Current through Register Vol. 49, No. 9, September, 2024
SECTION
1:
PREFACE
These rules and regulations have been prepared for the purpose
of establishing criteria for minimum standards for the licensure operation and
maintenance of hospices in Arkansas that is consistent with current trends in
patient care practices. By necessity they are of a regulatory nature but are
considered to be practical minimal design and operational standards for these
facilities. These standards are not static and are subject to periodic
revisions in the future as new knowledge and changes in patient care trends
become apparent. However, it is expected that facilities will exceed these
minimum requirements and that they will not be dependent upon future revisions
in these standards as a necessary prerequisite for improved services. Hospices
have a strong moral responsibility for providing optimum patient care and
treatment for the terminally ill and their families.
SECTION 2:
AUTHORITY
The following Rules and Regulations for Hospices in Arkansas
are duly adopted and promulgated by the Arkansas State Board of Health pursuant
to the authority expressly conferred by the laws of the State of Arkansas in
Ark. Code Ann. §
20-7-117 and §
20-7-123.
SECTION 3:
PURPOSE
To establish rules, regulations and minimum standards for
hospice programs operating in the State of Arkansas in accordance with Ark.
Code Ann. §
20-7-117. These rules will ensure
high quality professional care for terminally ill patients and their families
by providing for the safe, humane and appropriate palliative care of all
admitted to hospice program regardless of setting and shall apply to both new
and existing agencies.
SECTION
4:
DEFINITIONS
The word shall as used in these regulations means
mandatory.
A. Administrator means the
person responsible for the management of a hospice.
B. Attending physician means a doctor of
medicine or osteopathy who is licensed in the state of Arkansas; and is
identified by the patient, at the time he/she elects to receive hospice care,
as having the most significant role in the determination and delivery of the
patient's medical care.
C.
Autonomous means a separate and distinct entity which functions under its own
administrations and bylaws either within or independently of a parent
organization.
D. Bereavement
counseling means counseling services provided to the patient's family after the
patient's death.
E. Clergy or
Pastoral Counselor means an individual with training in spiritual
counseling.
F. Department means the
Arkansas Department of Health and Human Services and Human Services.
G. Election Statement means the initial
election for hospice care signed by the patient or patient's
representative.
H. Employee means
an individual paid either through a salary or on an hourly or per visit basis
and a W2 is issued on his/her behalf. An "employee" also refers to a volunteer
under the jurisdiction of the hospice.
I. Health Facility Services is the facility
licensing division of the Department.
J. Hospice Agency means any agency, person,
partnership, association,
corporation, or other organization whether public or private,
proprietary, or nonprofit, that provides hospice service.
K. Hospice or hospice care means an
autonomous, centrally administered, medically directed, coordinated program
providing a continuum of home, outpatient, and home-like inpatient care for the
terminally ill patient and family, employing an interdisciplinary team to
assist in providing palliative and supportive care to meet the special needs
arising out of the physical, emotional, spiritual, social and economic stresses
which are experienced during the final stages of illness and during dying and
bereavement, with such care being available 24 hours a day, 7 days a week and
provided on the basis of need regardless of ability to pay
L. Informed Consent specifies the type of
care and services agreed upon by the hospice patient or the patient's
representative.
M. In-patient
Direct Care Hospice means a licensed hospice facility that provides direct
in-patient care to the terminally ill.
N. Functional Program describes those
services to be provided by the Hospice for the operation of the
facility.
O. Registered Nurse (RN)
means a person licensed in the State of Arkansas as a registered
nurse.
P. Representative means a
person who is, because of the patient's mental or physical incapacity,
authorized in accordance with State law to execute or revoke an election for
hospice care or terminate medical care on behalf of the terminally ill
patient.
Q. Satellite Office or
Alternate Delivery Site - An approved location or site from which a hospice
provides services within a portion of the total geographic area served by the
parent hospice agency.
R. Service
Area - The geographic land area for which the agency shall be licensed
consistent with the agency's Permit of Approval (POA) or the service area of
record prior to the requirement for a POA.
S. Social Worker means a person who has at
least a Bachelor's Degree from a school accredited or approved by the Council
on Social Work Education and is licensed by the State of Arkansas as a Social
Worker.
T. Terminally ill means
that the patient is in the last phases of an incurable illness or condition and
has a limited prognosis.
SECTION
5:
REQUIREMENTS AND CODES
All agencies providing hospice services in the home shall
comply with Sections 1 thru 21. In-Patient Direct Care Hospices shall comply
with Sections 1 thru 34.
A. Licensure
1. No public or private agency or person
shall establish, conduct, or maintain a hospice or hold itself out to the
public as a hospice without first obtaining licensure from the
department.
2. Licensure to operate
a hospice issued by the Department shall be based upon the results of an
operational and physical plant survey conducted by the Department to determine
compliance with the Rules and Regulations of Hospice.
Licensure for the operation of a hospice program shall, unless
sooner revoked, be for a period of one year.
B. Revocation
1. The department may deny, suspend or revoke
a license on any of the following grounds:
a.
Violation of any of the rules and regulations promulgated as developed under
the authority of Ark. Code Ann. §
20-7-117.
b. Permitting, aiding or abetting the
commission of any unlawful act in connection with the operation of a
hospice.
2. Revocation
shall be effective for a minimum of 90 days before the Department accepts
reapplication.
3. Right of Appeal
shall be through the Arkansas Board of Health.
C. Application
1. An applicant shall file applications under
oath with the Department upon forms prescribed by the Department. The
application shall be signed by the owner; if a partnership or corporation, by
two of its officers; in the case of a governmental unit by the head of the
governmental unit having jurisdiction.
2. The application shall set forth the full
name and address of the hospice for which state licensure is sought and such
additional information as the department may require.
3. An agency making initial application or
requesting a change in service area shall submit a Permit of Approval (POA)
from the appropriate agency.
D. Change of Ownership
1. The hospice shall notify Health Facility
Services in writing at least 30 days prior to the effective date of change of
ownership.
2. The following
information shall be submitted:
a) License
application;
b) Request for
Medicare Certification (where applicable);
c) Legal documents, ownership agreements, the
license previously issued to the hospice, and other information to support
re-license requirements; and d) Licensure fee.
E. Name/Address Change
1. The hospice shall notify Health Facility
Services in writing of any name and/or address change.
2. The following information shall be
submitted:
a) The new address.
b) The previously issued license shall be
returned to Health Facility Services.
c) Appropriate fee.
F. Management Contract
The licensed hospice shall notify Health Facility Services in
writing at least 30 days prior to entering into a contract for overall
management of the hospice. A copy of the contract shall be submitted to Health
Facility Services.
G.
Inspections
Any authorized representative of the department shall have the
right to enter a hospice at any time in order to make whatever inspection is
deemed necessary in accordance with the minimum standards and regulations
prescribed herein.
SECTION
6:
GOVERNING BODY
A. The hospice shall have a Governing Body
that assumes full legal responsibility for determining, implementing and
monitoring policies governing the hospice's total operation.
B. The Governing Body shall designate an
individual who is responsible for the day-to-day management of the hospice
program.
C. The Governing Body
shall designate a medical director who assumes overall responsibility for the
medical component of patient care.
D. The Governing Body's records shall reflect
direct involvement in hospice policy development and oversight to include but
not limited to:
1. Responsibilities of the
administrator and medical director;
2. Management of contracted
services;
3. Patient admission
criteria;
4. Patient and family
involvement in patient care planning;
5. An ongoing, comprehensive self-assessment
of the quality of care provided to patients.
E. There shall be a schedule of not less than
quarterly meetings during each calendar year and minutes shall be maintained of
the meetings.
F. The Governing Body
shall ensure:
1. Nursing services, physician
services, drugs and biologicals are routinely available on a 24-hour
basis;
2. All other services are
available on a 24-hour basis to the extent necessary to meet the needs of
patients for care that is reasonable and necessary for the palliation and
management of terminal illness and related conditions; and
3. All services provided are consistent with
accepted standards of practice.
SECTION 7:
PATIENT RIGHTS AND
RESPONSIBILITIES
A. A hospice shall
inform and document that each patient, or when appropriate the patient's
representative, has been informed of the following before or during the initial
evaluation:
1. The right to appropriate and
professional quality services regardless of race, creed, color, religion, sex,
national origin, sexual preference, disability or age, and to be free from
physical abuse, mental abuse and/or neglect. The patient and property shall be
treated with dignity and respect by all that provide services;
2. The right to receive an explanation of the
informed consent and election statement that is signed by the patient or
patient's representative for the provision of hospice care;
3. The right to participate in the
decision-making process regarding where care is to be delivered and the options
available;
4. The right to receive
a timely response from the hospice agency regarding any request for
services;
5. The right to privacy
and confidentiality;
6. The right
to be informed of the name of the hospice agency, services offered by the
agency, services being provided to the patient, and how to contact that agency
during all hours;
7. The right to
be informed of the process of submitting and addressing complaints to the
hospice agency and be informed of the address and phone number of the State
Licensing Agency;
8. The right to
be informed that a hospice may not discontinue or diminish care because of the
lack of a payor source; and
9. The
right to be informed orally and in writing, prior to service, of expected
payment sources, i.e., Medicare, Medicaid, and various other payers.
10. Services the hospice does not
cover.
B. The agency
shall provide each patient and patient's representative with a list affirming
the patient's and patient's representative's responsibility to:
1. Assist in developing and maintaining a
safe environment, when possible;
2.
Treat all agency staff with respect;
3. Participate in the development and update
of the plan of care; and
4. Adhere
to the plan of care as developed by the agency and assist in the care as
necessary.
SECTION
8:
ADMINISTRATION
A. Administration shall provide and document
the following:
1. Job descriptions for all
employees and volunteers;
2.
Policies and procedures for each available service;
3. In-services pertinent to hospice care
shall be ongoing for employees, volunteers, and contracted staff;
4. Orientation for all employees, volunteers
and contracted staff; and
5. Annual
review of policies and procedures.
B. Services by Arrangement
A hospice may arrange for another individual or entity to
furnish services to the patients. If services are provided under arrangement
(i.e. under contract), the following standards shall be met:
1. Continuity of Care
The hospice program shall ensure the continuity of
patient/family care in home, outpatient, and in-patient settings.
2. Written Agreement
The hospice shall have a written agreement for the provision of
contracted services. The contract shall include at least the following:
a) Identification of services to be provided;
and
b) Qualifications of personnel
providing the services.
C. Short Term Inpatient care
The hospice shall have a written agreement approved with an
area hospital, hospice in-patient facility, or qualified skilled nursing
facility which states that the hospice may continue to follow any hospice
patient admitted to that facility.
