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007.05.10-70. Physical Facilities, Mechanical Requirements.

AR ADC 007.05.10-70Arkansas Administrative Code

West's Arkansas Administrative Code
Title 007. Department of Health
Division 05. Health Facility Services
Rule 10. Rules for Critical Access Hospitals in Arkansas (Refs & Annos)
Ark. Admin. Code 007.05.10-70
007.05.10-70. Physical Facilities, Mechanical Requirements.
A. General.
1. Prior to acceptance of the facility, all mechanical systems shall be tested and operated to demonstrate to the owner or his designated representative that the installation and performance of these systems conform to design intent. Test results shall be documented for maintenance files.
2. Upon completion of the special systems equipment installation contract, the owner shall be furnished with a complete set of manufacturers' operating, maintenance, and preventive instructions, parts list, and complete procurement numbers and descriptions. Operating staff shall be provided with instructions for proper operation of systems and equipment.
3. Rotating mechanical equipment, shall be mounted on vibration isolators as required to prevent unacceptable structure-borne vibration.
4. Supply and return mains and risers for cooling, heating, and steam systems shall be equipped with valves to isolate the various sections of each system and each piece of equipment.
B. Thermal and Acoustical Insulation.
1. Insulation within the building shall be provided to conserve energy, protect personnel, prevent vapor condensation, and reduce noise.
2. Insulation on cold surfaces shall include an exterior vapor barrier. Material that will not absorb or transmit moisture will not require a separate vapor barrier.
3. Insulation, including finishes and adhesives on the exterior surfaces of ducts, piping, and equipment, shall have a flame-spread rating of 25 or less and a smoke-developed rating of 50 or less as determined by an independent testing laboratory in accordance with NFPA 255.
4. Interior duct linings shall not be used. This requirement shall not apply to air terminals and sound attenuation devices that have special coverings over such linings.
5. Existing accessible insulation within areas that are renovated shall be inspected and addressed, as appropriate.
C. Steam and Hot Water Systems and Pressure Vessels.
1. All pressure vessels shall meet the requirements of the Arkansas Boiler Inspector, Arkansas Department of Labor.
D. Air Conditioning, Heating and Ventilating Systems.
1. The systems shall be designed to provide the dry bulb temperatures noted in Table 3 of the appendix. The systems shall be designed and operated to provide the relative humidity noted in Table 3 of the appendix.
2. All rooms and areas in the facility used for patient care shall have provisions for ventilation. The ventilation rates shown in Table 4 shall be used only as minimum standards; they do not preclude the use of higher, more appropriate rates. Fans serving exhaust systems shall be located at the discharge end and shall be readily serviceable. Air supply and exhaust in rooms for which no minimum total air change rate is noted may vary down to zero in response to room load. For rooms listed in Table 4 where VAV systems are used, minimum total air change shall be within limits noted. Temperature control shall also comply with these standards. To maintain asepsis control, airflow supply and exhaust should generally be controlled to ensure movement of air from “clean” to: less clean areas, especially in critical areas. The ventilation systems shall be designed and balanced according to the requirements shown in Table 4 and in the applicable notes.
3. Exhaust systems may be combined to enhance the efficiency of recovery devices required for energy conservation. Local exhaust systems shall be used whenever possible in place of dilution ventilation to reduce exposure to hazardous gases, vapors, fumes, or mists. Airborne infection isolation rooms shall not be served by exhaust systems incorporating energy recovery devices that permit cross-contamination.
4. Fresh air intakes shall be located at least 25 feet from exhaust outlets of ventilating systems, combustion equipment stacks, medical-surgical vacuum systems, plumbing vents, or areas that may collect vehicular exhaust or other noxious fumes. (Prevailing winds and/or proximity to other structures may require greater clearances.) Plumbing and vacuum vents that terminate at a level above the top of the air intake may be located as close as 10 feet. The bottom of outdoor air intakes serving central systems shall be as high as practical, but at least six feet above ground level, or, if installed above the roof, three feet above roof level. Exhaust outlets from areas that may be contaminated shall be above roof level and arranged to minimize recirculation of exhaust air into the building.
5. In new construction and major renovation work, air supply for operating and delivery rooms (excluding LDR/LDRP rooms) shall be from ceiling outlets near the center of the work area. Return air shall be near the floor level. Each operating and delivery room shall have at least two return-air inlets located as remotely from each other as practical. (Design should consider turbulence and other factors of air movement to minimize fall of particulates onto sterile surfaces.) Where extraordinary procedures, such as organ transplants, justify special designs, installation shall properly meet performance needs as determined by applicable standards. These special designs should be reviewed on a case-by-case basis. Temperature shall be individually controlled for each operating and cesarean section room.
6. The operating and delivery room (excluding LDR/LDRP rooms) room ventilation systems should operate at all times to maintain the “air movement relationship to adjacent areas.” The cleanliness of the spaces is compromised when the ventilation system is shut down, e.g., airflow from a less clean space such as the corridor can occur, and standing water can accumulate in the ventilation system (near humidifiers or cooling coils).
