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.
This chapter contains specific requirements for residential settings for individuals with intellectual and/or developmental disabilities.
A4.4-1.1.1.1 Setting types for individuals with intellectual and/or developmental disabilities. Settings for persons with intellectual and/or developmental disabilities are a component of the continuum of care for those being served and provide a supportive residential environment for services. They can be freestanding facilities, part of a residential health, care, or support facility, or a setting embedded in the community at-large.
These settings can vary substantially from one state to the next and even in the same state. In some states, the entity that provides services is licensed rather than the building itself.
For the purposes of this chapter, the term "resident" is intended to be interchangeable with the term "client," as both are used by different jurisdictions.
The requirements in Part 2 (Common Elements for Residential Health, Care, and Support Facilities) shall apply to settings for persons with intellectual and/or developmental disabilities as referenced in this chapter.
See Section 2.2-2 (Sustainable Design Criteria) for requirements for residential settings for individuals with intellectual and/or developmental disabilities.
Where the care population includes needs for persons of size, see Section 2.2-3 (Design Criteria for Accommodations for Care of Persons of Size) for requirements.
Where the care population includes residents with dementia, mental health issues, or cognitive and developmental disabilities, see Section 2.2-4 (Design Criteria for Dementia, Mental Health, and Cognitive and Developmental Disability Facilities) for requirements.
This chapter identifies the minimum requirements for residential settings for persons with intellectual and/or developmental disabilities, recognizing various configurations for small, medium, and large residential settings, which must comply with applicable state and local requirements.
A4.4-1.1.3 This chapter acknowledges that both residential and day care programs are available to serve residents and participants who have intellectual and/or developmental disabilities. The chapter does not include larger residential health settings (nursing homes) or hospitals for residents or patients who have intellectual and/or developmental disabilities, but is intended to cover intermediate care facilities for individuals with intellectual disabilities (ICF/ID), community residences, and personal care homes. For information on day care settings for these individuals, see Chapter 5.1, Specific Requirements for Adult Day Care and Adult Day Health Care Facilities.
The common goal of this chapter and local and state requirements is to facilitate accountability and protection for individuals with intellectual and/or developmental disabilities by providing basic standards for supportive environments for these individuals.
See Section 1.2-2.1 (Functional Program-General) for requirements in addition to those in this section.
The sponsor of each project shall provide a functional program that:
*(1)  Defines the scope and scale of the setting for individuals with intellectual and/or developmental disabilities (including the care model).
(2)  Identifies resident needs.
(3)  Facilitates the application of licensure and occupancy approvals by authorities having jurisdiction (AHJs).
(4)  Addresses applicable provisions of the Guidelines for Design and Construction of Residential Health, Care, and Support Facilities.
A4.4-1.2.1.2 (1) Care model characteristics. See appendix table A4.4-a (Characteristics of Settings for Individuals with Intellectual and/or Developmental Disabilities) for additional information.
  1. Care model types. The care model will vary depending on whether provision of services is centralized or decentralized and on the size of a residential setting. Following are general descriptions of the different size models commonly used for individuals with intellectual and/or developmental disabilities.
    Small Setting Care Model
    The small setting care model includes personal care homes, which are single-family-style homes that typically have the following characteristics:
    • -Integration into communities to create residential settings that are part of the community at-large (e.g., use of residential roof lines, heights, etc. to avoid institutional appearance and stigma)
    • -Four or fewer residents living in a shared house setting, such as an apartment/home/triplex with private or shared rooms based on resident choice
    • -Bedrooms directly accessible to common living areas such as a kitchen, living room, dining room, and other shared community spaces
    • -Shared or private bathrooms based on individual resident needs, with shower or tub provided in the resident bathroom
    • -Shared kitchen based on individual resident needs and capabilities. For example, based on the care population, it may be necessary to support staff supervision of resident use of the kitchen or to provide a key-operated switch on an electric range or oven to prevent unsafe use of a cooking appliance, but the goal is to allow residents to be as independent as possible.
    • -Shared living/dining room based on needs of the care population for circulation and access
    • -Views of and access to nature
    • -Support for decentralized and self-administered medications
    • -Dedicated staff space usually located in a residential unit (e.g., a two-bedroom apartment could include a third bedroom for staff). Alternatively, if residents share community space, staff space could be included in the community area. Because staff space is usually located in a residential setting in the small setting model, it would include residential equipment and furnishings.
    Medium Setting Care Model
    The medium setting model includes community residences and intermediate care facilities for individuals with intellectual disabilities (ICF/ID), which typically have the following characteristics:
    • -Integration into the community to create residential settings that are part of the community at-large
    • -Resident rooms for up to 16 residents and shared common space. Smaller groups of resident rooms (e.g., two settings of eight resident rooms each) attached to shared common space would be considered a "small house" setting. These smaller-scaled homes may be freestanding or grouped together in attached or detached configurations.
    • -A combination of private and shared resident rooms based on resident choice and the care population being served
    • -Shared or private bathing area(s) based on individual resident needs, with a shower provided in resident room bathrooms
    • -Shared common areas for every eight resident beds
    • -Separate facilities for food service and food-handling activities
    • -Views of and access to nature
    • -Support for decentralized and self-administered medications
    • -Dedicated staff space, which is often located in the "garage" area of a residential home that includes resident rooms and common spaces. Alternatively, staff space could be included in the community area.
    Large Setting Care Model
    A large setting model typically includes the following:
    • -Seventeen or more residents using a "household" model of care
    • -Resident rooms assembled in smaller groups with shared common space to create a household concept similar to that used in nursing homes or assisted living facilities
    • -Neighborhood(s) of two or more households that may or may not be integrated into the community at-large. An overall community is composed of one or more neighborhoods.
    • -Shared or private bathing areas based on individual resident needs, with a shower in the resident room bathroom(s)
    • -Shared common spaces that serve 12 to 16 resident rooms per household
    • -An optional larger event space. This may be included in the overall community for larger activities or gatherings for all residents, family, and the community at-large.
    • -Separate facilities for food service and food-handling, including a commercial kitchen or satellite kitchens that serve the households and/or neighborhoods
    • -Facilities for decentralized or centralized support services, depending on the care model and services provided. For example, laundry services for linens may be centralized or outsourced, but personal laundry is completed in the household.
