1. (a) Building and grounds.

   1. (1) The building and equipment shall be maintained in a state of good repair at all times.
   2. (2) Facility premises shall be kept clean, neat, and free of litter and rubbish.
   3. (3) All openings to attics and to spaces between ceilings and roof decks shall be kept closed at all times.
   4. (4) Rooms containing gas-fired equipment shall not be used for storage except for noncombustible materials.

   5. (5)

      1. (A) Corridors, attics, and passageways shall be free of storage.
      2. (B) Exits shall not be blocked by storage of furniture or equipment at any time.
   6. (6) Emergency wireless communication shall be provided and maintained in a state of good repair.

   7. (7)

      1. (A) Each freestanding birthing center shall develop a written preventive maintenance plan.
      2. (B) This plan shall be available to the Department of Health for review at any time.
      3. (C) Such plans shall provide for maintenance as recommended by:

2. (i) Manufacturer;

   1. (ii) Applicable codes; or

      1. (iii) Designer.

   2. (8) All handwashing facilities shall be equipped with:

      1. (A) Hands-free handles;
      2. (B) Disposable soap dispenser;
      3. (C) Paper towel dispenser; and
      4. (D) Trash receptacle.
   3. (9) Vertical and horizontal transport systems shall be operated and maintained in a manner to provide for safe transport.
   4. (10) Hazardous cleaning solutions, compounds, and substances shall be labeled and kept in an enclosed storage area or approved cabinet separate from other cleaning materials.

   5. (11)

      1. (A) Doors located on exit access corridors and those for entry to patient care areas shall be labeled as to their intended use for convenience and emergency purposes.
      2. (B) All patient rooms shall be labeled and hazardous rooms labeled as to classification.
   6. (12) Fire safety and other safety systems shall be operated and maintained in a manner to protect patients, personnel, visitors, and property from fire and the products of combustion.

   7. (13)

      1. (A) A supply of hot water for patient use shall be available at all times in accordance with Centers for Disease Control and Prevention guidelines.
      2. (B) A monthly log shall be maintained as to presence/absence of hot water.

   8. (14)

      1. (A) Heating, ventilating, and air conditioning systems shall be operated and maintained in a manner to provide a comfortable and safe environment for:

         1. (i) Patients;
         2. (ii) Personnel; and
         3. (iii) Visitors.
      2. (B) In large freestanding birthing centers, an air filter changeout log shall be maintained.
   9. (15) Plumbing systems, including equipment and systems for the supply and distribution of potable, nonpotable, and/or high purity (such as deionized and sterilized) water, and equipment and systems for the complete and safe removal or dispersion of storm water and waste water, shall be operated and maintained in a manner to be adequate, safe, and reliable for all required facility operations.
   10. (16) Boiler systems and hot water delivery systems shall be operated and maintained in a manner to provide a safe supply of steam and/or hot water for all required facility operations.
   11. (17) If provided, medical gas and vacuum systems shall be operated and maintained in accordance with NFPA 99: Standard for Health Care Facilities in a manner to provide an adequate and safe supply for all required activities.
   12. (18) Exit lights shall be illuminated at all times in accordance with NFPA 101: Life Safety Code.

   13. (19) Facilities shall have lighting levels that are conducive to:

       1. (A) Efficient work;
       2. (B) Safety; and
       3. (C) Patient comfort.

   14. (20)

       1. (A) In large freestanding birthing centers, the required emergency power generator shall be exercised:

          1. (i) Weekly for thirty (30) minutes; and
          2. (ii) Under load conditions monthly for thirty (30) minutes.

       2. (B) An equipment log shall be maintained of all:

          1. (i) Tests;
          2. (ii) Malfunctions; and
          3. (iii) The immediate corrective actions.
       3. (C) Preventive maintenance work or repairs shall be noted.
   15. (21) Communication systems including telephone, nurse call, and internal/external paging shall operate effectively and reliably at all times.
   16. (22) The electrical distribution system shall be operated and maintained in a manner to provide safe electrical power for all required activities.

3. (b) Maintenance and engineering.

   1. (1) The physical plant and equipment maintenance programs shall be under the direction of a person:

      1. (A) Qualified by training and/or experience; and
      2. (B) Licensed where required.

   2. (2) Equipment management program.

      1. (A) There shall be a preventive maintenance program designed to ensure the electrically powered patient care equipment used to monitor or diagnose performs properly and safely.