D. Continuation of Care
A hospice may not discontinue or diminish care because of the
lack of a payor source.
E.
Licensure
The hospice and all hospice employees shall be licensed in
accordance with applicable Federal, State and local laws.
F. Core Services
A hospice shall ensure all core services (i.e., Nursing,
Medical Social Services, and Counseling) described in the following section are
routinely provided directly by hospice employees. A hospice may use contracted
staff if necessary to supplement hospice employees in order to meet the needs
of patients during periods of peak patient loads or under extraordinary
circumstances. If contracting is used, the hospice shall maintain professional,
financial, and administrative responsibility for the services and shall assure
the qualifications of staff and services provided meet the requirements
specified for Nursing, Medical Social Services, Physician Services, and
Counseling.
NOTE: Physician Services may be provided by an individual
contract. The contract must specify the physician will assume all
responsibilities as outlined in Section 11.
G. Post Mortem Procedures The Hospice Agency
shall have a procedure addressing post mortem procedures.
H. Pet Therapy
Pet Therapy may be provided by the hospice in the patient's
home. Birds, cats, dogs, and other animals may be permitted in the patient's
home. Therapy animals shall have appropriate vaccinations and licenses. A
veterinary record shall be kept on all therapy animals to verify vaccinations
and be made readily available for review and shall not negatively affect the
well being of the patient.
I. Employee Health
It shall be the responsibility of Administration, with advice
and guidance from the Medical Staff and the Infection Control Committee, to
establish and enforce policies concerning pre-employment physicals and employee
health. The policies shall include but are not limited to:
1. Requirements for an up-to-date health file
for each employee;
2. Annual
testing of each employee having direct patient contact for tuberculosis. Each
employee having direct patient contact, regardless of whether the employee is a
reactor, non-reactor, or converter, shall be tested or evaluated in accordance
with the applicable section of the Tuberculosis Manual of the Arkansas
Department of Health and Human Services; and
3. Work restrictions shall be placed on
personnel who are known to be affected with any disease in a communicable
stage. Such individuals shall not work in any area in any capacity in which
there is the likelihood of transmitting disease to patients, personnel or other
individuals within the hospice or a potential of contaminating food, food
contact surfaces, supplies or any surface with pathogenic organisms.
J. Complaints
Each agency shall keep a record of complaints received.
Documentation shall include the name of the complainant, the relationship to
the patient, the nature of the complaint, and the action taken to resolve the
complaint.
K. Informed
Consent
.
An informed consent shall be signed by the patient or patient's
representative for provision of hospice care.
L. Certification of Terminal Illness
The agency shall have certification signed by the attending
physician and medical director or physician designee stating the patient has a
terminal illness.
M.
Election of Hospice Care
1. Duration of
election. An election to receive hospice care shall be considered to continue
as long as the patient remains in the care of a hospice or does not revoke the
election for hospice care and remains certified as appropriate for
hospice.
2. Effective date of
election. A patient or patient's representative may designate an effective date
for the election period that begins with the first day of hospice
care.
3. Waiver of other benefits.
A patient or patient's representative can elect hospice care from only one
hospice provider at any given time.
N. Elements of the Election Statement. The
election statement shall include the following:
1. Identification of the hospice that
provides care to the patient;
2.
The patient's or the patient's representative's acknowledgment that he or she
has been given a full understanding of the palliative rather than curative
nature of hospice care, as it relates to the patient's terminal
illness;
3. The effective date of
the election; and
4. The signature
of the patient or patient's representative.
O. Revoking the Election of Hospice Care
1. A patient or patient's representative may
revoke the patient's election of hospice care at any time during an election
period.
2. To revoke the election of
hospice care, the patient or patient's representative shall file a statement
with the hospice that includes the following information:
a) A signed statement that the patient or
patient's representative revokes the patient's election for hospice
care.
b) The date the revocation is
effective. (A patient or patient's representative may not designate an
effective date earlier than the date that the revocation is made.)
SECTION 9:
QUALITY IMPROVEMENT (QI)
A. The
organization shall develop, implement, and maintain an ongoing program to
assess and improve the quality of care and services provided. A Quality
Improvement (QI) plan shall be developed and maintained to describe the manner
in which QI activities shall be conducted. The QI plan shall be reviewed and
approved by the Medical Staff and Governing Body annually.
1. All hospice programs, services,
departments and functions, including contracted services related to patient
care, shall participate in ongoing quality improvement activities.
2. The hospice shall collect and assess data
on the functional activities identified as priorities in the QI plan.
3. Improvement strategies shall be developed
for programs, services, departments and functions identified with opportunities
for improvement.
4. The
effectiveness of improvement strategies and actions taken shall be monitored
and evaluated, with documentation of conclusions regarding
effectiveness.
B. The QI
program shall include, but not be limited to, ongoing assessment and
improvement activities regarding the following:
1. Access to care, processes of care,
outcomes of care and hospice-specific clinical data;
2. Customer satisfaction (patients and
families, physicians, and employees).
SECTION 10:
INFECTION CONTROL
Each hospice shall develop an infection control program which
protects patients, family and personnel from nosocomial or community acquired
infections.
A. The hospice shall
develop and use a coordinated process that effectively reduces the risk of
endemic and epidemic nosocomial infections in patients, health care workers and
visitors.
B. It shall be the duty
of the Administrator or his/her designee to report all known infectious or
communicable diseases as required by Ark. Code Ann. §
20-7-109 to the Arkansas
Department of Health and Human Services and Human Services, Division of
Epidemiology.
C. There shall be
policies and procedures establishing and defining a comprehensive Infection
Control program to include:
1. Provisions for
education of universal precautions to patients, families, and hospice employees
including but not limited to:
a) Hand hygiene
including procedures for soap and water as well as alcohol based hand rub if
used;
b) Disinfections;
c) Liquid and solid waste disposal of
infectious waste;
d) Needle
disposal; and e) Other means of limiting the spread of contagion.
2. A plan for monitoring and
evaluating all aseptic and sanitation techniques employed in the hospice to
ensure that approved infection control procedures are followed.
D. There shall be an orientation
program for all new health care workers concerning the importance of infection
control and each health care worker's responsibility in the infection control
program.
E. There shall be a plan
for each employee to receive annual in-services and educational programs as
indicated based on assessments of the infection control process.
F. No items shall be used past the expiration
date.
G. One-time patient care
items shall not be reused.
SECTION
11:
PHYSICIAN SERVICES
A. Medical Director
The overall responsibility for the medical component of patient
care shall be under the direction of a physician, qualified by training and
experience in hospice care, who shall also be responsible for no less than the
following:
1. Ensuring and maintaining
quality standards of medical practice;
2. Achievement and maintenance of quality
assurance of medical practices through a mechanism for the assessment of
patient/family care outcomes;
3.
Certification of terminally ill patients admitted to the hospice
program;
4. Participation as a
member of the interdisciplinary team in the development, implementation and
assessment of the patient/family plan of care; and
5. Consulting with the attending physician
regarding patient care plans.
B. Physician Services
1. Physician Services shall be provided in
accordance with hospice policies.
2. Such policies shall include provisions
governing the relationship of the staff physicians, attending physician and the
Medical Director to each other, and to the interdisciplinary team.
3. In addition to palliation and management
of the terminal illness and related conditions, physician employees of the
hospice, including the physician member(s) of the interdisciplinary group, must
also meet the general medical needs of the patients to the extent that these
needs are not met by the attending physician.
SECTION 12: NURSING SERVICES
A. A registered nurse shall assign the
nursing care of each patient to other personnel in accordance with the
patient's needs.
B. A registered
nurse shall plan, supervise and evaluate the care for each patient.
C. Nursing services shall be provided in
accordance with recognized standards of practice.
SECTION 13:
INTERDISCIPLINARY
GROUP
The Interdisciplinary Group or groups shall be composed of
individuals who provide or supervise the care and services offered by the
hospice.
A. Composition of the
Interdisciplinary Group
The Interdisciplinary Group or groups shall include at least
the following individuals:
1. A doctor
of medicine or osteopathy;
2. A
registered nurse;
3. A social
worker; and
4. A pastoral or other
counselor.
B. Role of
the Interdisciplinary Group The Interdisciplinary Group shall:
1. Participate in the establishment of the
plan of care;
2. Provide
supervision of hospice care and services;
3. Periodically review and update the plan of
care to reflect the needs of each patient receiving hospice care.
SECTION 14:
VOLUNTEERS
The hospice shall use volunteers, in defined roles, under the
supervision of a designated hospice employee. The hospice shall maintain
documentation of active and ongoing efforts to recruit and retain
volunteers.
A. Training
Orientation and training shall be provided consistent with
acceptable standards of hospice practice.
B. Role Volunteers may be used in
administrative services or direct patient care.
C. Level of Activity
A hospice shall maintain a volunteer staff sufficient to
provide administrative or direct patient care at a minimum that equals five
percent of the total patient care hours of all paid hospice employees and
contract staff. The hospice shall maintain a continuing level of volunteer
activity. Expansion of care and services achieved through the use of
volunteers, including the type of services, and the time worked, shall be
recorded.
D. Employees as
Volunteers
Hospice employees may be used as volunteers only after
completing a hospice volunteer training program.
SECTION 15:
COUNSELING SERVICES
Counseling services sliall be available to the patient and the
family and shall include the following:
A. Bereavement Services
There shall be an organized program for provision of
bereavement services under the supervision of an individual with specialized
bereavement training. The plan of care for these services shall reflect family
needs which shall include personal visits up to one year following the
patient's death. Refusal or variations from the visits or contacts shall be
documented.
B Dietary
Counseling
A qualified dietitian shall provide dietary counseling, when
required.
C. Spiritual
Counseling
The hospice shall notify the patient of the opportunity for
spiritual counseling either from the hospice pastoral counselor or clergy of
the patient's choice. If the patient elects to have his/her clergy visit, the
hospice shall make reasonable efforts to arrange for the visit(s).
D. Social Services
Social Services shall be provided by a qualified Social
Worker.
SECTION
16:
OTHER SERVICES
A hospice shall ensure the following services are available and
provided directly by hospice employees or under arrangement and offered in a
manner consistent with acceptable standards of practice:
A. Physical Therapy;
B. Occupational Therapy; and
C. Speech-Language Pathology.
SECTION 17:
HOSPICE AIDE
AND HOMEMAKER SERVICES
A. Hospice aide
services sliall be available and adequate in frequency to meet the needs of the
patient. A hospice aide is a person who meets at least one of the following
requirements:
1. Has at least one year of
experience in an institutional setting (home health agency, hospital, hospice,
or long-term care facility). This experience shall be verified by a previous
employer;
2. Has a certificate
issued by the State of Arkansas for work in long-term care facilities. A copy
of this certificate shall be available for review; or
3. Has completed a 40-hour aide training
course that meets requirements set forth in these regulations. In lieu of the
requirement for completion of the hospice aide training course, a nursing
student may qualify as a hospice aide by submitting documentation from the
Director of Programs and/or the Dean of a School of Nursing that reflects the
nursing student has demonstrated competency in providing basic nursing care in
accordance with the school's curriculum.
