COMPLIANCE CHECKLIST

 Hospice Inpatient Facility – Common Areas

The following checklist is for plan review of hospice inpatient facilities.  This checklist is derived from Section 105 CMR 141.299 (Appendix A) of hospice licensure regulations 105 CMR 141.000, entitled "Licensing of Hospice Programs".  This checklist is intended as a reference for the design of hospice inpatient facilities and is recommended to be included in the plan submission for “Full Review”. 

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   PATIENT 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 Regulation or Policy requirement that is not met (for each waiver request, complete separate waiver form).
	
3.	Requirement lines followed by asterisks (*) are adopted as policies based on DPH interpretations of the Regulations. 

Facility Name: 
.........................................................................................................................................................	Dates: 
Initial:	..........................................................
Revisions:	..........................................................	
Facility Address:
.........................................................................................................................................................		
		
	Bed Complement: 
Current Number of Beds 	=	...............
Proposed Number of Beds	= 	...............	
Project Reference:
.........................................................................................................................................................
.........................................................................................................................................................	 Building/Floor Location: 
...........................................................................
...........................................................................	

		ARCHITECTURAL REQUIREMENTS	MECHANICAL/PLUMBING/
ELECTRICAL REQUIREMENTS	

(C)
(1)

(2)

(A)

(B)	____	SITE IMPROVEMENTS
____	Non handicapped off street parking
	____	at least 1 parking space for each 4 beds
____	Provisions for the handicapped
____	handicapped parking
	____	at least 2 handicapped parking spaces
		____	near main entrance
		____	min. 12'-0" wide 
____	walkways from parking areas to main entrance
	____	min. 4'-0" wide
	____	max. slope 1:12
	____	no abrupt changes in grade level
	
Lighting in following areas:
____	walkways
____	parking lots
____	building entrances	

(A)
(1)
(2)
(B)
	____	OFFICE SPACE
____	Administrative offices
	____	storage of medical records
	____	Administrator & Director of Nurses office
____	Consultants offices
		
	____	STAFF & PUBLIC TOILETS
____	handicapped accessible toilet room
	____	for staff & visitors only
		
____	Handwashing sink
____	Vent. min. 10 air ch./hr (exhaust)

(A)

(B)
(1)

(2)	____	STORAGE AREAS
____	General storage
	____	direct access from corridor
____	Linen storage
	____	central clean linen storage room

	____	central soiled linen holding room

	
____	Vent. min. 2 air ch./hr 

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

		____	Central food storage
	____	Vent. min. 2 air ch./hr
	____	positive pressure*	

(A)

(B)

	____	NOURISHMENT KITCHEN
____	Minimum one per floor
____	Available for patient use
____	Refrigerator
____	Storage cabinets	
____	Sink
____	Vent. min. 10 air ch./hr (exhaust)
____	Emergency lighting	

		____	Surface cooking unit 	or	____	Microwave oven		

		ARCHITECTURAL REQUIREMENTS	MECHANICAL/PLUMBING/
ELECTRICAL REQUIREMENTS	

(B)	___	MEAL SERVICE FACILITIES
____	on-site kitchen           or
	
____	outside meal delivery 
	____	facilities for sanitary food handling

	
(C)

(3)	____	ON-SITE KITCHEN
 check if on-site kitchen not included in project
____	Located to avoid through-traffic
____	Food receiving area
____	Administrative Space

	

(1)(d) 

(1)(e)

		____	Food preparation area
____  refrigerator
____	freezer
____	conventional cooking & baking equipment
	
____	Handwashing sink
____	Double-comp. vegetable sink
	____	drain board
	____	backsplash 
____	Pot washing service sink
	____	one drain board on each side
	____	backsplash
 ____	Vent. min. 10 air ch./hr
	____	negative pressure*
	____	air exhausted to outdoors
____	Emergency lighting	
(1)(f)

		____	Automatic dishwasher
	____	access of soiled dishware is not through 
food preparation area*	____	Vent. min. 10 air ch./hr
	____	negative pressure*
	____	air exhausted to outdoors	
(2)		____	Storage cabinets for dishes & silverware		
(4)

		____	Janitor's closet
	____	kitchen use only	____	Service sink
____	Vent. min. 10 air ch./hr (exhaust) 	

	____	CENTRAL LAUNDRY
____	Laundry facilities           or
	equipped for total laundry service
____	utility sink
____	washer
____	dryer
____	shelving
____	adjacent to clean linen storage room & soiled linen holding room*	
____	Outside laundry service 
	
____	Vent. min. 10 air ch./hr
	____	negative pressure*
	____	air exhausted to outdoors

	____	VISITORS ROOM		

	____	STAFF LOUNGE		

	____	SLEEP AREA
____	Comfortable sleep area for family members
____	Conveniently accessible		
	____	JANITOR'S CLOSET
____	Min. one per floor
____	Min. one per service wing or administrative wing
____	Shelving	

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

GENERAL STANDARDS

Architectural Details
	Corridors : 	Elevators
 check if service not included in project	
	Patient corridors
no current health care   or
inpatient facility license
____	min. 8'-0" wide	
current health care inpatient facility license
____	min. 4'-0" wide	(only if handicapped access to all patient areas from main entrance)
	____	hospital type
	____	interior cab min. 5'-0" x 7'-6"
	____	door opening min. 44"	
		____	handrails on both sides
			____	max. projection 3½"
			____	min. 30" AFF
			____	returns meet wall at each end
		Service corridors	
Mechanical
	Heating:
	____	heating capacity min. 75 °F
	____	temperature controls in each bedroom		
no current health care   or
inpatient facility license
____	min. 5'-0" wide	current health care inpatient facility license
____	min. 4'-0" wide		Ventilation :
	____	corridors not used as plenums for supply/return	
		____	all corridors free of encroachments
	Ramps : 	 Plumbing
____	min. water pressure 15 psi	
	 check if service not included in project
	____	max. slope 1:12
	Doors :
	____	min. 44" wide at bedrooms
	____	min. 36" at bathing rooms
	____	min. 36" at toilet rooms
	____	no locks or privacy sets in resident areas
	____	outswinging/double-acting doors for toilet rooms 
	Windows :	
	____	operable windows
	____	insect screens
		____	16 mesh wire screening	Electrical
	General lighting :
	____	uniform distribution of light in bedrooms
	Night lights
	____	min. height 12" AFF
	____	min. illumination level equivalent to 15 watts incandescent
	____	switch at nurses station or at BR door	
	Emergency power :
	____	generator
	____	all corridor receptacles on EP	
	____	draft-free
	____	height of sill or guard designed to prevent falls
  ____	Grab bars in all patient toilet & bathing facilities		____	electric components	or
		of heating system 
		on EP in bedrooms	____	2 electric utility sources 
	
	____	250 lb. capacity		Nurses call system :
____	nurse call system independent from systems in any adjacent facilities
	____	all calls register at nurses station
	____	light signal in corridor at origin of call
	____	call stations have 1 indicator light  per call button
	Telephones :
	____ at least 1 telephone per floor
	____ 1 telephone outlet in each bedroom