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COMPLIANCE CHECKLIST
IP5_Critical Care Unit
The following checklist is intended to be used in the plan review applications for health care facilities submitted to the Massachusetts
Department of Public Health. This checklist summarizes and references the applicable requirements from the Licensure Regulations and the
2018 Edition of the FGI Guidelines for Design and Construction of Hospitals. Applicants must verify compliance of the plans submitted to the
Department with all referenced requirements from the Licensure Regulations and FGI Guidelines when completing this Checklist. A separate
Checklist must be completed for each nursing unit, hospital or clinic department, or clinical suite.
Other jurisdictions, regulations and codes may have additional requirements which are not included in this checklist, such as:
 NFPA 101 Life Safety Code (2012) and applicable related standards contained in the appendices of the Code
 State Building Code (780 CMR)
 Accreditation requirements of The Joint Commission
 CDC Guidelines for Preventing the Transmission of Mycobacterium Tuberculosis in Health Care Facilities
 USP 797 & Regulations of the Massachusetts Board of Registration in Pharmacy
 Occupational Safety & Health Standards (OSHA)
 Accessibility Guidelines of the Americans with Disabilities Act (ADA)
 Architectural Access Board Regulations (521 CMR)
 Local Authorities having jurisdiction.
Instructions:
1. All requirement lines must be completed according to the following instructions and included in the plan submissions for Self-
Certification Process or Abbreviated Review Process.
2. This checklist must be completed by the project architect or engineer based on the design actually reflected in the plans at the
time of completion of the checklist.
3. Each requirement line (___) of this Checklist must be completed exclusively with one of the following marks, unless otherwise
directed in the checklist. If a functional space is not affected by a renovation project, the mark “E” may be indicated on the
requirement line (___) before the name of the functional space (associated requirements on indented lines below that name, or
associated MEP requirements do not have to be completed in this case). If more than one functional space serves a given
required function (e.g. patient room or exam room), that clarification should be provided in the Project Narrative, and the
requirement lines are understood to only address the functional spaces that are involved in the project.
X = Requirement is met, for new space, for renovated space, or = Check box under section titles or individual requirements
for existing direct support space for an expanded service. lines for optional services or functions that are not included
in the project area.
E = Requirement relative to an existing suite or area that has been W = Waiver requested for specific section of the Regulations or
licensed for its designated function, is not affected by the FGI Guidelines, where hardship in meeting requirement can
construction project and does not pertain to a required direct be demonstrated (a Physical Plant Waiver Form must be
support space for the specific service affected by the project. completed for each waiver request). An explicit floor plan or
“E” must not be used for an existing required support space plan detail must be attached to each waiver request.
associated with a new patient care room or area.
4. All room functions marked with "X" must be shown on the plans with the same name labels as in this checklist.
5. Mechanical, electrical & plumbing requirements are only partially mentioned in this checklist. The relevant section of the FGI
Guidelines must be used for project compliance with all MEP requirements and for waiver references.
6. Oxygen, vacuum, medical air, waste anesthesia gas disposal and instrument air outlets (if required) are identified respectively
by the abbreviations "OX", "VAC", "MA", “WAGD” & “IA”.
7. Requirements referenced with “FI” result from formal interpretations from the FGI Interpretations Task Group.
8. The location requirements including asterisks (*) refer to the definitions of the Glossary in the beginning section of the FGI
Guidelines and reproduced in this checklist.
Facility Name: DoN Project Number: (if applicable)

Facility Address: Patient Care Unit Bed Complements:

Current = Proposed =

Satellite Name: (if applicable) Building/Floor Location:

Satellite Address: (if applicable)

Submission Dates:
Project Description: Initial Date:
Revision Date:

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Architectural Requirements Building Systems Requirements

2.2-2.6 CRITICAL CARE UNIT

2.1-1.2.3 Shared Services:

No combined functions unless specifically
allowed in this checklist

2.2-2.6.1.2 Location:
(1) critical care unit located in same
building as services and/or departments
required to provide care to critical care
patients (e.g. emergency, respiratory
therapy, laboratory, radiology, surgery)
(2) unit be located so that medical
emergency resuscitation teams can
respond promptly to emergency calls
with minimum travel time
(3) location does not permit unrelated
traffic of staff, public or other patients
through unit (except for emergency
egress)

2.2-2.6.2 CRITICAL CARE PATIENT CARE AREAS

2.2-2.6.2.2 Space Requirements: Ventilation:

(1) each patient care station is single-patient Min. 6 air changes per hour Table 7.1
room
(2) each patient room has min. clear floor Lighting:
area 200 sf General lighting 2.1-8.3.4.3(1)
min. headwall width 13’-0” Lighting for bed permits staff (c)
observation of patient
(3)(a) min. clearance 1'-0" from head of bed minimizes glare
to wall
(3)(b) min. clearance 5’-0” from foot of bed to Power:
wall Min. 16 receptacles in total Table 2.1-1
(3)(c) min. clearance 5’-0” on transfer side convenient to head of
(3)(d) min. clearance 4’-0” on non-transfer bed with one on each
side wall
(5) patient room sized to allow for Nurse Call System:
minimum of two seated visitors without Patient station Table 2.1-2
interfering with providers’ access to Staff assistance station
patient & equipment Emergency call station
Medical Gases:
1 OX, 3 VAC, 1 MA per bed Table 2.1-3
2.2-2.6.2.3 Windows In Patient Rooms:
2.1-7.2.2.5(1) each patient room provided with natural
light by means of window to outside
2.1-7.2.2.5(3)
(a) minimum net glazed area be no less than
8% of required min. clear floor area of
room served
(b) maximum 36 inches windowsill height
above finished floor

