COMPLIANCE CHECKLIST

 Long-Term Care Facility - Common Areas 

The following checklist is for plan review of new long-term care facilities and new additions to existing long-term care facilities.  This checklist also applies to renovations projects affecting long-term care facilities constructed under the regulations effective March 19, 1968, or under their subsequent revisions.  This checklist is derived from long-term care licensure regulations 105 CMR 150.000 and 105 CMR 151.000, entitled "Licensing of Long Term Care Facilities", as well as relevant parts of Chapter 111 of Massachusetts General Laws (specific sections indicated below).  Applicants must verify project compliance with all licensure requirements when filling out this checklist, and must include the DPH affidavit when submitting project documents for self-certification or abbreviated review. 
Only one copy of this checklist needs to be submitted for each facility.  In the case of a bed increase not associated with alterations of the common areas, only the requirements marked with an asterisk (*) and the Square Footage Summary on Page 6 need to be completed.
Other jurisdictions, regulations and codes may have additional requirements which are not included in this checklist, such as:
•	NFPA 101 Life Safety Code and applicable related standards contained in the appendices of the Code.
•	708 CMR, the State Building Code.
•	Joint Commission on the Accreditation of Health Care Organizations.
•	CDC Guidelines for Preventing the Transmission of Tuberculosis in Health-Care Settings.
•	Accessibility Guidelines of the Americans with Disabilities Act (ADA).
•	Architectural Access Board.
•	Local Authorities having jurisdiction.
Instructions:
1.	The Checklist must be filled out completely with each application.
2.	Each requirement line (_____) of this Checklist must be filled in with one of the following codes, unless otherwise directed.  If an entire Checklist section is affected by a renovation project, “E” for existing conditions may be indicated on the requirement line (_____) next to the section title (e.g.   E   RESIDENTS BEDROOMS).  If more than one space serves a given required function (e.g. patient room or exam room), two codes separated by a slash may be used (e.g. “E/X”).  Clarification should be provided in that regard in the Project Narrative.

 X	=	Requirement is met.

		=	Check this box under selected checklist section titles or individual requirements for services that are not included in the project.
	
E	=	Functional space or area is existing and not affected by the construction project;  this category does not apply if the existing space or area will serve a new or relocated service or if the facility is currently not licensed & applying for licensure.
	W	= 	Waiver requested for Guidelines, Regulation or Policy requirement that is not met (for each waiver request, complete separate waiver form & list the requirement ref. # on the affidavit).
	
3.	Requirements referred to as "Policies" are DPH interpretations of the Regulations. 

Facility Name:
      		DoN Project Number: (if applicable)
     	
Facility Address:
     			
		Building/Floor Location:
     	
		
Submission Dates: 
	
Project Description:
     		Initial Date:	     
Revision Date:	     	

		ARCHITECTURAL REQUIREMENTS	MECHANICAL/PLUMBING/
ELECTRICAL REQUIREMENTS	

151.210

151.220

151.230

151.240

Policy
	     	SITE DEVELOPMENT
     	Roads & walkways to:
	     	main entrance
	     	ambulance entrance
	     	kitchen entrance
	     	delivery/receiving area
     	Walkways from parking areas to main entrance:
	     	min. 4'-0" wide
	     	max. slope 1:12
     	Off street parking:
	     	at least 1 parking space for each 4 beds
	     	plus at least 2 handicapped parking spaces
		     	near main entrance
		     	min. 12'-0" wide
     	Outdoor recreation area
	     	separate from parking areas
	     	min. 25 sf per bed
	     	wheelchair accessible	
Lighting in following areas:
     	walkways
     	parking lots
     	building entrances	
151.510
150.017

	     	GENERAL ACTIVITY ROOM(S)
     	Outside windows
     	min. 8 sf per bed total resident area*
     	Storage closet	
     	Emergency lighting
     	Nurses call station	
151.510	     	BEAUTY PARLOR & BARBER SHOP
 check if service not included in project
     	min. 120 sf
     	counter & cabinets	

