410 Ind. Admin. Code 15-1.5-8

Current through November 6, 2024

Section 410 IAC 15-1.5-8 - Physical plant, maintenance, and environmental services

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.

410 IAC 15-1.5-8

Indiana State Department of Health; 410 IAC 15-1.5-8; filed Dec 21, 1994, 9:40 a.m.: 18 IR 1273; errata filed Feb 23, 1995, 2:00 p.m.: 18 IR 1837; readopted filed Jul 11, 2001, 2:23 p.m.: 24 IR 4234; filed Dec 2, 2001, 12:35 p.m.: 25 IR 1135; filed Apr 16, 2004, 10:30 a.m.: 27 IR 2718; readopted filed May 22, 2007, 1:44 p.m.: 20070613-IR-410070141RFA; readopted filed Jul 14, 2011, 11:42 a.m.: 20110810-IR-410110253RFA

Readopted filed 9/13/2017, 4:08 p.m.: 20171011-IR-410170339RFA

Readopted filed 11/28/2023, 12:13 p.m.: 20231227-IR-410230639RFA