Part 1 General

Part 2 Common Elements for Residential Health, Care, and Support Facilities

Part 3 Residential Health Facilities

Part 4 Residential Care and Support Facilities

Part 5 Non-Residential Support Facilities

Heads up: There are no amended sections in this chapter.
Appendix material, shown in shaded boxes at the bottom of the page, is advisory only.
The provisions of this chapter shall apply to all residential health, care, and support facility projects.
To meet the objectives of this chapter, care provider organizations shall develop an integrated design process to guide facility design.
A1.4-1.2 The intent of an integrated design process is to improve building performance by incorporating input from all project team members (including constructors and installers) and considering sustainable design principles from project inception. See appendix section A1.2-5.5.1 (Sustainability planning) for additional information.
An interdisciplinary design team shall participate throughout the project design process.
A1.4-1.3 The interdisciplinary team should include administrators, facility managers, clinicians, infection preventionists, environmental services managers, safety officers, support staff, architecture and engineering consultants, residents/resident advocates and family members, construction specialists, and other identified stakeholders. See appendix section A1.2-1.2 (Planning process) for additional information.
A1.4-2.1 Acoustic terms. The definitions of acoustic terms used in this publication are based on American National Standards Institute (ANSI) S1.1: Acoustical Terminology. See "Sound and Vibration Design for Health Care Facilities," a white paper prepared by the Acoustics Working Group of the Acoustics Research Council and coordinated with the current edition of the FGI Guidelines, for the glossary of acoustic terminology used in this document.
Design for new and renovated residential health, care, and support facilities shall conform to the Guidelines and all applicable codes and regulations with respect to exterior environmental sound and interior sound in all occupied building spaces.
A1.4-2.1.1 Acoustic design codes, regulations, and guidelines
  1. Noise limits set by codes often are expressed as maximum A-weighted sound levels in dBA. Separate limits are typically set for day and night periods, with the nighttime limit typically 5 to 10 dBA lower than the daytime limit. Daytime limits typically vary between 55 and 65 dBA.
  2. Following are acoustic design codes, regulations, and guidelines for reference:
    • —U.S. Department of Health and Human Services regulations (including Health Insurance Portability and Accountability Act)
    • Building code used by the local or state jurisdiction
    • —Local and state limits on environmental sound
    • —Occupational Safety and Health Administration regulations for worker noise exposure in areas where sound levels exceed 85 dBA
    • —Professional society design guidelines for noise (e.g., American Society of Heating, Refrigerating, and Air-Conditioning Engineers guidelines for mechanical system sound and vibration control)
    • —American National Standards Institute guidelines for sound in building spaces and special spaces (e.g., booths for measuring hearing threshold)
    • —Manufacturers' guidelines for equipment that is sensitive to sound and vibration or produces sound and/or vibration
See Section 2.5-8 (Acoustic Design Systems) for specific design requirements.
Sustainable site and building design, construction, and maintenance practices to improve building performance shall be considered in the design and renovation of residential health, care, and support facilities. See Section 2.2-2 (Sustainable Design Criteria) for specific requirements.
Where residents who are persons of size are part of the care population, the facility shall be designed with support and clearances appropriate for these individuals. Other requirements for accommodating persons of size are contained in the facility chapters of this document. See Section 2.2-3 (Design Criteria for Accommodations for Care of Persons of Size) for additional information.
A1.4-2.3 Design considerations for accommodations for care of persons of size
"Person of size" is a term intended to describe a person whose height, weight, body width, weight distribution, and/or size requires increased space for care and use of expanded-capacity devices, equipment, furniture, technology, and supplies. The term is often interchangeable with obese, morbidly obese, and bariatric.
  1. The need to accommodate residents who are extremely obese or tall is increasing in the United States. In addition to requiring facilities with more space and patient handling equipment and furnishings with greater weight capacities (e.g., grab bars, chairs, toilets), these residents have a variety of special health care needs from climate control requirements to specialty bathing fixtures. Visiting family members of residents also may be persons of size.
  2. Creating residential health, care, and support environments that can accommodate persons of size requires attention to issues that significantly affect design. To determine the number of beds per unit, dwelling units per project, or needs required in a non-residential setting that should be able to accommodate a population of persons of size, the design team should consider design issues along with an analysis of factors such as resident volume, expected length of stay, the nature of the care population, current codes, and local regulation requirements.
    Another primary space driver is the staffing-per-resident (or participant or outpatient) ratio and associated space needed for maneuverability in environments accommodating persons of size. In some instances, additional caregivers are recommended for resident, participant, or outpatient transfers. Many users may also need enlarged facilities to accommodate resident-operated mobility devices, transfer and toileting assistance, and bathing assistance.
    Any environment sized to accommodate residents, participants, and outpatients who are persons of size will likely be the largest resident care environment in a facility. If so, all other resident types will become subsets of design parameters established for this environment.
