Idaho Admin. Code r. 16.03.14.378

Current through September 2, 2024

Section 16.03.14.378 - FREESTANDING EMERGENCY DEPARTMENT (FSED): PLANT, EQUIPMENT AND PHYSICAL ENVIRONMENT

01.Building Construction Standards. General requirements for construction of an FSED are as follows:

a. All new construction of an FSED must comply with any and all state and local building, fire, electrical, plumbing, zoning, heating, or other applicable codes adopted by the jurisdiction in which the FSED is located and that are in effect when construction is begun. Where a conflict in code requirements occurs, both requirements must be met, or at the discretion of the licensing agency, the most restrictive will apply.

b. The FSED must be structurally sound and must be maintained and equipped to assure the safety of patients, employees, and the public.

c. On the premise of an FSED where natural or man-made hazards are present, suitable fences, guards, and railings must be provided to protect patients, employees, and the public.

d. Minimum construction standards must be in accordance with the following standards incorporated by reference:

i. The 2006 Edition of National Fire Protection Association (NFPA) 101, the Life Safety Code, Chapter 18, New Health Care Occupancies, and the applicable provisions of chapters 1 through 11, as published by the NFPA. The NFPA documents referenced in these regulations are available from the National Fire Protection Association, 11 Tracy Drive, Avon, MA 02322-9908; 1-800-344-3555; and online at http://www.nfpa.org; and

ii. The 2006 Edition of the American Institute of Architects (AIA) Guidelines for Design and Construction of Health Care Facilities applicable to a Freestanding Emergency Department and General Hospital. The AI A documents referenced in these regulations are available from the American Institute of Architects, 1735 New York Avenue N.W., Washington, D.C. 20006; 1-800-242-3837; and online at http://www.aia.org.

e. The FSED must provide a Type 1 Essential Electrical System (generator and transfer switch) in accordance with NFPA 99, 2005 Edition.

f. The FSED must provide a Level 1 Medical Gas and Vacuum System (piped gas system) in accordance with NFPA 99, 2005 Edition.

02.Plans, Specifications, and Inspections. Plans, specifications, and inspections of any new facility construction or any addition, conversion, or remodeling of an existing structure are governed by the following:

a. Plans for new construction, additions, conversions, and remodels must be prepared by or executed under the supervision of an architect or engineer licensed in the state of Idaho. This requirement may be waived by the Department in connection with minor alterations provided the alterations comply with all construction requirements.

b. Prior to commencing work pertaining to construction of a new building, any addition or structural changes to existing facilities, or conversion of existing buildings to be used as an FSED, plans and specifications must be submitted to, and approved by, the Department.

c. Preliminary plans must be submitted and must include at least the following:

i. A functional program description as defined in 2006 Edition of AIA Guidelines for Design and Construction of Health Care Facilities;

ii. The assignment of all spaces, size of areas and rooms, and indicate in dashed outline the fixed equipment;

iii. Drawings of each floor including, but not limited to, the basement, approach or site plan, roads, parking areas, and sidewalks;

iv. The total floor area and number of beds;

v. Outline specifications describing the general construction, including interior finishes, acoustical materials, and HVAC;

vi. The plans must be drawn to scale of sufficient size to clearly present the proposed design, but not less than a scale of one-eighth (1/8) inch to one (1) foot;

vii. Before commencement of construction, working drawings must be developed in close cooperation and with approval of the Department and other appropriate agencies;

viii. The drawings and specifications must be well prepared and of accurate dimensions and must include all necessary explanatory notes, schedules, and legends. They must be stamped with the architect's or engineer's seal; and

ix. The drawings must be complete and adequate for contract purposes.

d. Prior to occupancy, the construction must be inspected and approved by the Department. The Department must be notified at least four (4) weeks prior to completion in order to schedule a timely final inspection.

e. Buildings used as a FSED must meet all the requirements of local, state, and national codes concerning fire and life safety that are applicable to hospitals.

03.Electrical Safety.

a. A preventative maintenance program must ensure an electrically safe environment within the FSED. Written policies and procedures must be established and implemented to ensure compliance with NFPA 99 Health Care Facilities, 2005 Edition.

b. Specific restrictions on the use of extension cords and adapters are: extension cords must be used in emergency situations only, be of the grounded type, and have wire gauge compatible to the piece of equipment being used; and

c. Prohibition of the use of personal electrical equipment by patients and employees. Specific items may be allowed if the hospital adopts formal policies for defining and inspecting them.

04.Smoking. Because smoking has been acknowledged to be a fire hazard, a continuous effort must be made to reduce its presence in all health care facilities. Written policy governing smoking must be conspicuously posted and made known to all freestanding emergency department personnel, patients, and the public. The policy must include provisions for compliance with Title 39, Chapter 55, Idaho Code "Clean Indoor Air" and Section 18.7 of NFPA 101, 2006 Edition.

