Current through Reg. 50, No. 13; March 28, 2025
(a) Compliance.
(1) A licensed ambulatory surgical center
(ASC) which is licensed prior to the effective date of these rules is
considered to be an existing licensed ASC and shall continue, at a minimum, to
meet the licensing requirements under which it was originally
licensed.
(2) In lieu of meeting
the requirements in paragraph (1) of this subsection, an existing licensed ASC
may, instead, comply with National Fire Protection Association (NFPA) 101, Life
Safety Code 2003 Edition (NFPA 101), Chapter 21, Existing Ambulatory Health
Care Occupancies. All documents published by NFPA as referenced in this section
may be obtained by writing or calling the NFPA at the following address or
telephone number: National Fire Protection Association, 1 Batterymarch Park,
Quincy, Massachusetts 02269-9101 or (800) 344-3555.
(b) Remodeling and additions. All remodeling,
renovations, additions and alterations to, or relocation of an existing ASC
shall be done in accordance with the requirements for new construction in
§ 135.52 of this title (relating to Construction Requirements for a New
Ambulatory Surgical Center). When existing conditions make such changes
impractical, the department may grant a conditional approval of minor
deviations from the requirements of § 135.52 of this title (relating to
Construction Requirements for a New Ambulatory Surgical Center), if the intent
of the requirements is met and if the care, safety, and welfare of patients
will not be jeopardized. The operation of the ASC, accessibility of individuals
with disabilities, and safety of the patients shall not be jeopardized by a
condition(s) which is not in compliance with these sections.
(1) Building equipment alterations or
installations. Any alteration or any installation of new building equipment,
such as mechanical, electrical, plumbing, fire protection, or piped medical gas
system, shall comply with the requirements for new construction and shall not
be replaced, materially altered, or extended in an existing ASC until complete
plans and specifications have been submitted to the department, and the
department has reviewed and approved the plans and specifications in accordance
with § 135.54 of this title (relating to Preparation, Submittal, Review
and Approval of Plans, and Retention of Records).
(2) Minor remodeling or alterations. Minor
remodeling or alterations within an existing ASC which do not involve
alterations to load bearing members and partitions, change functional
operation, affect fire safety, add or subtract services, or involve any of the
major changes listed in paragraph (3) of this subsection are considered to be
minor projects and require evaluation and approval by the department. An ASC
shall submit a written request for evaluation, a brief description of the
proposed changes, and sketches of the area being remodeled. Based on such
submittal, the department shall evaluate and determine whether any additional
submittals or inspections are required. The department shall notify the ASC of
its decision.
(3) Major remodeling
or alterations. All remodeling or alterations which involve alterations to load
bearing members or partitions, change functional operation, affect fire safety,
or add or delete services are considered major projects. An ASC shall comply
with this paragraph prior to beginning construction of major projects.
(A) Submittal of plans. Plans shall be
submitted in accordance with § 135.54 of this title for all major
remodeling or alterations.
(B)
Phasing of construction in existing facilities.
(i) Projects involving alterations of or
additions to existing buildings shall be programmed and phased so that on-site
construction will minimize disruptions of existing functions.
(ii) Access, exit access, and fire protection
shall be maintained so that the safety of the occupants will not be jeopardized
during construction.
(iii) A
noncombustible or limited combustible dust and vapor barrier shall be provided
to separate areas undergoing demolition and construction from occupied areas.
When a fire retardant plastic material is used for temporary daily usage, it
shall be removed at the end of each day.
(iv) The air inside the construction area
shall be protected by mechanical filtration that recirculates inside the space
or is exhausted directly to the exterior.
(v) The area shall be properly ventilated and
maintained. The area under construction shall have a negative air pressure
differential to the adjoining areas and shall continue to operate as long as
construction dust and odors are present.
(vi) Temporary sound barriers shall be
provided where intense, prolonged construction noises will disturb patients or
staff in the occupied portions of the building.
(c) Previously licensed ASCs. A
previously licensed ASC which has been vacated or used for other purposes shall
comply with all the requirements for new construction contained in §
135.52 of this title in order to be licensed.
