 - PTAC Units� ��01-2003 - Minimum Illumination in Cardiac Catheterization Lab and Operating Rooms� ��02-2003 - Clear Floor Area of Cubicles in Patient Holding Areas� ��03-2003 - Clearances at Chair Stations in Patient Holding Areas� ��04-2003 - Locations of Hand Wash Sinks in Isolation Anterooms/Vestibules� ��05-2003 - Emergency Department, Cubicle Sizes� ��06-2003 - Dialysis Service, Cubicle Sizes� ��07-2003 - Electrically Operated Hand Washing Faucets� ��09-2003 - Lamp Protection� ��10-2003 - Patient Window View, Unobstructed� ��11-2003 - Biological Safety Cabinets (Hoods) Used for Cytotoxic Drug Preparation� ��01-2004 - Energy Recovery Devices in HVAC Systems (Heat/Desiccant Wheels, Plate Exchangers)�Minimum Design Standards - Health Care Facilities ��2007 Design Standards Available Announcement Letter� ��2007 Minimum Design Standards for Health Care Facilities in Michigan� ��1998 Minimum Design Standards for Health Care Facilities� Interpretive Bulletins ��01-2006 - PTAC Units� ��01-2003 - Minimum Illumination in Cardiac Catheterization Lab and Operating Rooms� ��02-2003 - Clear Floor Area of Cubicles in Patient Holding Areas� ��03-2003 - Clearances at Chair Stations in Patient Holding Areas� ��04-2003 - Locations of Hand Wash Sinks in Isolation Anterooms/Vestibules� ��05-2003 - Emergency Department, Cubicle Sizes� ��06-2003 - Dialysis Service, Cubicle Sizes� ��07-2003 - Electrically Operated Hand Washing Faucets� ��09-2003 - Lamp Protection� ��10-2003 - Patient Window View, Unobstructed� ��11-2003 - Biological Safety Cabinets (Hoods) Used for Cytotoxic Drug Preparation� ��01-2004 - Energy Recovery Devices in HVAC Systems (Heat/Desiccant Wheels, Plate Exchangers)�

7. What We Do: Our primary duty is to enforce licensing and certification requirements But most of our efforts are spent on plan review & inspection of construction/renovation projects

8. What we regulate: Hospitals (178) Nursing Care Facilities (423) ESRDs � outpatient dialysis units (233) FSOFs � ambulatory surgical facilities (109) Homes For the Aged (191) Hospice (20) Over 1,000 facilities in total

9. Licensing & Certification related work involves: CMS ordered compliant investigations CMS ordered full facility surveys of hospitals, dialysis units, ambulatory surgical units, etc. Inspections of waste water treatment systems Various Consultations Hospital Baseline Surveys (every 6 yrs) Nursing Home Baseline Surveys

10. The Health Facility Engineering Section (HFES) reviews the design and construction of healthcare facilities to ensure that safe, efficient, and effective delivery of healthcare is supported.

11. When is Plan Review Required? A construction permit (based on our plan review) must be obtained prior to initiating a construction project involving new construction, additions, modernizations, or conversions of a healthcare facility involving minimum expenditures as follows: Hospitals $ 1,000,000.00 FSOFs $ 50,000.00 Nursing Homes $ 25,000.00 Homes For the Aged (HFA) All Hospice All End Stage Renal Disease (ESRD) Recommended

13. Information Only Projects Projects that are not required to have plan review may still be submitted for full review with corresponding fees or submitted as �information only� with no fees. Info Only projects are only reviewed after we�ve cleared our desks of all other work and normally construction permits and completion certificates will not be issued Note that opening survey is required for all projects, including Information Only projects

14. When is plan review not required? Routine maintenance, surface treatments work, or equipment replacement normally don�t require plan review or an opening survey. When replacing equipment or building elements that could impact critical patient care functions the project sponsor, designer, or builder should at least call us to discuss the matter and follow-up with written record of the conversation for our files.