B. Any aide who has not been employed as an
aide in an institutional setting in the last 24 months shall be observed by a
registered nurse performing the skills required to care for a patient including
bathing, transferring, range of motion exercises, toileting, dressing, nail
care and skin care. The registered nurse shall observe the aide performing
these skills on a person. Any other tasks or duties for which the aide may be
responsible shall be evaluated by written test, oral test or observation. There
shall be documentation by the agency to show evidence of this
evaluation.
C. A registered nurse
shall complete an aide assignment sheet for each patient receiving aide
services. Each aide caring for the patient shall receive a copy of the
assignment sheet and provide services as assigned. A copy of the assignment
sheet shall be left in the patient's home and in the patient's medical
record.
D. Each aide assignment
sheet shall be individualized and specific according to the patient's
needs.
E. The registered nurse
shall conduct a visit to the patient's place of residence at least every two
weeks to supervise the aide and update the aide assignment sheet.
F. In no event shall a hospice aide receive
or write verbal orders from a physician. A hospice aide shall not perform any
sterile procedure or any procedure requiring the application of medication
requiring a prescription.
G. Upon a
request by a patient and/or family member for assistance with medications, the
registered nurse may assign a hospice aide to assist with oral medications,
which are normally self-administered. Assistance shall be limited to reminding
a patient to take a medication at a prescribed time, opening and closing a
medication container and returning a medication to a proper storage
area.
H. Except as otherwise
provided in these rules, duties of the hospice aide may include:
1. Personal care (example: bathing, grooming,
feeding, ambulation, exercise, oral hygiene, and skin care, etc.);
2. Assistance with medications ordinarily
self-administered as assigned;
3.
Household services essential to health care in the home;
4. Completion of records and reporting to
appropriate supervisor;
5. Taking
and charting vital signs;
6.
Extension of therapy services; and
7. Any duty consistent with the State Board
of Nursing Regulations on Delegation of Duties may be assigned by a registered
nurse to meet the needs of the patient.
I. If the training is provided by the agency,
the training program for hospice aides shall be conducted under the supervision
of a registered nurse. The training program may contain other aspects of
learning, but shall include the following;
1.
A minimum of 40 hours of classroom and clinical instruction related
particularly to the hospice setting;
2. Written course objectives with expected
outcomes and methods of evaluation;
3. An assessment that the student knows how
to read and write and to carry out directions; and
4. Orientation to liospice pliilosopliy,
batliing, ambulation and exercise, personal grooming, principles of nutrition
and meal preparation, health conditions, developmental stages and mental
status, household services essential to health care at home, assistance with
medication, safety in the home, completion of appropriate records and reporting
changes to appropriate supervisor.
J. Aides shall receive a minimum of 12 hours
in-service training per 12 months. The in-services provided shall address areas
that directly relate to the patient care aspects of the aides' job.
K. Homemaker services shall be available and
adequate in frequency to meet the patient's needs.
SECTION 18:
PLAN OF CARE
A written plan of care shall be established, maintained, and
provided for each patient admitted to a hospice program. The plan shall include
an assessment of the patient's needs and identification of the services
including the management of discomfort and symptom relief. It shall state in
detail the scope and frequency of services needed to meet the patient's and
family's needs. A written plan of care shall be:
A. Developed by the attending physician, the
medical director or physician designee and interdisciplinary group prior to
providing care; and
B. Reviewed and
revised to reflect the patient and family's current needs, by the attending
physician, the medical director or physician designee, and interdisciplinary
group. The reviews shall be documented.
C. Content of plan. The plan must include
assessment of the individual's needs and identification of the services
including the management of discomfort and symptom relief. It must state in
detail the scope and frequency of services needed to meet the patient's and
family's needs.
SECTION
19:
CLINICAL RECORDS
In accordance with accepted principles of practice, the hospice
shall establish and maintain a clinical record for every patient receiving care
and services. The record shall be complete, accurate readily accessible and
systematically organized to facilitate retrieval.
A. Content
Entries shall be made for the day services are provided and
filed within seven days. Entries shall be signed by the person providing the
services. All entries shall be legible and readily accessible. The record shall
include all services whether furnished directly or under arrangement. Each
patient's record shall contain the following:
1. Initial and subsequent
assessments;
2. Plan of
care;
3. Identification
data;
4. Consent, authorization and
election forms;
5. Pertinent
medical history; and
6.
Documentation of all services and events.
B. Protection of Information
The hospice shall use reasonable precautions to safeguard the
clinical record against loss, destruction and unauthorized use.
C. Record Retention
Closed records shall be retained for a minimum of five
years.
SECTION
20:
MEDICAL SUPPLIES / MEDICATIONS
Medical supplies, appliances, drugs and biologicals, shall be
provided as needed for the palliation and management of the terminal illness
and related conditions.
A.
Administration
All drugs and biologicals shall be administered in accordance
with accepted standards of practice.
B. Controlled Drugs in the Patient's Home
Controlled substances no longer required by a patient receiving
in-home hospice services may be disposed of by the owner of the prescription or
a family member of a deceased patient to whom the controlled substances were
dispensed. If requested, the controlled substances may be disposed of in the
presence of a hospice nurse in which case the nurse shall document the disposal
by completing the Report of Drugs Surrendered Form and returning it to Pharmacy
Services and Drug Control, Arkansas Department of Health and Human Services and
Human Services. The patient or family member shall keep the blue copy of the
Report of Drugs Surrendered Form while the nurse places the yellow copy in the
medical record and returns the white copy to Pharmacy Services and Drug
Control, Arkansas Department of Health and Human Services.
C. Administration of Pharmaceuticals
A licensed nurse, physician, patient or caregiver shall
administer pharmaceuticals.
SECTION 21:
SHORT-TERM INPATIENT
CARE
Inpatient care shall be available for pain control, symptom
management, respite purposes, and shall be provided in licensed facilities, as
stated below:
A. Inpatient Care for
Symptom Control
Inpatient care for pain control and symptom management shall be
provided in one of the following:
1. A
hospice that meets the requirements for providing inpatient care directly as
specified in the Section, 22 "Inpatient Direct Care."
2. A hospital or a Skilled Nursing Facility
(SNF).
3. Each shift shall include
a registered nurse on site to supervise and provide direct patient
care.
B. Inpatient Care
for Respite Purposes
Inpatient care for respite purposes shall be provided by one of
the following:
1. A hospice that meets
the requirements for providing inpatient care directly as specified in the
Section, "Inpatient Direct Care", Section 22.
2. A hospital or a Skilled Nursing Facility
(SNF).
SECTION
22:
IN-PATIENT DIRECT CARE
In addition to the preceding sections, In-patient Direct Care
shall also comply with Sections 22 through 34.
A. Administration shall be responsible for
the following:
1. Policies and procedures
shall be provided for the general administration of the institution and for
each department, section or service in the facility. All policies and
procedures for departments or services shall have evidence of ongoing review
and/or revision. The first page of each manual shall have the annual review
date, signature of the department supervisor and/or person(s) conducting the
review.
2. The facility shall have
visitation policies determined by the Medical Staff, Governing Body and
Administration. Patients shall be permitted to receive visitors at any hour,
including small children.
3.
Disaster Preparedness
A written disaster preparedness plan shall be developed and
communicated to staff through orientation, education and ongoing reviews. The
plan shall include:
a) A definition of
"disaster" for the hospice inpatient facility's given location and
circumstances;
b) Arrangements for
prompt identification and transfer of patients and records to another facility
if necessary;
c) Arrangements for
coordination of community resource; and
d) Menus to coincide with a 24-hour supply of
perishable and 72 hours supply for non-perishable food available for
emergencies.
B. Nursing
1. The facility shall provide24 hour nursing
service sufficient to meet patient needs in accordance with the patient plan of
care. Each patient receives treatments, medications, and diet as prescribed,
and is kept comfortable, clean, well-groomed, and protected from accident,
injury, and infection.
2. Each
shift shall include a registered nurse on site to supervise and provide direct
patient care and one other nursing personnel type (e.g. RN, LPN and/or hospice
aide.) A ratio of at least 1 nursing personnel to each 4 patients shall be
maintained from 7 A.M. to 7 P.M. and a ratio of 1 to 6 from 7 P.M. to 7
A.M.
3. A registered nurse shall
assign the patient care of each patient to other nursing personnel in
accordance with the patient's needs.
C. Dietary
Meal service, menu planning and supervision. The hospice
shall:
1. Serve at least three (3)
meals or their equivalent each day at regular times, with not more than
fourteen (14) hours between an evening meal and breakfast. Meals may be
adjusted according to the request and as tolerated by the patient.
2. Procure, store, prepare, distribute and
serve all food under sanitary conditions in accordance with the current Rules
and Regulations Pertaining to Food Establishments.
3. Employ a registered dietician or have a
formal agreement with a registered dietician who is responsible for:
a) Planning menus that meet nutritional needs
of each patient, in accordance with the recommended dietary allowances of the
Food Nutrition Board of the National Research Council, National Academy of
Sciences; and
b) Supervising the
meal preparation and service to ensure the menu plan is followed.
4. Have menus prepared by a
registered dietitian for patients who require medically prescribed special
diets.
5. Have bedtime and between
meal snacks or supplements available.
D. Pharmaceutical Service
Appropriate methods and procedures for the dispensing and
administering of drugs and biologicals shall be developed. Whether drugs and
biologicals are obtained from community or institutional pharmacists or stocked
by the facility, the facility is responsible for drugs and biologicals for
patients, in so far as they are covered under the program and for ensuring that
pharmaceutical services are provided in accordance with accepted professional
principles and appropriate Federal, State and local laws.
1. In facilities that obtains drugs and
biologicals from community or institutional pharmacies:
a) The Hospice shall have contractual
arrangements to ensure services are available 24 hour 7 days a week to the
patients in the Hospice facility.
b) All prescription medications in the
facility shall be patient specific and appropriately labeled.
c) No prescription drug floor stock shall be
allowed in the facility.