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Architectural Requirements Building Systems Requirements

2.2-2.6.2.4 Patient Privacy:
(1) view panels to corridor with means to
allow visual privacy
(2) existing multiple patient care stations
in renovation projects
☐ check if not included in project
each patient care station has
provisions for visual privacy from
casual observation by other
patients & visitors

2.2-2.6.2.5 Handwashing Stations:

(1) handwashing station provided in each
patient room
(2) existing multiple patient care stations
in renovation projects
☐ check if not included in project
(a) at least one handwashing station
provided for every 3 patient care
stations
(b) handwashing station located near
patient care station

2.2-2.6.2.6 Toilet Room or Human Waste Disposal Room: Ventilation:

(1) enclosed toilet room Min. 10 air changes per hour Table 7.1
(a) toilet with bedpan-rinsing device Exhaust
direct access from patient room Negative pressure
or No recirculating room units
enclosed human waste disposal room

(b) flushing-rim clinical sink with

bedpan-rinsing device
direct access from patient room

2.2-2.6.4 SPECIAL PATIENT CARE AREAS

2.2-2.6.4.2 Airborne infection isolation (AII) room

(1) at least one AII room provided in one
critical care unit
2.1-2.4.2.2 complies with requirements applicable
to patient rooms
(1) capacity one bed
(2) personal protective equipment (PPE)
storage at entrance to room
(3) handwashing station
(4) patient toilet room Ventilation:
serves only one AII room Min. 10 air changes per hour Table 7.1
Exhaust
Negative pressure
No recirculating room units

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Architectural Requirements Building Systems Requirements

2.1-2.4.2.3 Anteroom
☐ check if not included in project
(1) provides space for persons to don Ventilation:
personal protective equipment Min. 10 air changes per hour Table 7.1
(PPE) before entering patient Exhaust
room No recirculating room units
(2) all doors to anteroom have
self-closing devices
or
audible alarm activated when AII
room is in use as isolation room

(3)(a) handwashing station

(3)(b) storage for unused PPE
(3)(c) disposal/holding container for
used PPE

2.1-2.4.2.4 Architectural Details & Furnishings:

(1)(a) perimeter walls ceiling & floor including
penetrations constructed to prevent air
exfiltration
(1)(b) self-closing devices on all room exit
doors
or
activation of audible alarm when AII
room is in use as isolation room

edge seals provided along sides & top

of doorframe for any door into AII room
(2) (a) window treatments do not include
fabric drapes & curtains
2.1-7.2.3.1(7)(a) floors are monolithic & integral coved
wall bases are at least 6” high & tightly
sealed to wall
2.1-2.4.2.5 room pressure visual or audible alarm

2.2-2.2.4.4 Protective environment (PE) room

☐ check if not included in project
2.1-2.4.2.2 complies with requirements applicable Ventilation:
to patient rooms Min. 12 air changes per hour Table 7.1
(1) capacity one bed Positive pressure
(2) personal protective equipment (PPE) No recirculating room units
storage at entrance to room
(3) handwashing station Supply air diffusers are Part 3/7.2.2
located above patient bed
Exhaust grilles or registers
located near patient room
door

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Architectural Requirements Building Systems Requirements

(4) Patient toilet room Ventilation:
serves only one PE room Min. 10 air changes per hour Table 7.1
2.1-2.2.6.3 Exhaust
(1) toilet Negative pressure
(2) handwashing station No recirculating room units
(3)
bedpan washer

2.1-2.4.2.3 Anteroom
☐ check if not included in project
(1) provides space for persons to don Ventilation:
personal protective equipment Min. 10 air changes per hour Table 7.1
(PPE) before entering patient room No recirculating room units
(2) all doors to anteroom have
self-closing devices
or
audible alarm activated when PE
room is in use as isolation room

(3)(a) handwashing station

(3)(b) storage for unused PPE
(3)(c) disposal/holding container for
used PPE

2.1-2.4.2.4 Architectural Details & Furnishings:

(1)(a) perimeter walls ceiling & floor
including penetrations constructed
to prevent air exfiltration
(1)(b) self-closing devices on all room
exit doors
or
activation of audible alarm when
PE room is in use as isolation room

edge seals provided along sides

& top of doorframe for any door
into PE room
(2) (a) window treatments do not include
fabric drapes & curtains
2.1-7.2.3.1(7)(a) floors are monolithic & integral
coved wall bases are at least 6”
high & tightly sealed to wall
2.1-2.4.2.5 room pressure visual or audible
alarm

2.2-2.2.4.4(5) Special Design Elements:

(a) monolithic ceiling
surfaces are cleanable
(b) lighting fixtures have lenses &
are sealed
2.1-7.2.3.1 floors are monolithic & integral
(7)(a) coved wall bases are at least 6”
high & tightly sealed to wall

