Current through Register Vol. 49, No. 6, March 15, 2024
PURPOSE: Section
197.225,
RSMo authorizes the Department of Health to establish physical standards for
birthing centers in order to provide care in a safe environment. Birthing
centers are considered ambulatory surgical centers as defined by section
197.200(1),
RSMo and are subject to licensure as
required by section
197.205,
RSMo. This rule establishes up-to-date construction requirements for new
birthing center construction to help ensure accessible, functional, fire-safe
and sanitary facilities. A new birthing center is one for which plans are
submitted to the Department of Health after the adoption of this rule for the
construction of a new facility, expansion or renovation of an existing birthing
center or the conversion of an existing facility not previously and
continuously licensed as a birthing center under Chapter 197,
RSMo.
PUBLISHER'S NOTE: The publication of the full text of
the material that the adopting agency has incorporated by reference in this
rule would be unduly cumbersome or expensive. Therefore, the full text of that
material will be made available to any interested person at both the Office of
the Secretary of State and the office of the adopting agency, pursuant to
section 536.031.4, RSMo. Such material will be provided at the cost established
by state law.
(1) Planning
and Construction Procedures.
(A) Any birthing
center constructed or renovated after the date of the adoption of this rule
shall have plans and specifications prepared by an architect registered in
Missouri. These plans and specifications shall be submitted to the department
for review and approval prior to beginning of construction. The design and
construction of birthing centers shall conform to the most stringent
requirements of this rule and the local governing building code.
(B) The Department of Health shall be
notified in writing within five (5) days after construction begins. If
construction of the project is not started within one (1) year after the date
of the approval of the plans and specifications, the plans and specifications
shall be resubmitted to the Department of Health for its approval and shall be
amended, if necessary, to comply with the then current rules before
construction work begins.
(C)
Requests for variations from requirements on physical facilities shall be
requested in writing to the Department of Health and must contain information
which demonstrates the providers ability to meet the intent or objectives of
the rule through alternative methods. Approvals for deviations shall be
requested in writing and both requests and approvals shall be made a part of
the permanent Department of Health records for the birthing center.
(D) Where renovation or replacement work is
done within an existing facility, all new work or additions, or both, shall
comply with the applicable sections of this rule.
(E) Birthing centers which expand their
capacity to four (4) or more birthing rooms must comply throughout the facility
with the applicable requirements for birthing centers of this size or
larger.
(F) References in this rule
to, National Fire Protection Association (NFPA), publications are those
contained in the twelve (12)-volume 1994 Compilation of NFPA Codes, Standards,
Recommended Practices and Guides. Where there are discrepancies between
referenced NFPA publication requirements and this rule, the requirements of
this rule shall apply.
(2) Design Considerations for the Physically
Handicapped. Roads, parking facilities, walks, ramps and entrances shall be
accessible and usable by persons who are physically disabled. At least one (1)
toilet, telephone and drinking fountain which are accessible for use by
handicapped public and clinic patients shall be provided on each floor of a
birthing center. Elevator controls and alarms shall be accessible to wheelchair
occupants and shall be provided with tactile signage for the visually impaired.
Design details for handicapped accessible facilities shall be consistent with
the Guidebook to: The Minimum Federal Guidelines of Requirements for
Accessible Design published January 6, 1981 by the United States
Architectural and Transportation Barriers Compliance Board.
(3) Site.
(A) Adequate vehicle and pedestrian access,
including loading and unloading space for delivery vehicles, shall be provided
within the lot lines to the main entrance, emergency vehicular entrance,
community activities and services.
(B) Adequate off-street parking shall be
provided. Space shall be provided at the ratio of one (1) space for each of the
maximum number of staff persons on duty at any given time plus one (1) parking
space for the patient capacity of the birthing and examination rooms in the
licensed facility.
(C) Fire lanes
shall be provided and kept clear to provide immediate access for fire fighting
equipment.
(4) General
Birthing Center Design Considerations. The arrangement of the physical plant
for a birthing center shall provide for separation of administrative/public,
prenatal clinic and birthing suite areas. The birthing suite shall be in a
location in the facility that precludes unnecessary traffic through the
suite.
(5) Administrative/Public
Areas. These areas shall include a business office with a public information
center and staff telephone, administrator's enclosed office, medical records
storage for at least two (2) years of patient records, public lobby and waiting
room, public telephone, public toilet and a drinking fountain.