      2. (B) This program shall be administered by:

         1. (i) Individuals qualified through training and/or experience; or
         2. (ii) Procuring a contractual maintenance agreement.

      3. (C) The following are minimum program elements:

         1. (i) A list of electrically powered patient care equipment shall be maintained regardless of location or ownership;
         2. (ii)
4. (a) (a) Each device or identical group of devices shall have a procedure establishing minimum criteria against which performance and safety are measured.

5. (b) (b) The elements of these procedures shall be based on NFPA 99: Standard for Health Care Facilities, and manufacturer’s directions;

   1. (iii) Each device shall be tested at intervals of not more than six (6) months unless there is documented evidence that less frequent testing is justified;

      1. (iv) Historical records documenting acceptable performance as established by the procedures shall be maintained;

         1. (v) A program to identify and repair equipment failures shall be maintained;
         2. (vi) In large freestanding birthing centers, user or owner departments shall be notified of the status of their equipment when it will be out of service more than twenty-four (24) hours;
         3. (vii) There shall be operator and maintenance instructions for each device on the electrically powered patient care equipment list; and
         4. (viii)
6. (a) (a) Individuals shall be trained to operate and maintain equipment used in the performance of their duties.

7. (b) (b) This training shall be documented.

   1. (3) Utilities management program.

      1. (A) There shall be a preventive maintenance program designed to ensure that the physical plant equipment and building systems perform properly and safely.

      2. (B) This program shall be administered by:

         1. (i) Individuals qualified through training and/or experience; or
         2. (ii) Procuring a contractual agreement.

      3. (C) This program shall consist of at least the following minimum elements:

         1. (i) A list of physical plant equipment and building systems shall be maintained regardless of location or ownership;
         2. (ii)
8. (a) (a) Equipment and building systems shall have a procedure establishing minimum criteria against which performance and safety are measured.

9. (b) (b) The elements of these procedures shall be based on the:

   1. (1) (1) NFPA 99: Standard for Health Care Facilities;
   2. (2) (2) Manufacturer's directions; and

   3. (3) (3) Experience of the repair technician or operator;

      1. (iii) Equipment and building system shall be tested, serviced, or inspected at intervals of not more than twelve (12) months unless there is documented evidence that less frequent service is justified;

         1. (iv) Historical records documenting acceptable performance as established by the procedures shall be maintained;
         2. (v) A program to identify and repair equipment failures shall be maintained;
         3. (vi) In large freestanding birthing centers, user or owner departments shall be notified of the status of their equipment or system when it will be out of service for more than twenty-four (24) hours;
         4. (vii) There shall be operator and/or maintenance instructions for each piece of equipment or building system on the list; and
         5. (viii)
10. (a) (a) Individuals shall be trained to operate and maintain physical plant equipment and/or building systems.

11. (b) (b) This training shall be documented.

    1. (4) Life safety management program.

       1. (A) There shall be a preventive maintenance program designed to ensure that all:

          1. (i) Circuits of fire alarm and detection systems are tested on a quarterly basis; and
          2. (ii) Components receive annual preventive maintenance.
       2. (B) Analog detection devices that provide automatic self-testing are exempt from the quarterly testing requirement.

       3. (C) This program shall be administered by:

          1. (i) Individuals qualified through training and/or experience; or
          2. (ii) Procuring a contractual maintenance agreement.

       4. (D) This program shall consist of the following minimum elements:

          1. (i) A list of all fire protection equipment or component groups shall be maintained;
          2. (ii)
12. (a) (a) Each piece of equipment and/or component groups shall have a procedure establishing minimum criteria against which performance and safety are measured.

13. (b) (b) The elements of these procedures shall be based on the:

    1. (1) (1) NFPA 72: National Fire Alarm Code;
    2. (2) (2) Manufacturer's recommendations; and

    3. (3) (3) Experience of the repair technician or operator;

       1. (iii) Fans or dampers in air handling and smoke management systems shall be reliable and functional at all times;

          1. (iv)
14. (a) (a) Automatic fire extinguishing systems shall be inspected and tested annually in accordance with NFPA 13: Standard for the Installation of Sprinkler Systems, and NFPA 96: Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations.

15. (b) (b) Actual discharge of the fire extinguishing system shall not be required.