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Architectural Requirements Building Systems Requirements

2.2-2.6.8 SUPPORT AREAS FOR CRITICAL CARE UNIT

2.2-2.6.8.2(1) Administrative center or nurse station

2.1-2.8.2.1(1) space for counters
2.1-2.8.2.1(2) handwashing station next to or directly
accessible*
or
hand sanitation dispenser next to or
directly accessible*

(2) direct or remote visual observation

between nurse station or staffed
charting stations & all patient care
stations in critical care unit
observation provides view of
patient while patient is in bed

2.2-2.6.8.3 Documentation areas

(1) provided for each patient in or Nurse Call System:
adjacent* to patient care station Duty station (light/sound 2.1-8.5.1.2(3)(b)
signal)
(2) Information review area located to facilitate
concentration

2.2-2.6.8.4 Nurse or supervisor office

(1) office space for critical care medical &
nursing management/administrative
personnel
immediately accessible* to critical care
unit
(2) offices linked with unit by telephone or
intercommunications system

2.2-2.6.8.5 Multipurpose room

at least one multipurpose room for
each facility for patient conferences,
reports, education, training sessions &
consultation (may serve several
patient care units & departments)

2.2-2.6.8.8 Medication safety zones

2.1-2.8.8.1(2) Design Promoting Safe Medication Use:
(a) medication safety zones located
out of circulation paths
(b) work space designed so that staff Lighting:
can access information & perform Task-specific lighting level 2.1-2.8.8.1(2)(d)
required tasks min. 100 foot-candles
(c) work counters provide space to
perform required tasks
(e) sharps containers placed at
height that allows users to see top
of container
(f) max. 45 dBA noise level caused
by building systems
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Architectural Requirements Building Systems Requirements

2.1-2.8.8.2(1) medication preparation room
(a) under visual control of nursing staff Ventilation:
(b) work counter Min. 4 air changes per hour Table 7.1
handwashing station Lighting:
lockable refrigerator Task lighting 2.1-2.8.8.1(2)(d)
locked storage for controlled drugs
sharps containers Nurse Call System:
☐ check if not included in project Duty station (light/sound Table 2.1-2
signal)
(c) self-contained
medication-dispensing unit
☐ check if not included in project
room designed with space to
prepare medications
or
2.1-2.8.8.2(2) automated medication-dispensing unit
(a) located at nurse station, in clean Lighting:
workroom or in alcove Task lighting 2.1-2.8.8.1(2)(d)
(c) handwashing station located next Nurse Call System:
to stationary medication- Duty station (light/sound Table 2.1-2
dispensing units or stations signal)

2.2-2.6.8.9 Nourishment area or room

(2) located within critical care unit
or
shared with another critical care unit
accessible from critical care unit
without travel through public
corridor
2.1-2.8.9.2 Ventilation:
(1) handwashing station Min. 2 air changes per hour Table 7.1
(2) work counter
(3) refrigerator
(4) microwave
(5) storage cabinets
(6) space for temporary storage of food Nurse Call System:
service implements Duty station (light/sound 2.1-8.5.1.2(3)(b)
signal)
2.1-2.8.9.3 provisions & space are included for
separate temporary storage of unused
& soiled meal trays

2.2-2.6.8.10 Ice-making equipment

(1) provides ice for treatment &
nourishment

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Architectural Requirements Building Systems Requirements

2.2-2.6.8.11 Clean workroom or clean supply room
(2) located within critical care unit
or
shared with another critical care unit
accessible from critical care unit
without travel through public
corridor

2.1-2.8.11.2 clean workroom Ventilation:

used for preparing patient care Min. 4 air changes per hour Table 7.1
items
(1) work counter Positive pressure
(2) handwashing station
(3) storage facilities for clean & Nurse Call System:
sterile supplies Duty station (light/sound Table 2.1-2
or signal)
2.1-2.8.11.3 clean supply room Ventilation:
used only for storage & holding as Min. 4 air changes per hour Table 7.1
part of system for distribution of Positive pressure
clean & sterile supplies

2.2-2.6.8.12 Soiled workroom or soiled holding room

(2) located within critical care unit
or
shared with another critical care unit
accessible from critical care unit
without travel through public
corridor

2.1-2.8.12.2 soiled workroom Ventilation:

Min. 10 air changes per hour Table 7.1
(1)(a) handwashing station Exhaust
(1)(b) flushing-rim clinical service sink Negative pressure
with bedpan-rinsing device or No recirculating room units
equivalent flushing-rim fixture
(1)(c) work counter
(1)(d) space for separate covered Nurse Call System:
containers for waste & soiled Duty station (light/sound Table 2.1-2
linen signal)
(2) fluid management system is used
☐ check if not included in project
(a) electrical & plumbing
connections that meet
manufacturer requirements
(b) space for docking station
or
2.1-2.8.12.3 soiled holding room Ventilation:
Min. 10 air changes per hour Table 7.1
(1) handwashing station or hand Exhaust
sanitation station Negative pressure
(2) space for separate covered No recirculating room units
containers for waste & soiled linen

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Architectural Requirements Building Systems Requirements