(6) Staff Areas. An area shall be provided to
include secure storage for personal effects, handicapped accessible toilet,
shower, change and lounge area sufficient to accommodate staff needs as defined
by the program.
(7) Prenatal Clinic
and Preadmission Screening Area. This area shall include:
(A) At least one (1) room with a minimum size
of two hundred fifty (250) square feet for group education. In birthing centers
with fewer than four (4) birthing rooms in response to the program of the
facility but in no case shall it be smaller than one hundred twenty (120)
square feet;
(B) At least one (1)
examination room of not less than ninety (90) square feet and a minimum
dimension of nine feet (9'). Each examination room shall be equipped with hand
washing facilities. In birthing facilities with only one (1) birthing room, the
required examination room shall be equipped to serve as a stand-by birthing
room. Examination facilities shall be separate from, but adjacent to, the
waiting room and birthing suite; and
(C) A laboratory equipped with a counter,
sink and refrigerator which is required if the laboratory performs on-site
laboratory work. This requirement may be met by a contractual provision for
off-premises laboratory services.
(8) Birthing Suite. The birthing suite shall
include at least one (1) birthing room with the following minimum dimensions:
length and width of twelve feet (12'), ceiling height of eight feet (8'), and a
door three feet (3') in width.
(A) Hand
washing facilities shall be located in each birthing room. Lavatories shall be
sized for scrubbing and equipped with faucets which are knee, foot or otherwise
designed to operate without the use of hands.
(B) Each birthing room shall be equipped with
a labor/delivery bed large enough for mother and baby, examination light,
capacity to keep the infant warm, storage facilities for supplies and
sufficient tables to hold an emergency tray and other necessary
equipment.
(C) A toilet with
lavatory shall be directly accessible to the birthing room so patients will not
be required to enter the corridor. One (1) toilet may serve up to two (2)
birthing rooms. No fewer than ten percent (10%) of the birthing rooms shall be
served by handicapped accessible toilets. In birthing centers with fewer than
four (4) birthing rooms, one (1) handicapped-accessible patient toilet may be
provided which is conveniently located to and easily accessible from the
birthing rooms without having patients traverse public areas.
(D) A shower shall be conveniently located to
and easily accessible from the birthing rooms without requiring patients to
traverse public areas. One (1) shower may serve not more than twelve (12)
birthing rooms. At least one (1) patient shower shall be
handicapped-accessible.
(E)
Piped-in oxygen and clinical vacuum shall be provided in each birthing room.
Birthing centers with fewer than four (4) birthing rooms may use portable
medical gas and vacuum services.
(F) Emergency equipment including intravenous
fluids and resuscitation equipment shall be located in near the birthing
rooms.
(9) Service and
Staff Support Facilities. The birthing suite shall include:
(A) A clean work and sterile storage room
equipped with a sterilizer, counter and sink, and storage space for clean
supplies;
(B) A separate
soiled/decontamination utility room equipped with a clinic sink, counter and
sink;
(C) A separate staff-only
toilet with a constant running exhaust and a lavatory conveniently located to
the birthing suite;
(D) A staff
station providing visual supervision of the birthing rooms and support
facilities;
(E) A medication
storage and preparation station equipped with a sink and
refrigerator;
(F) Storage space for
emergency equipment; and
(G)
Janitor's closet equipped with a mop sink and having sufficient space for the
cleaning equipment used to maintain the birthing procedure area. Birthing
centers with fewer than four (4) birthing rooms are required to have only one
(1) janitor's closet to serve the entire facility. In multi-storied birthing
centers at least one (1) janitor's closet shall be provided on each
floor.
(10) General
Support Facilities. Each birthing center shall include:
(A) Adequate space for the housing and
maintenance of mechanical, plumbing and electrical equipment;
(B) Oxygen storage facilities which, if
located inside the birthing center, shall be exhausted to prevent the
accumulation of quantities of spilled gases. Medical gas storage and
distribution systems shall comply with "NFPA 99, Standard for Health Care
Facilities, 1993 Edition" in 1994 National Fire Codes, Volume
5;
(C) Housekeeping supply and
general storage rooms;
(D) A
janitor's closet, including a mop sink, to serve the public, business and
preadmission clinic areas;
(E) In
birthing centers proposing to process laundry on-site, laundry facility design
and laundry equipment of a quality to be capable of producing sanitized linen;
and
(F) At a minimum, provisions
for shelf storage and refrigerated storage of prepackaged nourishments.
