HomeMy WebLinkAboutCBPR-3-10-4598 DHHS Plan rev comments 12-11-09.tif
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North Carolina Department of Health and Human Services
Division of Health Service Regulation
Construction Section
2705 Mail Service Center ■ Raleigh, North Carolina 27699-2705
Beverly Eaves Perdue, Governor William L. Warren, Chief
Lanier M. Cansler, Secretary Phone: 919-855-3893
Jeff Horton, Acting Director Fax: 919-733-6592
December 11, 2009
Michael Blackburn, CEO
j Frye Regional Medical Center
420 N Center Street
Hickory NC 28601
(via e-mail only: michael.blackburn@tenethealth.com)
Re: Project No. HL-8381-ND/ALH
FID No. 943182 CON No. E-008080-08
Frye Regional Medical Center
Catheterization Lab #4 - Ground Floor
Hickory (Catawba)
Dear Mr. Blackburn:
The engineering portion of final working drawings dated November 24, 2009 (received November 30,
2009; fee paid October 13, 2009) for the referenced project have been reviewed for conformance with
licensure's minimum standards for Hospitals (I OA NCAC 13B). The engineering drawings are approved
provided the following conditions are met:
1. Please insure that the pre-action fire sprinkler system annunciation at the facility fire alarm
panel(s) is clearly identifiable to the initiating area (Cath Lab 103). Reference Drawing FP-1.
2. Please provide a minimum of two medical vacuum station outlets to serve Cath Lab 103 as
required by Licensure l0A NCAC 13C.6226 Table 4. Reference Drawing P-2.
3. Please insure that no drainage piping is installed directly over Cath Lab 103, or provide alternative
means of protection for any existing drainage piping as required by Licensure l0A NCAC 13B
.6226 (f)(2). Reference Drawing P-2. j
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4. Please provide a minimum 15 air changes per hour for Cath Lab 103 as required by Licensure 10A
NCAC 13B .6225 Table 1 and 2007 ASHRAE HVAC Applications Chapter 7 Table 3. Reference
Drawing M-2.
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We must receive a written response from your engineer to this review.
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This project is being reviewed with the understanding that the project was designed under the 2009
edition of the NC State Building Codes as renovations within an existing fully-sprinklered building of
Location: 701 Barbour Drive ■ Dorothea Dix Hospital Campus ■ Raleigh, N.C. 27603 ~.a
An Equal Opportunity /Affirmative Action Employer
Project No. HL-83 8 1 -ND/ALH Page 2 of 4
Frye Regional Medical Center - Catheterization Lab #4 Ground Floor
ti December 11, 2009
Type I-B construction under Group I-2 occupancy. It has also been reviewed under NFPA 101 Chapter
19, Existing Health Care Occupancies, as NFPA Type 11(222) construction.
Please note that changes or revisions should be submitted to our office for review and approval prior to
completion of the work. When construction is not started within one year of the date of this letter, our
approval of these documents expires and they are subject to re-review for compliance with any changes in the
governing codes and regulations that may have occurred. Please understand that approval of these
C documents in no way relieves the owner, architect, or engineer from responsibility related to violations of
governing codes and regulations not found by our office or other reviewing agencies. When such violations
are found they must be corrected.
When construction is complete, we will need to receive from you (the owner) or your architect a letter
requesting a final inspection at least two weeks prior to the anticipated completion date.
Before the final inspection date we will need to receive a copy of the following document:
1. A copy of the Certificate of Occupancy issued by the local Code Enforcement Official having
jurisdiction. (NC Administrative Code, 2009 edition, Section 307)
If we have not received the certificate of occupancy prior to the inspection date, we will need to reschedule
the inspection.
The following documentation must be available at the time of the inspection or prior to our recommendation
for occupancy and licensure:
1. A letter from the design architect and engineer confirming that their firms have inspected the
project, and have found it to be constructed in conformance with approved plans and specifications;
and that all requirements of applicable codes and licensure regulations have been met in the
construction.
2. A copy of the Contractor's Material and Test Certificate completed and signed by the sprinkler
contractor showing that the sprinkler system has been installed in conformance with NFPA 13,
Standard for the Installation of Sprinkler Systems; and that flow control and supervisory valve alarms
are active. (NFPA 13, 2007 edition, Section 24.1(3)) It must be confirmed that the owner has
received a copy of NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based
Fire Protection Systems. (NFPA 25, 2007 edition, Section 4.1)
3. A copy of the form Fire Alarm System Record of Completion from the fire-alarm installer
confirming that the fire alarm system and placement of fire alarm devices have been inspected and
tested, and are in conformance with the NFPA 72, National Fire Alarm Code. (NFPA 72, 2007
edition, Section 10.4.1.1 and Figure 4.5.2.1)
4. Copies of UL designs for fire-stopping systems used in the project.
5. Confirmation that all electrical materials, devices, appliances, and equipment located in the project j
area have been evaluated for safety and suitability for their intended use by an approved testing
agency (such as Underwriters Laboratories). This evaluation must be conducted in conformance I
with nationally recognized standards, and must be conducted by a qualified testing laboratory. (N.C.