2.2-2.6.8.13(1) Clean linen storage
(b) located within critical care unit
or
shared with another critical care unit
accessible from critical care unit
without travel through public
corridor
2.1-2.8.13.1
(1) stored in clean workroom
or
separate closet
or
covered cart distribution system on
each floor
(2) storage of clean linen carts in
designated corridor alcoves,
clean workroom or closets

2.2-2.6.8.13(2) Equipment storage room or alcoves

(a) sized to provide min. 20 sf per patient
care station
(b) equipment storage room contains
space & provisions for recharging
equipment

(3) Wheelchair & gurney storage

(4) Emergency equipment storage

2.1-2.8.13.4
(1) each patient care unit has at least one
emergency equipment storage location
(2) provided under visual observation of staff
(3) storage locations in corridors do not
encroach on minimum required
corridor width

2.2-2.6.8.14 Environmental services room Ventilation:

Min. 10 air changes per hour Table 7.1
2.1-2.8.14.1 readily accessible* to unit or floor it Exhaust
serves (permitted to serve more than Negative pressure
one patient care unit on floor) No recirculating room units
2.1-2.8.14.2
(1) service sink or floor-mounted mop sink
(2) provisions for storage of supplies &
housekeeping equipment
(3) handwashing station
or
hand sanitation station

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Architectural Requirements Building Systems Requirements

2.2-2.6.8.15 Examination room
☐ check if not included in project
2.1-2.1.2 Patient Privacy:
provisions are made to address patient
visual & speech privacy

2.1-3.2.2.1 Space Requirements: Ventilation:

(1) min. clear floor area 120 sf Min. 6 air changes per hour Table 7.1
min. clear dimension 10’-0”
(2)(a) room size permits room Lighting:
arrangement with min. clearance Portable or fixed exam light 2.1-8.3.4.3(3)
3’-0” at each side & at foot of exam
table
room arrangement (layout #1) Power:
shown in the plans Min. 8 receptacles in total Table 2.1-1
(2)(b) exam table, recliner or chair is Min. 4 receptacles convenient
placed at angle closer to one wall to head of gurney or bed
than another or against wall to Nurse Call System:
accommodate type of patient Staff assistance station Table 2.1-2
being served Emergency call station
☐ check if not included in project
room arrangement (layout #2)
shown in the plans
2.1-3.2.2.2
(2) storage for supplies
(3) accommodations for written or
electronic documentation
(4) space for visitor’s chair
(5) handwashing station

2.2-2.6.8.16 Patient-monitoring equipment

(1) each unit contains equipment for
physiological monitoring with visual
displays for each patient at bedside &
at nurse station or centralized
monitoring area
(2) monitors located to permit easy viewing
monitors do not interfere with access to
patient

2.2-2.6.8.17 Image-viewing capability unit (may serve

more than one critical care unit)

2.2-2.6.9 SUPPORT AREAS FOR STAFF

2.2-2.6.9.1 Staff lounge
min.100 sf
(1) located in or adjacent* to critical care
(2) unit (may serve adjacent* critical care
units)
(3) telephone or intercom & emergency
call station connections to critical care
unit it serves
(4) equipment & space for seating

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Architectural Requirements Building Systems Requirements

2.2-2.6.9.2 Staff toilet rooms (permitted to be unisex)
readily accessible* to staff lounge
2.1-2.9.2.1 readily accessible* to each patient Ventilation:
care unit Min. 10 air changes per hour Table 7.1
2.1-2.9.2.2 toilet & handwashing station Exhaust
Negative pressure
No recirculating room units
2.2-2.6.9.3 Staff storage facilities
2.1-2.9.3.1 securable closets or cabinet
compartments for personal articles of
staff
located in or near nurse station

2.2-2.6.9.4 On-call staff accommodation

(1) accommodations for sleeping & rest
(a) space for chair
(b) space for bed
(2) individually secured storage for
personal items
(3) communication system
(4) at least one toilet, shower & Ventilation:
handwashing station Min. 10 air changes per hour Table 7.1
Exhaust
Negative pressure
No recirculating room units
2.2-2.6.10 SUPPORT AREAS FOR FAMILIES & VISITORS

2.1-2.10.1 Family & visitor lounge Communications:

each patient care unit provides access Public communication 2.1-2.10.1.6
to lounge for family & visitors services provided in each
family & visitor lounge
2.1-2.10.1.1 Size:
(1) accommodates at least 3 chairs &
1 wheelchair space
(2) accommodates at least 1.5 persons
for every adult critical care bed
2.1-2.10.1.2 immediately accessible* to patient care
units served (permitted to serve more
than one patient care unit)
2.1-2.10.1.4 designed to minimize impact of noise &
activity on patient rooms & staff functions

*LOCATION TERMINOLOGY:
Directly accessible: Connected to the identified area or room through a doorway, pass-through, or other opening
without going through an intervening room or public space
Adjacent: Located next to but not necessarily connected to the identified area or room
Immediately accessible: Available either in or adjacent to the identified area or room
Readily accessible: Available on the same floor or in the same clinic as the identified area or room

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Architectural Details & MEP Requirements