    • -Views of and access to nature, and areas for outdoor activities
    • -Support for decentralized or centralized medications. Medication distribution and storage locations may be located in a household, semi-decentralized in a neighborhood, or centrally located in a community. Decentralized or semi-decentralized medication delivery typically reduces staff travel distances.
    • -Dedicated staff space
  2. Physical setting. Settings for individuals with intellectual and/or developmental disabilities are further differentiated according to their functional and programmatic characteristics.
    Small Setting Care Model
    • -Single- or double-occupancy resident bedrooms based on availability and choice
    • -Common areas that include:
      • Shared kitchen
      • Dining room
      • Living room
      • Optional additional space for den or family room to accommodate activities and family visits
    • -Accommodation of staff space
    • -Access to the outdoors
    Medium Setting Care Model Characteristics
    • -Single- or double-occupancy resident bedrooms as determined to meet care population needs
    • -Space to accommodate decentralized services based on evaluation of need
    • -Common areas that include:
      • Residential kitchen
      • Dining room
      • Living room
      • Optional den and additional activity space for family and care provider visits
    • -Dedicated staff space
    • -Views of and access to nature, and areas for outdoor activities
    Large Setting Care Model
    • -Single- or double-occupancy resident bedrooms with direct access into a "household" that includes a residentially scaled kitchen, living room, and dining room
    • -Space to accommodate decentralized, semi-decentralized, or centralized services based on the care model
    • -Common areas that include:
      • Residentially scaled kitchen
      • Dining room
      • Living room
      • Den
      • Optional additional activity spaces
    • -Centralized or satellite commercial kitchens based on the care model
    • -Dedicated staff space
    • -Views of and access to nature, and areas for outdoor activities
    • -Travel distances for staff and residents based on household and neighborhood layout to maximize residents' independence and mobility
  3. Additional benefits. Some additional benefits of the small, medium, and large setting models for residents with intellectual and/or developmental disabilities include the following:
    Small Setting Care Model
    • -The small nature of this residential setting promotes strong personal relationships between residents and staff.
    • -This setting is typically provided by an owner-operator who is both the owner and provider of care.
    Medium Setting Care Model
    • -This residential setting typically allows for strong personal relationships between residents and staff.
    • -This setting provides a non-institutional setting for residents with intellectual and/or development disabilities.
    Large Setting Care Model
    • -The size of this community allows creation of multiple households or neighborhoods to serve populations with specialized care needs.
    • -This setting allows for smaller-scaled residential-type spaces in a larger community context supporting a larger number of residents for economies of scale.
    • -Reduction in the number of corridors as a result of using a household model reduces travel distances for staff.
Settings for residents with intellectual and/or developmental disabilities shall be permitted to be freestanding facilities or distinct parts of another residential health, care, or support facility.
Each setting for residents with intellectual and/or developmental disabilities shall, at minimum, contain the elements described in the applicable paragraphs of this chapter. However, when a project calls for sharing or purchasing services from another entity, modifications in space and parking requirements shall be permitted.
Where the setting for residents with intellectual and/or developmental disabilities is part of (or contractually linked with) another facility, sharing of facilities for services such as home health, dietary, storage, pharmacy, linen, and laundry services shall be permitted.
A4.4-1.2.2.3 Shared services and facilities. Services may be contractually provided or shared with other entities. In some cases, all ancillary service requirements will be met by the principal facility and the only modifications necessary will be in the setting for residents with intellectual and/or developmental disabilities. In other cases, programmatic concerns and requirements may dictate separate service areas.
See Section 1.2-3 (Resident Safety Risk Assessment) for requirements.
See Section 1.2-1.3 (Environment of Care and Facility Function Considerations) and Section 1.2-4 (Environment of Care Requirements) for requirements.
Settings for residents with intellectual and/or developmental disabilities shall be designed to provide flexibility to meet the changing physical, medical, and psychological needs of residents.
The facility design shall produce a supportive environment to:
  1. Enhance and extend quality of life for residents.
  2. Facilitate wayfinding.
  3. Promote resident privacy and dignity.
The physical environment of a setting for residents with intellectual and/or developmental disabilities shall support the services and levels of care provided in the residential setting, which are in larger part driven by the service needs and lifestyle preferences of the residents being served.
Settings for residents with intellectual and/or developmental disabilities shall be designed and constructed to provide a supportive residential environment that is conducive to day-to-day activities consistent with the cultural, emotional, and spiritual needs of residents. This supportive environment shall:
  1. Promote independence, privacy, and dignity for residents.
  2. Balance resident autonomy with resident safety.
  3. Provide choice for all residents in a manner that encourages family and community involvement.
The physical environment shall eliminate as many barriers as possible to effective access and use of the space, services, equipment, and utilities appropriate for daily living.
A4.4-1.4.4 Barrier-free environment
  1. "Universal design" practices that promote barrier-free environments should be encouraged. See appendix section A4.2-1.4-c (Environment of care design recommendations-Barrier-free environment) for more information.
  2. Facilities should provide accessibility for residents with disabilities in accordance with the state or local building code and the Americans with Disabilities Act.
See Chapter 1.3 (Site Selection) and Chapter 2.1 (Site Elements) for requirements.
A4.4-2.1 Settings for residents with intellectual and/or developmental disabilities include a variety of care models that are designed to meet differing social, economic, and care considerations. Descriptions of small, medium, and large care model settings are included in appendix section A4.4-1.2.1.2 (1) (Care model characteristics).
The requirements in this section are common to most settings for residents with intellectual and/or developmental disabilities and shall apply as indicated for each setting type.
Areas for the care and treatment of users not residing in the facility shall not interfere with or infringe on the space of residents who live in the facility.
Facility layout shall reflect the care model and related staffing.
  1. Small model. Four or fewer resident rooms shall be arranged in a residentially scaled home with centralized services and bathing, resident, and staff support areas.
  2. Medium model. Five to 16 resident rooms shall be arranged in a residentially scaled home that is freestanding or located in a larger community with centralized or decentralized services and bathing, resident, and staff support areas.
