Indiana Administrative Code
Title 410 - INDIANA DEPARTMENT OF HEALTH
Article 15 - HOSPITAL LICENSURE RULES
Rule 1.5 - Required Hospital Services
Section 1.5-8 - Physical plant, maintenance, and environmental services
Universal Citation: 410 IN Admin Code 1.5-8
Current through March 20, 2024
Authority: IC 16-21-1-7
Affected: IC 16-21-1
Sec. 8.
(a) The hospital shall be constructed, arranged, and maintained to ensure the safety of the patient and to provide facilities for services authorized under the hospital license as follows:
(1) The plant
operations and maintenance service, equipment maintenance, and environmental
service shall be:
(A) staffed to meet the
scope of the services provided; and
(B) under the direction of a person or
persons qualified by education, training, or experience.
(2) There shall be a safety officer
designated to assume responsibility for the safety program.
(3) The hospital shall provide a physical
plant and equipment that meet the statutory requirements and regulatory
provisions of the state department of fire and building services, including 675
IAC 22, Indiana fire prevention codes, and 675 IAC 13, Indiana building
codes.
(b) The condition of the physical plant and the overall hospital environment shall be developed and maintained in such a manner that the safety and well-being of patients are assured as follows:
(1) No condition in the
facility or on the grounds shall be maintained that may be conducive to the
harborage or breeding of insects, rodents, or other vermin.
(2) No condition shall be created or
maintained that may result in a hazard to patients, public, or
employees.
(3) There shall be
emergency power and lighting in accordance with National Fire Protection
Association (NFPA) 99.
(4) There
shall be a plan for emergency fuel and water supply.
(5) Provision shall be made for the periodic
inspection, preventive maintenance, and repair of the physical plant and
equipment by qualified personnel as follows:
(A) Operation, maintenance, and spare parts
manuals shall be available, along with training or instruction of the
appropriate personnel, in the maintenance and operation of the fixed and
movable equipment.
(B) Operational
and maintenance control records shall be established and analyzed periodically.
These records shall be readily available on the premises.
(C) Maintenance and repairs shall be carried
out in accordance with applicable codes, rules, standards, and requirements of
local jurisdictions, the administrative building council, the state fire
marshal, and the department.
(c) In new construction, renovations, and additions, the hospital site and facilities, or nonlicensed facilities acquired for the purpose of providing hospital services, shall meet the following:
(1) The 2001 edition of the national
"Guideline for Construction and Equipment of Hospital and Medical Facilities"
(Guidelines).
(2) All building,
fire safety, and handicapped accessibility codes and rules adopted and
administered by the state building commissioner shall apply to all facilities
covered by this rule and take precedence over any building, fire safety, or
handicapped accessibility requirements of the Guidelines.
(3) When renovation or replacement work is
done within an existing facility, all new work or addition, or both, shall
comply, insofar as practical, with applicable sections of the Guidelines and
for certification with appropriate parts of National Fire Protection
Association (NFPA) 101 (2000 Edition).
(4) Proposed sites shall be located away from
detrimental nuisances, well drained, and not subject to flooding. A site survey
and recommendations shall be obtained from the department prior to site
development.
(5) Water supply and
sewage disposal services shall be obtained from municipal or community
services. Outpatient facilities caring for patients less than twenty-four (24)
hours that do not provide surgery, laboratory, or renal dialysis services may
be served by approved private on-site septic tank absorption field
systems.
(6) Site utility
installations for water, sprinkler, sanitary, and storm sewer systems, and
wells for potable emergency water supplies, shall comply with applicable
sections of Bulletin S.E. 13, "On-Site Water Supply and Waste-water Disposal
for Public and Commercial Establishments", 1988 edition.
(7) As early in the construction, addition,
or renovation project as possible, the functional and operational description
shall be submitted to the division. This submission shall consist of, but not
be limited to, the following:
(A) Functional
program narrative as established in the Guidelines.
(B) Schematics, based upon the functional
program, consisting of drawings (as single-line plans), outline specifications,
and other documents illustrating the scale and relationship of project
components.