2.1-7.2.2 ARCHITECTURAL DETAILS

(4) Lever hardware or push/pull latch
CORRIDOR WIDTH: hardware
2.1-7.2.2.1 Aisles, corridors & ramps required for
NFPA 101, exit access in a hospital not less than (5) Doors for Patient Bathing/Toilet
18.2.3.4 8'-0" in clear & unobstructed width Facilities:
or (a) two separate doors
Detailed code review incorporated in or
Project Narrative
door that swings outward
Aisles, corridors & ramps in adjunct or
areas not intended for the housing, door equipped with emergency
treatment, or use of inpatients not less rescue hardware (permits quick
than 44” in clear & unobstructed width access from outside the room to
or prevent blockage of the door)
Detailed code review incorporated in or
Project Narrative sliding door other than pocket
door
2.1-7.2.2.2 CEILING HEIGHT:
(1) Min ceiling height 7'-6"in corridors & in (b) bathing area or toilet room opens
normally unoccupied spaces onto public area or corridor
(3) Min. height 7’-6” above floor of ☐ check if not included in project
suspended tracks, rails & pipes visual privacy is maintained
located in traffic path for patients in
beds & on stretchers 2.1-7.2.2.5 WINDOWS IN PATIENT ROOMS:
Min. ceiling height 7’-10” in other areas 2.1-7.2.2.5(1) Each patient room provided with
2.1-7.2.2.3 DOORS & DOOR HARDWARE:
(1) Door Type: natural light by means of window to
(a) doors between corridors, rooms, outside
or spaces subject to occupancy 2.1-7.2.2.5(2) Operable windows in patient rooms
swing type or sliding doors or suites
(b) sliding doors ☐ check if not included in project
☐ check if not included in project window operation is limited with
manual or automatic either stop limit/restrictor
sliding doors comply with hardware or open guard/screen
NFPA 101 prevents passage of 4-inch
detailed code review diameter sphere through
incorporated in Project opening
Narrative 2.1-7.2.2.6 insect screens
no floor tracks
(2) Door Opening: 2.1-7.2.2.5(3) Window Size In Patient Rooms:
(a) min. 45.5” clear door width for (a) minimum net glazed area be no
patient rooms less than 8% of required min.
min. 83.5” clear door height for clear floor area of room served
patient rooms (b) maximum 36 inches windowsill
(b) swinging doors for personnel
use in addition to sliding doors height above finished floor
☐ check if not included in project
2.1-7.2.2.7 GLAZING MATERIALS:
min. clear width 34.5”
Glazing within 1 foot 6 inches of floor
(3) Door Swing:
☐ check if not included in project
(a) doors do not swing into corridors must be safety glass, wire glass
except doors to non-occupiable or plastic break-resistant material
spaces (e.g. environmental
services rooms & electrical
closets) & doors with emergency
breakaway hardware

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2.1-7.2.2.8 HANDWASHING STATIONS: 2.1-7.2.2.12 NOISE CONTROL:

(1)(c) Handwashing stations in patient (1) Recreation rooms, exercise rooms
care areas located so they are equipment rooms & similar spaces
visible & unobstructed where impact noises may be
(3) generated are not located directly
(a) Handwashing station countertops over patient bed areas
made of porcelain, stainless steel, or
solid-surface materials or impervious Special provisions are made to
plastic laminate assembly minimize impact noise
(b) Countertops substrate
(2) Noise reduction criteria in Table 1.2-6
☐ check if not included in project applicable to partitions, floors & ceiling
marine-grade plywood (or construction are met in patient areas
equivalent material) with
impervious seal 2.1-7.2.2.14 DECORATIVE WATER FEATURES:
(4) Handwashing station casework (1) No indoor unsealed water features
☐ check if not included in project (2) Covered fish tanks
designed to prevent storage ☐ check if not included in project
beneath sink restricted to public areas
(5) Provisions for drying hands
(a) hand-drying device does not 2.1-7.2.3 SURFACES
require hands to contact 2.1-7.2.3.1 FLOORING & WALL BASES:
dispenser (1) Flooring surfaces cleanable &
(b) hand-drying device is enclosed to wear-resistant for location
protect against dust or soil & to (3) Smooth transitions provided
ensure single-unit dispensing
between different flooring materials
(6) Liquid or foam soap dispensers
(4) Flooring surfaces including those on
2.1-7.2.2.9 GRAB BARS: stairways are stable, firm &
(1) Grab bars anchored to sustain slip-resistant
concentrated load 250 pounds (5) Floors & wall bases of soiled
(2) Grab bars in toilet rooms used by workrooms, toilet rooms & other areas
patients of size anchored to sustain subject to frequent wet cleaning are
concentrated load 800 pounds constructed of materials that are not
(3) Ends of grab bars constructed to physically affected by germicidal or
prevent snagging clothes of other types of cleaning solutions
patients, staff & visitors
2.1-7.2.3.2 WALLS & WALL PROTECTION:
2.1-7.2.2.10 HANDRAILS: (1)(a) Wall finishes are washable
(1) Handrails installed on both sides of (1)(b) Wall finishes near plumbing fixtures
patient use corridors are smooth, scrubbable &
(3) Rail ends return to wall or floor water-resistant
(4) Handrail gripping surfaces & (2) Wall surfaces in areas routinely
fasteners are smooth (free of sharp
subjected to wet spray or splatter (e.g.
or abrasive elements) with 1/8-inch
environmental services rooms) are
min. radius
monolithic or have sealed seams that
(5) Handrails have eased edges & corners
are tight & smooth
(6) Handrail finishes are cleanable
(5) Wall protection devices & corner
guards durable & scrubbable