  3. Large model. Seventeen or more resident rooms shall be arranged using a household model with centralized or decentralized services and bathing, resident, and staff support areas.
Bedrooms or resident rooms shall be provided and sized to:
Allow for sleeping.
Afford privacy.
Provide access to furniture and belongings.
Accommodate the care and treatment provided to each resident.
A4.4-2.2.2 Resident room capacity. Bedrooms should be limited to single or double occupancy.
  1. Resident room size (area and dimensions) shall permit resident(s) to move about the room with the assistance of a resident-operated mobility device, allowing access to at least one side of a bed, window, closet or wardrobe, chair, dresser, and nightstand.
  2. Room size and configuration shall permit resident options for bed location(s) and shall comply with spatial requirements of the AHJ.
  3. Bedrooms shall not be used as passageways, corridors, or access to other bedrooms.
A.4.4-2.2.2.2 Space requirements. It should be considered for each resident to have the option of bringing his or her own furniture to their resident room depending on specific resident and safety needs in the setting.
See Section 4.4-5.2.2.6 (Windows) for requirements.
*(1)  Visual privacy shall be provided for each resident in double-occupancy rooms.
(2)  Design for privacy shall not restrict resident access to the toilet, room entrance, window, or other shared common areas in the resident room.
A4.4-2.2.2.4 (1) Consideration should be given to using a wall or partition as a divider to preserve visual and auditory privacy for each resident. Alcoves may be used in double-occupancy resident rooms.
Where a hand-washing station is provided, see Section 2.4-2.2.8 (Hand-Washing Stations) for requirements.
Each resident shall have access to a bathroom.
(1)  The bathroom shall contain the following:
(a)  Toilet
(b)  Hand-washing station. See Section 2.4-2.2.8 (Hand-Washing Stations) for requirements.
(c)  Mirror. See Section 2.4-2.2.8.7 (Mirror) for requirements.
(d)  Private individual storage for the personal effects of each resident. See Section 2.4-2.4.2 (Casework, Millwork, and Built-Ins) for requirements.
*(e)  Tub or shower. See Section 2.5-2.3.3.2 (Accessible showers) for requirements.
(2)  Where the bathroom is shared, privacy locks shall be permitted with provisions for emergency access.
A4.4-2.2.2.7 Resident bathrooms in small setting models. Because small setting models are located in a residential home setting, clearances and grab bars should be considered based on the needs of the care population. Since these settings are often in an existing house with standard residential bedrooms and bathrooms, meeting the requirements in Section 2.4-2.2.9 (Grab Bars), especially appendix section 2.4-2.2.9.2-b (For assisted transfers), may not be achievable.
  1. Clearances. Toilets used by residents should have sufficient clearance on both sides of the toilet to enable physical access and maneuvering by staff based on the care population and physical need requirements, appendix section A2.4-2.2.9.2-b (Grab bars in bathrooms-For assisted transfers) for additional information.
  2. Grab bars. Where independent transfers are feasible, alternative grab bar configurations should be permitted. See Section 2.4-2.2.9.3 (1) (Alternative grab bar configurations) for additional information.
A4.4-2.2.2.7 (1)(e) Tub or shower
  1. A curbless shower that is open to the surrounding bathroom should be considered for ease of access by resident and staff.
  2. For resident bathrooms that include a tub and/or shower, the need for lift(s), shower chair(s) and other equipment should be evaluated based on the care population.
(1)  Each resident shall be provided with an individual wardrobe or closet.
*(2)  Separate, enclosed storage in the resident room shall be provided for each resident.
A4.4-2.2.2.8 Resident storage
  1. Resident closets or wardrobes should have an adjustable-height bar for hanging clothes.
  2. Providing storage for resident mobility devices as required by the care population should be considered.
A4.4-2.2.2.8 (2) Lockable storage. Lockable drawers or cabinets should be provided to allow residents to secure some personal belongings.
See Section 2.3-2.3.1 (Resident, Participant, and Outpatient Community Areas-General) for requirements.
Where a lobby is provided, see Section 2.3-2.3.2 (Lobby) for requirements.
  1. See Section 2.3-2.3.3.1 (Dining, Recreation, and Lounge Areas-General) for requirements.
  2. Space for circulation of resident-operated mobility devices shall be provided in activity areas.
(1)  Space for dining shall be provided.
*(2)  Space requirements
(a)  Space provided for resident dining shall allow residents, including those using wheelchairs and resident-operated mobility devices, to access and leave their tables without disturbing other residents.
(b)  Where servers and food carts are utilized, clear and unobstructed circulation paths shall be provided.
(c)  Space shall be provided for staff to help residents who require assistance with eating based on the care population.
(3)  Location. For "small house" and "household" models, it is anticipated that dining areas will be adjacent to living areas to accommodate less densely populated groups of residents and to make dining areas easily accessible to residents.
(4)  Natural light shall be provided in resident dining areas.
A4.4-2.3.3.2 (2) Dining area size. Provision of a dining area(s) with a minimum floor area of 25 square feet per resident should be considered for new construction.
  1. Recreation areas shall accommodate both group and individual activities.
  2. Space requirements. Recreation, lounge, and activity areas shall provide the following:
    1. Space for planned resident activities
    2. Areas sufficient in number and configuration to accommodate the following:
      1. Gatherings of resident groups of various sizes
      2. Occurrence of separate and distinct activities
      3. Simultaneous dining and recreational activities
Toilet facilities that accommodate resident-operated mobility devices shall be readily accessible to all dining, recreation, activity, and lounge locations for medium and large setting models.
Where kitchen facilities that permit use by residents, family members, and visitors are provided, see Section 2.3-2.3.4 (Resident and Participant Kitchen) for requirements.
Outdoor spaces shall be provided for residents, visitors, and staff.
A4.4-2.3.8.1 Outdoor activity spaces
  1. Visual access to outdoor activity spaces from indoors should be provided for staff and residents.
  2. Outdoor spaces should be accessible via short, navigable distances.
  3. Location of outdoor spaces adjacent to community spaces as well as individual resident rooms or bedrooms should be considered based on the care population.