2. The Hospice shall:
a) Employ a licensed pharmacist; or
b) Have a formal agreement with a
licensed pharmacist to advise the hospice on ordering, storage, administration,
disposal, and record keeping of drugs and biologicals; and
c) Have a Pharmaceutical Service Committee
which meets quarterly consisting of at least the Medical Director, Pharmacist,
Nurse Manager, and Administrator. The committee shall be responsible for the
following:
1) Serve as an advisory group to
the medical staff;
2) Approve the
policies and procedures for pharmaceutical service annually;
3) Approve medication formulary
annually;
4) Approve floor stock
annually; and
5) Discuss medication
errors and adverse drug reactions.
3. Orders for Medications
a) All medications shall be ordered by the
physician or credentialed licensed practitioner according to their scope of
practice if approved by the Medical Staff and Governing Body.
b) If the medication order is verbal:
1) The physician shall give the order only to
a licensed nurse, pharmacist, or another physician; and
2) The individual receiving the order shall
record and sign immediately. The prescribing physician shall sign in the time
frame determined by hospice policy.
4. Administration of Medication
Medications shall be administered only by one of the following
individuals:
a) Licensed personnel in
accordance with their scope of practice; and
b) The patient with approval of the attending
physician and according to hospice policy.
5. Control and Accountability
The pharmaceutical service has procedures for control and
accountability of all drugs and biologicals throughout the facility. Drugs are
dispensed in compliance with Federal and State laws. Records of receipt and
disposition of all controlled drugs are maintained in sufficient detail to
enable an accurate reconciliation. The pharmacist determines drug records are
in order and an account of all controlled drugs is maintained and
reconciled.
6. Labeling of
Drugs and Biologicals
The labeling of drugs and biologicals is based on currently
accepted professional principles and includes the appropriate accessory and
cautionary instructions, as well as the expiration date when applicable.
7. Storage
In accordance with State and Federal laws, all drugs and
biologicals are locked and stored under proper temperature controls and only
authorized personnel shall have access to the keys. Scheduled drugs shall be
maintained as required by Federal and State regulations.
8. Drug Disposal
Controlled substances no longer required by a patient residing
in an inpatient hospice shall be disposed of by returning unused medications
and a Report of Drugs Surrendered Form to Pharmacy Services and Drug Control,
Arkansas Department of Health and Human Services and Human Services.
E. Linen.
The hospice has available at all times a quantity of linen
essential for proper care and comfort of patients. Linens are handled, stored,
processed, and transported in such a manner as to prevent the spread of
infection.
F. Pet Therapy
Therapy animals (Birds, cats, dogs, and other animals) may be
permitted to visit in the patient's room and shall not negatively affect the
well being of others. Animals shall have appropriate vaccinations and licenses.
A veterinary record shall be kept on all therapy animals to verify vaccinations
and be made readily available for review. Therapy pets shall not be allowed in
food preparation, food storage, dining or service areas.
G. If personal pets are allowed in the
facility the facility will have policy and procedures consistent with local
ordinances.
SECTION 23:
INFECTION CONTROL
A. There shall
be a comprehensive list of communicable diseases for which patients shall be
isolated and for which there are visitation restrictions. The list, and other
policies and procedures for isolation, shall conform to the latest edition of
the Centers for Disease Control and Prevention, (CDC) Guidelines.
B. There shall be policies and procedures
established and followed for:
1.
Sterilization;
2. Sanitary food
preparation;
3.
Housekeeping
4. Linen
Care;
5. Separation of clean from
dirty process; and
6. Use of
disinfectants, antiseptics and germicides according to the manufacturer's
directions.
SECTION
24:
PHYSICAL ENVIRONMENT.
A. A homelike setting design and functional
program shall include the following:
1. A
place where all family members, including children, may come and go in a
natural, family-like manner;
2.
Social areas where family members may bring food and dine together and enjoy
music, games, and other activities common to the family unit; and
3. A balance between privacy and opportunity
for social interaction.
4. Patients
Areas: Bedrooms, dining areas, lounges, and surroundings shall be designed to
promote privacy and dignity for the patient and family. The interior design of
patient use areas shall consider lighting, the use of finish materials,
furniture arrangement, and equipment to create a home like ambience without
compromising the ability of caregivers to attend to the needs of the patient.
Patient toilet rooms shall be accessible and provide adequate space for staff
assistance in wheelchair transfers as necessary for at least 50% of patient
capacity.
B. Building
and Grounds.
1. The building and equipment
shall be maintained in a state of good repair at all times.
2. Facilities and their premises shall be
kept clean, neat and free of litter, and rubbish. The facility shall have
written policies and procedures for housekeeping.
3. Rooms for gas fired equipment shall not be
used for storage except for noncombustible materials.
4. Portable equipment shall be supervised by
the department having control of such equipment and shall be stored in areas
which are not accessible to patients, visitors, or untrained
personnel.
5. Corridors, attics,
and passageways shall be free of storage. Exits shall not be blocked by storage
of furniture or equipment at any time.
6. Each hospice facility shall develop a
written preventive maintenance plan including all electrically powered patient
care equipment, physical plant equipment and fire alarms and detection systems.
This plan shall be available to the Department for review at any time. Such
plans shall provide for maintenance as recommended by the manufacturer,
applicable codes, or designer and ensure that equipment and systems perform
properly and safely.
7. Hand
washing stations shall be available in visitors' rest rooms and for use by
staff personnel.
8. A supply of hot
water for patient use shall be available at all times within the range of
110º - 120º. A weekly hot water temperature log shall be
maintained.
9. Heating, ventilating
and air-conditioning (HVAC) systems shall be operated and maintained in a
manner to provide a comfortable and safe environment for patients, personnel,
and visitors. An air filter change out log shall be maintained.
10. Steam and Hot Water Systems and Pressure
Vessels.
All pressure vessels shall meet the requirements of the
Arkansas Boiler Inspector, Arkansas Department of Labor. Boiler feed pumps,
heating circulating pumps, condensate return pumps, and fuel oil pumps shall be
connected and installed to provide normal and standby service.
C. Maintenance and
Engineering.
Emergency Procedures Program (EPP). There shall be written
emergency procedures or a disaster management plan for utility system
disruptions or failures which address the specific and concise procedures to
follow in the event of a utility system malfunction or failure of the water
supply, hot water system, medical gas system, sewer system, bulk waste disposal
system, natural gas system, commercial power system, communication system,
boiler or steam delivery system. These procedures shall be kept separate from
all other policy and procedure manuals as to facilitate their rapid
implementation. These procedures shall contain but are not limited to the
following information:
1. A method of
obtaining alternative sources of essential utilities;
2. A method of shutoff and location of valves
for malfunctioning systems;
3. A
method of notification of hospice staff in affected areas;
4. A method of obtaining repair
services.
D.
Environmental Services.
Solutions, cleaning compounds, disinfectants, vermin control
chemicals, and all other potentially hazardous substances that are used in
connection with environmental services shall be:
1. Kept in containers which accurately
reflect at least the following:
a. Content
name;
b. Concentration of
solution;
c. Expiration date and
lot number;
2. Stored in
a secured area. Under no circumstances shall these substances be stored in or
near food storage or food preparation areas;
E. Laundry Services.
1. Facility laundry service:
a. Sorting of soiled laundry shall be done in
a designated area;
b. Tables or
bins shall be provided for sorting of soiled laundry;
c. Lint traps shall be provided on dryers and
shall be cleaned regularly;
d.
Pre-rinsing shall be done in the laundry service not in showers, bathtubs or
lavatories;
e. Removal of solid
soil shall be done in soiled utility rooms or rooms that are designated for
this purpose;
f. Patient clothing
may be washed in the patient area if a separate equipped laundry room is
available;
g. A rinsing sink shall
be provided in the soiled linen area of the laundry;
h. Hot water supplied to laundry areas shall
be not be under 120ºF. Chlorine bleach, if used, shall be used at 150
parts per million. Provisions shall be made to provide 160ºF hot water at
the laundry equipment when needed. (This may be a steam jet or separate booster
heater.) However, this does not imply that all water used would be at this
temperature. Water temperatures required for acceptable laundry results will
vary. Lower temperatures may be adequate for most procedures in many facilities
but the higher 160ºF should be available when needed for special
conditions;
i. Linen contained in
hot water soluble plastic bags (identified as being contaminated) shall be
placed directly into the washing machine without being removed from the bag for
sorting;
j. A lavatory equipped
with wrist action controls, a soap dispenser and a towel dispenser shall be
provided in the laundry for use by the personnel;
2. Facilities which do not have laundry
services on site:
a. The facility shall
designate a person to determine that all launderable items processed in a
commercial laundry shall be in accordance with standards set forth in this
section;
b. Soiled, wet, and
contaminated laundry shall be stored in a designated area until pick up by the
commercial laundry;
c. A designated
clean area shall be provided for receiving clean laundry and shall be separate
from the soiled laundry area;
d.
Clean linen shall be packaged and protected from contamination during
transportation and storage.
F. Safety.
1. There shall be an effective program to
enhance safety within the facility and grounds
2. Any fire or disaster event at the facility
shall be reported immediately to the Arkansas Department of Health and Human
Services by telephone 501-661-2201 during regular working hours or to 1-800-554
-5738 or 501-661-2136 after normal working hours, holidays and
weekends.
3. Facilities that permit
smoking in the building shall post "No Smoking" signs in any room or
compartment where flammable liquids, combustible gases, or oxygen is used or
stored, and in any other hazardous locations.
4. There shall be keys available to assure
prompt access to all locked areas. All doors shall be devised so they can be
opened from the inside of the locked area. Special door locking devices are
acceptable in limited areas. Usage is subject to all codes and
regulations.
5. All required exit
doors shall remain unlocked per NFPA requirements.
SECTION 25:
PHYSICAL
FACILITIES
A. General Considerations.
1. The requirements set forth herein have
been established by the Department and constitute minimum requirements for the
design, construction, renovation, and repair of facilities requiring licensure
under these regulations.
2.
Facilities shall be accessible to the public, staff, and patients with physical
disabilities.
3. Projects involving
existing facilities shall be programmed and phased to minimize disruption of
the existing functions. Access, exits and fire protection shall be maintained
for the occupant's and the facility's safety.
4. Codes and Standards. Nothing stated herein
shall relieve the owner from compliance with building codes, ordinances, and
regulations which are enforced by city, county, or other State jurisdictions.
Where such codes, ordinances, and regulations are not in effect, the owner
shall consult the state building codes for all components of the building type
which are not specifically covered by these minimum requirements.
B. Occupancy: Each licensed
facility or portion of a licensed facility shall be classified as indicated
below:
In-patient Direct Care Hospice: In-patient Direct Care Hospice
means a licensed hospice facility that provides direct in-patient care to the
terminally ill.