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2.1-7.2.3.3 CEILINGS: Part 3/6.1.2 Heating & Cooling Sources:

(1) Ceilings provided in all areas Part 3/6.1.2.1 heat sources & essential
except mechanical, electrical & accessories are provided in
communications equipment rooms number & arrangement sufficient
(a) Ceilings cleanable with routine to accommodate facility needs
housekeeping equipment (reserve capacity) even when
(b) Acoustic & lay-in ceilings where used any one of heat sources or
do not create ledges or crevices essential accessories is not
operating due to breakdown or
2.1-7.2.4 FURNISHINGS: routine maintenance
2.1-7.2.4.1 Built-In Furnishings: capacity of remaining source or
☐ check if not included in project sources is sufficient to provide
upholstered with impervious for domestic hot water & heating
materials in patient treatment for intensive care rooms
areas
2.1-7.2.4.2 Window Treatments in Patient Part 3/6.1.2.2 Central cooling systems greater
Rooms & Other Patient Care Areas: than 400 tons (1407 kW) peak
(1) blinds, sheers or other cooling load
patient-controlled window ☐ check if not included in project
treatments provided to allow for number & arrangement of cooling
patient privacy & to control light sources & essential accessories
levels & glare is sufficient to support facility
(2) window treatments do not operation plan upon breakdown
compromise patient safety or routine maintenance of any
easy for patients, visitors & one of cooling sources
staff to operate
(3) window treatments selected for Part 3/6.2 AIR-HANDLING UNIT (AHU) DESIGN:
ease of cleaning, disinfection or Part 3/6.2.1 AHU casing is designed to prevent
sanitization water intrusion, resist corrosion &
2.1-7.2.4.3 Privacy curtains in patient rooms & permit access for inspection &
other patient care areas are washable maintenance
☐ check if not included in project .
Part 3/6.3 OUTDOOR AIR INTAKES & EXHAUST
2.1-8.2 HEATING VENTILATION & DISCHARGES:
AIR-CONDITIONING (HVAC) SYSTEMS Part 3/6.3.1 Outdoor Air Intakes:
Part 3/6.3.1.1 located min. of 25 ft from
Part 3/6.1 UTILITIES: cooling towers & all exhaust &
Part 3/6.1.1 Ventilation Upon Loss of Electrical vent discharges
Power: outdoor air intakes located such
space ventilation & pressure that bottom of air intake is at
relationship requirements least 6'-0" above grade
of Tables 7.1 are maintained for air intakes located away from
AII Rooms, PE Rooms in event public access
of loss of normal electrical power
Part 3/6.3.1.3 intakes on top of buildings
☐ check if not included in project
located with bottom of air
intake min. 3'-0" above
roof level

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Part 3/6.3.1.4 intake in areaway Part 3/6.5 HEATING & COOLING SYSTEMS:
☐ check if not included in project Part 3/6.5.3 Radiant heating systems
bottom of areaway air ☐ check if not included in project
intake opening is at least ceiling or wall panels with
6'-0" above grade exposed cleanable surfaces or
bottom of air intake radiant floor heating are provided
opening from areaway into in AII room, PE room & burn
building is at least 3'-0" unit
above bottom of areaway
Part 3/6.7 AIR DISTRIBUTION SYSTEMS:
Part 3/6.3.2 Exhaust Discharges for Infectious Part 3/6.7.1 pressure relationships required
Exhaust Air: in tables 7.1 maintained in all modes
☐ check if not included in project of HVAC system operation
Part 3/6.3.2.1 ductwork within building is under Spaces that have required pressure
negative pressure for exhaust of relationships are served by fully
contaminated air (i.e. air from ducted return systems or fully
AII rooms) ducted exhaust systems
exhaust discharge outlets with Inpatient facilities are served by fully
contaminated air located such ducted return or exhaust systems
that they reduce potential for
recirculation of exhausted air Part 3/6.7.2 Air Distribution Devices:
back into building supply air outlets comply
Part 3/6.3.2.2 exhaust discharge outlets with with Table 6.7.2
contaminated air is arranged to
discharge to atmosphere in Part 3/6.7.3 Smoke Barriers:
vertical direction at least 10'-0" HVAC zones coordinated with
above adjoining roof level compartmentation to minimize
exhaust discharge outlets from ductwork penetrations of fire &
AII rooms is located not less smoke barriers.
than 25 feet horizontally from
outdoor air intakes, openable Part 3/6.8 ENERGY RECOVERY SYSTEMS:
windows/doors & areas that are ☐ check if not included in project
normally accessible to public Part 3/6.8.1 Located upstream of Filter Bank No. 2
Part 3/6.8.2 AII room exhaust systems or
Part 3/6.4 FILTRATION: combination AII/PE rooms are not
Two filter banks for inpatient care used for energy recovery
(see Table 6.4)
Filter Bank No. 1: MERV 7 Part 3/6.8.3 Energy recovery systems with
Filter Bank No. 2: MERV 14 leakage potential
Each filter bank with efficiency of ☐ check if not included in project
greater than MERV 12 is provided arranged to minimize potential
with differential pressure measuring to transfer exhaust air directly
device to indicate when filter needs back into supply airstream
to be changed designed to have no more than
5% of total supply airstream
Part 3/6.4.1 Filter Bank No. 1 is placed upstream consisting of exhaust air
of heating & cooling coils
Part 3/6.4.2 Filter Bank No. 2 is placed Part 3/7 SPACE VENTILATION
downstream of all wet-air cooling Part 3/7.1.a Spaces ventilated according
coils & supply fan to Table 7.1
Part 3/7.1.a.1 Air movement is from clean to less-
clean areas