See Section 2.1-3.6.2 (Outdoor Activity Spaces) for additional requirements and information.
See Section 2.3-4.1 (Facilities for Support Services-General) for requirements.
These area(s) shall be provided where required by the care model to serve resident needs.
Lockable storage shall be provided for resident records.
Direct visualization of resident rooms or corridors from staff work areas shall not be required.
See Section 2.3-4.2.1 (Staff Work Area) for additional requirements.
See Section 2.3-4.2.2 (Medication Distribution and Storage Locations) for information as applicable to the care model-small, medium, or large.
*(1)  Where a shower is not provided in the resident bathroom, a central bathing or spa room or area shall meet the requirements in this section.
(2)  Where a central bathing or spa room or area is provided or required by the AHJ, see Section 2.5-2.3.3 (Showers and Tubs) for requirements in addition to those in this section.
A4.4-4.2.3.1 (1) Central bathing in medium and large settings. Central bathing or spa rooms or areas in medium and large settings should include the following:
  1. Entrances located with consideration for privacy
  2. Accessibility for residents in wheelchairs
  3. Shower rooms that allow for entry and maneuvering of portable/mobile mechanical lifts and shower chairs
  4. Separate toilet and hand-washing station in or directly accessible to the bathing area without requiring entry into a general corridor
Based on the needs of the care population, at least one central bathtub, spa tub, or shower shall be provided for resident use, where a shower is not provided in the resident bathroom.
Bathing fixtures shall be located in individual rooms or enclosures that provide the following:
  1. Space for private use of the bathing fixture
  2. Space for drying and dressing
  3. Access to a grooming location with a sink, mirror, and counter or shelf
A toilet shall be provided in or directly accessible to each resident bathing or spa room or area without requiring entry into the general corridor.
Where a shower is included in the bathing room or area, see Section 2.5-2.3.3.2 (Accessible showers) for requirements.
See Section 2.3-4.2.4 (Equipment and Supply Storage) for requirements in addition to those in this section.
  1. A separate closet or designated area shall be provided if required for the linen services offered by the facility.
  2. Where a closed-cart system is used, storage in an alcove where staff control can be exercised shall be permitted.
Storage space(s) for supplies and recreation items shall be immediately accessible and secured to support recreation and activities offered.
Storage space(s) for resident equipment and supplies shall be immediately accessible to support services offered and secured based on the care population.
Where a clean utility room is provided for storage and holding as part of a system for distribution of clean materials, see Section 2.3-4.2.5 (Clean Utility Room) for requirements.
Where a soiled utility room is provided for storage and holding as part of a system for collection of soiled materials, see Section 2.3-4.2.6 (Soiled Utility Room) for requirements.
Provision of decentralized facilities for washing and drying personal laundry shall be permitted where the care model supports this approach for small groups of residents.
Where shared personal laundry areas are provided, these shall be equipped with the following for use by residents/families:
  1. Washer and dryer
  2. Hand-washing station
  3. Folding area
Where personal laundry facilities are provided, see 2.3-4.2.7 (Personal Laundry Facilities) for additional requirements.
See Section 2.3-4.2.8 (Resident and Participant Telephone Access) for requirements.
See Section 2.3-4.3.1 (Support Areas for Staff-General) for requirements.
See Section 2.3-4.3.2 (Staff Lounge Area) for requirements.
Toilet rooms shall be permitted to be shared by the public, staff, and residents.
Community space for family and visitors shall be provided based on the care model and setting type.
Space for sleeping accommodations for overnight guests shall be provided based on the care model and setting type.
A4.4-4.4.2 Overnight guest accommodations.
Where visitor sleeping accommodations are provided in resident rooms, provision of the following should be considered:
  1. Sufficient circulation around the sleeping accommodation (e.g., recliner, sleep chair, sleep sofa) when it is fully open for use to allow staff to reach the resident in case of an emergency
  2. Storage space to accommodate and secure overnight guests' belongings
If pets are accommodated in the setting type, see Section 2.3-4.4.3 (Pet Accommodations) for requirements.
The type and size of the setting for residents with intellectual and/or developmental disabilities shall determine the dietary environment and the food service facilities provided.
Where a centralized commercial kitchen is provided, the food service facilities shall meet the requirements in Section 2.3-4.5 (Food Service Facilities).
For facilities that have a service contract with an outside vendor for food service, the following requirements shall be met:
Where an outside vendor is used to provide meals for a setting of 16 or more beds, dedicated space and equipment shall be provided for a warming kitchen, including space for minimal equipment for preparation of breakfast, emergency, or after-hours meals.
The resident kitchen shall be permitted to serve as an alternative location to accommodate the function of a warming kitchen. See Section 2.3-2.3.4 (Resident and Participant Kitchen) for requirements.
Where food preparation is conducted on-site for 16 or more beds, the facility shall have dedicated non-public staff space and equipment for preparation of meals. See section 2.3-2.3.4 (Resident and Participant Kitchen) for requirements.
A4.4-4.6.1 Based on the care model, laundry services may be decentralized using personal laundry facilities and/or a combination of personal laundry facilities and contracted services to provide linen service. See Section 2.3-4.2.7 (Personal Laundry Facilities) for additional information.
Each setting for residents with intellectual and/or developmental disabilities shall have provisions for storing and processing clean and soiled/contaminated linen for resident care based on the requirements of the care model and the setting type.
Based on the care model, personal laundry services can be combined with clean utility and/or soiled utility. See Section 2.3-4.2.5 (Clean Utility Room), Section 2.3-4.2.6 (Soiled Utility Room), and 2.3-4.2.7 (Personal Laundry Facilities) for additional requirements.
Where contracted services are used, the following shall be provided:
An area for soiled linen awaiting pickup
A separate area for storage and distribution of clean linen
  1. Where on-site laundry services are provided in a large setting for residents with intellectual and/or developmental disabilities, the requirements in this section shall apply.
  2. Facilities for processing shall be permitted to be located in the facility, in a separate building on- or off-site, or in a commercial or shared laundry.
  3. Layout. Equipment shall be arranged to permit a workflow that minimizes cross-traffic between clean and soiled operations.