15. The Plan Review Overview Designer or project sponsor sends first submittal & project is logged & assigned (projects for a given facility typically go to the last reviewer, but new or unassigned facilities normally go to the least busy reviewer) Plan review comments are issued (typically after about 2 weeks or so in our shop) to the designated contact persons on the plan review application form Subsequent submittal is made that includes responses to plan review comments and revised/completed project documents and are reviewed again (after another roughly 2 weeks in our shop) This is repeated until substantial resolution of all plan review comments has been obtained (we average 3 plan reviews per project) After that a construction permit is issued

16. First Submittal must include:

18. Subsequent Submittals must include: Revised/completed plans and specifications Individualized responses to each of our plan review comments. Suggestions: Respond to the exact plan review issue that complies with all applicable regulations Use the same project name, facility name, and contact person throughout (including with BFS) Don�t piecemeal submittals, send complete packages Don�t send huge e-mail responses or PDFs of full sized drawings (we have file & printing size limits)

19. List of Regulations: State licensing rules for Hospitals, Nursing Homes, FSOF, Hospice, Home For the Aged Federal certification regulations for Hospitals, Nursing Homes, FSOF, ESRD (including interpretations, S&C memos) 1998 or 2007 Minimum Design Standards for Health Care Facilities in Michigan (use one per project, no picking and choosing) Certificate of Need, Michigan Building Codes, Michigan Food Code, DEQ Cross Connection Rules, MiOSHA, etc. Links are available on our website

21. Operational Analysis We will accept narratives that don�t follow our suggested outline Paint in the operational narrative �a day in the life� picture of how the unit(s) will function Include the builder�s contact information if known Be sure to describe how the project will impact existing ancillary facility systems or functions. (Most say they don�t but that is rarely the case.)

22. General, meds, clean questions: How many staff will take report or lounge at once? What are the day/night shift staffing patterns like? How are medications secured in �clean catch all� room (meds, supplies, etc. all in the same room) designs? Does this particular unit need lots of bedding/etc.? What should the par levels be for linens & clean/sterile supplies for each given unit? How often are meds, supplies, linens delivered? Can we reasonably expect the same restocking frequencies well into the future?

23. Soiled utility questions: How would the double basin sinks we always see in soiled utility rooms get (properly) used (if used at all)? Why is a clinical sink shown on a nursing unit where bedpan washers are provided on all patient water closets? How can extra space needed for possible future mandated recycling be accommodated? Where are filled sharps containers held on the floor? Is this unit used to functioning without a trash/soiled linen chute? What about bulk body fluid disposal in surgery?

25. Operational Issues Note that CMS does not allow for more than 30 minutes of unused, storage in corridors. CMS has exceptions for crash carts and isolation carts (but not acceptable in renovation/new construction) How would future methods for charting be properly accommodated? How is routine housekeeping completed (with micro-fiber mopping is there still a need for floor sinks?) Can the housekeeping cart fit in the closet?

26. Operational Analysis - General How would a decentralized nursing unit function on nights and weekends? Does the nurse call system fill the needs of staff during all shifts and comply with code? Where can the crash cart be properly located? Have all the specialized equipment that might be needed been considered (connections and storage)?

27. Operational Analysis - Isolation Isolation confusion continues (higher pressurization requirements, monitoring) For the purpose of the narrative the need for various forms of isolation must be defined. Remember to accommodate the need for handicap access, handwashing at entry, glove/gown/mask storage, workcounters, sealed walls/ceiling, door closers, scrubbable ceilings

28. Unique Dept Characteristics I�ll just cover some high points Our Operational Narrative outline has been re-developed so you don�t have to read or reproduce the entire document each time Once you�ve gotten through part III of our outline you need only to complete the applicable sections of part IV

29. Sterilization/Reprocessing Need detailed step by step description for each process, and each must be fully facilitated Increased number of errors being reported Routine flashing or local reprocessing typically found in sub-sterile should be avoided whenever possible (Flashing is for immediate/emergent use only, locating central sterile immediately adjacent to surgery seems to be the only way of solving the problem of over flashing)

30. Emergency Explain: trauma or not? (this is not a �Level 1� question, it relates to compliance with the requirements of the MDS and the need to support the medicine to be performed) Dependence on lab, respiratory, radiology, and pharmacy for timely responses is critical Various decontamination needs (mostly hygenic, �real� decontamination primarily happens in small numbers before presenting at the hospital)

