General Design and Construction Standards for Ambulatory Surgical Centers

PURPOSE: The Division of Health Resources, Department of Health has the authority to establish construction standards for ambulatory surgical centers. This rule provides standards for facilities to ensure sanitary and fire-safe facilities. 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) All new ambulatory surgical centers and additions to and remodeling of existing licensed ambulatory surgical centers shall be designed to provide all of the facilities required by this rule and fire-safety standards, arranged to accommodate with maximum convenience all of the functions required by this rule and arranged to provide comfortable, attractive, sanitary, fire-safe, secure and durable facilities for the patients. This rule is applicable to ambulatory surgical centers which began operation or construction or renovation of a building to operate an ambulatory surgical center on any date after April 12, 1990. Existing ambulatory surgical centers licensed by the Department of Health prior to April 12, 1990 shall be maintained in compliance with the rules under which they were initially licensed and are not required to comply with the construction requirements for new ambulatory surgical centers until they are remodeled or expanded. The Department of Health, within its discretion and for good reason, may grant exceptions to this rule. These exceptions shall be in writing and shall be made a part of the Department of Health records for the facility. (A) General Construction—Related Authorities. 1. Construction of all ambulatory surgical centers and additions to or remodeling of ambulatory surgical centers shall comply with all local and state regulations and codes. (B) Planning and Construction Procedure. 1. Plans and specifications complying with 19 CSR 3030.040 shall be prepared for the construction of all ambulatory surgical centers and any additions to and remodeling of ambulatory surgical centers. Plans for ambulatory surgical centers which in addition to other surgical procedures will offer abortion services shall incorporate facilities for patient counseling as required for licensed abortion facilities in 19 CSR 30-30.070(2)(Z). The plans and specifications shall be prepared by an architect or a professional engineer licensed to practice in Missouri. The plans and specifications shall have received written approval of the Department of Health prior to the submission of an application for licensure of the new facility. The license for a new ambulatory surgical center will not be issued prior to the facility being inspected and found in substantial compliance with this rule. 2. The Department of Health shall be notified within five (5) days after construction begins. If construction of the project is not started within one (1) year after the date of approval of the plans and specifications, the plans and specifications shall be amended if necessary to comply with the then current regulations before construction work commences (see 19 CSR 30-30.040 Preparation of Plans and Specifications for Ambulatory Surgical Centers). (C) Site. 1. Adequate vehicular and pedestrian access shall be provided within the lot lines to the main entrance, ambulance entrance, community activities and services, including loading and unloading space for delivery trucks. Roads, walks, ramps and entrances shall be accessible to the physically handicapped. Details for accommodation of the handicapped shall be consistent with the guidelines contained in A Guidebook to: The Minimum Federal Guidelines & Requirements for Accessible Design published January 6, 1981, by the United States Architectural and Transportation Barriers Compliance Board. 2. Adequate off-street parking shall be provided. Space shall be provided at the ratio of two (2) spaces for each patient cart in the recovery room plus parking space to accommodate the maximum number of staff on duty at any one (1) time. A minimum of two (2) handicapped-accessible parking spaces shall be provided for use by the staff and patients. 3. Plans for proposed new ambulatory surgical centers and additions to ambulatory surgical centers should be reviewed by the local fire protection agency assigned to that area. Fire lanes shall be provided and kept clear to provide immediate access for fire-fighting equipment. (D) General Design—Facilities. 1. The arrangement of the physical plant shall provide for separation of the administrative, business and public areas from patient service areas. A. Administrative area—at a minimum shall consist of a business office with information center and telephone, administrator’s office, medical records storage (may be in patient service area), sufficient to satisfy the requirements of 19 CSR 30-30.020(1)(F)4., lobby and waiting room, telephone available to public, handicapped-accessible public toilets for each sex, handicapped-accessible drinking fountain, and janitor’s closet. B. Patient service areas—at a minimum shall consist of two (2) or more patient change areas per sex with access to toilets; secure storage facilities for each patient’s street clothing and belongings; staff lounge with storage for staff’s clothing and personal effects, and handwashing facilities; examination room of at least one hundred (100) square feet with handwashing facilities; preoperative holding room sized for at least two (2) patients per operating room with each patient location being at least thirty-five (35) square feet; janitors’ closet with sufficient space for equipment for maintaining the patient service area; laboratory, unless provisions have been made for off-premises laboratory services; postanesthesia recovery room with handwashing facilities, sized to accommodate at least two (2) patient stretchers per operating room with three feet (3') of clear space around the sides and foot of each stretcher; nurses’ work station with medication storage and preparation facilities, storage space for emergency equipment; doctors’ dressing room, toilet and handwashing facilities arranged to provide a one (1)-way traffic pattern so that personnel entering from outside