CODE REVIEW: DOH Article 28 Compliance

Establishing a Feasibility process that is focused on compliance with New York State Department of

Healthrules and regulations.

OBJECTIVES:

• Get it all out there up front! (avoid hidden scope)

• Streamline DOH submission and approval process

• Eliminate costly scope changes during design, construction, and DOH Survey Phases.

• Everyone saves time and money!

CONTENTS:

STEP 1: Define the Functional Program

STEP 2: Code Review

CONTENTS:

STEP 1: Define the Functional Program

• Owner’s Project Requirements (OPR)• DOH Article 28 Requirements• Deliverables

STEP 2: Code Review

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DEFINING THE FUNCTIONAL PROGRAM: Owner’s Project Requirements

FDC PM will:• Provide a brief scope narrative that summarizes the

clinical, administrative, and/or support functions and the anticipated boundaries of the project.

Regulatory Planning Will:• Make preliminary determination of whether or not

DOH filing is required and what type of filing that will be.

A/E Team Must: • Question, Confirm, Dig Deeper! • Get Specific - Who are your patients? What types of

procedures will take place? How often? Is Radiation involved? Has equipment been selected?

• Make an initial determination of DOH Article 28 requirements

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DEFINING THE FUNCTIONAL PROGRAM: Deliverables

• Preliminary Functional Space Program • Preliminary Room Data Sheets (temperature,

lighting, furniture, equipment, etc.)

• Article 28 Requirements with which the project must be in compliance.

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CONTENTS:

STEP 1: Define the Functional Program

STEP 2: Code Review• Introduction• Applicable Codes• Code Review Meeting• Code Analysis Format• Non-Conforming Conditions

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CODE REVIEW : Introduction

The A/E team must establish compliance with DOH Article 28 rules and regulations from day 1. CON Filing and Approvals are often delayed due to the following:

• Incomplete or inaccurate definition of the clinical functions that will be delivered within a project’s scope.

• Failure to incorporate the full Article 28 defined scope of the project:

• Full smoke compartment and path of egress compliance

• Compliance with all unit or departmental requirements under FGI Guidelines.

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CODE REVIEW: Applicable Codes

• The A/E team is responsible for identifying and reviewing compliance with ALL applicable Codes and Standards.

• The A/E team is responsible for correctly identifying the currently adopted versions of the Codes and Standards.

• The A/E team is responsible for reviewing all codes and standards referenced by Primary Codes and Standards. For instance, the FGI Guidelines reference over 85 other codes, standards and guidelines that should be reviewed for applicability depending on the specific project type and scope.

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CODE REVIEW: Examples of Applicable Codes

New York City Building Codes:

NYC Building Code (2008 edition)

NOTE: Depending on the original completion date of a facility and the specific scope, a project may have the option of utilizing the 1968 edition of the code.

NYC Building Bulletins, PPNs, Directives, Executive Orders and Memos

NYC Code Revisions

NYC Electrical Code (2011 edition)

NYC Mechanical Code (2008 edition)

NYC Fire Code (2008 edition)

NYC Fuel Gas Code (2008 edition)

NYC Energy Code (2008 edition)

New York State DOH / OMH Codes:

NYCRR Title 10 Part 712 – Standards for the Construction of General Hospital Facilities

FGI Guidelines for Design and Construction of Health Care Facilities (2010 edition)

NYCRR Title 14 – Mental Hygiene

Life Safety / Fire Protection Codes:

NFPA 101 – Life Safety Code (2012 edition)

NFPA 99 – Healthcare facilities Code (2012 edition)

NFPA 13 – Sprinkler Systems (2103 edition)

NFPA 14 – Standpipe and Hose Systems (2013 edition)

NFPA 72 – Fire Alarm and Signaling Code

Accessibility Codes:

ADA Accessibility Guidelines for Buildings and Facilities (ADAAG)

NYC Accessibility Code (NYCBC Chapter 11)

ANSI A117.1 (2009 edition)

Uniform Federal Accessibility Standard (UFAS)

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CODE REVIEW: Code Review Meeting (allow 3 hours – really!)

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• Purpose: To gain a complete understanding of the clinical functions and procedures that will occur within the project boundaries and identify other areas within the department or within the smoke compartment that may need to be incorporated within the project.

• Attendees: • Clinicians• Project Administrator (PA)• Infection Control• Regulatory Planning• Regulatory Compliance• Facilities Operations (Engineering) • Project Manager• Architect/Engineer

CODE REVIEW: Code Review Meeting

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Typical questions the architect must raise:

• Does the existing space have the required support spaces with the required ventilation?

• Are you changing occupancy or egress?

• Are you impacting floors above or below?

• Does the new procedure room you are designing require 65 degree temperatures because the clinical staff will be wearing heavy lead shielding and will the reduction of in-coming air temperature require that you add reheat coils in spaces up-stream or down-stream from yours?

CODE REVIEW: Code Analysis Format• Architect must

format Code Analysis as commentary within the actual code text.

• Architect must provide analysis for additional code sections referenced within the text.

• Review line by line in Code

Review Meeting. • Floor Plan to be on

large scale monitor during Review.

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CODE REVIEW: Identification of Non-Conforming Conditions

• Based upon the approved Functional Program, Existing Conditions Review, and Code Review analysis, a list of all existing and potential non-conforming conditions should be generated.

• This analysis should also include any existing waivers that have been granted from NYDOH that may require remediation as part of the project scope.

Note: Waivers from previous projects do NOT carry over to current projects.

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CODE REVIEW: Strategies for Resolution of Non-conforming Conditions

• Remediation (work with FDC PM to evaluate impact on cost and schedule)

• Waiver Request

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CODE REVIEW: Deliverables

• Code Review Analysis, including proposed

means of addressing non-conforming conditions

• Sign-off on Code Analysis by all participants in Code Review Meeting

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CONCLUSION:

A thorough and complete review of Functional Program and DOH Article 28 Code requirements during the Feasibility Phase results in a reliable project scope and budget that will

• Streamline the DOH approvals process

• Reduce or eliminate costly changes during later phases of design and construction.

• Result in owner savings and A/E profit