31. Dialysis/General Stores Often cited in hospitals due to dead leg conditions and lack of proper connections, handwashing, inappropriate testing, no PM Even though typically a contracted service, the hospital is still responsible for how its done Thankfully reprocessing is going away Proper separation and design for breakdown, flow, and clean storage

32. Nursing Units Staffing patterns (including nights and weekends) must be reflected in the nurse call system (don�t let the nurse call system design be an after thought) Don�t forget the requirements for central assisted bathing facilities (1:100 beds) Consider accommodating obese patients (and the staff that must care for them)

39. P.T./Radiology Physical therapy Describe various modes and provide equipment layout Radiology Gowned waiting patients must have separate male/female lockers and waiting areas (not in the corridor) Stretcher bound must have private cubicles/rooms, medical gases, nurse call, and electrical outlets available Address need for prepping and recovering of patients (including those using mobile units)

40. Surgery Use layman�s terms for us Address how cases will be documented Only items that might be used for the case should be in the operating room (exception is built-in storage) Beware of low center of room illumination Detail how anesthesia drugs are secured/administered and equipment is repaired/cleaned

41. Plan Review Tips Helpful: Label room functions on demolition plans Include separate plans showing each phase and a list of what room/function will be moved for each phase State drawing number in plan review responses where the changes can be found

42. Plan Review Tips (con�t) Not Helpful: Stating in the operational narrative that various practices will �continue as is currently done� Referencing facility policy or procedure numbers in the operational narrative Stating �will comply� in plan review responses (especially when the submitted drawings haven�t been accordingly revised or even submitted)

43. Project Submittal Tips (con�t) For repeat customers (typically hospitals) small scale floor plans of the entire facility are useful for orientation and answering all sorts of e-mails/phone calls For the best results in the plan review process, start with formal submission as soon as the sponsor has approved the schematic design Let us do the first plan review so that we�re fully up to speed on the project before asking specific questions or holding a meeting Use room mock ups (the more detailed the better) and have us review them

44. Suggestions For Success  Maintain good communications and an environment of teamwork Utilize exploratory demolition and pre-design air balance testing (required in Minimum Design Standards) Have drawings available during the opening survey Request that the HFES conduct consultative pre-opening surveys on very large projects Maintain good communications and an environment of teamwork among all parties including introduction of the project team to the community and regulatory agencies, keeping all parties involved, keeping the overall project intent in mind, being ready to work together to solve unforeseen problems, and keeping communications open and timely. 8. Utilize exploratory demolition and pre-design air balance testing to avoid unforeseen problems. 9. Have 2 sets of �as-built� drawings made (one for owner�s records and one for use by the maintenance staff). Update if needed, before design of the next project. 10. Use of room mock-ups on larger, more complex projects. 11. Request that the HFES conduct consultative pre-opening surveys on larger projects. Project designers should be encouraged to visit the site a year later to critique for operational issues not addressed within the scope of the work. Maintain good communications and an environment of teamwork among all parties including introduction of the project team to the community and regulatory agencies, keeping all parties involved, keeping the overall project intent in mind, being ready to work together to solve unforeseen problems, and keeping communications open and timely. Utilize exploratory demolition and pre-design air balance testing to avoid unforeseen problems. Have 2 sets of As-built drawings made (one for owner�s records and one for use by the maintenance staff). Update if needed, before design of the next project. Use of room mock-ups on larger, more complex projects. Request that the HFES conduct consultative pre-opening surveys on larger projects. Project designers should be encouraged to visit the site a year later to critique for operational issues not addressed within the scope of the work. Project team needs to set realistic expectations as they relate to schedule and how much function can fit into a given amount of space. Thorough planning and use of healthcare experienced individuals by the owner, designer, and builder which will help avoid/minimize most problems. Projects should fit into an overall master facility plan, yet be flexible enough to accommodate program/function changes and building additions in the years to come. Designs should follow standard practices to avoid obsolescence and not be over programmed by separating different functions into multiple/small spaces, limiting flexibility. The owner�s representative should be pro-active and experienced, be on-board throughout the entire process, and have the time necessary to be involved during key phases of the work. Selection of designers and contractors should be based on performance value, and not cost alone. Maintain good communications and an environment of teamwork among all parties including introduction of the project team to the community and regulatory agencies, keeping all parties involved, keeping the overall project intent in mind, being ready to work together to solve unforeseen problems, and keeping communications open and timely. 8. Utilize exploratory demolition and pre-design air balance testing to avoid unforeseen problems. 9. Have 2 sets of �as-built� drawings made (one for owner�s records and one for use by the maintenance staff). Update if needed, before design of the next project. 10. Use of room mock-ups on larger, more complex projects. 11. Request that the HFES conduct consultative pre-opening surveys on larger projects. Project designers should be encouraged to visit the site a year later to critique for operational issues not addressed within the scope of the work. Maintain good communications and an environment of teamwork among all parties including introduction of the project team to the community and regulatory agencies, keeping all parties involved, keeping the overall project intent in mind, being ready to work together to solve unforeseen problems, and keeping communications open and timely. Utilize exploratory demolition and pre-design air balance testing to avoid unforeseen problems. Have 2 sets of As-built drawings made (one for owner�s records and one for use by the maintenance staff). Update if needed, before design of the next project. Use of room mock-ups on larger, more complex projects. Request that the HFES conduct consultative pre-opening surveys on larger projects. Project designers should be encouraged to visit the site a year later to critique for operational issues not addressed within the scope of the work. Project team needs to set realistic expectations as they relate to schedule and how much function can fit into a given amount of space. Thorough planning and use of healthcare experienced individuals by the owner, designer, and builder which will help avoid/minimize most problems. Projects should fit into an overall master facility plan, yet be flexible enough to accommodate program/function changes and building additions in the years to come. Designs should follow standard practices to avoid obsolescence and not be over programmed by separating different functions into multiple/small spaces, limiting flexibility. The owner�s representative should be pro-active and experienced, be on-board throughout the entire process, and have the time necessary to be involved during key phases of the work. Selection of designers and contractors should be based on performance value, and not cost alone.

