Header:
TEXAS ADMINISTRATIVE CODE
TITLE 25. HEALTH SERVICES
PART 1. DEPARTMENT OF STATE HEALTH SERVICES
CHAPTER 135. AMBULATORY SURGICAL CENTERS
SUBCHAPTER C. PHYSICAL PLANT AND CONSTRUCTION REQUIREMENTS
Date:
08/31/2009
Document:
25 TAC § 135.54 (2011)
§ 135.54. Preparation, Submittal, Review and Approval of Plans, and Retention of Records
(a) General.
(1) Ambulatory surgical center (ASC) owners/operators shall not begin construction of a new building, additions to or renovations or conversions of existing buildings until the department approves final construction documents.
(2) Plans and specifications describing the construction of new buildings and additions to or renovations and conversions of existing buildings shall be prepared by registered architects and/or licensed professional engineers and meet the requirements of this subchapter.
(3) The names of spaces used in the functional program narrative, preliminary documents, final construction documents and specifications shall be consistent with the names of the spaces used in this chapter.
(4) The department shall notify the ASC owner/operator of the result of its review of each type of submission discussed in this section.
(5) The ASC owner/operator shall respond to all department requests for additional information, including providing a plan of correction for deficiencies cited by the department.
(6) Once final construction documents are approved, the ASC owner/operator shall request inspections in accordance with § 135.55 of this title (relating to Construction, Inspections, and Approval of Project).
(7) When construction is delayed for longer than one year from the plan approval or self-certification approval date, construction documents shall be resubmitted to the department for review and approval. The plans shall be accompanied by a new application for plan review and functional program narrative.
(8) The ASC owner/operator shall provide written notification to the department when a project has been placed on hold, canceled, or abandoned.
(9) The department may close a project file after one year of assigning an application number to a project if the project has been placed on hold.
(b) Submission of projects and assignment of application number.
(1) The ASC owner/operator or representative shall submit the following items to the department in care of the mailing or overnight delivery address that appears on the application for plan review:
(A) a completed and signed application for plan review. The application for plan review may be obtained by calling the department's architectural review group by telephone at (512) 834-6649 or visit the Architectural Review at www.dshs.state.tx.us/hfp;
(B) a functional program narrative in accordance with subsection (d) of this section; and
(C) final construction documents in accordance with subsection (f) of this section.
(2) The cost of submitting documents/plans and specifications shall be borne by the sender.
(3) Once the department has determined that the submission required in paragraph (1) of this subsection is complete, the department shall assign an application number to the project that shall be referenced on all documents and correspondence related to the project. Final construction documents shall be reviewed in the chronological order received.
(4) All deficiencies noted in the final plan review shall be satisfactorily resolved before approval of project for construction will be granted.
(5) Construction shall not begin until the ASC owner/operator of the facility receives written notification from the department that the final construction documents have been approved.
(c) Feasibility conference. An ASC owner/operator or representative may request a feasibility conference. A feasibility conference is an informal meeting between a member of the department's architectural review group staff and the ASC owner/operator or representative to determine the feasibility of a project, for consultation and informational purposes, and to facilitate and establish understanding of compliance with the rules and codes.
(1) A feasibility conference is not a substitute for plan review.
(2) An ASC owner/operator or representative may schedule a feasibility conference by calling the department's architectural review group by telephone number (512) 834-6649.
(3) The ASC owner/operator or representative shall provide at the feasibility conference the items in subsection (b)(1)(A) - (C) of this section and a set of preliminary plans or final construction documents.
(4) The ASC owner/operator or representative is responsible for recording conference notes and shall submit the notes to the department.
(d) Functional program narrative. The ASC owner/operator shall submit a functional program narrative to the department with each new project in accordance with subsection (b)(1)(B) of this section. The functional program narrative shall be presented on facility letterhead, signed by ASC administration, include the functional description of each space, and the following:
(1) departmental relationships and other basic information relating to the fulfillment of the facility's objectives;
(2) a description of each function to be performed, approximate space needed for these functions, occupants of the various spaces, projected occupant load, types of equipment required, interrelationship of various functions and spaces, and any special design features;
(3) energy conservation measures, included in building, mechanical, and electrical designs;
(4) a description of the type of asepsis control in diagnostic and treatment areas; and
(5) the type of construction (existing or proposed) as stated in § 20.1.6 of National Fire Protection Association 101, Life Safety Code, 2003 Edition (NFPA 101), published by the National Fire Protection Association. All documents published by the NFPA as referenced in this section may be obtained by writing or calling the NFPA at the following address and telephone number: 1 Batterymarch Park, Quincy, Massachusetts 02169-7471, (800) 344-3555.