(8) Prior to
the start of construction, addition, or renovation projects, detailed
architectural and operational plans for construction shall be submitted to the
plan review division of the department of fire and building services and to the
division of sanitary engineering of the department, as follows:
(A) Working drawings, project manual, and
specifications shall be included.
(B) Prior to submission of final plans and
specifications, recognized standards and codes, including infection control
standards, shall be reviewed as required in section 2(f)(2) of this
rule.
(C) All required approvals
shall be obtained from the state building commissioner and final approval from
the division of sanitary engineering of the department prior to issuance of the
occupancy letter by the division.
(9) All backflow prevention devices shall be
installed as required by
327 IAC 8-10 and the current
edition of the Indiana plumbing code. Such devices shall be listed as approved
by the department.
(10) Upon
receipt of a design release from the state building commissioner and
documentation of a completed plan review by the division of sanitary
engineering of the department, a licensure application shall be submitted to
the division on the form approved and provided by the department.
(11) Documentation from the state building
commissioner that the hospital is in compliance with the fire safety rules of
the fire prevention and building safety commission shall be furnished to the
division with the licensure application.
(12) Plans for constructing, expanding, or
remodeling x-ray or gamma ray facilities shall be accompanied by an evaluation
of the radiation protection features by a radiation qualified expert as
required by 410 IAC 5. After completion of the x-ray or gamma ray installation
and prior to use, a radiation safety survey shall be performed by a radiation
qualified expert to ensure that the facility meets all applicable requirements
of 410 IAC 5 and National Council on Radiation Protection and Measurements
(NCRP) Reports Number 49 and 102.
(13) Outpatient facilities, rehabilitation
facilities, psychiatric facilities, and mobile, transportable, and relocatable
units that are included under the hospital license may comply with appropriate
sections of the Guidelines. If not, they shall comply with the hospital section
of the Guidelines.
(d) The equipment requirements are as follows:
(1)
All equipment shall be in good working order and regularly serviced and
maintained.
(2) There shall be
sufficient equipment and space to assure the safe, effective, and timely
provision of the available services to patients, as follows:
(A) All mechanical equipment (pneumatic,
electric, or other) shall be on a documented maintenance schedule of
appropriate frequency and with the manufacturer's recommended maintenance
schedule.
(B) There shall be
evidence of preventive maintenance on all equipment.
(C) Appropriate records shall be kept
pertaining to equipment maintenance, repairs, and current leakage
checks.
(3)
Defibrillators shall be discharged at least in accordance with manufacturers'
recommendations and a discharge log with initialed entries shall be
maintained.
(4) Electrical safety
shall be practiced in all areas.
(e) The building or buildings, including fixtures, walls, floors, ceiling, and furnishings throughout, shall be kept clean and orderly in accordance with current standards of practice as follows:
(1) Environmental services shall be provided
in such a way as to guard against transmission of disease to patients, health
care workers, the public, and visitors by using the current principles of the
following:
(A) Asepsis.
(B) Cross-infection.
(C) Safe practice.
(2) Refuse and garbage shall be collected,
transported, sorted, and disposed of by methods that will minimize nuisances or
hazards.
(f) The safety management program shall include, but not be limited to, the following:
(1) An ongoing hospital-wide process to
evaluate and collect information about hazards and safety practices to be
reviewed by the safety committee.
(2) A safety committee appointed by the chief
executive officer that includes representatives from administration, patient
services, and support services.
(3)
The safety program that includes, but is not limited to, the following:
(A) Patient safety.
(B) Health care worker safety.
(C) Public and visitor safety.
(D) Hazardous materials and wastes management
in accordance with federal and state rules.
(E) A written fire control plan that contains
provisions for the following:
(i) Prompt
reporting of fires.
(ii)
Extinguishing of fires.
(iii)
Protection of patients, personnel, and guests.
(iv) Evacuation.
(v) Cooperation with firefighting
authorities.
(F)
Maintenance of written evidence of regular inspection and approval by state or
local fire control agencies.
(G)
Emergency and disaster preparedness coordinated with appropriate community,
state, and federal agencies.
Disclaimer: These regulations may not be the most recent version. Indiana may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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