Hospital Physical Environment Desk Reference Manual

Department of Health

• Hospital Licensing Regulations
  • Chapter 246-320 WAC (rule website) revised August 2015
  • Chapter 246-320 WAC (Word) revised September 2011
  • Chapter 246-320 WAC (PDF) revised September 2011
• Construction Review Services
  • Chapter 246-314 WAC (Word) revised June 2012
  • Chapter 246-314 WAC (PDF) revised June 2012
• Plan Review/ Survey Process flowchart (PDF) added November 2009
• Infection Control Risk Assessment (ICRA)
• Acknowledgment of Risk Form (Word)
• Acoustical Ceiling Materials for Healthcare Facilities (Word) added November 2010
• Guideline for Creating a Functional Program (PDF)
• Guideline for Creating a Basis of Design document (PDF)
• Guideline for Creating a Risk assessments (PDF)
• Patient Lift Systems Remember to submit installations to CRS (Technical Assistance fee applies.) added November 2007

Centers for Disease Control and Prevention

• Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Facilities (PDF)
• Guideline for Hand Hygiene in Health-Care Settings (PDF)

Sustainability in Healthcare

• Practice Greenhealth added April 2010

Centers for Medicaid & Medicare Services (CMS)

• Centers for Medicaid & Medicare Services (CMS) website
• Adoption of the 2000 edition, Life Safety Code (PDF)
• Fire Smoke Zone Evaluation Worksheet for Healthcare Facilities (PDF)
• Fire and Life Safety Report for Healthcare Facilities (PDF)

Centers for Medicaid & Medicare Services Survey and Certification

• Conditions of Participation: CMS Physical Environment Section of the State Operations Manual for Hospitals (PDF)
• General Information
• Relative Humidity: CMS Revised State Operations Manual Appendices A, I, L, and W
• S&C-03-22 Clarification of CMS Payment Policies Regarding Ambulatory Surgical Centers/Independent Diagnostic Testing Facilities Conducting Business From the Same Location (PDF)
• S&C-04-15 Major vs. Minor Alteration and Application of the Life Safety Code Existing / New Chapters (PDF)
• S&C-04-41 Corridor Mounted Touch Screen and Corridor Obstructions (PDF)
• S&C-05-33 Fire Safety Amendment for the Use of ABHR's (PDF)
• S&C-06-18 Air Movement between Corridors and Resident Rooms (PDF)
• S&C-07-01 Use of ABHR (PDF)
• S&C-07-05 Exit Discharge Requirements & Fire Safety Evaluation System (FSES) (PDF)
• S&C-07-10 Medical Gas Storage and Usage Considerations (PDF)
• S&C-07- November Use of Alcohol-based Skin Preparations (PDF)
• S&C-07-18 Gaps in Corridor and Smoke Barrier Doors (PDF)
• S&C-07-21 Generators in Ambulatory Surgical Centers (ASC's) (PDF)
• S&C-07-29 Canopy and Overhang Sprinkler Requirements (PDF)
• S&C-08-04 Infection Control Guidelines (PDF)
• S&C-08-09 Food Prepared Off Site (PDF)
• S&C-08-34 Compliance With State Fire and Safety Code in Lieu of Life Safety Code (PDF)
• S&C-09-24 End Stage Renal Disease - Life Safety Code (PDF)
• S&C-09-24 End Stage Renal Disease Interpretive Guidance (PDF)
• S&C-09-37 Ambulatory Surgical Centers Revisions to State Operations Manual (PDF)
• S&C-09-51 Clarification of Ambulatory Surgical Center (ASC) Interpretive Guidelines (PDF)
• S&C-09-55 Flash Sterilization Clarification - Ambulatory Surgery Center (PDF)
• S&C-09-56 End Stage Renal Disease - FAQ's (PDF)
• S&C-10-04 Waiver to Allow Hospitals to Use the NFPA 6-Year Damper Testing Interval (PDF)
• S&C-10-18 Revision of S&C-04-41 dated Aug. 12, 2004. Corridor Width and Corridor Mounted Computer Touch Screens in Health Care Facilities. - Clarification Effective Immediately (PDF)
• S&C-12-21-LSC Updates to the CMS policy regarding Capacity of the Means of Egress: Cooking Facilities; Heating, Ventilating, and Air Conditioning; and Furnishings, Mattresses, and Decorations (PDF)
• S&C 13-25-LSC and Ambulatory Surgical Center (ACS) Waiver of Life Safety Code (LSC) Anesthetizing Location Requirements; Discussion of Ambulatory Surgical Center Operating Room Requirements (PDF) added April 2013
• S&C-13-58 2000 Edition National Fire Protection Association (NFPA) 101® Life Safety Code (LSC) Waivers (PDF) added September 2013
• S&C-14-21 Proposed Rule Making for Fire Safety Requirements (PDF)