45. Most Common Project Pitfalls Unrealistic expectations Inexperienced project sponsors, designers, and/or builders Changes relating to project design Personnel changes during the project Operational issues not fully understood or communicated Plans not submitted for HFES review in a timely fashion Unrealistic expectations, especially in terms of cost, extremely tight schedules, attempts to fit more function into spaces that are too small, failure to provide the necessary lead time for owner purchased items. 2. Inexperience among various participants relative to the specific type of healthcare facility or project, or the various design requirements applicable in Michigan. 3. Changes relating to project design, especially at the last minute that change design intent or scope of project which subsequently cause delay in occupancy. 4. Personnel changes during the project that results in deviations from the original operational intent. 5. Operational issues not fully understood or communicated e.g. designs that do not provide for what is necessary to support good care. 6. Plans not submitted for HFES review in a timely fashion (not submitted until ready for bids). Unrealistic expectations, especially in terms of cost, extremely tight schedules, attempts to fit more function into spaces that are too small, failure to provide the necessary lead time for owner purchased items. 2. Inexperience among various participants relative to the specific type of healthcare facility or project, or the various design requirements applicable in Michigan. 3. Changes relating to project design, especially at the last minute that change design intent or scope of project which subsequently cause delay in occupancy. 4. Personnel changes during the project that results in deviations from the original operational intent. 5. Operational issues not fully understood or communicated e.g. designs that do not provide for what is necessary to support good care. 6. Plans not submitted for HFES review in a timely fashion (not submitted until ready for bids).