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Part 3/7.1.a.3 Min. number of total air changes PE rooms have permanently
required for positive pressure rooms installed device to constantly
is provided by total supply airflow monitor differential air pressure
Min. number of total air changes between room & corridor local
required for negative pressure rooms Visual means is provided to indicate
is provided by total exhaust airflow whenever positive differential
pressure is not maintained
Part 3/7.1a.5 Air recirculation through room unit
☐ check if not included in project Part 3/7.2.3 Combination Airborne Infectious Isolation/
complies with Table 7.1 Protective Environment Room (AII/PE)
room unit receive filtered & ☐ check if not included in project
conditioned outdoor air Supply air diffusers are located
serve only a single space above patient bed
provides min. MERV 6 filter Exhaust grilles or registers are
located upstream of any cold located near patient room door.
surface so that all of air passing Anteroom
over cold surface is filtered ☐ check if not included in project
anteroom is at positive pressure
Part 3/7.2 ADDITIONAL ROOM-SPECIFIC with respect to both AII/PE room
REQUIREMENTS: & corridor or common space
Part 3/7.2.1 Airborne Infection Isolation (AII) Rooms or
☐ check if not included in project anteroom is at negative pressure
AII rooms have permanently with respect to both AII/PE room
installed device and/or mechanism to & corridor or common space
constantly monitor differential air
pressure between room & corridor First device monitors pressure
Local visual means is provided to differential between AII/PE room &
indicate whenever negative differential anteroom
pressure is not maintained Second device monitors pressure
Air from AII room is exhausted differential between anteroom &
directly to outdoors corridor or common space
Exhaust air from AII rooms, Local visual means are provided to
associated anterooms & toilet rooms is indicate whenever differential
discharged directly to outdoors without pressures are not maintained
mixing with exhaust air from any other
non-AII room or exhaust system 2.1-8.3 ELECTRICAL SYSTEMS
Part 3/7.2.1 Exhaust air grille or register in
patient room is located directly 2.1-8.3.2.2 Panelboards:
above patient bed on ceiling or on (1) panelboards serving life safety
wall near head of bed branch circuits serve floors on
which they are located & floors
Anteroom immediately above & below
☐ check if not included in project (2) panelboard critical branch
AII room is at negative circuits serve floors on which
pressure with respect to they are located
anteroom (3) panelboards not located in exit
Anteroom is at negative enclosures or exit passageways
pressure with respect to corridor
2.1-8.3.2.3 Ground-Fault Circuit Interrupters in
Part 3/7.2.2 Protective Environment (PE) Rooms Critical Care Areas:
☐ check if not included in project ☐ check if not included in project
Part 3/7.2.2 Supply air diffusers are located (2) each receptacle individually
above patient bed protected by single GFCI device
Exhaust grilles or registers are
located near patient room door. 2.1-8.3.3 POWER-GENERATING & -STORING
EQUIPMENT
2.1-8.3.3.1 Essential electrical system or

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emergency electrical power 2.1-8.4 PLUMBING SYSTEMS

(1) essential electrical system
complies with NFPA 99 2.1-8.4.2 Plumbing & Other Piping Systems:
(2) emergency electrical power 2.1-8.4.2.1(3) no plumbing piping exposed
complies with NFPA 99 overhead or on walls where
possible accumulation of dust or
2.1-8.3.4 LIGHTING: soil may create cleaning problem
2.1-8.3.4.2 Luminaires in wet areas have
smooth cleanable shatter-resistant 2.1-8.4.2.2 Hemodialysis/Hemoperfusion Water
lenses & no exposed lamps Distribution:
☐ check if not included in project
2.1-8.3.4.3(1) Reading light for each patient bed (1)(a) separate treated water
(a) incandescent & halogen light distribution system
☐ check if not included in project (2)(b) outlet at each individual
placed or shielded to hemodialysis treatment bay
protect patient from injury outlet at hemodialysis
light source covered by diffuser equipment repair area
or lens outlet at dialysate
flexible light arms preparation area
☐ check if not included in project or
mechanically controlled to (1)(b) dialysis equipment includes
prevent lamp from sufficient water treatment
contacting bed linen provisions for use of domestic
cold water
2.1-8.3.4.3(2) Patient care unit corridors have
general illumination with provisions (1)(a) drainage system independent
for reducing light levels at night from tap water drainage
(4) liquid waste & disposal system
2.1-8.3.5 ELECTRICAL EQUIPMENT: for hemodialysis treatment area
2.1-8.3.5.1 Handwashing sinks & scrub sinks are designed to minimize odor
that depends on building electrical & prevent backflow
service for operation are connected (5) hemodialysis distribution piping
to essential electrical system is readily accessible* for
☐ check if not included in project inspection & maintenance