05.Emergency Plans for Protection and Evacuation of Patients.

a. The FSED must develop a prearranged written plan for employee response for protection of patients and for orderly evacuation and relocation of occupants in case of an emergency in accordance with Section 18.7 of the Life Safety Code, 2006 Edition.

b. Fire drills must be planned by key personnel and conducted on an unannounced basis. Fire drills must be held as required by Section 18.7 of the Life Safety Code, 2006 Edition.

06.Report of Fire. A separate report on each fire incident occurring within the FSED must be submitted to the Department within thirty (30) days of the occurrence. The reporting form, "Facility Fire Incident Report" is provided by the Department to secure specific data concerning date, origin, extent of damage, method of extinguishment, and injuries, if any.

09.Maintenance of Equipment. The FSED must establish routine test, check, and maintenance procedures for alarm systems, extinguishment systems, and all essential electrical systems. Frequency of testing, checks, and maintenance must be in accordance with applicable National Fire Protection Association Standards referenced in Chapter 2 of the 2006 "Life Safety Code" or as adopted by the Idaho State Fire Marshal.

10.Disaster Plans.

a. The FSED must have written plans for the care of casualties from both external and internal disasters.

b. The plans must be developed with the assistance of the local emergency planning committee and all appropriate community resources.

c. The plan must be reviewed and revised at least annually.

d. The plan must be a part of the overall community emergency response plan.

e. As part of the disaster and mass casualty program, a plan for the emergency supply of water must be available. This plan must include at least written contracts with any outside firms, a listing of procedures to be followed, the amounts of water needed by different departments, the means of dispensing water within the facility, and procedures for sanitizing in the case of contamination. Plans utilizing existing piping are recommended.

11.External Disaster Plan.

a. The hospital and FSED must conduct a hazard vulnerability analysis and develop a plan for external disasters for the geographic area served and within the capability of each physical location.

b. The plan must consider the performance of structural and critical non-structural building systems and the likelihood of loss of externally supplied power, gas, water, sanitary sewer, and communications under local or regional disaster situations.

c. The plan must contain the following elements:

i. Storage or a functional contingency plan to obtain; food, sterile supplies, pharmacy supplies, linen, and water for sanitation, sufficient for four (4) days;

ii. A procedure for notifying and assigning personnel;

iii. Unified medical command;

iv. Space and procedure for decontamination and triage;

v. Procedure for casualty transfer to an appropriate facility;

vi. Agreement with other agencies for communications.

d. The External Disaster Plan for the FSED may be an annex or appendix to the Hospital Plan, copies of which must be maintained onsite at the FSED.

12.Internal Disaster Plans.

a. The hospital and FSED must conduct a hazard vulnerability analysis and develop a plan for internal disasters for the building and personnel assigned to function in each physical location. The plan must consider the performance of the facility in dealing with an internal emergency such as the loss of building systems, supplied power, gas, vacuum, domestic water, blocked sanitary sewer, and loss of building communications. The plan must contain the following elements:

i. Those listed in Subsections 378.11. a. through 378.11.d., of these rules;

ii. Back up communications;

iii. Building security and lockdown;

iv. Internal traffic and crowd control;

v. Loss of, or isolation of, other related departments; and

vi. Evacuation or relocation security.

b. Drills. The plans must be exercised annually at the FSED.

c. The Internal Disaster Plan for the FSED may be an annex or appendix to the Hospital Plan, copies of which must be maintained on site at the freestanding emergency department.

13.Preventative Maintenance. The FSED must be equipped and maintained to protect the health and safety of the patient, personnel, and visitors. The FSED must have a written preventive maintenance program to include at least the following elements:

a. Designation of person responsible for maintaining the facility;

b. Written preventive maintenance procedures and appropriate inspection intervals in accordance with NFPA 99 and additional mandatory references listed in NFPA 101, 2006 Edition must be made for at least the following:

i. Heating systems;

ii. Air conditioning and mechanical systems;

iii. Electrical systems;

iv. Vacuum systems and gas systems;

v. All air filters in heating, air conditioning and ventilating systems; and

vi. Equipment related directly and indirectly to patient care, and any other equipment deemed essential under the emergency plan.

c. Maintenance and testing of Essential Electrical System, Vacuum, and Gas Systems must be in accordance with National Fire Protection Association 99; Health Care Facilities, 2005 Edition.

14.Safety. The FSED and hospital must have a safety committee and must be responsible for at least the following:

a. There must be comprehensive written safety procedures for all areas of the FSED that must include the safe use of equipment and handling of patients;

b. Safety orientation of new employees; and

c. Establishment of an incident or accident system for all patients, personnel, and visitors, that includes:

i. Reporting procedure;

ii. Investigation of incidents or accident;

iii. Documentation of investigation and disposition; and

iv. Evaluation of incidents or accidents and implementation of mitigation efforts.

Idaho Admin. Code r. 16.03.14.378

Effective March 17, 2022