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Tn Dept of Health

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Tn Dept of Health
Tennessee Department of Health
Bureau of Health Licensure and
Regulations
Division of Health Care Facilities
1
Bill Harmon
Facilities Construction
Director
(615)741-6998
Nelson Rodriguez
Fire Safety Supervisor
(615)306-8424
East
Middle
West
Stuart Hurwitz
Jendy Avens
Ricky Gore
Fire Safety Specialist 2
Fire Safety Specialist 2
Fire Safety Specialist 2
(865)320-8922
(615)806-
(731)513-1270
Dustin Phillips
Colby Henson
Wanda Browning
Fire Safety Specialist 1
Fire Safety Specialist 1
Fire Safety Specialist 1
(865)320-8921
(615)306-5856
(731)571-0313
Larry Stafford
Donald Tate
Brandon Maness
Fire Safety Specialist 1
Fire Safety Specialist 1
Fire Safety Specialist 1
(615)806-4720
(615)306-1133
(731)571-1665
Jim McCall
Alexander Warner
Vacant
Fire Safety Specialist 1
Fire Safety Specialist 1
Fire Safety Specialist 1
(865)320-8916
(615)306-0257
(731)511-1303
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Topics
• Rules and Regulations
• Progress and Final Inspections
• Top 5 Deficiencies for Hospitals
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Rules and Regulations
1.
2.
3.
4.
Hospitals
Tennessee Department of Health 1200-08-01 (June 2015)
Nation Fire Protection Association (NFPA) 101 Life Safety
Code (2000 Ed) and the referenced publications per
chapter 2. (CMS)
Nation Fire Protection Association (NFPA) 101 Life Safety
Code (2012 Ed) and the referenced publications per
chapter 2.
International Building Code (IBC) 2012 Ed
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WWW.cms.gov (CMS-2786R)
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Progress and Final Inspections
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Phasing a project
UL systems
Fire Stop systems
Fire/Smoke Dampers
Med Gas
Sprinklers
Fire Alarm
Final Inspection
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Fire Dampers
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Hospitals Top 5 Deficiencies (5)
K-130
Miscellaneous
List in the REMARKS sections, any items that are
not listed previously, but are deficient. This
information, along with the applicable Life
Safety Code or NFPA standard citation, should
be included on Form CMS-2567.
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Penetrations
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Penetrations
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Penetrations
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Hospitals Top 5 Deficiencies (4)
K-77
• Piped in medical gas systems comply with
NFPA 99, Chapter 4.
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NH Top 10 Deficiencies (3)
K-147
Electrical wiring and equipment is in accordance with
NFPA 70, National Electrical Code. 9.1.2
• Broken outlet covers
• Power strips (back to back)
• Exposed electrical junction boxes
• Electrical panels blocked with equipment
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Power Strips in Patient Care Areas
• S&C: 14-46-LSC DATE: September 26, 2014
• SUBJECT: Categorical Waiver for Power Strips
Use in Patient Care Areas
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Hospitals Top 5 Deficiencies (2)
K-29
One hour fire rated construction (with ¾ hour firerated doors) or an approved automatic fire
extinguishing system in accordance with 8.4.1
and/or 19.3.5.4 protects hazardous areas. When
the approved automatic fire extinguishing system
option is used, the areas are separated from other
spaces by smoke resisting partitions and doors.
Doors are self-closing and non-rated or fieldapplied protective plates that do not exceed 48
inches from the bottom of the door are permitted.
19.3.2.1
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K-29
•
•
•
•
•
•
Penetrations in fire rated walls.
Door self-closing device removed.
Penetrations in fire doors
Improper gaps in fire doors
Damaged fire doors
Fire doors not latching
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NH Top 10 Deficiencies (1)
K-62
Required automatic sprinkler systems are
continuously maintained in reliable operating
condition and are inspected and tested
periodically. NFPA 101, 19.7.5, NFPA 13, and
NFPA 25.
• No quarterly
• No annuals
• Obstructions
• Corroded sprinklers
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Sprinklers
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Sprinklers
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Sprinklers
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Sprinklers
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Other Deficiencies
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Questions?
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Thank You
Health Care Facilities Offices
ETRO: (865) 594-9396: Knoxville
WTRO: (731) 984-9684: Jackson
Central Office Nashville (615) 741-7221
Plans Review Office (615) 741-6998
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