COMPLIANCE CHECKLIST

 Long Term Care Facility - Hospital Based

The following checklist is for plan review of new hospital based long-term care facilities (HB/LTCF) and renovations to existing HB/LTCF.  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.
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: 
.........................................................................................................................................................	Dates: 
Initial:	..........................................................
Revisions:	..........................................................	
Facility Address:
.........................................................................................................................................................		
	DON Identification: (if applicable) 
...........................................................................	
	Bed Complement: 
Current Number of Beds 	=	...............
Proposed Number of Beds	= 	...............	
Project Reference:
.........................................................................................................................................................
.........................................................................................................................................................	 Building/Floor Location: 
...........................................................................
...........................................................................	

		ARCHITECTURAL REQUIREMENTS	MECHANICAL/PLUMBING/
ELECTRICAL REQUIREMENTS	

151.220

151.230

151.240

Policy	
		SITE DEVELOPMENT
	Parking spaces of hospital parking lot for LTCF use:
	____	parking spaces nearest LTCF visitors entrance 
	____	at least 1 parking space for each 4 beds
	____	plus at least 2 handicapped parking spaces
		____	min. 12'-0" wide
____	Outdoor recreation area
	____	separate from parking areas
	____	min. 25 sf per bed
	____	wheelchair accessible			
151.150
(A)
(C)
(B)
Policy
151.300
(C)
151.300 (D)
		LTCF LOCATION & SIZE
____	Contiguous space 
____	Not used as thoroughfare to access hospital areas
____	LTCF separated from hosp. space by walls & doors
	____	separation is a 2-hour fire barrier
____	Nursing unit located on one floor only
	Number of beds in nursing unit =  ____
	____	min. bed total 20 beds
	____	max. bed total 41 beds	

	

151.320(E)	____	RESIDENTS BEDROOMS
____	Floor level 6" above grade		
(A)
(B)

(H)		____	Single-bed room: 
	____	min. 100 sf 

	____	Multibed room:
	____	min. 80 sf/bed 
	____	max. 4 beds
	____	3 beds or less  
		// window on 1 side	Lighting:
____	general lighting
	____	switch adjacent to bedroom door on latch side
____	reading light for each bed	
				____	privacy curtains	____	bolted to        or	____  wall	
(D)		      	____	min. 3'-0" clear on each side of each bed		nightstand		mounted	
				____	min. 4'-0" wide passageway
			____	at end of each bed		____	illumination level equivalent to 60 watts incandescent	

(I)

(J)

150.017

					____	continuous to the bedroom door
	____	one closet per bed
		____	min. 2'-0" x 2'-0"
		____	5'-0" vertical clearance under clothes rod
		____	convenient access outside of bed cubicles
	____	bureau
		____	min. 2'-0" wide
		____	at least 1 drawer per resident
	____	hospital-type beds
		____	min. mattress dim. 36" x 76"
	____	nightstand for each bed
		____	drawer & cabinet
		____	towel rack
	____	1 armchair for each bed		____  elec. connection separate from  required receptacles
	____	switch usable by resident
____	night light

Power:
____	1 duplex receptacle per bed on headwall
	____	on emergency power
____	1 duplex receptacle on another wall

Nurses call system:
____	1 call station for each bed	
151.320(G)
(F)
Policy
			____	bedroom opens into corridor
	____	outside window (also see Page 6)
		____	min. 20'-0" outside clearance to any walls	

151.370 (C)

Policy
Policy			____	toilet room
		____	direct access from bedroom
		____	towel bar
		____	robe hook	
or	____	serves a maximum    
		of 4 beds

____	Handwashing sink
____	Vent. min. 10 air ch./hr (exhaust)
____	Night light
____	Emergency nurses call station	

		ARCHITECTURAL REQUIREMENTS	MECHANICAL/PLUMBING/
ELECTRICAL REQUIREMENTS	
151.330

	____	SPECIAL CARE ROOM
(also see 151.320)
____	Located in close proximity to nurses station
____	Single-bed 
____	Min. 100 sf 	

	

Policy

		____	Private bathroom
	____	toilet
	____	shower	
		____	min. 4'-0" x 4'-0" stall
		____	no curb
		____	sloped toward center drain
		____	shower curtain	

or	____	tub	____	Handwashing sink
____	Shower controls outside stall
	____	easily operable by nursing staff
____	Vent. min. 10 air ch./hr (exhaust)
____	Emergency nurses call station
	____	accessible from toilet & shower (or tub)	
151.340
(A)