Provisions shall be made for serving prepackaged nourishments to birthing
patients. In birthing centers proposing to prepare food on-site, the design of
the dietary facilities must be acceptable to the department and comply with
19 CSR
20-1.010.
(11) Details and Finishes.
(A) A continuous system of unobstructed
corridors and aisles shall be provided which connects all rooms and space with
each other and all entrances, exits and elevators. Corridors shall be separated
from other areas by walls which resist the passage of smoke.
(B) Each exit shall discharge to the outside
or through an enclosed stairway or passageway to the outside.
(C) Required exit stairs shall discharge
directly to the outside or into a rated fire corridor which extends from the
stair discharge to the outside. The fire-resistance rating of fire corridor
walls shall be not less than the rating of the stair enclosure requirement
located in section (12) of this rule.
(D) Corridors shall be at least six feet (6')
wide. All other corridors and aisles shall be at least four feet (4')
wide.
(E) Exit doors shall swing in
the direction of exit travel.
(F)
All doors, procedure rooms and exits shall be at least three feet (3')
wide.
(G) All corridor doors shall
be of solid wood construction or its equivalent.
(H) Each birthing room shall have an operable
window in the outside wall. The window sill shall be not more than three feet
(3') above the floor. Easily washable window treatments, such as vertical
hanging vinyl blinds, shall be installed to control light and glare. All window
treatments shall be inherently flame retardant.
(I) At least one (1) ABC-type fire
extinguisher, compliant with "NFPA 10, Standard for Portable Fire
Extinguisher," 1990 Edition, 1994 National Fire Code, Volume
1, shall be located near each exit on each floor of the birthing center and at
the birthing suite's staff station.
(J) A paper towel dispenser and soap
dispenser shall be provided at all lavatories used for hand washing.
(K) Finish materials installed on the walls,
floors and ceilings in the birthing rooms shall be smooth and
washable.
(L) Ceiling, wall and
floor finishes shall be smooth and easily cleanable in toilets and bath
facilities. Utility and storage rooms used for washing, sterilization and
supplies shall have smooth and easily cleanable ceiling, wall and floor
finishes.
(M) Floor and wall
penetrations by pipes, ducts, and conduits shall be tightly sealed to minimize
entry of rodents and insects. Joints of structural elements shall be similarly
sealed.
(12)
Construction, Including Fire-Resistive Requirements.
(A) Construction of freestanding birthing
centers shall comply with "NFPA 101 Section 12-6, New/Ambulatory Health Care
Centers, 1994 Edition", 1994 National Fire Codes, Volume 5 and
this rule.
(B) Multistoried
buildings rated combustible Type V shall be protected throughout by an approved
automatic sprinkler system. The number of stories in a building housing a
birthing center shall be determined by counting all occupiable levels in the
building.
(C) Birthing centers
shall be separated from other tenants and occupancies by walls having at least
a one (1)-hour fire-resistance rating. These walls shall extend from the floor
slab below to the floor or roof slab above.
(D) Every stairway, elevator shaft, light and
ventilation shaft, chute and other openings between stories shall be enclosed
or protected to prevent the spread of fire or smoke from one (1) floor to
another. The fire-resistance rating of the enclosure or protection shall be not
less than the structural floor separation requirements of "NFPA 220, Standard
on Types of Building Construction, 1992 Edition," 1994 National Fire
Code, Volume 5 for the fire-resistive building type classification
required by subsection (12)(A).
(13) Elevators.
(A) Multistoried buildings shall have at
least one (1) elevator if birthing room services are located on any floor other
than the grade level (main entrance) floor.
(B) The elevator cab shall be at least five
feet by seven feet (5' x 7') clear inside. The car door shall have a clear
opening of not less than three feet (3').
(C) Elevators shall be equipped with a two
(2)-way special service switch to permit cars to bypass all landing button
calls and be dispatched directly to any floor.
(D) Elevators shall be equipped with an
automatic leveling device of the two (2)-way automatic maintaining type with an
accuracy of plus or minus one-half inch (+-1/2").
(E) Elevator call buttons, controls and door
safety stops shall be of a type that will not be activated by heat or
smoke.
(14) Mechanical
Requirements.