(e) Preliminary documents. The department may request preliminary documents. If requested by the department, the submission shall consist of the items in subsection (b)(1)(A) - (C) of this section, preliminary plans, and outline specifications. The documents shall contain sufficient information to establish the project scope, description of functions to be performed, project location, required fire safety and exiting requirements, building construction type, compartmentation showing fire and smoke barriers, and the usage of all spaces, areas, and rooms on every floor level.
(f) Final construction documents. Final construction documents and specifications shall be submitted to the department for review and approval prior to start of construction. All final documents and specifications shall be appropriately sealed and signed by the projects's registered architect and professional engineer(s) licensed by the State of Texas.
(1) Submission of final construction documents. The ASC owner/operator shall submit to the department for review and approval the items in subsection (b)(1)(A) - (C) of this section (if not previously submitted with preliminary documents) and one set of final construction documents and specifications covering the construction of new buildings or alterations, additions, conversions, modernizations, or renovations to existing buildings.
(2) Preparation of final construction documents. Construction documents shall be well-prepared so that clear and distinct prints may be obtained, shall be accurately and adequately dimensioned, shall include all necessary explanatory notes, schedules, and legends, and shall be adequate for contract purposes. Compliance with model building codes and this chapter shall be indicated. The type of construction, as classified by National Fire Protection Association 220, Standard on Types of Building Construction, 1999 Edition, shall be provided for existing and new facilities. Final plans shall be drawn to a sufficiently large-scale to clearly illustrate the proposed design but not less than one-eighth inch equals one foot. All spaces shall be identified by usage (using the names of spaces used in this chapter) on all plans (architectural, fire safety, mechanical, electrical, etc.) submitted. Separate drawings shall be prepared for each of the following branches of work.
(A) Architectural plans. Architectural drawings shall include the following: (i) a map of the area within a 500 foot radius of the facility site shall be provided and any hazardous and undesirable location noted in § 135.52(a) of this title (relating to Construction Requirements for a New Ambulatory Surgical Center) shall be identified; (ii) site plan showing all new topography, newly established levels and grades, existing structures on the site (if any), new buildings and structures, roadways, parking, walks, easement, overhead or underground utilities or service lines, and the extent of the areas to be landscaped. All structures which are to be removed under the construction contract and improvements shall be shown. A general description of the immediate area surrounding the site shall be provided; (iii) plan of each floor and roof to include fire and smoke separation, means of egress, and identification of all spaces; (iv) schedules of doors, windows, and finishes; (v) elevations of each facade; (vi) sections through building; and (vii) scaled details as necessary.
(B) Fire safety plans. These drawings shall be provided for all newly constructed buildings, conversions of existing buildings for facilities, additions to existing licensed facilities, and remodeled portions of existing buildings containing licensed facilities. Fire safety plans shall be of a sufficiently large-scale to clearly illustrate the proposed design but not less than one-sixteenth inch equals one foot and shall include the following information: (i) separate fire safety plans (preferably one floor plan per sheet) shall indicate location of fire protection rated walls and partitions, location and fire resistance rating of each fire damper, and the required means of egress (corridors, stairs, exits, exit passageways);
(I) when a new building is to contain a proposed facility, when an existing building is converted to a facility, or when an addition is made to an existing facility building, plans of each floor and roof shall be provided;
(II) when a portion of a building is remodeled or when a new service is added, only the plan of the floor where the remodeling will take place or new service will be introduced, and the plan of the floor of discharge shall be provided; (ii) designated smoke compartments with floor areas of each compartment, location, and fire resistance rating (one or two hour) of each smoke partition, location, type, and fire resistance rating of each smoke damper; (iii) location of all required fire alarm devices, including all fire alarm control panels, manual pull stations, audible and visual fire alarm signaling devices, smoke detectors (ceiling and duct-mounted), fire alarm annunciators, fire alarm transmission devices, fire sprinkler flow switches, and control valve supervisory switches on each of the floor plans; and (iv) areas protected with fire sprinkler systems (pendant, sidewall or upright, normal or quick response, and temperature rating shall be indicated), stand pipe system risers and sizes with valves and inside and outside fire department connections, fire sprinkler risers and sizes, location and type of portable fire extinguishers.
