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Occupancy designation for Physician Offices

  • 1.  Occupancy designation for Physician Offices

    Posted 02-16-2017 11:15
    We have been notified that a ruling by CMS may cause some physician offices to conform to the Ambulatory Health Care Occupancy in the LSC if they have one person that meets the definition of an Ambulatory Health Care Occupancy and that all existing facilities that meet this requirement will need to be upgraded.  This will mean meeting ASHRAE standards for Type A Procedure Rooms, ducted returns, and smoke compartments that are more restrictive than the Business Occupancy.  We are in  the process of researching this before we meet with our AHJ.


    Has anyone worked with their AHJ on this issue?  If you have information on this issue can you please shed some light on it?

    Thanks

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    Gregg Ostrow AIA
    Architect
    Gregg D. Ostrow, AIA
    Boise ID
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  • 2.  RE: Occupancy designation for Physician Offices

    Posted 02-17-2017 17:23

    In Illinois, IDPH notes that only ASTCs and departments reviewed by CMS (like Dialysis) need to be design to meet Ambulatory Care Occupancy and as such need to be 1-hour separated from the rest of the building, including structure.



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    Michael Moran AIA ACHA LEED AP
    Smith Group JJR

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  • 3.  RE: Occupancy designation for Physician Offices

    Posted 02-18-2017 08:14
     Generally speaking, the CMS notification sounds odd but without the benefit of reviewing it here, read carefully the LSC definition of ambulatory health care occupancy.   Also note, "...treatment is not merely a routine medical visit such as to a doctor's office, but rather a procedure that renders the patient incapable of self-preservation."  What if any anesthetizing agents planned for procedures in the physician office?

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    Mark Yeager AIA
    Principal
    Design Consultants International, Inc
    Townsend GA
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  • 4.  RE: Occupancy designation for Physician Offices

    Posted 02-18-2017 08:58
    2012 and 2015 IBC state: Ambulatory Care Facility: Buildings or portions thereof used to provide medical, surgical, psychiatric, nursing or similar care on a less than 24-hour basis to persons who are rendered incapable of self-preservation by the services provided.
    It does not have a 4-person threshold, so 1 person incapable would move the facility from business to ACF.

    2012 NFPA Life Safety Code states: Ambulatory Health Care Occupancy: "four or more patients".

    However, in Michigan, the state has Fire Safety Rules that adopt the Life Safety Code and revise several items, including "four or more" which is revised to "Freestanding surgical outpatient facility, type II facility means a freestanding surgical outpatient facility that uses anesthetics or medications which render a person incapable of taking action in an emergency within 2 minutes of being notified of an emergency."

    This does not answer the original question if it is specific to CMS requirements. These are other AHJ requirements that come into play regardless of CMS.

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    Tom Dillenbeck AIA
    Associate Vice President
    Hobbs & Black Associates, Inc.
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  • 5.  RE: Occupancy designation for Physician Offices

    Posted 02-18-2017 12:27
    I believe you are referring to the requirement in NFPA 101, stating that "up to four persons" under sedation or incapable of self preservation are allowed under a business occupancy, more than that requires an ambulatory occupancy. A CMS Bulletin (dated 2009 I believe) states if "any person" under sedation or incapable of self preservation must be an Ambulatory occupancy.
    The stated goal in the Bulletin was to comply with NFPA, even though it did the opposite. I mentioned this to the guy who wrote the Bulletin and he agreed that this is the ruling that CMS is inspecting to.
    I have heard that more recent versions of NFPA will change to match this Bulletin but have not verified it and don't know which version.
    Somehow I think this could be tied to the attempt to shutter healthcare facilities which provide abortion services, under the ruling that dr.s must have hospital admitting privileges but that's just a guess. 
    We ran into this a few years ago designing a pediatric oncology unit. Unfortunately this ruling puts many facilities designed as business occupancies in violation of this ruling by CMS.




    Jon Boyd, AIA, LEED AP                                                                                                                         

    associate

    jboyd@e4harchitecture.com            

     

    e4harchitecture

    MorrisSwitzer Environments for Health

    183 middle street, portland, maine  04101

    888.781.8441 t 207.773.8841 207.318.8444

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  • 6.  RE: Occupancy designation for Physician Offices

    Posted 02-21-2017 08:00
    The 2015 NFPA 101 defines Ambulatory Care Facilities as "an occupancy used to provide services or treatment simultaneously to four or more patients that provides on an outpatient basis, one or more of the following.." and it goes on to define basically situations where patients are rendered incapable of taking self preservation actions in case of an emergency. But the term simultaneously indicates that the facility would have to have at least four treatment or procedure rooms in order to meet this definition.  