     	Shampoo basin
     	Nurses call station	
151.520

	     	EXAMINATION/TREATMENT ROOM
 check if service not included in project 
(only if facility is Level IV)
     	Min. 125 sf
     	Min. dimension 10'-0"
     	Storage cabinet	

     	Handwashing sink
     	Nurses call station
	
151.530
(A)

(B)

	     	OFFICE SPACE
     	Administrative offices
	     	administrator's office
		     	min. 80 sf
	     	director of nurses office
		 check if service not included in project
		(only if facility is Level IV)
		     	min. 80 sf
	     	storage of medical records
     	Consultants office(s)
	     	min. 100 sf		
151.550

	     	STAFF & PUBLIC TOILETS
     	Visitors toilet rooms
	     	one for each gender
	     	handicapped accessible
     	Staff toilet rooms
	     	convenient to kitchen	
     	Handwashing sink
     	Vent. min. 10 air ch./hr (exhaust)

     	Handwashing sink
     	Vent. min. 10 air ch./hr (exhaust)	

		ARCHITECTURAL REQUIREMENTS	MECHANICAL/PLUMBING/
ELECTRICAL REQUIREMENTS	
151.860
150.015
(C)(10)

	     	PUBLIC TELEPHONE
     	Located in separate room or alcove
     	Provides for privacy 
     	Wheelchair accessible
       Sound volume control		
151.560
(I)

(A)
(H)	     	CENTRAL KITCHEN
     	Located to avoid through-traffic
     	Food receiving area
     	Food preparation area min. 5 sf per bed*
     	Min. aisle width 42" for fixed equipt.
     	Min. aisle width 60" for mobile equipt.
	 check if mobile equipt. not included in project	

     	Handwashing sink
     	Double-comp. vegetable sink
	     	30" drain board
	     	backsplash	
		     	Equipment sealed 	or
	to wall
     	Filler strip between	or
	pieces of equipt.	     	min. 8" clear between equipt. & wall 
     	min. 8" clear between pieces of equipt. 	     	Triple-comp. pot washing sink
	     	one 30" drain board on each side
	     	backsplash
     	Floor drain	
(L)

		     	Storage cabinets for dishes & silverware
	     	Vent. min. 10 air ch./hr
	     	negative pressure (Policy)
	     	air exhausted to outdoors
     	Exhaust hoods at cooking areas
     	Emergency lighting	
(F)

		     	Dishwashing area
	     	separate from food prep. area
	     	direct entrance from corridor
	     	access of soiled dishware is not through 
food preparation area	     	Vent. min. 10 air ch./hr
	     	negative pressure (Policy)
	     	air exhausted to outdoors	
(J)
		     	Food cart washing/ can washing
	     	separate defined area		
(K)
		     	Dietician office
	     	min. 100 sf		
(M)

		     	Janitor's closet
     	at least one per floor
     	min. 25 sf
     	min. 5'-0" dimension
     	shelving	

     	Service sink
     	Vent. min. 10 air ch./hr (exhaust) 	
151.750

		       Refrigerator
	     	min. 1.5 cubic feet per bed*
     	Freezer
	     	min. 0.5 cubic feet per bed*		
151.570
Policy 
(A) 	     	CENTRAL DINING
     	Located for outside exposure
     	Min. 10 sf per bed*	
     	Emergency lighting
     	Nurses call staff station	
151.370
(C)
Policy
Policy
(C)

	     	CENTRAL RESIDENT TOILET ROOMS
     	At least 2 central toilet rooms
	     	off main corridor
	     	convenient to dining & activity rooms
	     	wheelchair accessible
	     	designated for each gender	
     	Handwashing sink
     	Vent. min. 10 air ch./hr (exhaust)
     	Emergency nurses call station	