    For specific details for accommodating residents, participants, and outpatients who are persons of size, see Section 2.2-3 (Design Criteria for Accommodation of Persons of Size).
  3. Worker's compensation costs for nurses and nursing assistants amount to nearly $1 billion per year (Bureau of Labor Statistics). Caring for obese patients presents challenges to patient positioning, mobility tasks, and overall patient and staff safety. The Bureau of Labor Statistics has reported that nursing employees suffer more than 200,000 work-related injuries and illnesses a year, including sprains/strains; low back pain; and wrist, knee, and shoulder injuries, especially when manually moving or lifting patients who are overweight or obese (S. D. Choi and K. Briggs, "Work-related musculoskeletal risks associated with nurses and nursing assistants handling overweight and obese patients: A literature review," Work vol. 53, no. 2, pp. 439-448, 2016). Restricted space increases exposure to high-risk events known to cause injury (G.T. Holman, T. Blackburn, and S. Maghsoodloo, "The Effects of Restricting Space: A Study Involving a Patient-Handling Task," Journal of the American Society of Safety Engineers July 2010:38-46). Clear floor space for correct positioning may reduce injuries during patient handling activities.
Projects involving renovation of existing buildings shall use phasing to minimize disruption of existing resident services.
A1.4-3.1 Phasing is essential to maintenance of a safe environment in resident care areas during construction.
Phasing provisions shall include:
Clean-to-dirty airflow
Emergency procedures
Criteria for interruption of protection
Construction of roof surfaces
Written notification of interruptions
Communication authority
Phasing plans shall include consideration of noise and vibration control during construction activities.
During construction, renovation areas shall be isolated from occupied areas based on an infection control risk assessment. See Section 1.2-3.2 (Infection Control Risk Assessment) for requirements.
Existing air quality requirements for occupied areas shall be maintained during any renovation or construction.
Existing utility requirements for occupied areas shall be maintained during any renovation or construction.
It is not always financially feasible to renovate an entire existing structure in accordance with the Residential Guidelines. Therefore, authorities having jurisdiction shall be permitted to grant approval for renovation of a portion of a building as long as preexisting features in unrenovated areas do not jeopardize facility operations and resident safety in renovated areas.
Existing conditions and operations shall be documented prior to initiation of renovation and new construction projects. This shall include documentation of existing mechanical, electrical, plumbing, and structural capacities and quantities.
A1.4-3.6 Existing conditions
  1. Documentation of existing conditions should cover the following:
    • —Subsurface conditions (e.g., soil testing reports, soil type identification, known water table information, active/abandoned utility locations)
    • —Foundation and superstructure information, including the ability of the structure and equipment (elevator) to handle the movement of heavy and/or large loads from one location to another
    • —Types of fire suppression, detection, and alarm systems, including whether the building is fully sprinklered
    • —Communications systems (e.g., telephone, nurse call, overhead paging)
    • —Plumbing systems (e.g., domestic water, treated water, wastewater, pneumatic control, medical gas/vacuum)
    • —Existing airflow of affected areas
    • —Main electrical service and electrical service affected by construction, including rating and actual load/peak and feeder sizes, as applicable, and power factor
    • —Emergency power system, including rating and actual load/peak and feeder sizes, as applicable, for life safety, emergency and critical systems, and equipment branches
  2. The potential for reusing existing structures and interiors should be evaluated and considered when conducting a renovation.
Upon occupancy of the building or a portion thereof, the care provider shall receive a complete set of as-built documents that shows construction, fixed equipment, and mechanical, electrical, plumbing, and structural systems that reflect known changes from the construction documents.
Drawings shall include a life safety plan for each floor that reflects NFPA 101 requirements.
Upon completion of the contract, the care provider shall be furnished with the following for each piece of equipment installed as part of the project:
Complete set of manufacturers' operations, maintenance, and preventive maintenance instructions (O & M manual) for installed systems and equipment
Operating staff shall be provided with instructions for the correct operation of installed systems and equipment.
The provider shall receive a complete set of design data for the facility, including the following:
A1.4-4.3 The provided design data will be used to facilitate future alterations, additions, and changes, including energy audits and retrofits for energy conservation.
Structural design loads
Summary of heat loss assumption and calculations
Estimated water consumption
Medical gas outlet list, if applicable to the residential health, care, and support facility
List of applicable codes
Electric power requirements of installed equipment
A1.4-5 Commissioning. Commissioning is a quality control process used to document and validate the planning, construction, installation, testing, and operation of facilities and component infrastructure systems. The goal is to ensure that infrastructure systems and equipment are capable of being operated and maintained in conformity with the care model and design intent to meet the owner's project requirements (OPR).