7. In new construction and major renovation work, air supply for rooms used for invasive procedures such as autopsy rooms, cardiac cath labs, cystoscopic rooms, trauma rooms, endoscopy rooms, bronchoscopy rooms, and/or rooms where anesthesia gases are used shall be from ceiling outlets near the center of the room and/or work area. Return or exhaust air inlets shall be near the floor level. Exhaust inlets for anesthesia evacuation and other special applications shall be permitted to be installed in the ceiling.
8. Each space routinely used for administering inhalation anesthesia and inhalation analgesia shall be served by a scavenging system to vent waste gases. If a vacuum system is used, the gas-collecting system shall be arranged so that it does not disturb patients' respiratory systems. Gases from the scavenging system shall be exhausted directly to the outside. The anesthesia evacuation system may be combined with the room exhaust system, provided the part used for anesthesia gas scavenging exhausts directly to the outside and is not part of the recirculation system. Scavenging systems are not required for areas where gases are used only occasionally, such as the emergency room, offices for routine dental work, etc.
9. The bottoms of ventilation openings shall be at least three inches above the floor.
10. The space above ceilings in new construction shall not be used as plenum space to supply to, return air from, or to exhaust air from any patient room, operating room, trauma room, critical care room, delivery room, endoscopy room, cardiac cath lab, bronchoscopy room, autopsy room, exam room, treatment room, airborne infection isolation room, protective environment room, radiology suite, laboratory suite, soiled workroom, soiled holding, physical therapy and hydrotherapy, ETO-sterilizer room, sterilizer equipment room, and central medical and surgical supply areas or rooms. Plenum return air space conforming to NFPA 90A requirements shall be acceptable in areas where it is not listed above.
11. All central ventilation or air conditioning systems shall be equipped with filters with efficiencies equal to, or greater than, those specified in Table 1 of the Appendix. Where two filter beds are required, filter bed number one shall be located upstream of the air conditioning equipment and filter bed number two shall be downstream of any fan or blowers. Filter efficiencies, tested in accordance with ASHRAE 52-92, shall be average. Filter frames shall be durable and proportioned to provide an airtight fit with the enclosing ductwork. All joints between filter segments and enclosing ductwork shall have gaskets or seals to provide a positive seal against air leakage. A manometer or equal equivalent method of monitoring high and low pressure drop shall be installed across each filter bed having a required efficiency of 90 percent or more including hoods requiring HEPA filters.
12. If duct humidifiers are located upstream of the final filters, they shall be located in a manner to prevent condensation on the surface of the filters. Ductwork with duct-mounted humidifiers shall have a means of water removal. An adjustable high-limit humidistat shall be located downstream of the humidifier to reduce the potential of condensation inside the duct. All duct take-offs should be sufficiently downstream of the humidifier to ensure complete moisture absorption. Steam humidifiers shall be used. Reservoir-type water spray or evaporative pan humidifiers shall not be used.
13. Air-handling duct systems shall be designed with accessibility for duct cleaning, and shall meet the requirements of NFPA 90A.
14. Ducts that penetrate construction intended to protect against X-ray, magnetic, RFI, or other radiation shall not impair the effectiveness of the protection.
15. Fire and smoke dampers shall be constructed, located, and installed in accordance with the requirements of NFPA 101, 90A, and the specific damper's listing requirements. Fans, dampers, and detectors shall be interconnected so that damper activation will not damage ducts. Maintenance access shall be provided at all dampers. All damper locations shall be indicated on design drawings. Dampers should be activated by fire or smoke sensors, not by fan cutoff alone. Switching systems for restarting fans may be installed for fire department use in venting smoke after a fire has been controlled. However, provisions should be made to avoid possible damage to the system due to closed dampers. When smoke partitions are required, heating, ventilation, and air conditioning zones shall be coordinated with compartmentation insofar as practical to minimize need to penetrate fire and smoke partitions.
16. Hoods and safety cabinets may be used for normal exhaust of a space provided that minimum air change rates are maintained. If air change standards in Table 4 of the Appendix do not provide sufficient air for proper operation of exhaust hoods and safety cabinets (when in use), supplementary makeup air (filtered and preheated) shall be provided around these units to maintain the required airflow direction and exhaust velocity. Use of makeup air will avoid dependence upon infiltration from outdoor and/or from contaminated areas. Makeup systems for hoods shall be arranged to minimize “short circuiting” of air and to avoid reduction in air velocity at the point of contaminant capture.
17. Laboratory hoods shall meet the following general standards:
a. Have an average face velocity of at least 75 feet per minute.
b. Have an exhaust fan located at the discharge end of the system.
c. Have an exhaust duct system of noncombustible corrosion-resistant material as needed to meet the planned usage of the hood.