General Statue 66-25)
Project No. HL- 8 3 8 1 -ND/ALH Page 3 of 4
Frye Regional Medical Center - Catheterization Lab #4 Ground Floor
December 11, 2009
6. Documentation showing the values of voltage measurements (not to exceed 20 mV) made under no-
fault conditions between a reference grounding point and the exposed conductive surfaces of fixed
electrical equipment in all patient-care areas. Please include the location of the common ground point
in the documentation. (NFPA 99, Health Care Facilities, 2005 edition, Section 4.3.3.1.3)
7. Documentation showing the values of impedance (not to exceed 0.1 ohms) from the ground point of
the receptacles and a common ground point in all patient care areas. Please include in the
documentation the location of the common ground point. (NFPA 99, Health Care Facilities, 2005
edition, Section 4.3.3.1.4)
8. Documentation showing that the isolated from ground electrical systems in areas such as OR, OB,
ICU, CCU, etc. have been specially tested for current leakage per line per circuit and for grounding
performance, and are operating properly. (NFPA 99, Health Care Facilities, 2005 edition, Section
4.3.2.6)
9. Documentation from the manufacturer/installer of large diagnostic and treatment equipment (such
as CAT scan machines, X-ray equipment, MRI units, etc.) stating that the equipment has been
installed in conformance with its listing requirements or restrictions, and that the interconnecting field
wiring associated with the equipment is also installed in conformance with all applicable
requirements of the National Electrical Code, 2008 edition when located in hospitals.
10. Confirmation, including actual test results, that the manufacturer/installer of large diagnostic and
treatment equipment (such as CAT scan machines, X-Ray equipment, MRI units, etc.) has
performed the required chassis leakage test with grounds lifted. Permanently wired appliances in
the patient care vicinity shall be tested prior to installation while the equipment is temporarily
insulated from ground, when located in NFPA New Health Care Occupancies. (NFPA 99, Health
Care Facilities, 2005 edition, Section 8.4.1.3.4)
11. A copy of the air-balance report for each HVAC system located in project areas of hospitals and
ambulatory surgical facilities (Hospital Licensure Section l0A NCAC 13B .6225(a), Ambulatory
Surgical Licensure Section 10A NCAC 13C.1405 (b)(10))
12. Manufacturer's current detailed installation instructions for the specific fire dampers, ceiling
radiation dampers, smoke dampers, and duct smoke detectors installed in the project area.
13. Verification that the medical gas piping system is ready for use, including:
a. Documentation by a medical gas certification company that contains copies of the various
tests and field reports required by NFPA 99, Health Care Facilities, 2005 edition, Section
5.1.12.3. Any deficiencies noted by the third party verifier must be corrected prior to our
inspection.
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b. A copy of the brazers' current certification, and a list of the brazing procedures done.
C. A separate document, on the facility's letterhead, showing that each medical gas outlet and
inlet was tested prior to use by qualified facility staff to assure correct gas connections and
pressures.
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• •Project No. HL- 8 3 8 1 -ND/ALH Page 4 of 4
Frye Regional Medical Center - Catheterization Lab #4 Ground Floor
December 11, 2009
14. The radiological physicist's report of on-site testing confirming that radiation shielding of
imaging rooms is in compliance with the designer's requirements as approved by the Radiation
Protection Division of NC Department of Environmental Health and Natural Resources for projects
located in new or renovated hospital construction.
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At the time of the final inspection we will expect to find that all building systems have been completed and
tested, and that they are operating properly. All fire-resistant construction, fire stopping, and smoke stopping
must be complete. Representatives of the various trades and equipment installers must be present to
demonstrate that all systems are functioning as designed, or as required by governing codes and regulations.
Failure to have knowledgeable personnel at the final inspection may result in an incomplete inspection. Due
to our current workload, there may be considerable delay in scheduling a re-inspection should the building
not be ready on the scheduled date.
Please use our Project No.HL-8381-ND/ALH on all correspondence related to this project.
If you have any questions or if we can be of any further service, please let us know.
Sincerely,
Alex Harwell
Engineer
Construction Section
alex.harwell@dhhs.nc.gov
(919) 855-3887
ALH
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cc: McCulloch England - Jim Wiley, RA (via e-mail only)
McCracken & Lopez - Chris Mills, PE (via e-mail only)
Catawba County Building Inspections (via e-mail only)
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