  1. Commissioning guidance. Many organizations, including NEBB, BCA, and ASHE, have published commissioning manuals, guidelines, standards, and handbooks. The ASHE Health Facility Commissioning Guidelines (HFCx Guidelines) is structured to foster a successful transition from planning, design, and construction to high-performance operations (i.e., operations that are code-compliant, safe, and energy-efficient and that support positive outcomes and high levels of resident, participant, or outpatient and visitor satisfaction).
    The ASHE HFCx Guidelines includes the following unique features:
    • —Establishment of a project energy-efficiency goal
    • —Involvement of health care facility operations and maintenance staff in the design review process
    • —Development of a utility management plan during the design process instead of during the postoccupancy period
    • —Comprehensive training of the operations and maintenance staff, including pre-testing to assess training needs and post-testing to assure competency
    • —Testing of fire and smoke dampers prior to occupancy
    • —Measurement and verification of actual energy performance as compared to the energy-efficiency goal or model
  2. Total building commissioning (TBC)
    • —Objective: TBC is a process whereby the owner is assured all building systems and components (not just the HVAC system) will function according to design intent, specifications, equipment manufacturers' data sheets, and operational criteria. Because all building systems are integrated and validated during commissioning, the owner can expect the commissioning process to improve occupant comfort, energy savings, environmental conditions, system and equipment function, building operations and maintenance, and building occupant productivity.
    • —Feedback: The TBC process should include a feedback mechanism that can be incorporated into the owner's postoccupancy evaluation process to enhance future facility designs.
    • —Acceptance building testing: Facility acceptance criteria should be based on the commissioning requirements specified in the contract documents. These criteria specify the tests, training, and reporting the owner must complete to validate that each building system complies with the performance standards of the basis of design before final acceptance of the facility.
    • —Systems and components included in TBC: Key systems and components that need to be tested and validated, at minimum, during the TBC process include design and operations of HVAC, plumbing, electrical, emergency power, fire protection/suppression, telecommunication, nurse call, intrusion and other alarm device, medical gas (if applicable), daylight harvesting, and artificial lighting control systems as well as any specialty equipment.
      • • Air balancing, pressure relationships, and exhaust criteria for mechanical systems should be clearly described and tested to create an environment of care that provides for infection control.
      • • Areas requiring emergency power should be specified and tested.
      • • Special plumbing systems should be certified for support of the chemicals scheduled for use in them.
      • • Water lines, taps, showers, and ice machines to which service has been disrupted or stagnant should be flushed before use by building occupants.
    • —Areas to be included in commissioning: While all areas of a residential health, care, and support facility are included in the commissioning process, areas of particular concern are isolation rooms used for airborne infection and spaces containing hazardous substances.
  3. Total environment commissioning (TEC). While the objective of TBC is to assure the owner that all facility systems and components will function as designed, TEC is intended to assure the owner—to the fullest extent possible—that the facility meets the user needs and desires defined during the functional programming process. This requires the owner to identify those needs and desires with the understanding that the ultimate measure of a facility's success is its ability to provide positive user experiences and outcomes.
    To achieve a facility that consistently provides positive user experiences, the owner must identify all potential users, all activities in which they may participate, and what they would consider a positive experience in each activity. The owner must then evaluate and design all dimensions of the environment other than the physical setting to provide such experiences. The physical setting design team will use this information to create a facility that supports the other dimensions in providing the experiences users desire. This approach is becoming known in the design/construction field as "experience-based design."
    TEC is the process for evaluating whether all dimensions of the environment work together to provide the user experiences defined during the functional programming process and making adjustments accordingly. Just as in TBC, changes can be made to align the environment with expectations articulated by the owner.
    TEC is part of a feedback loop—Plan, Do, Check, Act—intended to provide continuous learning and quality improvement for the owner and the design team. The functional and architectural programs are the "Plan" stage; the design of operations and the physical setting are the "Do" phase; commissioning is the "Check" phase; and corrections are the "Act" phase.
    A multidisciplinary team should be used to design every aspect of the operations and physical setting that support the care model. This team remains in place throughout the continuous quality improvement process established for a facility. TEC requires staff and end users to evaluate the effectiveness of the interaction of operations and the physical setting in providing desired user experiences.
    The next step is to determine corrective changes needed in operations, the care model, and the physical setting. TEC requires acoustical instrumentation that can determine compliance with sound absorption, isolation, and noise reduction requirements. A light meter is needed to determine the adequacy of light levels for different activities. An infiltration review of the building envelope should be performed. The effectiveness of the wayfinding system, staff preparation and teamwork, staff and resident satisfaction, and all operating systems and processes should also be evaluated.
    The TEC process should include a feedback mechanism that can be incorporated into the owner's postoccupancy evaluation process to inform future facility designs and renovations.
At minimum, the following commissioning activities shall be undertaken:
The OPR shall identify the building systems and elements to be commissioned as part of the project scope.