		ARCHITECTURAL REQUIREMENTS	MECHANICAL/PLUMBING/
ELECTRICAL REQUIREMENTS	
151.570
(B)
	     	STAFF DINING
     	Separate staff dining room		
151.590

	     	CENTRAL LAUNDRY
     	Laundry facilities           or
	equipped for total laundry service
     	Double-comp. tub	
     	Outside laundry service 
     	Laundry room 
	     	min. 70 sf
	     	washer & dryer
	     	double-comp. tub	
     	Vent. min. 10 air ch./hr
	     	negative pressure (Policy)
	     	air exhausted to outdoors
	
151.500
(A)
Policy

(B)
(B) (1)

(B) (2)

	     	STORAGE AREAS
     	General storage
	     	direct access from corridor
	     	min. 10 sf per bed*
     	Linen storage
	     	central clean linen storage
		     	min. 6'-0" x 9'-0"
		     	shelving min. 18" deep
	     	central soiled linen holding
		     	min. 6'-0" x 9'-0"

	

     	Mechanical ventilation

     	Vent. min. 10 air ch./hr
	     	positive pressure (Policy)

     	Handwashing sink
     	Vent. min. 10 air ch./hr
	     	negative pressure (Policy)
	     	air exhausted to outdoors
	
(C)

		     	Central food storage
	     	min. 150 sf
	     	shelving
		     	max. 18" deep
		     	max. 72" high	     	Vent. min. 10 air ch./hr
	     	positive pressure (Policy)	
150.016
(E)(3)

	     	JANITOR'S CLOSET
     	Min. one per floor
     	Min. one per service wing or administrative wing
     	Min. 25 sf
     	Min. 5'-0" dimension
     	Shelving	

     	Service sink
     	Vent. min. 10 air ch./hr (exhaust)

		ARCHITECTURAL REQUIREMENTS	MECHANICAL/PLUMBING/
ELECTRICAL REQUIREMENTS	
151.540
(B)

	     	RESTORATIVE SERVICE
     	Physical therapy room
	 check if service not included in project
	     	min. 200 sf therapy area
	     	min. dimension 10'-0"
	     	storage closet	
     	Handwashing sink

     	Mechanical or natural ventilation
     	Nurses call station
	
(C)		     	Occupational therapy room
	 check if service not included in project
	     	min. 300 sf therapy area
	     	min. dimension 10'-0"
	     	storage closet	     	Service sink
     	Nurses call station	

(A)(3)

(a)	
     	
OUTPATIENT RESTORATIVE SERVICE*
 check if service not included in project
*A separate letter of intent must be filed with the Department 
prior to plan approval

       Direct handicapped access		
			       from the outside or	        from the main lobby		
(b)
(c)

		       Convenient parking
       Resident toilet rooms
	       separate from nursing unit toilets

      Staff toilet rooms	
     	Handwashing sink
     	Vent. min. 10 air ch./hr (exhaust)
     	Emergency nurses call station

     	Handwashing sink
     	Vent. min. 10 air ch./hr (exhaust	
(d)
(e)
(f)
		       Waiting/reception area
       Record storage
       Office space		
(B)(3)		       Physical therapy room 
	(shared with LTCF residents restorative program)
	     	min. 200 sf therapy area
	     	min. dimension 10'-0"
	     	storage closet 
       Provisions for patient privacy
       Dressing facilities
       Lockers