(A) Heating, ventilating and
air conditioning (HVAC) equipment shall be mandated to operate at an ambient
temperature of sixty-eight to eighty-five degrees Fahrenheit
(68-85oF).
(B) Air supplied to all areas shall be
filtered through a filter with at least a twenty-five percent (25%) efficiency
rate. Filter efficiencies shall be average atmospheric dust spot
efficiencies.
(C) Required exhaust
fans shall be non-switched and constant running. All exhaust fans shall be
installed at the discharge end of the duct.
(D) The HVAC systems shall be designed and
balanced to provide pressure relationships and air change rates shown in the
following table:
|
Pressure Relationships and Ventilation
of Areas in Birthing Centers
|
|
Area Designation
|
Pressure Relationship to Adjacent Areas
|
Minimum
Air Changes
of
Outside Air
Per Hour Supplied
to Room
|
Minimum
Total Air
Changes Per
Hour Supplied
to Room
|
All Air Exhausted Directly to Outdoors
|
Recirculated Within Room
|
| Birthing Room |
P |
2 |
10 |
Optional |
No |
| Birthing Suite Corridor |
E |
2 |
4 |
Optional |
No |
| Examination Rooms |
E |
2 |
6 |
Optional |
No |
| Soiled/Decontamination Wor |
kroom N |
2 |
10 |
Yes |
No |
| Clean/Sterile Workroom |
P |
2 |
4 |
Optional |
Optional |
| Laboratory |
N |
2 |
6 |
Optional |
No |
| Toilet Room |
N |
- |
10 |
Yes |
No |
| Janitor's Closet |
N |
- |
10 |
Yes |
No |
| Other Area |
E |
2 |
4 |
Optional |
No |
P=Positive N=Negative E=Equal
(15) Plumbing and Other Piping Systems.
(A) Systems shall be designed to supply water
to the fixtures and equipment on every floor at a minimum pressure of fifteen
pounds per square inch (15 psi) during maximum demand periods.
(B) Each water service main, branch main,
riser and branch to a group of fixtures shall be valved. Stop valves shall be
provided at each fixture.
(C) Cold
and chilled water piping and waste piping shall be insulated. Insulation of
cold and chilled water lines shall include an exterior vapor barrier.
(D) Reduced pressure backflow preventers
shall be installed where the water service enters the building and on hose
bibbs and on all fixtures to which hoses or tubing can be attached such as
janitors' sinks and laboratory fixtures.
(E) Hot water distribution systems shall
provide one hundred ten degree Fahrenheit (110oF)
water at each fixture at all times.
(F) Sinks in patient service areas shall have
the water supply spout mounted so that its discharge point is a minimum
distance of five inches (5") above the rim of the fixture. All lavatories used
by medical and nursing staff shall have valves which can be operated without
the use of hands.
(16)
Electrical Requirements.
(A) Every room,
including storage rooms, corridor and all other areas shall be sufficiently
illuminated.
(B) Trickle charge
battery pack units, complying with the standards of "Article 700, Emergency
Systems, NFPA 70, National Electrical Code, 1994 Edition," in
National Fire Code, Volume 3, shall be located to provide
emergency lighting in the birthing rooms, exit corridors, exit signs,
electrical branch panel rooms and exit stairs to point of discharge at grade.
These fixtures shall be tested at least quarterly with the tests documented in
writing. An emergency stand-by power system is not required in birthing
centers.
(C) There shall be one (1)
electrical outlet in each birthing room for the trickle charge emergency light
and at least one (1) duplex outlet on each wall.
(D) Electrical outlets installed in wet
locations, such as the patient toilet areas, shall be ground fault interrupter
types.
(E) In birthing center of
four (4) or more birthing rooms, an electrically powered fire alarm system
shall be installed which will alert all areas of the facility when activated. A
fire alarm manual pull station shall be located near each exit and at the staff
station. The initiation of this fire alarm system shall be by manual means and
by automatic means of any required detection devices.
(F) Birthing centers shall have smoke
detectors interconnected with the fire alarm system in all rooms and at
thirty-foot (30') intervals in corridors. Birthing centers located in
completely sprinklered buildings require only the corridor detectors. In
birthing centers of fewer than four (4) birthing rooms, the fire alarm system
may consist of the individual required smoke detectors, provided the local
alarm may be heard throughout the occupied areas of the birthing
center.
*Original authority 1975, amended
1986.