surgery can change and move directly into the surgical suite corridor; nurses’ dressing room, toilet and handwashing facilities; one (1) scrub-up facility for each operating room; materials processing facilities including a decontamination utility room with workcounter, sink, clinic sink with bedpan cleanser and space for holding soiled materials and trash, and a pass-thru window to an adjacent clean workroom with workcounter, sink, high speed sterilizer and space for storing sterilized and packaged clean supplies; and one (1) or more operating rooms. (I) Operating rooms shall have a floor area of not less than two hundred twenty-five (225) square feet with a minimum dimension of not less than fifteen feet (15'). (II) The administration of general anesthetics in new ambulatory surgical centers is restricted to nonflammable agents. Any new ambulatory surgical center desiring to administer flammable anesthetics shall first receive the written permission of the Missouri Department of Health and will be required to include National Fire Protection Association (NFPA) safety design features for flammable anesthetizing locations into the building. C. Support facilities—space for mechanical equipment, standby electric generator with automatic transfer switch, medical gas storage, housekeeping supply storage and a general storage room providing at least one hundred (100) square feet per operating room. (E) General Design—Details. 1. A continuous system of unobstructed corridors and aisles shall extend through the enclosed portion of each story of the facility, connecting all rooms and spaces with each other and with all entrances, exitways and elevators except that mechanical equipment space need not be connected to the corridor system. Corridors providing access to operating rooms and postanesthesia recovery rooms shall be at least eight feet (8') wide, all other corridors shall be at least five feet (5') wide. 2. At least two (2) exits, remote from each other, shall be provided for each floor. 3. Exit doors and doors to operating rooms and recovery rooms shall be at least forty-four inches (44") wide. All other doors through which patients and personnel will pass shall be at least thirty-two inches (32") wide. 4. The width of stairways except stairways, to mechanical spaces, shall not be less than forty-four inches (44"). 5. Exit discharge doors shall swing in the direction of exit traffic. 6. Ceilings in operating rooms shall not be less than nine feet (9'). Ceilings in all other rooms shall not be less than eight feet (8'), except that ceilings in corridors and storage rooms may be seven feet six inches (7' 6"). 7. Ceilings in operating rooms shall have a smooth washable surface. All other ceilings may be of acoustical material. 8. The floor finish in operating rooms shall be seamless with an integral base covered with the floor and tightly sealed with the wall. 9. Walls shall be smooth and easily cleanable. Walls in operating rooms and recovery rooms shall have waterproof painted, glazed or similar washable surfaces. 10. Floors in the lobby, waiting room and offices shall be easily cleanable. Floors in operating rooms and recovery rooms shall be smooth, slip-resistant and washable. 11. Wall and ceiling surfaces of all required corridors and exitways shall be of a material treated so it does not have a flame-spread classification of more than twenty-five (25) according to the method for the Fire Hazard Classification of Building Materials of Underwriters’ Laboratories, Inc. Rooms and small office spaces shall have wall and ceiling surfaces with a flame-spread rating of not more than seventy-five (75) when tested according to American Society of Testing and Materials (ASTM) Standard E-84. All floor covering shall have a minimum flame-spread rating of forty-five one hundredths (0.45) watts per square centimeter when tested according to NFPA 253-1978 (Flooring Radiant Panel Test). 12. Paper towel dispensers and soap dispensers shall be provided at all lavatories used for handwashing. (F) Fire Safety Construction—Specifications and Details. 1. One (1)-story buildings shall be of not less than Type II (111) construction as described in the Standard on Types Building Construction 1979 published by the NFPA. Fully sprinklered one (1)-story buildings may be of type II (000) construction. 2. Multistory buildings shall be of not less than Type II (222) construction. Fully sprinklered multistory buildings may be of not less than Type II (111) construction. 3. Walls enclosing stairways, elevator shafts, other vertical openings between floors and boiler rooms shall be of construction having a fire rating not less than that required for the structure. 4. The number of stories in any building housing an ambulatory surgical center shall be determine by counting the number of occupiable levels in the structure regardless of their location above or below grade. 5. Ambulatory surgical centers with a floor area of two thousand (2000) square feet or more shall be divided by one (1)-hour rated walls into at least two (2) smoke zones; each zone not exceeding one hundred fifty feet (150') in any dimension. Each smoke zone shall have at least one (1) means of egress which discharges directly to the outside. 6. In a building of multitenant occupancy, the ambulatory surgical center and the entirety of the surgical center’s access to exit system shall be separated from other tenants by walls having a fire-resistance rating of at least one (1) hour. 7. Smoke detectors shall be installed in all habitable spaces in the ambulatory surgical center and in the access to exit corridor system at intervals not exceeding seventy-five feet (75') and no more than thirty feet (30') from the ends of corridors. (G) Elevators. 1. If patient services are located on any floor other than the grade level, at least one (1) elevator is to be provided. 2. Inside dimensions of the elevator shall be at least five feet by seven feet (5' × 7') clear inside to accommodate a wheeled stretcher and attendants. The elevator car door shall have a clear opening of not less than forty-four inches (44"). (H) Electrical Requirements. 