     	Handwashing sink

     	Mechanical or natural ventilation
     	Nurses call station

GENERAL STANDARDS
Architectural Details
	Corridors (151.600):
		resident corridors 	
Elevators (151.740)
 check if service not included in project
(only if entire facility on one floor)	
		     	min. 8'-0" wide
		     	handrails on both sides 
			     	max. projection 3½"
			     	min. 30" AFF
			     	returns meet wall at each end		up to 82 beds on
	floors other than entrance floor:
	     	at least 1 elevator		more than 82 beds on floors other than entrance floor:
	     	at least 2 elevators	
		service corridors
		     	min. 5'-0" wide
	Ramps (151.610):		     	hospital type
	     	interior cab min. 5'-0" x 7'-6"
	     	door opening min. 44"	
	 check if service not included in project
	     	max. slope 1:12
	Stairs (151.620):
	     	non-slip treads & landings
	     	handrails on both sides 
		     	max. projection 3½"	
Mechanical
	Heating (151.700):
	     	heating capacity min. 75 °F 
	Air Conditioning (151.700(D)):
	     	cooling capacity max. 75 °F in areas listed below:	
		     	min. 30" AFF
	     	max. riser height 7"
	     	tapered risers
	Doors (151.630):
	     	min. 44" wide at din. rooms, act. rooms, PT/OT 		rooms, stairs
	     	min. 32" at toilet rooms		 New Construction
	& Major Renovations
 Original facility plan approval on or after 4/14/00
	     	AC in all resident areas	Minor Renovations
     	original facility plan approval prior to 04/14/00
     	AC in dining rooms, activity rooms, day rooms, etc. 	
	     	no locks or privacy sets in resident areas
	     	outswinging/double-acting doors for toilet rms
	     	kitchen doors min. 42" wide	
	Windows (151.640):
	     	sill or guard min. 30" AFF
	     	operable windows
	     	insect screens
     	Grab bars in all resident toilet rooms
	     	250 lb. capacity
     	Min. 8'-0" ceiling height in resident areas
     	Washable wall finishes in toilet rooms & kitchen (151.660(B))
     	Impervious floor finish in toilet rooms & kitchen (151.660 (C)&(D))

		Refrigeration (151.750):
	     	max. cooler temperature 45 °F
	     	max. freezer temperature -10 °F
	Ventilation (151.710):
	     	corridors not used as plenums for supply/return

Plumbing
     	min. water pressure 15 psi (151.720)

Electrical
	Emergency power (151.830):
	     	generator
		     	dedicated to emerg. elec. system
		     	adequate capacity
	     	automatic transfer switches 
	     	all corridor receptacles on EP
	     	1 elevator on EP
	Nurses call system (151.850):
	     	all calls register at nurses station
	     	light signal activated in corr. at origin of call
	Telephones (151.860):
	      at least 1 telephone per floor	

Space Dependent on Bed Count:  Square Footage Summary
 check if not applicable 
(only if the project will not result in a bed increase or will not affect areas identified in 1st column)
Complete box and table below: 

Total number of beds in facility N =		     	

	FUNCTIONAL AREA		S = SF PER BED
	REQUIREMENT		TOTAL SF REQUIRED
	= S x N		TOTAL SF PROVIDED	
DAY ROOMS	9		    			    	    	
DINING ROOM(S)	10		    	    		    	    	
GENERAL ACTIVITY ROOMS	8		    	    		    	    	
KITCHEN FOOD PREP. AREA	5		    	    		    	    	
GENERAL STORAGE ROOM(S)*	10		    	    		    	    	
 	*Excluding specific storage rooms serving nursing units, activity rooms, PT/OT rooms or kitchen.

Fire-Resistance Ratings of Structural Elements 
(Type 1B construction per M.G.L. Chapter 111 §71 and 780 CMR Table 601) 
Complete table below with fire-resistance ratings and U.L. numbers for structural elements constituting the proposed structure.

FIRE RESISTANCE
 (HOURS)	RATING REQUIRED	RATING PROVIDED	U.L. NUMBER	
STRUCTURAL ELEMENTS	Supporting Floor 	Supporting Roof Only	Supporting Floor 	Supporting Roof Only	Supporting Floor 	Supporting Roof Only	
EXTERIOR 
BEARING WALLS		2		2		   		   		     		     	
INTERIOR 
BEARING WALLS		2		1		   		   		     		     	
COLUMNS		2		1		   		   		     		     	
BEAMS		2		1		   		   		     		     	
FLOOR STRUCTURE
		2				   				     			
ROOF STRUCTURE				1