(C) Equipment drawings. Equipment drawings shall include the following: (i) all equipment necessary for the operation of the facility as planned. The design shall indicate provisions for the installation of large and special items of equipment and for service accessibility; (ii) fixed equipment (equipment which is permanently affixed to the building or which must be permanently connected to a service distribution system designed and installed during construction for the specific use of the equipment). The term "fixed equipment" includes items such as laundry extractors, walk-in refrigerators, communication systems, and built-in casework (cabinets); (iii) movable equipment (equipment not described in clause (ii) of this subparagraph as fixed). The term "moveable equipment" includes wheeled equipment, plug-in type monitoring equipment, and relocatable items; and (iv) equipment which is not included in the construction contract but which requires mechanical or electrical service connections or construction modifications. The equipment described in this clause shall be identified on the drawings to ensure its coordination with the architectural, mechanical, and electrical phases of construction.
(D) Structural drawings. Structural drawings shall include: (i) plans for foundations, floors, roofs, and all intermediate levels; (ii) a complete design with sizes, sections, and the relative location of the various members; (iii) a schedule of beams, girders, and columns; (iv) dimensioned floor levels, column centers, and offsets; (v) details of all special connections, assemblies, and expansion joints; and (vi) special openings and pipe sleeves dimensioned or otherwise noted for easy reference.
(E) Mechanical drawings. Mechanical drawings shall include: (i) complete ventilation systems (supply, return, exhaust), all fire and smoke partitions, locations of all dampers, registers, and grilles, air volume flow at each device, and identification of all spaces (e.g., corridor, patient room, operating room); (ii) boilers, chillers, heating and cooling piping systems (steam piping, hot water, chilled water), and associated pumps; (iii) cold and warm water supply systems, water heaters, storage tanks, circulating pumps, plumbing fixtures, emergency water storage tank(s) (if provided), and special piping systems such as for deionized water; (iv) nonflammable medical gas piping (oxygen, compressed medical air, vacuum systems, nitrous oxide), emergency shutoff valves, pressure gages, alarm modules, gas outlets; (v) drain piping systems (waste and soiled piping systems, laboratory drain systems, roof drain systems); (vi) fire protection piping systems (sprinkler piping systems, fire standpipe systems, water or chemical extinguisher piping system for cooking equipment); (vii) piping riser diagrams, equipment schedules, control diagrams or narrative description of controls, filters, and location of all duct-mounted smoke detectors; and (viii) laboratory exhaust and safety cabinets.
(F) Electrical drawings. Electrical drawings shall include: (i) electrical service entrance with service switches, service feeders to the public service feeders, and characteristics of the light and power current including transformers and their connections; (ii) location of all normal electrical system and essential electrical system conduits, wiring, receptacles, light fixtures, switches, and equipment which require permanent electrical connections, on plans of each building level:
(I) light fixtures marked distinctly to indicate connection to critical or life safety branch circuits or to normal lighting circuits; and
(II) outlets marked distinctly to indicate connection to critical, life safety, or normal power circuits; (iii) telephone and communication, fixed computers, terminals, connections, outlets, and equipment; (iv) nurses calling system showing all stations, signals, and annunciators on the plans; (v) in addition to electrical plans, single line diagrams prepared for:
(I) complete electrical system consisting of the normal electrical system and the essential electrical system including the on-site generator(s), transfer switch(es), emergency system (life safety branch and critical branch), equipment system, panels, subpanels, transformers, conduit, wire sizes, main switchboard, power panels, light panels, and equipment for additions to existing buildings, proposed new facilities, and remodeled portions of existing facilities. Feeder and conduit sizes shall be shown with schedule of feeder breakers or switches;
(II) complete nurses calling system with all stations, signals, annunciators, etc. with room number noted by each device and indicating the type of system (nurses regular calling system, nurses emergency calling system, or staff emergency assistance calling system);
(III) a single line diagram of the complete fire alarm system showing all control panels, signaling and detection devices and the room number where each device is located; and (vi) schedules of all panels indicating connection to life safety branch, critical branch, equipment system or normal system, and connected load at each panel.
(3) Construction document changes. Any changes to the final construction documents which affect or change the function, design, or designated use of an area shall be submitted to the department for approval prior to authorization of the modifications.
(g) Special submittals.
(1) Self-certification.
(A) In an effort to shorten the plan review and approval process, the ASC owner/operator or representative may request approval of final construction documents under the self-certification review process. (i) The owner/operator shall submit the items in subsection (b)(1)(A) - (C) of this section and a completed self-certification form, signed by the ASC owner/operator, architect of record, and engineer(s) of record attesting that the plans and specifications are based upon and comply with the requirements of this chapter. (ii) By signing and submitting the self-certification form, the ASC owner/operator accepts the following conditions.