2.1-8.3.6 ELECTRICAL RECEPTACLES: 2.1-8.4.2.5 Heated Potable Water Distribution

2.1-8.3.6.1 Receptacles In Corridors: Systems:
(1) duplex-grounded receptacles (2) heated potable water
for general use installed 50’-0” distribution systems serving
apart or less in all corridors patient care areas are under
duplex-grounded receptacles constant recirculation
for general use installed within non-recirculated fixture branch
25’-0” of corridor ends piping max. length 25’-0”
(2) receptacles in pediatric & (3)(a) no installation of dead-end piping
psychiatric unit corridors are of (except for empty risers mains &
tamper-resistant type (3)(c) branches for future use)
(3)(b) any existing dead-end piping is
2.1-8.3.6.3 Essential Electrical System removed
Receptacles: ☐ check if not included in project
(1) cover plates for electrical (4)(a) water-heating system supplies
receptacles supplied from water at temperatures &
essential electrical system are amounts indicated in Table 2.1-4
distinctively colored or marked
for identification
(2) same color is used throughout
facility

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2.1-8.4.2.6 Drainage Systems: 2.1-8.4.3.4 Ice-Making Equipment:

(1)(a) drainage piping installed above copper tubing provided for
ceiling of or exposed in supply connections to
electronic data processing ice-making equipment
areas & electric closets 2.1-8.4.3.5 Clinical Flushing-Rim Sinks:
☐ check if not included in project ☐ check if not included in project
special provisions to protect (1) trimmed with valves that can
space below from leakage & are operated without hands
condensation (a) (may be single-lever or wrist
(1)(b) drip pan for drainage piping blade devices)
above ceiling of sensitive area (b) handles are at least 6 in. long
☐ check if not included in project (2) integral trap wherein upper
accessible portion of water trap provides
overflow drain with outlet visible seal
located in normally 2.1-8.4.3.7 Bedpan-Rinsing Devices:
occupied area (1) bedpan-rinsing devices provided
2.1-8.4.3 PLUMBING FIXTURES: in each inpatient toilet room
2.1-8.4.3.1(1) Materials used for plumbing fixtures (2) use cold water only
are non-absorptive & acid-resistant
2.1-8.4.3.2 Handwashing Station Sinks: 2.1-8.4.4 MEDICAL GAS & VACUUM SYSTEMS
(1) designed with basins that will Station outlets provided as indicated
reduce risk of splashing to in Table 2.1-3
areas for direct patient care &
medication preparation 2.1-8.5.1 CALL SYSTEMS
(2) sink basins have nominal size of 2.1-8.5.1.1
no less than 144 square inches (1) Nurse call stations provided as
sink basins have min. dimension required in Table 2.1-2
9 inches in width or length (2) Nurse call systems report to attended
(3) sink basins are made of location with electronically supervised
porcelain, stainless steel or visual & audible annunciation as
solid-surface materials indicated in Table 2.1-2
(5) faucet water discharge point (4) Call system complies with UL 1069
min. 10” above bottom of basin “Standard for Hospital Signaling &
(7) anchored so that allowable Nurse Call Equipment”
stresses are not exceeded (5) Wireless nurse call system
where vertical or horizontal ☐ check if not included in project
force of 250 lbs. is applied complies with UL 1069
(8) sinks used by staff, patients, &
public have fittings that can be 2.1-8.5.1.2 Patient Call Stations:
operated without using hands (1) each patient sleeping bed except
(may be single-lever or wrist nursery beds provided with
blade devices) patient call station equipped for
(a) blade handles two-way voice communication
☐ check if not included in project (use of dual call station are
at least 4 inches in length permitted when beds are located
adjacent to each other)
provide clearance required
(2)(a) indicator light that remains
for operation
(b) lighted as long as voice circuit
sensor-regulated water fixtures
is operating
☐ check if not included in project (2)(b) reset switch for canceling call
meet user need for (3)(a) visible signal in corridor at
temperature & length of
patient’s door
time water flows
Multi-Corridor Patient Areas:
designed to function at all
☐ check if not included in project
times and during loss of
normal power additional visible signals at
corridor intersections
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2.1-8.5.1.3 Bath Stations: 2.1-8.6.2 ELECTRONIC SURVEILLANCE

bath station that can be SYSTEMS
activated by patient lying on ☐ check if not included in project
floor provided at each patient
toilet, bathtub, sitz bath or 2.1-8.6.2.2 monitoring devices are located so
shower stall they are not readily observable by
(1) alarm in these areas can only general public or patients
be turned off at bath station 2.1-8.6.2.3 electronic surveillance systems
where it was initiated receive power from essential
(2) shower/tub bath stations electrical system
located 3'-0" to 4’-0” above floor
within view of user & within
reach of staff without need to
step into shower or tub
(3) toilet bath stations located on
the side of toilets within 12” of
front of toilet bowl & 3'-0" to
4’-0” above floor

2.1-8.5.1.5 Emergency call stations are

equipped with continuous audible or
visual confirmation to person who
initiated the code call

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