C. Multiple
Occupancy: Facilities may contain more than one provided each different
occupancy is separated from all other occupancies by a 2-hour fire resistive
rated smoke barrier.
D.
Construction Projects: Each construction project shall be classified as
indicated below:
1. New
2. Addition: A project that increases the
floor area of a licensed facility.
3. Repair: A project that provides for the
repair or renewal of a licensed facility or portion of a licensed facility
solely for the purpose of its maintenance.
4. Simple Renovation: A project other than
repair that meets all of the criteria listed below:
a. The project does not increase the floor
area of a licensed facility.
b. The
project does not change the occupancy of a licensed facility or portion of a
licensed facility.
c. The project
does not involve more than two (2) smoke compartments.
d. The smoke compartments affected by the
project were completely protected by an automatic sprinkler system prior to the
project or the project provides for the installation of a complete automatic
sprinkler system in all smoke compartments that are affected by the
project.
5. Complex
Renovation: A project other than Addition, Repair, or Simple
Renovation.
E.
Applicable Requirements Based upon Occupancy:
Existing Facilities: Existing facilities that do not comply
with these regulations shall be permitted to continue in service, provided the
lack of conformity with these regulations does not present a serious hazard to
the occupants as determined by Health Facility Services or other authorities
having jurisdiction.
F.
Applicable Requirements Based upon the Type of Project:
1. General:
a. Where renovation work is done within an
existing facility, all new work, or additions, or both, shall comply, insofar
as practical with applicable sections of these regulations and appropriate
sections of National Fire Protection Association (NFPA) 101 Life Safety Code
covering new occupancies.
b. In
renovation projects and projects involving additions to existing facilities,
only that portion of the total facility affected by the project shall comply
with applicable sections of these regulations and with appropriate parts of
NFPA 101 covering new occupancies. Existing portions of the facility that are
not included in the project but essential to the functioning of a complete
facility shall comply (at a minimum) with the appropriate sections of NFPA 101
covering existing occupancies. Existing portions of the facility that receive
less than substantial amounts of new work, shall also comply (at a minimum)
with the appropriate sections of NFPA 101 covering existing
occupancies.
c. Facilities or
portions of facilities shall be permitted to be occupied during construction,
renovation, and repair only where required means of egress and required fire
protection features are in place and continuously maintained for the portion
occupied or where alternate life safety measures acceptable to the Division and
other authorities having jurisdiction are in place.
2. New, Addition, Simple Renovation, and
Complex Renovation shall be designed, constructed, and renovated in accordance
with the applicable Sections of these regulations and all Appendices and
publications referenced by these Sections.
3. Repair projects shall be designed and
constructed in a manner that does not diminish the safety level that existed
prior to the start of the work.
G. Project Review and Approval Process.
1. Coordination: Health Facilities Services
will coordinate the review and approval process for all offices of the
Department.
2. New, Addition,
Simple or Complex Renovation Projects shall be reviewed and approved by the
Division as indicated below:
a. Drawing Review
and Approval Process:
1) Submission of Plan
Review Fee: A plan review fee in the amount of one percent of the total cost of
construction or $500.00, whichever is less, shall be paid for the review of
plans and specifications. The plan review fee check is to be made payable to
the Arkansas Department of Health and Human Services. A detailed estimate shall
accompany the plans unless the maximum fee of $500.00 is paid.
2) Submission of Functional Program and Cost
Estimate.
3) Submission of Site
Location.
4) Submission of
Preliminary Plans.
5) Review of
functional program, site location, and preliminary plans: Health Facility
Services shall review the functional program, site location, and preliminary
plans and forward a written response with comments to the Facility.
6) Submission of Final Construction
Documents.
7) Review and Approval
of Final Construction Documents: Health Facility Services shall review the
final construction documents and forward a written response with comments to
the Facility. Health Facility Services shall have a minimum of six (6) weeks to
review final construction Documents. The written response shall indicate
whether or not the final construction documents are approved. If the final
construction documents are not approved, the written response shall indicate
the design modifications required to secure approval.
b. Approval to Begin Construction: Facilities
may proceed with New construction, Addition, Simple or Complex renovation
projects after receiving a letter from Health Facility Services stating that
the final construction documents have been reviewed and approved and after
receiving approval from other authorities having jurisdiction.
c. Site Inspections During
Construction.
d. Final Site
Inspection.
3. Repair:
Repair projects do not require Health Facility Services review and
approval.
H. Site
Location.
1. Roads and Parking.
a. Paved roads and walks shall be provided
within the lot lines to provide access to the main entrance and service
entrance, including loading and unloading docks for delivery trucks. Paved
walkway shall be provided for necessary pedestrian traffic.
b. Each facility shall have parking spaces to
satisfy the minimum needs of patients, employees, staff, and visitors. In the
absence of a formal parking study, each facility shall provide not less than
one space for each day shift staff member and one space for each patient bed.
This ratio may be reduced in an area convenient to a public transportation
system or to a public parking facility if proper justification is given and
provided that approval of any reduction is obtained from the
Department.
2. Subsoil
Investigation. Subsoil investigation shall be made to determine the subsurface
soil and water conditions. The investigation shall include a sufficient number
of test pits or test borings to determine, in the judgment of the architect and
the structural engineer, the true subsurface conditions. Results of the
investigation shall be available in the form of a soil investigation report or
a foundation engineering report. The investigation shall be made in close
cooperation with the architect and structural engineer and shall contain
detailed recommendations for foundation design and gradings.
3. Approval. The new building site shall be
inspected and approved by the Department before construction begins.
I. Preliminary Plans: Preliminary
plans submitted to the Division shall include as a minimum the following
information:
1. Floor plans drawn to scale
that indicate room names, room dimensions, corridor dimensions, locations of
fire resistive rated partitions, and locations of rated smoke
barriers.
2. An existing floor plan
indicating existing spaces and exits and their relationship to the new
construction (renovation projects only).
3. Building sections that establish the
proposed construction type and fire rating. Sections shall be drawn at a scale
sufficiently large to clearly present the proposed construction
system.
4. A site plan that
indicates the location of proposed roads, walks, service and entrance courts,
parking, and orientation.
5. Simple
horizontal and vertical space diagrams that indicate the relationship of
various departments and services to each other and the general room arrangement
in each department.
6. A narrative
description of proposed mechanical, electrical, and fire protection
systems.
J. Final
Construction Documents.
1. Construction
Documents shall be prepared by an architect and/or professional engineer
licensed by the State of Arkansas.
2. Architectural construction documents shall
be prepared by an architect and engineering construction documents (structural,
mechanical, electrical, and civil) shall be prepared by a qualified engineer.
The documents shall be stamped with appropriate seals for each
discipline.
3. Periodic
observations of construction shall be provided and documented by each design
professional. Design professionals shall verify that the construction is in
accordance with the construction documents and that the Record Drawings are
properly maintained.
4. The
construction contract shall contain a provision to withhold progress payments
to the contractor until the Record Drawings are current.
5. Final Construction Documents shall include
drawings and specifications. Separate drawings and specifications shall be
prepared for each of the following branches of work: architectural, structural,
mechanical, electrical, life safety and fire protection.
a. Specifications: Specifications shall
supplement the drawings to fully describe types, sizes, capacities,
workmanships, finishes, and other characteristics of all materials and
equipment and shall include the following:
1)
Cover or title sheet with architectural seal;
2) Index;
3) General conditions;
4) General requirements;
5) Sections describing material and
workmanship in detail for each class of work.
b. All construction documents and
specifications shall be approved by the Department prior to the beginning of
construction and a letter shall be issued from the licensing agency granting
approval to commence with construction. The Department shall have a minimum of
six (6) weeks to review construction documents and specifications. Health
Facility Services shall coordinate the plan review with other Divisions in the
Department.
K. Site Inspection During Construction. The
Department shall inspect the project during the construction process as
indicated below:
1. This Department is to be
notified when construction begins and a construction schedule shall be
submitted to determine inspection dates.
2. Representatives from the Department shall
have access to the construction premises and the construction project for
purposes of making whatever inspections deemed necessary throughout the course
of construction.
3. Any deviation
from the accepted construction documents shall not be permitted during
construction, until the written request for change(s) in the construction is
approved by the Department.
L. Final Site Inspection.
1. Upon completion of construction and prior
to the approval by the Department to occupy and use the facility, the owner
shall be furnished a complete set of Record Drawings and a complete set of
installation, operation, and maintenance manuals and parts lists for the
installed equipment.
2. A list of
final site inspection items has been provided in Table 5 of the
Appendix.
3. No facility shall
occupy any new structure or major addition or renovation space until the
appropriate permission has been received from the local building and fire
authorities and licensing agency.
SECTION 26:
PHYSICAL FACILITIES,
PATIENT ACCOMMODATIONS FOR HOSPICE FACILITIES
A. Patient Rooms. Each patient room shall
meet the following requirements.
1. Maximum
room capacity shall be two patients.
2. In new construction, patient rooms shall
have a minimum of 100 square feet of clear floor area per bed in semi-private
rooms and 120 square feet of clear floor area for single-bed rooms, exclusive
of toilet rooms, closets, lockers, wardrobes, alcoves or vestibules. The
dimensions and arrangement of rooms shall be such that there is a minimum of
three feet between the sides and foot of the bed and any wall, other fixed
obstruction, or another bed. In semi-private bed rooms, a clearance of four
feet shall be available at the foot of each bed to permit the passage of
equipment and beds.
Minor encroachments, including columns and lavatories, that do
not interfere with functions may be ignored when determining space requirements
for patient rooms. Where renovation work is undertaken, every effort shall be
made to meet the above minimum standards.
3. Each patient room shall have a window with
outside exposure and where the operation of windows or vents requires the use
of tools or keys, such devices shall be on the same floor and easily accessible
to staff. The windowsills shall not be higher than three feet above the floor
and shall be above the grade. Patient rooms in new construction intended for 24
hour occupancy shall have windows. If operable windows are installed, such
devices shall be restricted to inhibit possible escape or suicide.
4. Each patient shall have access to a toilet
room without having to enter the general corridor area. One toilet room shall
serve no more than four patient beds and no more than two patient rooms. In new
construction, an additional hand washing station or sanitizing station shall be
placed in the patient room where the toilet room serves more than one bed. The
toilet room shall contain a water closet and a hand washing station and the
door shall swing outward or be double acting.
5. Each patient shall have within the room a
separate wardrobe or closet that is suitable for hanging full length garments
and for storing personal items.
6.