18. Laboratory exhaust and ventilation systems shall comply with NFPA 45.
19. Laboratory hoods shall meet the following special standards:
a. Fume hoods, and their associated equipment in the air stream, intended for use with perchloric acid and other strong oxidants, shall be constructed of stainless steel or other material consistent with special exposures, and be provided with a water wash and drain system to permit periodic flushing of duct and hood. Electrical equipment intended for installation within such ducts shall be designed and constructed to resist penetration by water. Lubricants and seals shall not contain organic materials. When perchloric acid or other strong oxidants are only transferred from one container to another, standard laboratory fume hoods and the associated equipment may be used in lieu of stainless steel construction.
b. In new construction and major renovation work, each hood used to process infectious or radioactive materials shall have a minimum face velocity of 90 feet per minute with suitable pressure-independent air modulating devices and alarms to alert staff of fan shutdown or loss of airflow. Each shall also have filters with 99.97 percent efficiency (based on dioctylphthalate (DOP) test method) in the exhaust stream, and be designed and equipped to permit the safe removal, disposal, and replacement of contaminated filters. Filters shall be as close to the hood as practical to minimize duct contamination. Fume hoods intended for use with radioactive isotopes shall be constructed of stainless steel or other material suitable for the particular exposure and shall comply with NFPA 801, Facilities for Handling Radioactive Materials. Radioactive isotopes used for injections, etc. without probability of airborne particulates or gases may be processed in a clean-workbench-type hood where acceptable to the Nuclear Regulatory Commission.
20. Exhaust hoods handling grease-laden vapors in food preparation centers shall comply with NFPA 96. All hoods over cooking ranges shall be equipped with grease filters, fire extinguishing systems, and heat-actuated fan controls. Cleanout openings shall be provided every 20 feet and at changes in direction in the horizontal exhaust duct systems serving these hoods. (Horizontal runs of ducts serving range hoods should be kept to a minimum.
21. The ventilation system for anesthesia storage rooms shall conform to the requirements of NFPA 99.
22. The ventilation system for the space that houses ethylene oxide (ETO) sterilizers should be designed to:
a. Provide a dedicated (not connected to a return air or other exhaust system) exhaust system. Refer to 29 CFR Part 1910.1047.
b. All source areas shall be exhausted, including the sterilizer equipment room, service/aeration areas, over the sterilizer door, and the aerator. If the ETO cylinders are not located in a well-ventilated, unoccupied equipment space, an exhaust hood shall be provided over the cylinders. The relief valve shall be terminated in a well-ventilated, unoccupied equipment space, or outside the building. If the floor drain which the sterilizer(s) discharges to is not located in a well-ventilated, unoccupied equipment space, an exhaust drain cap shall be provided (coordinate with local codes).
c. Ensure that general airflow is away from sterilizer operator(s).
d. Provide a dedicated exhaust duct system for ETO. The exhaust outlet to the atmosphere should be at least 25feet away from any air intake.
23. An audible and visual alarm shall activate in the sterilizer work area, and a 24hour staffed location, upon loss of airflow in the exhaust system.
24. Rooms with fuel-fired equipment shall be provided with sufficient outdoor air to maintain equipment combustion rates.
25. Gravity exhaust may be used, where conditions permit, for nonpatient areas such as boiler rooms, central storage, etc.
26. The energy-saving potential of variable air volume systems is recognized and these standard herein are intended to maximize appropriate use of that system. Any system utilized for occupied areas shall include provisions to avoid air stagnation in interior spaces where thermostat demands are met by temperatures of surrounding areas.
27. Special consideration shall be given to the type of heating and cooling units, ventilation outlets, and appurtenances installed in patient-occupied areas of psychiatric units. The following shall apply:
a. All air grilles and diffusers shall be of a type that prohibits the insertion of foreign objects. All exposed fasteners shall be tamper-resistant.
b. All convector or HVAC enclosures exposed in the room shall be constructed with round corners and shall have enclosures fastened with tamper-resistant screws.
c. HVAC equipment shall be of a type that minimizes the need for maintenance with the room.
28. Rooms or booths used for sputum induction, aerosolized pentamidine treatments, and other high-risk cough-inducing procedures shall be provided with local exhaust ventilation. See Table 4 of the Appendix for ventilation requirements.
29. Non-central air handling systems, i.e., individual room units that are used for heating and cooling purposes (fan-coil units, heat pump units, etc.) in areas permitted by Table 4 to utilize air recirculated by means of a room unit shall be equipped with permanent (cleanable) or replaceable filters. The filters shall have a minimum efficiency of 68percent weight arrestance. These units may be used as recirculating units only. All outdoor air requirements shall be met by a separate central air handling system with the proper filtration, as noted in Table 1 of the Appendix.
30. For special needs pharmacy work area and equipment requirements refer to Laws and Regulations -Arkansas State Board of Pharmacy.


Amended Jan. 1, 2016.
<Statutory authority: Promulgated under the Authority of Ark. Code Ann. § 20-7-123, 20-9-201 et seq.>
Current with amendments received through May 15, 2024. Some sections may be more current, see credit for details.
Ark. Admin. Code 007.05.10-70, AR ADC 007.05.10-70
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