46. Most Common Project Pitfalls Incomplete first submittals (wall of shame) Failure to effectively communicate design changes to our office after we�ve reviewed the plans No contingency plans made Projects not patient/resident ready at time of opening survey Incomplete first submittals (without detailed operational narrative, application or fee). 8. Failure to effectively communicate design changes (addenda, bulletins, etc.), often the changes are difficult to understand, don�t get sent out in a timely fashion or at all, and/or are not fully thought out. 9. Contingency plans not made for construction related incidents, unforeseen problems, and emergencies. 10. Storage space is often reduced during the design/construction phase of projects. 11. Documents are misdirected when submitted to the HFES without making consistent use of project number and name. 12. Projects not patient/resident ready at time of opening survey often caused by late delivery of owner furnished items, missing/incomplete/incorrect documentation, lack of code compliant air balance report, outstanding punch list items, and the owner�s rush to occupy. Incomplete first submittals (without detailed operational narrative, application or fee). 8. Failure to effectively communicate design changes (addenda, bulletins, etc.), often the changes are difficult to understand, don�t get sent out in a timely fashion or at all, and/or are not fully thought out. 9. Contingency plans not made for construction related incidents, unforeseen problems, and emergencies. 10. Storage space is often reduced during the design/construction phase of projects. 11. Documents are misdirected when submitted to the HFES without making consistent use of project number and name. 12. Projects not patient/resident ready at time of opening survey often caused by late delivery of owner furnished items, missing/incomplete/incorrect documentation, lack of code compliant air balance report, outstanding punch list items, and the owner�s rush to occupy.

48. Infection Control Risk AssessmentICRA Two application areas: Design (isolation, handwashing, finishes) Protection of patient care functions during the project (phasing, barriers, net air flow, monitoring, enforcement)

49. ICRA - Design Types & number of isolation rooms (airborne infectious, contact, and/or protective) Proper handwashing design (sink design, splash, travel distances) Finishes (countertop materials, scrubbable ceilings) Design to minimize dead leg plumbing lines Your Infection Preventionist should review & weigh in on all these issues!

50. Nice Solid Surface with Integral Bowl butInadequate Sink Dimensions

51. No Clean Supplies in Splash Zone of Sink

52. Recommend Splash Guards

53. Even New Areas That Aren�t Crowded Have Potential Splash Problems

54. This Stand Alone Sink Avoids Issue of Contamination from Splashing

55. ICRA - Protection Phasing (may require one ICRA per phase) Barriers (should include partition design � stop fire, dust, noise, airborne contaminants) Access (mats, define travel paths, hours of operation) Net Air Flow (emergency powered/dual exhaust fans, check where they�re being discharged to) Enforcement (monitoring methods, monitoring frequency, shut-down authority) All this should be discussed as early as possible, certainly before the pre-bid award meeting

56. All Ductwork Protected from Dust

57. Maybe Not All � Be Sure to Check

59. Wet, Dry & Sticky Floor Mats

60. Project Phasing Some compromise or reduction of capacity or function may be tolerable, but the essential elements of care must be supported throughout the work The acceptable level of capacity or function must be clearly communicated and agreed to by all involved parties (including us) during the planning stage of the project Prior to patient use, each phase is required to have an opening survey with full documentation of code compliance

61. All required patient/resident functions shall be protected from all demolition, construction, and renovation activities during each phase of the project. This includes control of dust, excessive noise/vibration, and leaks. All necessary means of egress and handicap access routes must be maintained throughout the work.

62. An Example of Adequate Separation of Construction Area/ Zone * Fire marshal made hosp install gyp board over window � since an addition was going up right outside the window � As a result, this hosp was no longer able to use this room for a licensed inpatient bed. * One hosp had wooden scaffold up 6 stories to work on gable roof � some welding caught the wood scaffold on fire right along side of hosp building � smoke from fire entered through hospital windows and filled top floor with heavy smoke in only a few minutes ! Note: Stairwell smoke evacuation system worked well.* Fire marshal made hosp install gyp board over window � since an addition was going up right outside the window � As a result, this hosp was no longer able to use this room for a licensed inpatient bed. * One hosp had wooden scaffold up 6 stories to work on gable roof � some welding caught the wood scaffold on fire right along side of hosp building � smoke from fire entered through hospital windows and filled top floor with heavy smoke in only a few minutes ! Note: Stairwell smoke evacuation system worked well.