(I) The department retains the right to review the final construction documents, conduct inspections of the project, and withdraw its approval.
(II) The ASC owner/operator has a continuing obligation to make any changes the department requires to comply with the licensing rules whether or not physical plant construction or alterations have been completed.
(III) The ASC owner/operator is ultimately responsible for compliance with Health and Safety Code, Chapter 243, Texas Ambulatory Surgical Center Licensing Act, and this chapter.
(B) The department shall review the request for self-certification and notify the ASC owner/operator if the request is approved or denied. If denied, the department shall review the final construction documents in the chronological order in which the documents were received. Construction shall not begin until the final construction documents have been reviewed and approved.
(2) Minor project. If a ASC owner/operator believes that a proposed project is a minor project, the ASC owner/operator shall provide to the department a brief written description of the proposed project and floor plans of the areas of work. The minor project request shall be mailed or faxed.
(A) If it is determined that the proposed project is a minor project, the department shall notify the ASC owner/operator of the approval, and state the number of inspections that shall be required. A minimum of one inspection shall be conducted.
(B) The department shall notify the ASC owner/operator that a proposed project is not approved as a minor project, if the project involves any of the following: (i) remodeling or alterations which involve alterations to load bearing members or partitions; (ii) a change in functional operation; (iii) a change that affects fire safety (e.g., modifications to the fire, smoke, and corridor walls); (iv) additional services for which the ASC is not currently licensed; and (v) a significant change to the mechanical, electrical, plumbing, fire protection, or piped medical system.
(C) The ASC owner/operator shall submit final construction documents in accordance with subsection (f) of this section if the department determines the project is not a minor project.
(3) Fire sprinkler systems.
(A) When the sole purpose of a project is installation of a sprinkler system, whether a partial or complete system, the ASC owner/operator shall submit to the department for approval the items in subsection (b)(1)(A) - (C) of this section and sprinkler documents.
(B) Fire sprinkler systems shall comply with the requirements of National Fire Protection Association 13, Standard for the Installation of Sprinkler Systems, 2002 Edition (NFPA 13), and shall be designed or reviewed by an engineer who is registered by the Texas Board of Professional Engineers in fire protection specialty or is experienced in hydraulic design and fire sprinkler system installation. A short resume shall be submitted if registration is not in fire protection specialty. (i) Fire sprinkler working plans, complete hydraulic calculations and water supply information shall be prepared in accordance with NFPA 13, §§ 14.1, 14.2 and 14.3, for new fire sprinkler systems, alterations of and additions to existing ones. (ii) One set of fire sprinkler working plans, calculations, and water supply information shall be forwarded to the department together with the professional engineer's (P.E. licensed in the State of Texas) certification letter stating that the sprinkler system design complies with the requirements of NFPA 13. Certification of the fire sprinkler system shall be submitted prior to system installation. (iii) Upon completion of the fire sprinkler system installation and any required corrections, written certification by the engineer, stating that the fire sprinkler system is installed in accordance with NFPA 13 requirements, shall be submitted prior to or with the written request for the final construction inspection of the project.
(h) Retention of drawings, manuals, and design data.
(1) As built drawings. Upon occupancy of the building or portion thereof, the owner shall retain as part of the ASC's permanent records, a complete set of legible architectural plans of each building level, fire safety plans as described in subsection (f)(2)(B) of this section for each floor reflecting fire safety requirements, and all single line diagrams described in subsection (f)(2)(F)(v) of this section, drawings for fixed equipment, and mechanical and electrical systems, as installed or built.
(2) Manuals. Upon completion of the contract, the owner shall retain as part of the ASC's permanent records a complete set of manufacturers' operating, maintenance, and preventive maintenance instructions; parts lists; and procurement information with numbers and a description for each piece of equipment. Facility staff shall also be provided with instructions on how to properly operate systems and equipment. Required information shall include energy ratings as needed for future conservation calculations.
(3) Design data. The owner shall retain in the ASC's permanent records complete design data for the facility. This shall include structural design loadings; summary of heat loss assumption and calculations; estimated water consumption; medical gas outlet listing; list of applicable codes; and electric power requirements of installed equipment. All such data shall be supplied to facilitate future alterations, additions, and changes, including, but not limited to, energy audits and retrofit for energy conservation.
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