Visual privacy from casual observation by other patients and visitors shall be
provided for each patient in semi-private rooms with cubicle curtains or
equivalent built-in or movable dividers. The method for providing privacy shall
not obstruct passage of other patients either to the entrance, toilet, or
lavatory. All curtains shall have a flame spread of 0 to 25 and shall comply
with NFPA 13 requirements for clear space below sprinklers.
7. Each room shall connect directly with a
corridor without passage through another patient's room.
8. Rooms existing partially below grade level
shall not be used for patients unless they are dry, well ventilated, and are
otherwise suitable for occupancy.
9. Beds shall be arranged to provide adequate
room for all patient care procedures and to prevent the transmission of
infections.
10. Suitable beds shall
be provided. Bed rails shall be provided on beds for children.
11. A reading light shall be provided for
each patient bed. The location and design shall be such that the light is not
annoying to other patients.
12. A
bedside table with drawer shall be provided for each bed. The lower portion of
the table and/or enclosed shelves shall be provided for individual nursing care
equipment.
13. A bathing facility
containing either a bathtub or a shower accessible to a wheeled shower chair
shall be conveniently accessible to patient rooms. An accessible toilet room
shall be accessible to the bathing room.
B. Service Areas. Each service area may be
arranged and located to serve more than one nursing unit but at least one such
service area shall be provided on each nursing floor. Some of the service areas
may be combined in a single space. The following service areas shall be located
in or readily available to each nursing unit:
1. Nursing Station. Facilities for charting,
clinical records, work counter, communication system, space for supplies and
convenient access to hand washing stations shall be provided. It may be
combined with or include centers for reception and communication;
2. Dictation area shall be provided. This
area shall be adjacent to but separate from the nurses' station;
3. Toilet room(s) for staff convenient to
nurses' station (may be unisex);
4.
Multi-purpose room(s) for staff, patients, patients' families for patient
conferences, reports, education, training sessions, and consultation
5. Clean workroom or clean supply room. If
the room is used for preparing patient care items, it shall contain a work
counter, a hand washing fixture, and storage facilities for clean and sterile
supplies. If the room is used only for storage and holding as part of a system
for distribution of clean and sterile materials, the work counter and hand
washing fixture may be omitted. Soiled and clean workrooms or holding rooms
shall be separated and have no direct connection;
6. Soiled workroom or soiled holding room.
This room shall be separate from the clean workroom. The soiled workroom shall
contain a clinical sink (or equivalent flushing-rim fixture). The room shall
contain a lavatory (or hand washing fixture). The above fixtures shall both
have a hot and cold mixing faucet. The room shall have a work counter and space
for separate covered containers for soiled linen and waste. Rooms used only for
temporary holding of soiled material may omit the clinical sink and work
counter. If the flushing-rim clinical sink is eliminated, facilities for
cleaning bedpans shall be provided elsewhere;
7. Medication Station. Provisions shall be
made for distribution of medications. This may be done from a medicine
preparation room or unit, from a self-contained medicine dispensing unit, or by
another approved system;
a. Medicine
preparation room. This room shall be designed to allow for visual supervision
by the nursing staff. It shall contain a work counter, a sink adequate for hand
washing, refrigerator, and locked storage for controlled drugs. When a medicine
preparation room is to be used to store one or more self-contained medicine
dispensing units, the room shall be designed with adequate space to prepare
medicines with the self-contained medicine dispensing unit(s)
present.
b. Self-contained medicine
dispensing unit. A self-contained medicine dispensing unit may be located at
the nurses' station, in the clean workroom, or in an alcove, provided the unit
has adequate security for controlled drugs and adequate lighting to easily
identify drugs. Convenient access to hand washing stations shall be provided.
(Standard cup-sinks provided in many self-contained units are not adequate for
hand washing.)
8.
Nourishment Station. This shall contain a sink equipped for handwashing,
equipment for serving nourishment between scheduled and unscheduled meals,
refrigerator, storage cabinets, and ice maker units to provide ice for
patients' service and treatment. Ice for human consumption shall be from
self-dispensing units. Hand washing stations shall be in or immediately
accessible to the nourishment station;
9. Equipment Storage Room. This shall be for
equipment such as I.V. stands, inhalators, air mattresses, walkers and
wheelchairs; and
10. A comfortable
and easily accessible sleep area for family members.
C. A common kitchen area if provided shall
contain a refrigerator, sink and microwave.
D. Dining and/or gathering space for patients
and families shall be provided as required by the narrative program.
E. Airborne Infection Isolation Room(s).
Rooms for patients who are suffering from airborne infections shall be provided
at the rate of one for each 36 beds or fraction thereof.
SECTION 27:
PHYSICIAL FACILITIES,
PHARMACY
The size and type of services to be provided in the pharmacy
can largely depend upon the type of medication distribution system used, number
of patients to be served, and extent of shared or purchased services. This
shall be described in the narrative functional program. The pharmacy room or
suite shall be located for convenient access, staff control, and security.
Facilities and equipment shall be as necessary to accommodate the functions of
the program. See Section 22(D) Pharmacy for additional requirements. As a
minimum, the following elements shall be included:
A. Dispensing.
1 A pickup and receiving area.
2. An area for reviewing and
recording.
3. An extemporaneous
compounding area that includes a sink and sufficient counter space for
medication preparation.
4. Work
counters and space for automated and manual dispensing activities.
5. An area for temporary storage, exchange,
and restocking of carts.
6.
Security provisions for medications and personnel in the dispensing counter
area.
B. Manufacturing.
1. A bulk compounding area.
2. Provisions for packaging and
labeling.
3. A quality control
area.
C. Storage (may be
cabinets, shelves, and/or separate rooms or closets).
1. Bulk storage.
2. Active storage.
3. Refrigerated storage.
4. Volatile fluids and alcohol storage
constructed according to applicable fire safety codes for the substances
involved.
5. Double-locked storage
for controlled substances.
6.
Storage for general supplies and equipment not in use.
D. Administration.
1. An area for education and training (may be
in a multipurpose room shared with other departments).
2. A separate area for office
functions.
E. Other.
1. Hand washing facilities stations shall be
provided within each separate room where open medication is handled and readily
accessible.
2. Provide for
convenient access to toilet and locker.
3. If unit dose procedure is used, provide
additional space and equipment for supplies, packaging, labeling, and storage,
as well as for the carts.
4. If IV
solutions are prepared in the pharmacy, provide a sterile work area with a
laminar-flow work station designed for product protection. The laminar-flow
system shall include a nonhydroscopic filter (HEPA) rated at 99.97 percent, as
tested by DOP tests and have a visible pressure gauge for detection of filter
leaks or defects.
5. Hoods used for
chemotherapy shall be 100 percent exhausted to the exterior.
6. As a minimum the partitions enclosing the
pharmacy shall extend from the floor to the deck above, with gypsum board on
both sides of metal studs.
SECTION 28:
PHYSICAL FACILITIES, WASTE
PROCESSING SERVICES
A. Hazardous Waste
and Antineoplastic Agent Disposal. The facility shall have policies and
procedures for the identification, segregation, labeling, storage, transport
and disposal of hazardous waste. The policies and procedures shall conform with
the latest edition of Hazardous Waste Management Regulation 23,
Arkansas Department of Environmental Quality, Little Rock,
Arkansas. Within the facility, hazardous waste, especially
antineoplastic agents, shall be labeled in a manner that it shall be easily
recognized from all other waste. The facility shall compile a list of all
antineoplastic agents used in the facility. The facility shall have policies
and procedures for the clean up of spills, decontamination and treatment of
personnel exposed to hazardous waste and antineoplastic agents.
B. Regulated Medical Waste (Infectious Waste)
Disposal. The facility shall have policies and procedures for the
identification, segregation, labeling, storage, transport and disposal of
regulated medical waste. All policies and procedures shall conform to the
latest edition of the Rules and Regulations Pertaining to the
Management of Medical Waste from Generators and Health Care Related Facilities,
Arkansas Department of Health and Human Services, Little Rock,
Arkansas. The facility shall have policies and procedures for the
clean up of spills, and for decontamination and treatment of personnel exposed
to regulated medical waste.
C.
Solid Waste Disposal (Non-Infectious Waste). The facility shall have policies
and procedures for the identification, segregation, labeling, storage,
transport and disposal of solid waste. Policies and procedures shall conform
with the latest edition of the Solid Waste Management Regulation
22, Arkansas Department of Environmental Quality, Little Rock,
Arkansas.
D. Other
Waste. The facility shall have policies and procedures for the identification,
segregation, labeling, storage, transport, and disposal of any waste not
specifically mentioned in this section.
SECTION 29:
PHYSICAL FACILITIES,
DETAILS AND FINISHES
All details for alteration or expansion projects as well as for
new construction shall comply with the following.
A. Details.
1. Compartmentation, exits, automatic
extinguishing systems, and other details relating to fire prevention and fire
protection shall comply with requirements listed in the NFPA referenced codes,
shall be maintained at the facility and shown on the Fire Protection
Plan.
2. Corridor partitions, smoke
stop partitions, horizontal exit partitions, exit enclosures, and fire rated
walls required to have protected openings shall be effectively and permanently
identified with signs or stenciling in a manner acceptable to the Health
Facility Services. Such identification shall be above any decorative ceiling
and in concealed spaces.
3. Rooms
containing bathtubs, sitz baths, showers, and water closets, subject to
occupancy by patients, shall be equipped with doors and hardware which shall
permit access from the outside the room.
4. Glass doors, lights, sidelights, borrowed
lights, and windows located within 12 inches of a door jamb (with a bottom
frame height of less than 60 inches above the finished floor) shall be
constructed of safety glass, wired glass, or plastic, break resistant material
that creates no dangerous cutting edges when broken. Safety glass-tempered or
plastic glazing materials shall be used for shower doors and bath enclosures.
In renovation projects, only glazing within 18 inches of the floor shall be
changed to safety glass, wire glass, or plastic, break-resistant
material.
5. Thresholds and
expansion joint covers shall be installed flush with the floor surface to
facilitate use of wheelchairs and carts. Expansion and seismic joints shall be
constructed to restrict the passage of smoke.
6. Grab bars shall be provided in all
patients' toilets, showers, tubs, and sitz baths. The bars shall have one and
one-half inch clearance to walls and shall have sufficient strength and
anchorage to sustain a concentrated load of 250 pounds.
7. Lavatories and hand washing stations shall
be securely anchored to withstand an applied downward vertical load of not less
than 250 pounds on the front of the fixture.
8. The minimum ceiling height shall be seven
feet ten inches with the following exceptions:
a. Boiler rooms shall have ceiling clearances
not less than two feet six inches above the main boiler header and connecting
piping.
b. Ceilings in corridors,
storage rooms, and toilet rooms shall be not less then seven feet eight inches
in height. Ceiling heights in small, normally unoccupied spaces may be
reduced.
c. Where existing
structures make the above ceiling clearance impractical, clearances shall be as
required to avoid injury to individuals up to six feet four inches
tall.