1. Every room, including storage rooms, corridors and all other areas shall be sufficiently illuminated to facilitate efficient performance of all necessary work. 2. Operating and recovery rooms shall have general lighting in addition to special lighting units at the surgical tables and for each recovery unit. 3. All sources of light and power in the operating room SENIOR SERVICES shall comply with the Standard for the use of Inhalation Anesthetics (Flammable and Nonflammable 1978) published by the NFPA. 4. An approved automatically-operated, electricallypowered fire alarm system which will alert all areas of the facility when activated shall be installed including audible and visual alarm devices located throughout the ambulatory surgical center and its access-to-exit corridor system, manual pull stations near each exit door. The fire alarm system shall be interconnected with all required smoke detectors and extinguishment systems, if provided. The fire alarm system shall be connected directly to the fire department or a dispatch service. 5. An intercom, nurse call system or other means of communication connecting each operating room and the recovery room area to a constantly staffed location shall be installed to summon assistance during emergencies. 6. A generator with on-site fuel storage for at least four (4) hours of operation under load shall be provided as an emergency source of electricity and connected by an automatic transfer switch to certain circuits for lighting and power. The emergency electrical service shall be installed and arranged so that full voltage and frequency is available and supplying power to emergency loads within ten (10) seconds after normal power is interrupted. Emergency electric services shall be provided for the following: A. Lighting—exitways, including exit signs; all operating room lights; all recovery room lights; minimal task lighting in all clinical areas; generator set location; and elevator if required; and B. Power—all alarm systems; receptacles in operating and recovery rooms; the operating room communication system; the pump for central suction system, if provided; and elevator, if required. (I) Heating, Ventilating and Air-Conditioning Equipment. 1. Air-conditioning, heating and ventilating equipment shall be provided, maintained and operated so as to provide an adequate degree of comfort to all occupants. 2. All air delivered to operating rooms shall be delivered at or near the ceiling of the room served and all air returned or exhausted shall be removed near the floor level. At least two (2) return or exhaust outlets shall be used in each operating room and located not closer than three inches (3") to the floor and not more than twelve inches (12") above the floor. 3. The ventilation systems shall be designed and balanced to provide the pressure relationship shown in Table I. 4. For the clinical areas, requirements for outdoor air changes may be deleted or reduced and total air changes per hour supplied may be reduced to twenty-five percent (25%) of the figures listed in Table I when the room is unoccupied and unused, provided that indicated pressure relationships are maintained. An interconnect with the general illumination light switch for each operating room shall be included to insure that the required ventilation rates including outdoor air are automatically resumed upon reoccupancy of the space. This does not apply to certain areas such as toilets and storage which would be considered as in use even though unoccupied. 5. Ventilation systems for the surgical suite which includes the operating rooms, surgical corridor and support areas, and recovery rooms shall have two (2) filter beds. Filter bed no. 1 shall be located upstream of the air-conditioning equipment and have an efficiency rating of not less than twenty-five percent (25%). Filter bed no. 2 shall be located downstream of the air-conditioning equipment and have an efficiency rating of not less than ninety percent (90%). The ventilation systems serving all other areas shall have at least one (1) filter having an efficiency rating of not less than twenty-five percent (25%). 6. Space and access panels shall be provided for the easy maintenance and replacement of all filters installed in the ventilation equipment. 7. Ducts supplying air to the operating suite and recovery rooms shall be externally insulated downstream from the final filter. 8. Variable volume-ventilation systems may be used only in the administrative areas of ambulatory surgical centers. (J) Plumbing. 1. The requirements of the current edition of the National Plumbing Code shall be complied with insofar as they may apply and to the extent they are not superseded by requirements specifically stated in these regulations. 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 should be valved. Stop valves shall be provided at each fixture. C. Hot, cold and chilled water piping and waste piping on which condensation may occur shall be insulated. Insulation of cold and chilled water lines shall include an exterior vapor barrier. D. Backflow preventers (vacuum breakers) shall be installed on hose bibbs and on all fixtures to which hoses or tubing can be attached such as janitor’s sinks and laboratory fixtures. E. Hot water distribution systems with recirculating loops and pumps shall be arranged to provide hot water service at each fixture at all times. F. The hot water-heating equipment shall have sufficient capacity to supply the water at temperatures between one hundred five degrees and one hundred fifteen degrees Fahrenheit (105°F–115°F) at a rate not less than five (5) gallons per hour per recovery stretcher. G. Lavatories and 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 and food handlers except those in public toilets shall be trimmed with valves which can be operated without the use of hands. H. Scrub sinks shall be equipped with faucets which can be operated without the use of hands. AUTHORITY: section 197.225, RSMo 1986. This rule was previously filed as 13 CSR 50-30.030. Original rule filed Dec. 2, 1975, effective Feb. 1, 1976. Amended: Filed Jan. 3, 1990, effective April 12, 1990.