    1. Areas dedicated to laundry shall be separate from food preparation areas.
    2. Laundry rooms shall not open directly into resident rooms.
At minimum, the following elements shall be included:
  1. Rooms and spaces for sorting, processing, and storage of soiled materials
  2. Soiled holding room(s). Separate central or decentralized room(s) shall be provided for receiving and holding soiled linen for pickup or processing.
    1. Room(s) shall have ventilation and exhaust.
    2. Discharge from soiled linen chutes shall be received in this room or in a separate room as required by the local AHJ.
    3. Room(s) used for processing shall be provided with a laundry or deep sink.
  3. Central clean linen storage. A central clean linen storage and issuing room(s) shall be provided in addition to the linen storage required at individual resident units.
  4. Linen carts
    1. Storage. Provisions shall be made for parking clean and soiled linen carts separately and out of traffic.
    2. Cleaning. Provisions shall be made for cleaning linen carts on-premises (or exchange of carts off-premises).
  5. Hand-washing stations. Hand-washing stations shall be provided in each area where unbagged soiled linen is handled. See Section 2.4-2.2.8 (Hand-Washing Stations) for additional requirements.
All settings shall provide for the delivery, breakdown, and storage of materials and supplies in a manner that does not conflict with resident living areas.
Materials management facilities provided in large settings shall meet the requirements in Section 2.3-4.7 (Materials Management Facilities).
All settings shall provide for the collection and storage of waste materials in a manner that does not have a negative impact on resident living areas.
Waste management facilities provided in large settings shall meet the waste collection, storage, and disposal requirements in Section 2.3-4.8 (Waste Management Facilities).
All settings shall provide for safe storage of, and safe access to, cleaning materials and equipment.
In medium and large settings, see Section 2.3-4.9 (Environmental Services Rooms) for requirements.
See Section 2.3-4.10 (Facilities for Engineering and Maintenance Services) for requirements.
Where an office(s) or an open office area with private conference space is provided for business transactions, admissions, and social services and for use by administrative and professional staff, the following shall be required:
Space for private interviews; staff, resident, and family meetings; conferences; and health education shall be sized according to operational needs.
  1. Space shall include provisions for use of visual aids and technology.
  2. Sharing of space for various uses shall be permitted.
A4.4-4.11.1.1 Kitchenette for conference space. Provision of kitchenette facilities, including under-counter refrigerator, microwave, and sink should be considered for the private conference space.
Office space shall be provided for staff and file storage.
Space for storage of files, office equipment, and supplies shall be provided.
See Section 2.4-1.2 (Building Codes and Standards) for requirements.
A code-compliant, safe, and accessible environment shall be provided.
A facility that seeks accreditation, certification, licensure, or other credentials shall comply with applicable design and construction standards.
Where institutional codes are required, the facility shall maintain the residential environment desired by residents.
The facility shall comply with applicable federal, state, and local requirements; see Section 1.1-4.1 (Design Standards for Accessibility).
See Section 2.4-2.1 (Architectural Details, Surfaces, and Furnishings-General) for requirements.
See Section 2.4-2.2.1 (Architectural Details-General) for requirements.
See Section 2.4-2.2.2 (Corridors) for requirements.
See Section 2.4-2.2.3 (Ceiling Height) for requirements.
(1)  Door type
*(a)  Doors to all rooms containing bathtubs, showers, and toilets for resident use shall be hinged, sliding, or folding.
*(b)  Resident unit doors
(i)  Egress from the unit shall be possible at all times and locking hardware shall enable occupant(s) to gain egress from within by means of a simple operation.
(ii)  All resident units shall be accessible by staff or safety personnel.
(c)  Manual or automatic sliding doors shall be permitted where their use does not compromise fire and other emergency exiting requirements.
(2)  Door openings. See Section 2.4-2.2.4.2 (Door openings) for requirements.
(3)  Insect screens. See Section 2.4-2.2.4.3 (Insect screens) for requirements.
A4.4-5.2.2.4 Door protection. See appendix section A2.4-2.2.4 (Door protection) for recommendations.
A4.4-5.2.2.4 (1)(a) Provisions should be made for auditory and visual privacy and usability for doors to rooms containing bathtubs, showers, and toilets for resident use.
A4.4-5.2.2.4 (1)(b) Resident unit doors. Based on the care population, use of doors that occupants can lock should be evaluated.
See Section 2.4-2.2.5 (Thresholds and Expansion Joint Covers) for requirements.
*(1)  See Section 2.4-2.2.6 (Windows) for requirements in addition to those in this section.
(2)  Windows shall be provided in all sleeping areas.
A4.4-5.2.2.6 (1) Windows. Each room in a resident setting should have a window(s) that meets the requirements of Section 2.4-2.2.6 (Windows).
See Section 2.4-2.2.7 (Glazing Materials) for requirements.
Where hand-washing stations are provided, they shall comply with Section 2.4-2.2.8 (Hand-Washing Stations).
See Section 2.4-2.2.9 (Grab Bars) for requirements.
See Section 2.4-2.2.10 (Handrails and Lean Rails) for requirements for medium and large settings.
See Section 2.4-2.2.11 (Protection from Heated Surfaces) for requirements.
See Section 2.4-2.2.12 (Signage and Wayfinding) for requirements.
Where decorative water features are used in the facility design, see appendix section A2.4-2.2.13 (Decorative water features) for recommendations.
(1)  See Section 2.4-2.3.1 (Surfaces-General) for requirements in addition to those in this section.
*(2)  To reduce surface contamination linked to health care-associated infections (HAIs), surface materials selected for use in medium and large settings shall possess the following performance characteristics:
(a)  Surfaces shall be cleanable.
(b)  Surfaces shall have no surface crevices, rough textures, joints, or seams.
(c)  Surfaces shall be non-absorptive, nonporous, and smooth.
A4.4-5.2.3.1 (2) Surfaces and materials selected should be easy to use and have clear, written, manufacturer-recommended cleaning and disinfection protocols to assure the product will remain durable and effective at meeting Centers for Disease Control and Prevention and other clinical bacterial-elimination requirements.