9. Rooms
containing heat-producing equipment (such as boiler or heater rooms and
laundries) shall be insulated and ventilated to prevent any floor or partition
surface from exceeding a temperature of ten degrees Fahrenheit above ambient
room temperature.
10. Noise
reduction criteria shown in Table 2 of the Appendix shall apply to partition,
floor, and ceiling construction in patient areas. (Careful attention shall be
given to penetrations.)
11. Light
fixtures shall be provided with protective covers in food preparation, serving
areas, and patient care and treatment spaces. Protective light fixture covers
are not required in corridors.
12.
Handrails shall be provided in all corridors used by patients.
B. Finishes.
Floors and walls penetrated by pipes, ducts, and conduits shall
be tightly sealed to minimize entry of rodents and insects.
SECTION 30:
PHYSICAL
FACILITIES, CONSTRUCTION, INCLUDING FIRE RESISTIVE REQUIREMENTS
A Design. Every building and every portion
thereof shall be designed and constructed to sustain all dead and live loads in
accordance with American Society of Civil Engineers, (ASCE), "Minimum Design
Loads for Buildings and Other Structures."
B. Foundations. Foundations shall rest on
natural solid bearing if a satisfactory bearing is available at reasonable
depths. Proper soil-bearing values shall be established in accordance with
recognized standards. If solid bearing is not encountered at practical depths,
the structure shall be supported on drive piles or drilled piers designed to
support the intended load without detrimental settlement, except that one story
buildings may rest on a fill designed by a soils engineer. When engineered fill
is used, site preparation and placement of fill shall be performed under the
direct full-time supervision of the soils engineer. The soils engineer shall
issue a final report on the compacted fill operation and certification of
compliance with the job specifications. All footings shall extend to a depth
not less than one foot below the estimated maximum frost line.
C. Construction.
1. Construction shall comply with the
applicable requirements of NFPA 101, and the Arkansas Fire Protection Code
Volumes I and II and Arkansas State Building Services, Minimum Standards and
Criteria - Accessibility for the Physically Disabled Standards.
NOTE: NFPA 101 generally covers fire/safety requirements only,
whereas most model codes also apply to structural elements. The fire/safety
items of NFPA 101 would take precedence over other codes in case of conflict.
In the event NFPA 101 does not specifically address a life safety requirement
found only in the Arkansas Fire Prevention Code, compliance with the
requirement is not mandatory. Appropriate application of each would minimize
problems. For example, some model codes require closers on all patient doors.
NFPA 101 recognizes the potential fire/safety problems of this requirement and
stipulates that if closers are used for patient room doors, smoke detectors
shall also be provided within each affected patient room.
2. For renovation projects, the extent of new
construction shall be determined by the licensing agency. Construction shall
comply with applicable requirements of NFPA 101.
D. Elevators. All facilities located on other
than the grade-level entrance floor shall have electric or hydraulic elevators.
Elevator cars shall have inside dimensions that accommodate a patient bed with
attendants. Cars shall be at least five feet eight inches wide by nine feet
deep. Car doors shall have a clear opening of not less than four feet wide and
seven feet high. In renovations, existing elevators that can accommodate
patient beds used in the facility will not be required to be increased in size.
NOTE: Additional elevators installed for visitors and material
handling may be smaller than noted above, within restrictions set by standards
for disabled access.
SECTION
31:
PHYSICAL FACILITIES, PLUMBING AND OTHER PIPING
SYSTEMS
All plumbing systems shall be designed and installed in
accordance with the requirements of the latest edition of the Arkansas State
Plumbing Code and the latest edition of the Laws, Rules, and Regulations
Governing Boiler Inspection, Arkansas Department of Labor.
SECTION 32:
PHYSICAL FACILITIES,
ELECTRICAL STANDARDS
A. Lighting.
1. Approaches to buildings and parking lots,
and all occupied spaces within buildings shall have fixtures that can be
illuminated as necessary.
2.
Patient rooms shall have general lighting and night lighting.
3. Nursing unit corridors shall have general
illumination with provisions for reducing light levels at night.
4. Egress and exit lighting shall comply with
NFPA 101.
B.
Nurse/Patient Communication Station.
1. A
nurse/patient communication system shall be provided for each patient bedside
as in accordance with the functional program.
2. An emergency call system shall be provided
in each patient's toilet, bath and shower room.
C. Emergency electrical generators shall have
a minimum 48 hours of on-site fuel.
D. All health care occupancies shall be
provided with a fire alarm system in accordance with NFPA 101 and NFPA
72.
SECTION 33:
SEVERABILITY
If any provision of tliese Rules and Regulations for Hospice in
Arkansas or the application thereofto any person or circumstances is held
invalid, such invalidity shall not affect other provisions or applications of
the Rules which can be given effect without the invalid provision or
application and to this end the provisions of these Rules are declared to be
severable.
SECTION 34:
SATELLITE OFFICE OR ALTERNATE DELIVERY SITE
A licensed agency shall file an application under oath with the
Department upon forms prescribed by the Department prior to beginning operation
of a satellite office. The Department will review the application and issue a
written approval or denial of the application. A satellite office must provide
the same full range of services that is required of the licensed parent
hospice. The governing body and administration of the parent hospice must be
able to exert the supervision and control necessary to assure that all hospice
services continue to be responsive to the needs of the patient / family. Each
patient of the satellite office must be assigned to a specific IDG. Current
active patient records will be maintained by the satellite office but must be
available to the state surveyors at the parent location if requested. Locations
that do not meet these criteria will not be approved as a satellite office and
must obtain a separate license.
APPENDIX TABLE
1
|
Filter Efficiencies for Central Ventilation and
Air Conditioning Systems in Health Care Facilities
|
|
Area Designation
|
No. Filter Beds
|
Filter Bed No.1 (%)
|
Filter Bed No.2 (%)
|
|
All areas for patient care, treatment, and diagnosis,
and those areas providing direct service or clean supplies such as sterile and
clean processing.
|
2
|
30
|
90
|
|
Positive Protective Environment Room
|
2
|
30
|
99.97
|
|
Laboratories
|
1
|
80
|
-
|
|
Administrative, Bulk Storage, Soiled Holding Areas,
Food Preparation Areas, and Laundries
|
1
|
30
|
-
|
Notes: The filtration efficiency ratings are based on average
dust spot efficiency per ASHRAE 52-76.1 - 1992.
Additional roughing or prefilters should be considered to
reduce maintenance required for filters with efficiencies higher than 75
percent.
TABLE 2
|
Sound Transmission Limitations in Health Care
Facilities
|
|
|
Airborne Sound Transmission Class
(STC)1
|
|
Partitions
|
Floors
|
|
NEW CONSTRUCTION2
|
|
|
|
Patients' Room to Patients' Room
|
45
|
40
|
|
Public Space to Patients'
Room2
|
55
|
40
|
|
Service Areas to Patients'
Room3
|
65
|
45
|
|
Patient room access corridor
4
|
45
|
45
|
|
Toilet room to public space
|
45
|
____
|
|
Consultation rooms/
conference rooms to public space
|
45
|
____
|
|
Consultation rooms/
Conference rooms to patient rooms
|
45
|
____
|
|
Staff lounges to patient rooms
|
45
|
____
|
|
Existing
Construction
|
|
|
|
Patient room to patient room
|
35
|
40
|
|
Public space to patient room
2
|
40
|
40
|
|
Service areas to patient room
3
|
45
|
45
|
1. Sound
transmission class (STC) shall be determined by tests in accordance with
methods set forth in ASTM Standard E90 and ASTM E413. Where partitions do not
extend to the structure above, sound transmission through ceilings and
composite STC performance shall be considered.
2. Public space includes corridors (except
patient room access corridors), lobbies, dining rooms, recreation rooms, and
similar spaces.
3. Service areas
include kitchens, elevators, elevator machine rooms, laundries, and similar
spaces garages, maintenance rooms, boiler and mechanical equipment rooms, and
similar spaces of high noise. Mechanical equipment located on the same floor or
above patient rooms, offices, nurses stations, and similar occupied space shall
be effectively isolated from the floor.
6. Patient room access corridors contain
composite walls with doors/windows and have direct access to patient
TABLE 3
|
Temperature and Relative Humidity
Requirements
|
|
Area Designation
|
Dry Bulb Temperatures oF1
|
Relative Humidity (%)
Minimum-Maximum2
|
|
Sterile Storage
|
75
|
70 (max)
|
1 Note: Where temperature ranges are
indicated, the systems shall be capable of maintaining the rooms at any point
within the range. A single figure indicates a heating or cooling capacity of at
least the indicated temperature. This is usually applicable when patients may
be undressed and require a warmer environment. Nothing in these guidelines
shall be construed as precluding the use of temperatures lower than those noted
when the patients' comfort and medical conditions make lower temperatures
desirable. Unoccupied areas such as storage rooms shall have temperatures
appropriate for the function intended.
TABLE 4
Ventilation, Medical Gas, and Air Flow Requirements
in Health Care Facilities1
|
Area Designation
|
Air
Movement
Relationship
To Adjacent
Area2
|
Minimum Air
Changes Outside
Air Per Hour3
|
Minimum Total Air Changes Per
Hour4,5
|
Air Recirculated By Means of
Room Units7
|
All Air Exhausted Directly
Outdoor6
|
|
NURSING AREAS
|
|
|
|
|
|
|
Patient Room
|
-
|
2
|
6
9
|
Optional
|
Optional
|
|
Toilet Room
|
In
|
-
|
10
|
Optional
|
Yes
|
|
Protective environment room
8,
10
|
Out
|
2
|
12
|
No
|
Optional
|
|
Airborne Infectious Isolation
8,
11
|
In
|
2
|
12
|
No
|
Yes
|
|
Patient Corridor
|
-
|
-
|
2
|
Optional
|
Optional
|
|
ANCILLARY AREAS
|
|
|
|
|
|
|
Pharmacy
|
Out
|
-
|
4
|
Optional
|
Optional
|
|
DIAGNOSTIC AND TREATMENT AREAS
|
|
|
|
|
|
Soiled Workroom or Soiled Holding
|
In
|
-
|
10
|
No
|
Yes
|
|
Clean Workroom or Clean Holding
|
Out
|
-
|
4
|
Optional
|
Optional
|
|
SERVICE AREAS
|
|
|
|
|
|
|
Food Preparation
Centers12
|
-
|
-
|
10
|
No
|
Optional
|
|
Warewashing
|
In
|
-
|
10
|
No
|
Yes
|
|
Dietary Day Storage
|
In
|
-
|
2
|
Optional
|
Optional
|
|
Laundry, General
|
-
|
-
|
10
|
Optional
|
Yes
|
|
Soiled Linen Sorting and Storage
|
In
|
-
|
10
|
No
|
Yes
|
|
Clean Linen Storage
|
Out
|
-
|
2
|
Optional
|
Optional
|
|
Soiled Linen and Trash Chute Room
|
In
|
-
|
10
|
No
|
Yes
|
|
Bedpan Room
|
In
|
-
|
10
|
Optional
|
Yes
|
|
Bathroom
|
In
|
-
|
10
|
Optional
|
Optional
|
|
Janitor's closet
|
In
|
-
|
10
|
No
|
Yes
|
Notes for Table 4
1.