63. Adequate Separation of Construction Area/ Zone * Fire marshal made hosp install gyp board over window � since an addition was going up right outside the window � As a result, this hosp was no longer able to use this room for a licensed inpatient bed. * One hosp had wooden scaffold up 6 stories to work on gable roof � some welding caught the wood scaffold on fire right along side of hosp building � smoke from fire entered through hospital windows and filled top floor with heavy smoke in only a few minutes ! Note: Stairwell smoke evacuation system worked well.* Fire marshal made hosp install gyp board over window � since an addition was going up right outside the window � As a result, this hosp was no longer able to use this room for a licensed inpatient bed. * One hosp had wooden scaffold up 6 stories to work on gable roof � some welding caught the wood scaffold on fire right along side of hosp building � smoke from fire entered through hospital windows and filled top floor with heavy smoke in only a few minutes ! Note: Stairwell smoke evacuation system worked well.

64. Few compromises of mechanical or electrical systems can be tolerated if the affected care functions are to be maintained. (Note this also applies to each phase of a project.) Scheduling for off-hours work or providing temporary replacement equipment offer possible solutions. A written protocol for notification and definition of the extent for partial or full interruptions should be in place and agreed to by all stakeholders prior to demolition/renovation work. Mechanical/Electrical Systems:

65. ICRA � �The Matrix�

66. ICRA � �The Matrix� Define the scope and extent of construction activities Determine the susceptibility of potentially affected patients/residents to infection throughout the building (above, below, all sides) The Matrix is a good tool but must reflect a true assessment and not a rubber stamped piece of paper.

67. ICRA � �The Matrix� Develop the needed measures to protect care functions from construction related contamination and disease transmission Remember that �The Matrix� is for surrounding areas, not what you�re building

68. Water Intrusion During Construction � A BIG Problem

69. Opening Surveys

70. Opening Survey Overview The purpose of the opening survey is to allow HFES to confirm that the project (or each phase of the project) is fully ready to support patient/resident care (not just completion of the contract), therefore it should be scheduled accordingly A field report will be provided from the opening survey that identifies all items that must be completed and which need to be resolved prior to occupancy approval being issued

71. Schedule 2 � 4 weeks ahead (including for each phase) All documentation should be submitted 1 week prior so we can review beforehand and to allow for owner training/equipment installations/commissioning Should be patient/resident ready (furniture OK, but don�t stock shelves) Upon resolution of any critical items we will approve for patient/resident use (except for new facilities) Opening Survey:

72. The Opening Survey Process For New Facilities All of the previous, plus� The project sponsor should contact the appropriate licensing agency 60 � 90 days prior to anticipated patient/resident use Upon successful opening survey and resolution of ALL comments from our opening survey we can only recommend occupancy to the appropriate licensing agency Approval to begin patient/resident use will come from the licensing agency, not our office

73. Which Projects Get Opening Surveys?

74. Opening Survey Related Problems Inadequate time given at the end of the project for commissioning, air balance, installation of owner supplied items Failure to submit proper/complete documentation prior to opening survey Failure to comply with various approval stipulations as stated in HFES construction permits or in some cases failure to submit for plan review at all Inadequate time given at the end of the project for commissioning, air balance, installation of owner supplied items, which delays the planned move in date Failure to submit proper/complete documentation prior to opening survey (this should be reviewed by owner and designer � e.g. if air balance report or med gas report identify problems, they should be corrected and/or addressed � don�t just pass along non-compliance documentation to HFES) Failure to comply with various approval stipulations as stated in HFES construction permits or in some cases failure to submit for plan review at all (designers not following up or involved at the end of the project) Inadequate time given at the end of the project for commissioning, air balance, installation of owner supplied items, which delays the planned move in date Failure to submit proper/complete documentation prior to opening survey (this should be reviewed by owner and designer � e.g. if air balance report or med gas report identify problems, they should be corrected and/or addressed � don�t just pass along non-compliance documentation to HFES) Failure to comply with various approval stipulations as stated in HFES construction permits or in some cases failure to submit for plan review at all (designers not following up or involved at the end of the project)