United States Pharmacopeia (USP)

• United States Pharmacopeia website

Facilities Guidelines Institute (FGI)

• Facilties Guidelines Institute (FGI) website
• New – State Amendment Insert Pages 2014 Edition (PDF)
• State Amendment Insert Pages 2010 Edition (PDF)
• Formal Interpretations, 2006 Edition (PDF)

National Fire Protection Association (NFPA)

• List of National Fire Protection Association (NFPA) Healthcare Codes and Standards (This link has been temporarily removed. Please check back for updates.)
• NFPA 101 Formal Interpretations, 2000 edition (PDF)
• Healthcare Interpretations Task Force
  • HITF Interpretations, January 2014 (PDF)
    • Placement of large screen monitors
  • HITF Interpretations, June 2011 (PDF)
    • Exit access from suites
    • Door locking
    • Alcohol based hand rub dispensers
    • Standpipe system flow tests
  • HITF Interpretations, June 2010 (PDF)
    • Sprinkler clearance
    • Fire pins in fire doors
    • Exit access from suites
    • Two Hour Floor/Ceiling
  • HITF Interpretations, November 2009 (PDF)
    • Soiled linen and trash containers
  • HITF Interpretations, June 2009 (PDF)
    • Exit discharge
    • Utility penetrations in corridor walls and smoke barriers
    • Exterior exit discharge lighting requirements
    • On-site fuel supplies for emergency generators
    • Patient lift equipment sprinkler obstruction
    • Fire alarm system out-of-service requirements
  • HITF Interpretations, December 2008 (PDF)
    • Exit discharge
    • Utility penetrations in corridor walls and smoke barriers
    • Exterior exit discharge lighting requirements
    • On-site fuel supplies for emergency generators
    • Patient lift equipment sprinkler obstruction
    • Fire alarm system out-of-service requirements
  • HITF Interpretations, June 2008 (PDF)
    • Inspection of portable fire extinguishers
    • Existing fire alarm systems
    • Storage rooms 50 s.f. or less
    • Operation of doors
  • HITF Interpretations, December 2007 (PDF)
    • Portable devices/equipment in corridors
    • Cooking equipment
  • HITF Interpretations, June 2007 (PDF)
    • Items in corridors
    • Corridor width in suites
  • HITF Interpretations, December 2006 (PDF)
    • Door gaps
    • Smoking restrictions in nursing homes
    • Nursing home staff and fire drills
  • HITF Interpretations, June 2006 (PDF)
    • Top of wall blocking to protect the cavity in corridor walls
    • Linen and waste chute termination rooms
    • Frequency of Fire Drills at SNF
  • HITF Interpretations June 2005 (PDF)
    • Suspended-grid ceiling tile clipped or specific weight
    • Delayed egress locks
  • HITF Interpretations January 2004 (PDF)
    • Door locking
  • HITF Interpretations May 2003 (PDF)
    • Personal furnishings and smoke detection
  • HITF Interpretations, November 2000 (PDF)
    • Coded announcements

Washington State Building Code Council

• Washington State Building Code Council website
• Current Statewide Amendments to the International Building Code
• List of International Codes Adopted by the State Building Code Council

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