(D)

(C)
(E)	____	NURSES STATION
____	Centrally located
____	Max. 100 ft n. station entrance to furthest bedrm door
____	Counter
	____	max. 42" high
____	Charting surface
____	Storage cabinets
____	Nurses toilet room	

____	Vent. min. 10 air ch./hr 
____	Emergency lighting
____	Emergency power
____	Nurses call master station
	____	bedroom numbers displayed
	____	room functions displayed	
151.350
(A)
(B)
(C)

(D)
	____	MEDICINE ROOM
____	Opens into nurses station
____	Counter
____	Top & base cabinets
____	Lockable compartment
____	Refrigerator	

____	Handwashing sink
____	Vent. min. 10 air ch./hr
____	Lighting on emergency power
____	Refrigerator on emergency power 	
151.360
Policy 
150.017
151.360
	____	DAY ROOM
____	Centrally located
____	Outside window
____	Min. 9 sf per bed	
____	Emergency lighting
____	Nurses call station	
151.310

	____	DRINKING FOUNTAIN
____	Centrally located		
151.370
Policy
Policy
(A)

	____	BATHING
____	Centrally located
____	Solid partition enclosure for each tub or shower
____	At least one central free-standing tub
	____	accommodates wheelchair residents

____	Vent. min. 10 air ch./hr
	____	negative pressure (Policy)
	____	air exhausted to outdoors
____	Emerg. nurses call	
(B)

Policy
Policy			____	Shower rooms:
	____	min. 4'-0" x 4'-0" stall
		____	no curb
		____	sloped toward center drain
		____	shower curtain
	____	dressing area
		____	door or privacy curtain	____	Vent. min. 10 air ch./hr
	____	negative pressure (Policy)
	____	air exhausted to outdoors
____	Shower controls outside stall
	____	easily operable by nursing staff
____	Emerg. nurses call within reach of patient in shower room	

		ARCHITECTURAL REQUIREMENTS	MECHANICAL/PLUMBING/
ELECTRICAL REQUIREMENTS	

Type of Bathing Fixture	Required Ratio (1:N)	Number of Fixtures
With Corridor Access (B)	Number of 
Beds Served (B x N)	
Free-Standing Tub	1:15			
Automated Bather	1:30			
Corridor Accessible Shower	1:15			
TOTAL				
	  Number of beds without direct access to bathing  =  ______

(C)
Policy
Policy
(C)

	____	CENTRAL TOILET ROOMS
____	At least 2 central toilet rooms
	____	off main corridor
	____	convenient to day room and bathing
	____	wheelchair accessible
	____	designated for each gender	
____	Handwashing sink
____	Vent. min. 10 air ch./hr (exhaust)	
151.390
(B)

	____	CLEAN UTILITY ROOM
____	Direct access from corridor
____	Counter
____	Top & base cabinets	

____	Sink w/ goose‑neck faucet
____	Vent. min. 10 air ch./hr	
151.390
(C)
	____	SOILED UTILITY ROOM
____	Direct access from corridor
____	Counter	
____	Handwashing sink
____	Service sink w/ goose‑neck faucet	
			____	Clinical       or
	flushing-rim sink			____	Bedpan washer/
	sanitizer	
			____	Vent. min. 10 air ch./hr
	____	negative pressure (Policy)
	____	air exhausted to outdoors	
151.380
(A)

	____	LINEN CLOSET
____	Non‑combustible shelving 
 	____	max. 6'-0" high	

151.580

	____	NOURISHMENT KITCHEN
____	Min. 1 per floor
____	Refrigerator
____	Storage cabinets	
____	Sink
____	Vent. min. 10 air ch./hr (exhaust)
____	Emergency lighting	
Policy
		____	Surface cooking unit      or	____	Microwave oven		

151.380
	____	STORAGE CLOSET
____	size meets unit storage needs		
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
	
151.570
Policy 
(A)		____	RESIDENT DINING
____	Located for outside exposure
____	Min. 10 sf per bed	
____	Emergency lighting
____	Nurses call staff station	

		ARCHITECTURAL REQUIREMENTS	MECHANICAL/PLUMBING/
ELECTRICAL REQUIREMENTS	
151.570
(B)	