The ventilation rates in this table cover ventilation for comfort, as well as
for asepsis and odor control in areas that directly affect patient care and are
determined based on healthcare facilities being predominantly "No Smoking"
facilities. Where smoking may be allowed, ventilation rates will need
adjustment. Areas where specific ventilation rates are not given in the table
shall be ventilated in accordance with ASHRAE Standard 62, Ventilation for
Acceptable Indoor Air Quality; and ASHRAE Handbook-HVAC Applications.
OSHA standards and/or NI0SH criteria require special ventilation
requirements for employee health and safety within healthcare
facilities.
2. Design of the
ventilation system shall provide air movement which is generally from clean to
less clean areas. If any form of variable air volume or load shedding system is
used for energy conservation, it shall not
3. compromise the corridor-to-room pressure
balancing relationships or the minimum air changes required by the
table.
4. To satisfy exhaust needs,
replacement air from the outside is necessary. Table 4 does not attempt to
describe specific amounts of outside air to be supplied to individual spaces
except for certain areas such as those listed. Distribution of the outside air,
added to the system to balance required exhaust, shall be as required by good
engineering practice. Minimum outside air quantities shall remain constant
while the system is in operation.
5. Number of air changes may be reduced when
the room is unoccupied if provisions are made to ensure that the number of air
changes indicated is reestablished any time the space is being utilized.
Adjustments shall include provisions so that the direction of air movement
shall remain the same when the number of air changes is reduced. Areas not
indicated as having continuous directional control may have ventilation systems
shut down when space Is unoccupied and ventilation is not otherwise needed, if
the maximum infiltration or exfiltration permitted in Note 2 is not exceeded
and if adjacent pressure balancing relationships are not compromised. Air
quantity calculations shall account for filter loading such that the indicated
air change rates are provided up until the time of filter change-out.
6. Air change requirements indicated are
minimum values. Higher values should be used when required to maintain
indicated room conditions (temperature and humidity), based on the cooling load
of the space (lights, equipment, people, exterior walls and windows,
etc.).
7. Air from areas with
contamination and/or odor problems shall be exhausted to the outside and not
recirculated to other areas.
8.
Recirculating room HVAC units refers to those local units that are used
primarily for heating and cooling of air, and not disinfection of air. Because
of cleaning difficulty and potential for buildup of contamination,
recirculating room units shall not be used in areas marked "No." However, for
airborne infection control, air may be recirculated within Individual isolation
rooms if HEPA filters are used. Isolation rooms may be ventilated by reheat
induction units in which only the primary air supplied from a central system
passes through the reheat unit.
9.
Differential pressure shall be a minimum of 0.01" water gauge (2.5 Pa). If
alarms are installed, allowances shall be made to prevent nuisance alarms of
monitoring devices.
10. Total air
changes per room for patient rooms may be reduced to 4 when supplemental
heating and/or cooling systems (radiant heating and cooling, baseboard heating,
etc.) are used.
11. The protective
environment airflow design specifications protect the patient from common
environmental airborne infectious microbes (i.e., Aspergillus spores). These
special ventilation areas shall be designed to provide directed airflow from
the cleanest patient care area to less clean areas. These rooms shall be
protected with HEPA filters at 99.97 percent efficiency for a 0.3 micron sized
particle in the supply airstream. These Interrupting filters protect patient
rooms from maintenance-derived release of environmental microbes from the
ventilation system components. Recirculation HEPA filters can be used to
increase the equivalent room air exchanges. Constant volume airflow is required
for consistent ventilation for the protected environment. It the facility
determines that airborne infection isolation is necessary for protective
environment patients, an anteroom shall be provided. Rooms with reversible
airflow provisions for the purpose of switching between protective environment
and airborne infection isolation functions are not acceptable.
12. The infectious disease isolation room
described in these guidelines is to be used for isolating the airborne spread
of infectious diseases, such as measles, varicella, or tuberculosis. The design
of airborne infection isolation (All) rooms should include the provision for
normal patient care during periods not requiring Isolation precautions.
Supplemental recirculating devices may be used in the patient room, to increase
the equivalent room air exchanges; however, such recirculating devices do not
provide the outside air requirements. Air may be recirculated within individual
isolation rooms if HEPA filters are used. Rooms with reversible airflow
provisions for the purpose of switching between protective environment and All
functions are not acceptable.
12.
Food preparation centers shall have ventilation systems whose air supply
mechanisms are interfaced appropriately with exhaust hood controls or relief
vents so that exfiltration or infiltration to or from exit corridors does not
compromise the exit corridor restrictions of NFPA 90A, the pressure
requirements of NFPA 96, or the maximum defined in the table. The number of air
changes may be reduced or varied to any extent required for odor control when
the space is not in use.
TABLE 5
Final Occupancy Inspection Check List
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Referenced Publications
1. General: These regulations include
references to other codes and standards. The most current codes and standards
adopted at the time of this publication are used. Later issues will normally be
acceptable where requirements for function and safety are not reduced; however,
editions of different dates may have portions renumbered or re-titled. Care
shall be taken to ensure that appropriate sections are used.
2. Publications adopted in whole by these
regulations are as listed below:
a. American
National Standards Institute (ANSI) Standard A17.1, "American National Standard
Safety Code for Elevators, Dumbwaiters, Escalators and Moving
Stairs."
b. American Society of
Civil Engineers, (ASCE), "Minimum Design Loads for Buildings and Other
Structures."
c. National Fire Codes
- 2002.
d. Rules and Regulations
Pertaining to the Management of Regulated Waste from Health Care Related
Facilities, Arkansas Department of Health and Human Services.
3. Publications adopted in part
(only the sections specifically identified by these regulations are applicable)
by these regulations are as listed below:
a.
American Society of Heating, Refrigerating and Air Conditioning Engineers
(ASHRAE), "Handbook of Fundamentals" and "Handbook of Applications."
b. American Society of Heating, Refrigerating
and Air Conditioning Engineers (ASHRAE), Standard 52, "Method of Testing Air
Cleaning Devices Used in General Ventilation for Removing Particulate
Matter."
c. Illuminating
Engineering Society of North America, IESNA Publication CP29, "Lighting for
Health Care Facilities."
4. A partial list of other publications that
are applicable to the design and construction of healthcare facilities that are
not a part of these regulations but may be enforced by other authorities having
jurisdiction is provided below:
a. Arkansas
State Fire Prevention Code Volumes I, II, and III (based on the
2000 International Building Code).
b. Arkansas State Mechanical Code, Arkansas
Department of Health and
Human Services.
c. Arkansas State Plumbing Code, Arkansas
Department of Health and Human
Services.
d. Arkansas Boiler Code, Arkansas Department
of Labor.
5.
Publications that are not a part of these regulations but potentially helpful
as reference material in the design and construction of healthcare facilities
are as listed below:
a. American Institute of
Architects (AIA), "Guidelines for Design and Construction of Hospital and
Health Care Facilities 2001 Edition".
b. American Society of Heating,
Refrigeration, and Air Conditioning Engineers (ASHRAE), "HVAC Design Manual for
Hospitals and Clinics".
6. Availability of Codes and Standards.
Referenced publications can be ordered, if they are Government publications,
from the Superintendent of Documents, U.S. Government Printing Office (GPO),
Washington, DC 20402. Copies of non-government publications can be obtained at
the addresses listed below.
a. Air
Conditioning and Refrigeration Institute, 1501 Wilson Boulevard, Arlington, VA
22209.
b. American National
Standards Institute, 1430 Broadway, New York, NY10018.
c. American Society of Civil Engineers, 345
East 47th Street, New York, NY 10017.
d. American Society for Testing and
Materials, 1916 Race Street, Philadelphia, PA 19103.
e. American Society of Heating,
Refrigerating, and Air Conditioning, 1741 Tullie Circle, NE, Atlanta GA
30329.
f. Arkansas Building
Authority, 1515 West 7th Street, Suite 700, Little Rock, AR 72201.
g. Arkansas Department of Labor, 10421 West
Markham, Little Rock, AR 72205.
h.
Illuminating Engineering Society of North America (lESNA), 120 Wall
Street, 17th Floor, New York, NY 10005.
i. National Fire Protection Association, 1
Batterymarch Park, Post Office
Box 9101, Quincy, MA 02269-9101.
j. International Building Code Congress
International, Inc., 900 Montclair
Road, Birmingham, AL 35213.
7. Interpretations of Requirements.
Memorandum of Understanding: Conflicts between the Arkansas Fire Prevention
Code and NFPA 101 Life Safety Code are to be resolved using the Memorandum of
Understanding as indicated below:
a. The
Arkansas Fire Prevention Code is the fire prevention code for the State of
Arkansas.
b. When the Arkansas
State Fire Prevention Code conflicts with the chapters of NFPA 101 Life Safety
Code governing new and existing health care and ambulatory health care
occupancies (Chapters 18, 19, 20, and 21), the provisions of the Life Safety
Code shall govern.
c. Requirements
found only in the Arkansas Fire Prevention Code (requirements not addressed by
NFPA 101) may be provided at the option of the facility (compliance with these
requirements is not mandatory).
7. Safety Improvement Plans: Nothing in these
regulations shall be construed as restrictive to a facility that chooses to do
work as a part of a long-range safety improvement plan.
8. Provisions in Excess of Regulatory
Requirements: Nothing in these regulations shall be construed to prohibit a
better type of building construction, an additional means of egress, or an
otherwise safer condition than that specified by the minimum requirements of
these regulations.
9. Equivalency:
The Division may approve alternate methods, procedures, design criteria, and
functional variations from these regulations, because of extraordinary
circumstances, new programs, new technology, or unusual conditions when the
facility can effectively demonstrate that the intent of the regulations is met
and that the variation does not reduce the safety or operational effectiveness
of the facility below that required by the exact language of the
regulations.