The Center for Health Design report "Designing for Patient Safety: Developing Methods to Integrate Patient Safety Concerns in the Design Process" identified environmental factors as "latent conditions that can be designed to help eliminate harm." Such "built environment latent conditions [holes and weaknesses] that adversely impact patient safety" should be identified and eliminated during planning, design, and construction of health care facilities. Reduction of surface contamination linked to health care-associated infections is one of these factors. See Section 1.2-3 (Resident Safety Risk Assessment) for additional information.
See Section 2.4-2.3.2 (Flooring and Wall Bases) for requirements.
See Section 2.4-2.3.3 (Walls and Wall Protection) for requirements.
See Section 2.4-2.3.4 (Ceilings) for requirements.
See Section 2.4-2.4 (Furnishings) for requirements.
See Section 2.5-1 (Building Systems-General) for requirements.
See Section 2.5-2.1 (Plumbing Systems-General) for requirements.
See Section 2.5-2.2 (Plumbing and Other Piping Systems) for requirements.
See Section 2.5-2.3.1 (Plumbing Fixtures-General) for requirements.
  1. See Section 2.5-2.3.2 (Hand-Washing Sinks) for requirements.
  2. Design of sinks shall not permit storage beneath the sink basin in casework or in areas below a sink open to the floor for accessible units.
See Section 2.5-2.3.3 (Showers and Tubs) for requirements.
Where portable hydrotherapy whirlpools are used in a setting for residents with intellectual and/or developmental disabilities, see Section 2.5-2.3.6 (Portable Hydrotherapy Whirlpools) for requirements.
  1. For small and medium-sized settings for residents with intellectual and/or developmental disabilities, see ANSI/ASHRAE Standard 62.2: Ventilation and Acceptable Indoor Air Quality in Low-Rise Residential Buildings for basic HVAC system requirements.
  2. For large settings for residents with intellectual and/or developmental disabilities, see ANSI/ASHRAE Standard 62.1: Ventilation for Acceptable Indoor Air Quality for basic HVAC system requirements.
See Section 2.5-3.2 (Mechanical System Design) for requirements.
Where these are provided, see Section 2.5-3.3.2 (Fuel-Fired Equipment Rooms) for requirements.
See Section 2.5-3.3.3 (Areas of Refuge) for requirements.
Where these are provided, see Section 2.5-3.3.4 (Commercial Food Preparation Areas) for requirements.
See Section 2.5-3.4 (Thermal and Acoustic Insulation) for requirements.
See Section 2.5-3.5 (HVAC Air Distribution) for requirements.
(1)  For centralized recirculated systems, MERV 7 shall be the minimum filter efficiency for the first filter bank. There is no minimum filter efficiency requirement for the second filter bank.
(2)  For non-central recirculating room systems, HVAC units shall:
(a)  Not receive nonfiltered, nonconditioned outdoor air.
(b)  Serve only a single space.
*(c)  Include the manufacturer's recommended filter for airflow passing over any surface that is designed to condense water. This filter shall be located upstream of any such cold surface so that all of the air passing over the cold surface is filtered.
A4.4-6.3.6.1 (2)(c) Filters for recirculating room systems. Filters should be replaced and/or cleaned per the manufacturer's recommendations to maintain indoor air quality.
  1. Filter frames shall be durable and proportioned to provide an airtight fit with the enclosing ductwork.
  2. All joints between filter segments and the enclosing ductwork shall have gaskets or seals to provide a positive seal against air leakage.
See Section 2.5-3.7 (Heating Systems, Cooling Systems, and Equipment) for requirements in addition to those in this section.
Settings for residents with intellectual and/or developmental disabilities shall have a permanently installed heating system capable of maintaining an interior minimum temperature of 72° F (22° C) under heating design temperatures.
Settings for residents with intellectual and/or developmental disabilities shall be configured and equipped with a cooling system capable of maintaining an interior maximum temperature of 75° F (24° C) under cooling design temperatures..
See Section 2.5-4.1 (Electrical Systems-General) for requirements.
*(1)  Applicable standards for care models
(a)  Facilities with a large setting care model shall have essential electrical systems as required in NFPA 101: Life Safety Code.
(b)  For facilities with small and medium setting care models, local codes shall dictate minimum requirements for the essential electrical service.
(c)  For all settings for residents with intellectual and/or developmental disabilities, local codes and care model needs shall dictate emergency lighting requirements.
(2)  Where residents on life support equipment are served in a setting for residents with intellectual and/or developmental disabilities, essential electrical power shall be provided to the life support equipment.
(3)  Where fuel for electricity generation is stored on-site, the following requirements shall be met:
(a)  Storage capacity shall permit continuous operation for at least 24 hours.
(b)  Fuel storage for electricity generation shall be separate from heating fuel storage.
(c)  Where heating fuel is used for diesel generators after the required 24-hour supply of diesel fuel has been exhausted, positive valving and filtration shall be provided to avoid entry of water and/or contaminants into the storage tank.
A4.4-6.4.2.1 (1) Care models are defined in appendix section A4.4-1.2.1.2 (1) (Care model characteristics).
Where generators are used for a setting for residents with intellectual and/or developmental disabilities, exhaust systems (including mufflers and vibration isolators) for internal combustion engines shall be located, designed, and installed to minimize objectionable noise.
See Section 2.5-4.3.1 (Electrical Receptacles-General) for requirements.
See Section 2.5-4.3.2 (Receptacles in Corridors) for requirements.
Each resident room shall have duplex-grounded receptacles, including at least one on each wall.
A4.4-6.4.3.3 Because settings for residents with intellectual and/or developmental disabilities often include one or more bedrooms, living spaces, and private bathrooms, furniture layouts should be used to establish receptacle locations.
See Section 2.5-4.3.4 (Essential Electrical System Receptacles) for requirements.
See Section 2.5-4.3.5 (Ground Fault Interrupter Receptacles) for requirements.
The requirements in this section shall apply to the following systems based on the care model and the needs of residents:
  1. Call systems
  2. Information systems
  3. Telecommunication systems
  1. Each resident room shall be equipped for a television and telephone.
  2. See Section 2.5-5.1.2 (Communication System Equipment Requirements) for additional requirements.
Where call systems are provided, the following requirements shall be met:
  1. The system shall be capable of activation/operation from resident toilets, bedrooms, and bathing areas.
  2. The signal shall be transmitted to on-duty staff through fixed locations and/or resident wearable devices.
  3. Use of alternative technologies, including wireless systems, shall be permitted.
    1. Where wireless systems are used, consideration shall be given to electromagnetic compatibility between internal and external sources.