	____	STAFF DINING
____	within LTCF 	or
____	separate from resident dining room		
____	use of hospital cafeteria		
	
151.860
150.015
(C)(10)	
	____	PUBLIC TELEPHONE
____	Located in separate room or alcove
____	Provides for privacy 
____	Wheelchair accessible			

151.520

	____	EXAMINATION/TREATMENT ROOM
____	Min. 125 sf
____	Min. dimension 10'-0"
____	Storage cabinet	
____	Handwashing sink
____	Nurses call station
	
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	
151.530
(A)

(B)
		____	OFFICE SPACE
____	Administrative offices
	____	administrator's office
		____	min. 80 sf
	____	director of nurses office 
		____	min. 80 sf
	____	storage of medical records
____	Consultants office(s)
	____	min. 100 sf		
	
151.550		____	PUBLIC & STAFF TOILETS
____	Visitors toilet rooms
	____	one for each gender
	____	handicapped accessible		
	
				____	located in LTCF		or	____	hospital public toilets		
			____	Staff toilet rooms convenient to LTCF			
151.380

		____	JANITOR'S CLOSET
____	Equipped with shelving		
____	Service sink
____	Vent. min. 10 air ch./hr (exhaust)	
150.018 (C)	

	____	ANCILLARY SERVICES
	Dietary
	____	provided by LTCF   or
	Laundry
	____	provided by LTCF   or	

____	contracted with hospital

____	contracted with hospital	
	
151.500 (A)		____	GENERAL STORAGE
____	10 sf/bed
____	located in LTCF              or

____	designated storage space within the hospital		

GENERAL STANDARDS
Architectural Details
	Resident corridors (151.600):	
Mechanical
	Heating (151.700):	
	renovated for LTCF
	____	min. 8'-0" wide	or	existing hosp. corridor
	____	min. 4'-0" wide		_____	heating capacity min. 75 °F 
	Air Conditioning (151.700(D)):	
	____	handrails on both sides		_____	cooling capacity max. 75 °F in areas listed below:	
		____	max. projection 3½"
		____	min. 30" AFF
		____	returns meet wall at each end 
	Staff corridors (151.600):		 New Construction
	& Major Renovations
 Original facility plan approval on or after 4/14/00	Minor Renovations
_____	original facility plan approval prior to 04/14/00	
	renovated for LTCF 
	____	min. 5'-0" wide	or	existing hosp. corridor
	____	min. 4'-0" wide		_____	AC in all resident areas	_____	AC in dining rooms, activity rooms, day rooms, etc.	
	Doors (151.630):
	____	min. 44" wide at bedrooms, day room, din. rooms, act. rooms, stairs	____	Temperature controls in each bedroom
	Ventilation (151.710):
	____	corridors not used as plenums for supply/return	
	____	min. 36" at bathing rooms (Policy)
	____	min. 32" at toilet rooms
	____	no locks or privacy sets in resident areas
	____	outswinging/double-acting doors for toilet rms
	Windows (151.640):
	____	sill or guard min. 30" AFF
	____	window glass area min. 10% of BR floor area
	____	operable windows (min. opening 4% of BR floor area)
	____	insect screens
____	Grab bars in all resident toilet & bathing facilities
	____	250 lb capacity
____	Min. 8"-0" ceiling height in resident areas
____	Washable wall finishes in toilet, bathing, food prep., utility rooms (151.660(B))
____	Impervious floor finish in toilet, bathing, food prep., utility rooms (151.660 (C)&(D))	
Plumbing 
____	min. water pressure 15 psi (151.720)

Electrical
	Lighting (151.800):
	____	uniform distribution of light in bedrooms
		night lights
		____	min. illumination level equivalent to 15 watts incandescent
		____	switch at nurses station or at BR door
		____	min. height 12" AFF
	Emergency power (151.830):
	____	all corridor receptacles on EP
	____	electric components of heating syst. on EP in bedrooms
	Nurses call system (151.850):
	____	all calls register at nurses station
	____	light signal in corridor at origin of call
	____	multiple call stations within same room have indicator lights 
	____	LTCF not connected to hospital paging system
	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 ROOM(S)	9			
DINING ROOM(S)	10			
GENERAL ACTIVITY ROOM(S)	8