75. Opening Survey Related Problems Failure to comply with Michigan Barrier Free Standards Failure to comply with illumination standards Air balance report not reviewed by the designer Air balance report does not indicate compliance with minimum standards (values must be within 10% of approved design, if not a plan of correction must be submitted) Failure to comply with Michigan Barrier Free Standards (construction not within acceptable tolerances, vendor supplied items not compliant, excessive shower stall threshold heights, etc.) Failure to comply with illumination standards (suggest turning on all lights in project area 30 minutes prior to survey so surveyor does not have to wait for lights to brighten) Air balance report does not indicate compliance with minimum standards (values must be within 10% of approved design. Also, it may be OK when report shows values less than design if still above minimum standards) Failure to comply with Michigan Barrier Free Standards (construction not within acceptable tolerances, vendor supplied items not compliant, excessive shower stall threshold heights, etc.) Failure to comply with illumination standards (suggest turning on all lights in project area 30 minutes prior to survey so surveyor does not have to wait for lights to brighten) Air balance report does not indicate compliance with minimum standards (values must be within 10% of approved design. Also, it may be OK when report shows values less than design if still above minimum standards)

76. Opening Survey Related Problems Architectural: Caulking incomplete Signs not mounted for room designations, handicapped facilities, etc. Single use towel and soap dispensers not installed adjacent to handwashing fixtures 1. Lack of awareness of a series of additional requirements beyond contractor�s substantial completion that are required prior to patient/resident care related use. 2. Inadequate time given at the end of the project for commissioning, air balance, installation of owner supplied items, which delays the planned move in date 3. Failure to submit proper/complete documentation prior to opening survey (this should be reviewed by owner and designer) 4. Failure to comply with various approval stipulations as stated in HFES construction permits or in some cases failure to submit for plan review at all 5. Failure to comply with accessibility standards (construction not within acceptable tolerances, vendor supplied items not compliant, excessive shower stall threshold heights, etc.) 6. Having to re-schedule or repeat the opening survey resulting in occupancy delays 7. Failure to comply with illumination standards 8. Air balance report does not indicate compliance with minimum standards or include a POC (specifying steps/schedule)1. Lack of awareness of a series of additional requirements beyond contractor�s substantial completion that are required prior to patient/resident care related use. 2. Inadequate time given at the end of the project for commissioning, air balance, installation of owner supplied items, which delays the planned move in date 3. Failure to submit proper/complete documentation prior to opening survey (this should be reviewed by owner and designer) 4. Failure to comply with various approval stipulations as stated in HFES construction permits or in some cases failure to submit for plan review at all 5. Failure to comply with accessibility standards (construction not within acceptable tolerances, vendor supplied items not compliant, excessive shower stall threshold heights, etc.) 6. Having to re-schedule or repeat the opening survey resulting in occupancy delays 7. Failure to comply with illumination standards 8. Air balance report does not indicate compliance with minimum standards or include a POC (specifying steps/schedule)

77. Must have soffit or sloped top 4/12 Patient Care Area surfaces >68� high

83. Proper Signage Please

84. Opening Survey related problems

85. Opening Survey related problems HVAC: Air intakes not properly separated from sources of contamination (e.g. isolation or diesel exhaust fans by at least 25 feet, toilet or natural gas fired equipment exhaust by at least 10 feet)

86. Air Intake Separation Distance?

87. HVAC: The 0.01 inch w.g. pressurization must be provided for critical environment rooms

89. Opening Survey related problems Plumbing: Required backflow assemblies missing, wrong type, or not certified Medical gas valves/alarms not properly labeled Hot water temperatures at patient fixtures not adjusted between 105 F to 120 F (a common problem for HW sinks with thermostatic mixing valves) Water pressure and temperature not adjusted to meet manufacturers criteria on dishwashers, sterilizers, etc. Mechanical (con�t): Hot water temperatures at patient fixtures not adjusted between 105 degrees to 120 degrees Fahrenheit, especially at sinks with thermal mixing valves. Mechanical (con�t): Hot water temperatures at patient fixtures not adjusted between 105 degrees to 120 degrees Fahrenheit, especially at sinks with thermal mixing valves.