    2. Wireless systems shall comply with UL Standard 2560: Emergency Call Systems for Assisted Living and Independent Living Facilities.
  1. Where a hardwired system is used:
    1. Each bed location shall be provided with a call device accessible to the resident.
    2. One call station shall be permitted to serve two call devices.
  2. Use of wireless call stations shall be permitted.
Where an emergency call system is provided, an emergency call device shall be located at each toilet, bath, and shower used by residents.
  1. The device shall be accessible to a resident in any position in the room, including lying on the floor. Inclusion of a pull cord or portable wireless device shall satisfy this requirement.
  2. The emergency call system shall be designed so that when a call is activated a signal is initiated that is distinct from the resident room call device and can be turned off only at the activated emergency call device.
  3. The signal shall activate at the staff work area and/or signal a handheld mobile device carried by staff.
  4. Emergency call systems shall comply with UL 2560: Emergency Call Systems for Assisted Living and Independent Living Facilities.
See Section 2.5-5.3 (Technology Equipment and Teledata Room) for requirements.
See Section 2.5-5.4 (Grounding for Telecommunication Spaces) for requirements.
See Section 2.5-5.5 (Cabling Pathways and Raceway Requirements) for requirements.
See Section 2.5-6 (Electronic Safety and Security Systems) for requirements.
See Section 2.5-7.1 (Daylighting and Artificial Lighting Systems-General) for requirements.
See Section 2.5-7.2 (Daylighting Systems in Resident Living, Participant, and Outpatient Areas) for requirements.
See Section 2.5-7.3.1 (Light Fixtures) for requirements.
See appendix section A2.5-7.3.2 (Lighting in transition spaces) for recommendations.
(1)  Resident unit corridors in large and medium settings
(a)  Resident unit corridors shall have general illumination with provisions for reducing light levels at night.
(b)  Corridors and common areas used by residents shall have even light distribution to avoid glare, shadows, and scalloped lighting effects.
*(2)  Resident rooms, bedrooms, and bathrooms
(a)  Task light controls shall be readily accessible to residents.
(b)  Where night-lighting is provided, it shall be located in the pathway to and from the bedside and the bathroom.
(i)  Night-lighting shall be mounted no higher than 2 feet (61 centimeters) above the floor.
(ii) Night-lighting shall be controlled separately from ambient lighting.
*(iii)  Night-lighting shall have a low light level.
(iv) Because night-lights may disturb resident sleep even when properly specified, located, and operated, care providers shall be permitted to use portable light sources or switched night-lights for added control of this light source.
A4.4-6.7.3.2 (2) Lighting in resident rooms, bedrooms, and bathrooms. Resident rooms, bedrooms, and bathrooms should have general lighting and task lighting.
  1. Provision of movable task lighting should be considered.
  2. Resident bathrooms should provide general illumination with provision for reducing light levels at night.
A4.4-6.7.3.2 (2)(b)(iii) Night-lighting in resident rooms. Research has established that older adults sleep best in total darkness. Therefore, to minimize resident sleep disruption, night-lights should provide very low levels of illumination and be located to minimize light scatter and reflections on room surfaces. To achieve a low light level, night-lighting should include amber or red lamping. White, blue, or green lamping should not be used. Switches for night-lights are recommended for some care populations.
See Section 2.5-8 (Acoustic Design Systems) for requirements.
Where elevators are provided in large settings for residents with intellectual and/or developmental disabilities the following requirements shall be met:
Engineered traffic studies are recommended, but in their absence the following guidelines for the minimum number of elevators shall apply:
  1. At least one elevator sized to accommodate a gurney and/or medical carts and resident-operated mobility device users shall be installed where residents are living or receiving care or support services on any floor other than the main entrance floor.
  2. At least two elevators shall be installed where 60 to 200 residents are living or receiving care or support services on floors other than the main entrance floor.
  3. At least three elevators shall be installed where 201 to 350 residents are living or receiving care or support services on floors other than the main entrance floor.
  4. For facilities with more than 350 residents living or receiving care or support services above the main entrance floor, the number of elevators shall be determined from a study of the facility plan and from the estimated vertical transportation requirements.
A4.4-6.9.1.2 Number of elevators. These standards may be inadequate for moving large numbers of people in a short time; adjustments should be made as appropriate to the care model and population served.
Elevator car doors shall have a clear opening of no less than 3 feet 8 inches (1.12 meters).
A4.4-6.9.2 Elevator dimensions and clearances
  1. Handrail projections of up to 3.5 inches (8.89 centimeters) should not be construed as diminishing the clear inside dimensions.
  2. If required to serve the care population and indicated by a mobility transfer assessment, at least one facility elevator should accommodate attending staff and an ambulance gurney 7 feet 6 inches (2.29 meters) in length and/or an expanded capacity width of 4 feet (1.22 meters) for persons of size.
  3. Additional elevators required for passenger service should be sized to accommodate resident-operated mobility devices.
See Section 2.5-9.3 (Leveling Device) for requirements.
See Section 2.5-9.4 (Installation and Testing) for requirements.
Elevator cars shall have handrails on all sides without entrance door(s). See Section 2.4-2.2.10 (Handrails and Lean Rails) for additional requirements.
Appendix Table A4.4-a
Characteristics of Settings for Individuals with Intellectual and/or Developmental Disabilities*
Setting Type Typical # of Units Food Service/Dining Type Resident Accommodations Bathing Facility Type Design Drivers Environment of Care and Relevant Descriptions
Small 5 or fewer Centralized: residential kitchen Single- or double-occupancy bedrooms with a bathroom shared by no more than two residents Centralized: residential accessible bathroom
• Resident-centered care supportive of residential versus institutional living
• Strong personal relationship opportunities between staff and residents supported by the smaller scale
• Embedded within the community at-large
1.  Light: Maximal access to daylight should be a priority in private bedroom spaces, work areas, and shared social spaces. Where the care population has low vision issues, the design should avoid glare.