A1.4-5.1.1.1 Systems and elements to be commissioned. At minimum, the following should be commissioned for projects that involve installation of new physical environment elements critical to resident care and safety or facility resource use or that modify such physical environment elements already existing in the facility:
  1. HVAC systems
  2. Lighting systems and controls
  3. Automatic temperature control systems
  4. Energy and water measurement devices
  5. Plumbing systems. At least the following should be commissioned:
    • —Domestic hot water systems
    • —Any specialty plumbing systems provided (e.g., medical and laboratory gas systems)
    • —Domestic and process water pumping and mixing systems
    • —Irrigation systems
  6. Fire alarm and fire protection systems. Integration of the fire alarm and fire protection systems with other systems that affect health, safety, and welfare (e.g., the nurse call system) should be evaluated.
  7. Essential electrical power systems
  8. Renewable energy systems
  9. Building envelope systems
In addition to the systems listed above, consider commissioning communication systems and acoustic systems. Reference the Senior Living Sustainability Guide from With Seniors in Mind for additional information.
The OPR shall define the parameters required to meet the owner's expectations, including the following:
  1. Performance
  2. Operations
  3. Maintenance
  4. Longevity
  5. Energy and water efficiency
In response to the OPR, the design team shall prepare a BOD narrative describing the design intent and systems to be commissioned. The BOD narrative shall include, at minimum, the following elements:
Description of the systems, components, and methods used to meet the OPR
Levels of redundancy planned
Limitations and restrictions of systems and assemblies assumed
Indoor and outdoor conditions assumed (e.g., space temperature, relative humidity, lighting power density, glazing fraction, U-value and shading coefficient, wall and ceiling R-values, ventilation and infiltration rates, etc.).
Description of emergency operation intended. See Table 1.2-1 (Resident Safety Risk Assessment Components) for additional information.
This document shall establish the scope, structure, and schedule of the commissioning activities and address how the commissioning process will verify that the OPR and BOD are achieved.
These specifications shall establish requirements for physical environment elements to be included in the project scope and identify responsibilities related to commissioning.
These documents shall establish inspections and individual component tests that will be used to verify proper functioning of physical environment elements that have been installed or modified.
A1.4-5.1.3.3 Construction checklists. The commissioning agent provides subcontractors with a list of items to inspect and elementary component tests to conduct to verify proper installation of equipment. Items on construction checklists are primarily static inspections and procedures to prepare the equipment or system for initial operation (e.g., checking belt tension, oil levels, labeling, installation of gauges, calibration of sensors, etc.). However, some construction checklist items entail simple testing of the function of a component, piece of equipment, or system (e.g., measuring the voltage imbalance of a three-phase pump motor in a chiller system). Construction checklists augment and are combined with the manufacturer's start-up checklist. Even without a commissioning process, contractors typically perform some, if not all, of the construction checklist items on their own. The commissioning agent requires documentation of procedures in writing and does not necessarily witness much of the construction checklist testing, except for testing of larger or more critical pieces or where desired by the owner.
Testing of the dynamic function and operation of the physical environment elements under full operation shall be performed. Elements shall be tested in various modes included in the OPR and run through all sequences of operation.
A1.4-5.1.4 Functional performance tests. Functional testing assesses the dynamic function and operation of equipment and systems (rather than components) under full operation using manual (direct observation) or monitoring methods. (For example, the chiller pump is tested interactively with the chiller functions to see if the pump ramps up and down to maintain the differential pressure setpoint.) Systems are tested in various modes, such as during low cooling or heating loads, component failures, unoccupied conditions, varying outside air temperatures, fire alarm activation, and power failure. The systems are run through all the control system's sequences of operation, and the responses of components are verified to make sure they match what the sequences state.
Traditional air or water testing and balancing (TAB) is not functional testing. The primary purpose of TAB is to set up the system flows and pressures as specified. Functional testing, on the other hand, is used to verify the performance of that which has already been set up.
The commissioning agent develops the functional test procedures in a sequential written form, then coordinates, oversees, and documents the actual testing, which is usually performed by the installing contractor or vendor. Functional tests are performed after items on the construction checklists and start-up procedures are complete.
A commissioning report shall be prepared and presented to the owner to formally document the following:
Description of systems commissioned
Performance of the physical environment elements
Performance issues identified
Mitigation or resolution of performance issues
Maintenance staff training to achieve operational sustainability
Compliance with the OPR and BOD
If commissioning is completed for a project, it shall be led by an independent commissioning agent with experience and expertise relevant to the project.
A1.4-5.2 Commissioning agent. An independent commissioning agent with residential health care experience compensated directly by the owner and not affiliated or associated with either the design team or the contractor should lead the commissioning process. Use of an independent commissioning agent assures the commissioning agent is a focused owner advocate who can objectively complete the commissioning tasks without real or perceived conflict.
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