90. SAFE PLUMBING � NOT!

92. RPZ Usually Required for Specialty Fixtures

93. Certificate of Acceptability

94. RPZ Needed for Dialysis Water Box(e.g. ICU patient room)

95. Separate Water Supply for Automated Chemical Dispensing

96. Or provideWasting Teeso there is NO shutoff downstream of atmospheric vacuum breaker

97. Hand Wash Sinks Proper Temperature

98. This hand wash sink needs wrist blades or other hands free operationThis hand wash sink needs wrist blades or other hands free operation

100. Opening Survey related problems Electrical: Light levels do not meet minimum illumination requirements Emergency circuits not properly designated The nurse call system not operative, not on emergency power system, or numbering doesn�t match room signage Safety covers/lenses not installed over fluorescent or incandescent bulbs which may be contacted, causing breakage Electrical: 28. Light fixtures obstructed by (moving) shelving, ventilation ducts, or partitions. 29. Safety covers not installed over fluorescent or incandescent bulbs which may be contacted, causing breakage. Electrical: 28. Light fixtures obstructed by (moving) shelving, ventilation ducts, or partitions. 29. Safety covers not installed over fluorescent or incandescent bulbs which may be contacted, causing breakage.

102. ASC Separate Waiting Rm Rqmnt

103. ASC - OK until MOB was added to Share Rotunda Waiting Area

105. ASC � 1 hr wall to be added down �middle� of Rotunda

107. HFESFrequently AskedQuestions

108. FAQ: OK to combine medication & clean supply rooms? Routine access to medication rooms is limited to R.N.�s or pharmacy staff. So unless medications, syringes, and needles are secured in an automated drug dispensing units the same room cannot served both functions.

109. FAQs: Combined nourishment & clean supply rooms OK? Answer: No - if patients/visitors have access to clean supplies or if the room would be used to hold soiled dietary trays. But if separation is provided between the clean and nourishment functions and separate workcounter/sink are provided for each function (not required where clean work/assembly will not be done) and only staff can access the clean supplies, then yes.

110. FAQs: Are ante rooms required for isolation rooms? No, but the facilities that support needed functions of an ante-room are required at the entry to the room (handwashing, clean storage, trash/soiled linen holding, workcounter, and clean air) plus the ante-room provides a more effective airlock.

111. FAQs: Can Special care newborns (growers) be housed with neonates? No, for the following reasons: Special care nurseries serve only those born in the (larger) obstetrical departments, which is required to be segregated from the rest of the hospital due to infection concerns; NICUs can admit from outside the hospital could lead to infection of the �known� special care newborn population (born in the hospital); NICU bassinets are counted as licensed beds while special care are not; Discharge from NICU can only legitimately go to another licensed bed (pediatric or PICU) or to home.

112. FAQs: Can doors from a large room swing into the corridor? Not if the doors swing into the normal path of corridor travel which would present a routine hazard. The solution would be to provide an alcove(s) to recess the doors while still allowing the doors to open in the direction of egress and provide latch side (wheelchair user) access in accordance with the Michigan Building Code.

113. FAQs: Can clean/soiled utility room doors be held open? No, even if the hold open device is approved by the State Fire Marshal. These rooms are required in Table 2A to have positive or negative pressure which would be defeated when the room door is held open.

115. FAQs: Can ventilation rates be reduced for unoccupied areas? Footnote 4 of Table 2A of the 1998/2007 Minimum Design Standards for Health Care Facilities in Michigan allows for this as long as the specified net air flows to adjacent areas are maintained and the required ventilation to provide comfort and comply with the assurance that the minimum specified air changes per hour reestablished before the space is used again.

116. BONUS PICTURES FROM ROUTINE SURVEYS

117. Miscellaneous Construction RelatedProblems  Start this discussion out with a bangStart this discussion out with a bang

120. Dialysis Water Boxes Not only Bad but also Ugly!Not only Bad but also Ugly!

121. Common BF Shower problem BF transfer showers require 12 inches of clearance beyond stall opposite controls (note bench).

122. Design for Plenty of StorageDo Not Use Shower areas for Storage

123. Don�t Do This � Not CleanableProhibited in Section 7.28.A26

124. Be Consistent re Med Gas Valve Labeling Use room identifiers that match room signage or commonly understood/known terminologyUse room identifiers that match room signage or commonly understood/known terminology

125. Section 7.10.B15 requires Housekeeping facilities convenientlyprovided for separate MRI nonmagnetic cleaning equipment

127. How Can We Design to Avoid Corridor Clutter?

128. More Alcoves Please

131. Exiting Problems: MRI Trailer

132. No Floor Tracks Please

135. New Trend for Natural Daylight in ORs?

136. THE END