General Design and New Construction Standards for Birthing Centers

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) handicappedaccessible 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 SENIOR SERVICES 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 fireresistance 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 (68–85°F). (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 nonswitched 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: (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 (110°F) 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. AUTHORITY: section 197.225, RSMo 1994.* Emergency rule filed May 1, 1995, effective May 10, 1995, expired Sept. 7, 1995. Original rule filed May 1, 1995, effective Nov. 30, 1995. Emergency amendment filed June 19, 1998, effective July 1, 1998, expired Feb. 25, 1999. Amended: Filed June 19, 1998, effective Jan. 30, 1999. *Original authority 1975, amended 1986.