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    Tyler Scott AIA
    Scott + Partners, Inc.
    Essex Junction VT
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  • 7.  RE: Occupancy designation for Physician Offices

    Posted 02-22-2017 17:25

    What will this do for regular Dental Clinics that provide sedation, will the City start counting Chairs?

     

    Phillip Craddock, NCARB, AIA

    OWNER / ARCHITECT

    CRADDOCK ARCHITECTURE, PLLC

    TX FIRM# BR2108

    750 E. Interstate 30, Ste. 160

    Rockwall, TX 75087

    214-952-0527 cell

    469-769-1015 office

    469-533-3900 fax

    phillip@craddockarchitecture.com

     

     

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  • 8.  RE: Occupancy designation for Physician Offices

    Posted 02-23-2017 17:21
    No more Nitorus.

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    Michael Moran AIA
    Smith Group JJR
    Wheaton IL
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  • 9.  RE: Occupancy designation for Physician Offices

    Posted 02-23-2017 17:23
    Rather Nitrous

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    Michael Moran AIA
    Smith Group JJR
    Wheaton IL
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  • 10.  RE: Occupancy designation for Physician Offices

    Posted 02-24-2017 16:38
    It also depends on the level of sedation used. When deeper levels of sedation or general anesthesia are used, as for oral surgery, the question of "capable of self preservation" may come into play. This generally has not been an issue with general dentistry. The California State Fire Marshal had an interpretation on this a few years back: http://osfm.fire.ca.gov/codeinterpretation/pdf/2005/05_034.pdf (as always, other jurisdictions may have different interpretations).
    The American Dental Association website has definitions and guidelines for the use of sedation and general anesthesia.  

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    Nicholas Krauja AIA ACHA
    Phoenix, AZ
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  • 11.  RE: Occupancy designation for Physician Offices

    Posted 02-27-2017 19:12
    Medical Office Buildings including Physicians offices are trending toward including more services and procedures that have been traditionally done in hospitals. While CMS has referenced the FGI Guidelines for design and construction of healthcare facilities, there is still a lot of interpretation and review by state & local officials. the best practice is to have a clear understanding of who reviews plans for the facility you’re designing and have a consultation with those officials before finalizing design. The client representative should be included in these conversations because many of the interpretations are driven by clinical and procedural intentions and processes.




  • 12.  RE: Occupancy designation for Physician Offices

    Posted 02-20-2017 08:47

    This has been brought up from time to time through the years. One of the CMS Life Safety Engineers explained to our Fire Safety Officer, that it has to do with what is the normal practice. If a physician routinely performs office based surgery, that makes the patient incapable of self-preservation, that is possibly an ASC. If it is not the norm, then it is a business occupancy.

     

    What you should be more concerned about is the requirements of the International Building Code and if your State has adopted it by reference.  In 2009, ICC added the definition of Business Ambulatory to the Code and additional requirements of construction if you have one or more incapacitated patients at any given time.  This would apply to a doctor's office which is generally defined under Business Occupancy.

     

    Julia F. Herschelman AIA NFPA ICC CSI

    Resident Architect, Space & Capital Planning

    Beaumont Health

    P:  248-551-3632

    F:  248-551-3624

    E:  julia.herschelman@beaumont.org

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  • 13.  RE: Occupancy designation for Physician Offices

    Posted 02-23-2017 20:35
    This is nothing new - basically it dates from the 2008 memo mentioned below - but would only apply IF the dental facility is certified by CMS for Medicare/Medicaid reimbursement, i.e. as an Ambulatory Surgery Center. And yes, CMS essentially requires every ASC to be an Ambulatory Health Care Occupancy, regardless of number of patients. But no, if it isn't an ASC, the CMS position is irrelevant.  Period, end of story.

    Now, there are any number of scenarios under which the local or state AHJ could require the facility to comply with AHCO, per whatever version of NFPA 101 is applicable there.  Or any number of other life safety design standards that the jurisdiction in question might have adopted, and it can get quite arcane.

    For example, in CA any facility with "more than 5" patients receiving "care that may render the patient incapable of unassisted self-preservation" must be designed as an Institutional occupancy, per the (IBC-based) state building code. But, any location where anesthesia is administered in does that...well, let's say moderate or higher levels of sedation, or general anesthesia, must be "licensed, accredited or certified", potentially bringing in NFPA requirements enforced by accreditation organizations. Even that's largely simplified (I'm interested to see if any fellow Californians chime in), but my point is that it can get very complicated and depends greatly on your AHJ.  Good luck!

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    S. Ross Bogen AIA
    Prinicpal Architect/Planner
    Kaiser Permanente National Facilities Services
    Oakland CA
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