2.  Views of and access to nature: Maximal access to views of nature and outdoor spaces should be a priority. Where direct access is not possible, alternative access may include indoor gardens with natural light (sky lights), roof gardens, and green roofs.
3.  Signage and wayfinding: The smaller size of this facility type generally makes it easier to provide a layout with direct visual access to key destinations.
4.  User control of environment: The goal is to support greater resident autonomy in all aspects of the environment.
5.  Privacy and confidentiality: Provision of all single-occupancy rooms enhances privacy, although availability of another space outside the bedroom for visiting is important.
6.  Safety and security: The smaller scale of this facility type makes staff monitoring easier. Outside spaces should be visible from indoors. Multi-story residences need to conform to accessibility standards. All residences conform to local and state fire and life safety standards.
7.  Characteristics and criteria for selection of materials and products for architectural details, surfaces, and furnishings: Personalization of individual spaces should be supported.
8.  Cultural responsiveness: The cultural orientation and needs, customs, desires, etc. of the care population and staff should inform the design of the physical environment. This understanding addresses the "who" element of the functional programming process, considered critical to developing the environment of care. For example, the designer would provide a physical environment that helps a caregiver from Jamaica caring for an orthodox Jewish woman understand and support kosher customs and resident and family expectations.
9.  Support for person-centered care: The goal of this model is to offer residents a full experience of home.
Medium 16 or fewer Centralized: residentially scaled kitchen with dedicated food service staff Single- or double-occupancy resident rooms with private or shared full bathrooms (shared by no more than two residents) Decentralized in resident room bathrooms but may also include a centralized bathing core
• Resident-centered care supportive of residential versus institutional living
• Strong personal relationship opportunities between staff and residents supported by the smaller scale
• Most services are decentralized in smaller residential environments of eight residents each
• Total of two eight-person homes
1.  Light: Maximal access to daylight should be a priority in private bedroom spaces, work areas, and shared social spaces. The care population's low vision issues should be addressed in the design, including avoidance of glare.
2.  Views of and access to nature: Maximal access to views of nature and outdoor spaces should be a priority. Where direct access is not possible, alternative access may include indoor gardens with natural light (sky lights), roof gardens, and green roofs.
3.  Signage and wayfinding: The smaller size of this facility type generally makes it easier to provide a layout with direct visual access to key destinations. Signage should be able to be easily read by residents who are visually impaired.
4.  User control of environment: The goal is to support resident autonomy in all aspects of the environment, providing resident choice wherever possible.
5.  Privacy and confidentiality: Provision of all single-occupancy rooms enhances privacy, although availability of another space outside the bedroom for visiting is important.
6.  Safety and security: The smaller scale makes staff monitoring easier. Outside spaces should be visible from indoors. Multi-story residences need to conform to accessibility standards. All residences conform to local and state fire and life safety standards.
7.  Characteristics and criteria for selection of materials and products for architectural details, surfaces, and furnishings: Personalization of individual spaces should be supported.
8.  Cultural responsiveness: The cultural orientation and needs, customs, desires, etc. of the care population and staff should inform the design of the physical environment. This understanding addresses the "who" element of the functional programming process, considered critical to developing the environment of care. For example, the designer would provide a physical environment that helps a caregiver from Jamaica caring for an orthodox Jewish woman understand and support kosher customs and resident and family expectations.
9.  Support for person-centered care: The goal of this model is to offer residents a full experience of home.
Large 17 or more Decentralized and/or centralized: residentially scaled kitchen, commercial kitchen as required based on care model, and dedicated food service staff Single- or double-occupancy resident rooms with private or shared full bathrooms (shared by no more than two residents) Decentralized in resident room bathrooms but may also include a centralized bathing core
• Resident-centered care supportive of residential versus institutional living
• Often a multidisciplinary team approach in a household setting
• Cross-training a consideration for care staff and housekeeping staff
• Staff travel distances shorter due to use of a household model except for food service staff where food is prepared in a centralized kitchen
• Household model is operationally conducive to providing some/all decentralized services and activity areas
• Consideration for larger event space to gather various household residents into a larger group for activities and events
1.  Light: Maximal access to daylight should be a priority in private bedroom spaces, work areas, and shared social spaces. The care population's low vision issues should be addressed in the design, including avoidance of glare.
2.  Views of and access to nature: Maximal access to views of nature and outdoor spaces should be a priority. Where direct access is not possible, alternative access may include indoor gardens with natural light (sky lights), roof gardens, and green roofs. Provision of outdoor dedicated staff space and staff break areas with views should be considered.
3.  Signage and wayfinding: A wayfinding program should be provided to help residents, staff, and visitors distinguish one apartment from another. In a larger building, this can include landmarks to assist with orientation. Signage should be able to be easily read by residents who are visually impaired.
4.  User control of environment: The goal is to support resident autonomy in all aspects of the environment, providing resident choice wherever possible.
5.  Privacy and confidentiality: Provision of all single-occupancy apartments enhances privacy. Two-bedroom or shared one-bedroom apartments (e.g., shared by a couple) provide separate seating areas for private discussions.
6.  Safety and security: Because decentralized staffing is recommended, staff presence near residents and points of activity is greater. Outside spaces should be visible from indoors. Multi-story residences need to conform to accessibility standards. All residences conform to local and state fire and life safety standards.
7.  Characteristics and criteria for selection of materials and products for architectural details, surfaces, and furnishings: Personalization of individual spaces should be supported. Resident input on community spaces should periodically be reviewed to verify compliance with needs expressed in the functional program.
8.  Cultural responsiveness: The cultural orientation and needs, customs, desires, etc. of the care population and staff should inform the design of the physical environment. This understanding addresses the "who" element of the functional programming process, considered critical to developing the environment of care. For example, the designer would provide a physical environment that helps a caregiver from Jamaica caring for an orthodox Jewish woman understand and support kosher customs and resident and family expectations.
9.  Support for person-centered care: The goal of this model is to offer residents a full experience of home and more opportunities for social interaction.
*Payment source requirements may influence design characteristics.
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