    1. (c) (c) Records documenting acceptable performance as established by the procedures shall be maintained;

       1. (v) A program to identify and repair equipment and/or component group failures shall be maintained;

          1. (vi) Systems for transmitting fire alarms to the local fire department shall be reliable and functional at all times;
          2. (vii) There shall be operator and maintenance instructions for each piece of equipment and/or component group on the list;
          3. (viii) Individuals shall be trained to operate and maintain all equipment and/or component group on the list; and
          4. (ix)
16. (a) (a) Portable fire extinguishers shall be clearly identified.

17. (b) (b) Refer to subsection (e) of this section, safety services.

    1. (5) Emergency procedures program.

       1. (A) There shall be written emergency procedures or a disaster management plan for utility system disruptions or failures that addresses the specific and concise procedures to follow in the event of a utility system malfunction or failure of the:

          1. (i) Water supply;
          2. (ii) Hot water system;
          3. (iii) Medical gas system;
          4. (iv) Sewer system;
          5. (v) Bulk waste disposal system;
          6. (vi) Natural gas system;
          7. (vii) Commercial power system;
          8. (viii) Communication system; and
          9. (ix) Boiler or steam delivery system.

       2. (B) These procedures shall contain but are not limited to the following information:

          1. (i) A method of obtaining alternative sources of essential utilities;
          2. (ii) A method of shutoff and location of valves for malfunctioning systems;
          3. (iii) A method of notification of facility staff in affected areas; and
          4. (iv) A method of obtaining repair services.

    2. (6) There shall be sufficient supervisory and support personnel to provide maintenance services in relation to the:

       1. (A) Size and complexity of the facility; and
       2. (B) Services that are provided.

    3. (7) In large freestanding birthing centers, a liaison with the QI, Infection Control, and Safety Committees shall be maintained.

       1. (c) Environmental services.

    4. (1) The environmental services shall be under the direction of a person:

       1. (A) Qualified by training and/or experience; and
       2. (B) Licensed where required.
    5. (2) In large freestanding birthing centers, a designee from this department shall be a member of the Infection Control Committee.

    6. (3) Dry or untreated dusting, sweeping, or mopping, except vacuum type cleaning, shall be prohibited within the facility.

       1. (d) Laundry services.

    7. (1)

       1. (A) Laundry may be done onsite or offsite.
       2. (B) If onsite, an area for laundry equipment with counter and storage space shelving shall be provided.
       3. (C) Depending on size and occupancy of center, ordinary household laundry equipment may be provided.
       4. (D) Soiled laundry shall be held in the soiled holding area until deposited in the washer.

    8. (2)

       1. (A) Hot water supplied to laundry areas shall be a minimum of one hundred ten degrees Fahrenheit (110°F).
       2. (B) Chlorine bleach and other laundry chemicals shall be used at effective concentrations that disinfect for the laundry size, cycle time, and water temperature as recommended by the chemical manufacturer or manufacturers.
    9. (3) Clean laundry shall be mechanically dried only.
    10. (4) Separate containers for the disposal of infectious waste and sharps shall be located in the soiled linen area.

18. (e) Safety services.

    1. (1)

       1. (A) There shall be an effective program to enhance safety within the facility and grounds.
       2. (B) In large freestanding birthing centers, the program shall be established and monitored by a safety committee appointed by the administrator.
       3. (C) Safety Committee members shall be selected from administration, nursing, maintenance, housekeeping, the medical staff, and others as appropriate.

    2. (2)

       1. (A) In large freestanding birthing centers, the Safety Committee shall meet a minimum of once every three (3) months to fulfill safety objectives.
       2. (B) Minutes of each meeting shall be recorded and kept in the facility.
    3. (3) The administrator shall designate a specific individual to carry out policies established by the safety program.

    4. (4) The orientation program for the facility personnel shall include the:

       1. (A) Importance of general safety and fire safety; and
       2. (B) Responsibility of each individual to the program.

    5. (5) The Safety Committee of large freestanding birthing centers and designated individuals of small freestanding birthing centers shall have the following functions:

       1. (A) Investigation and evaluation of each accident, injury, or safety hazard report;
       2. (B) Provision for safety-related information to use in orientation and education programs;
       3. (C) Monitoring the results of the safety program and analyzing the effectiveness of the program annually;
       4. (D) Conducting fire drills and disaster drills at required intervals;
       5. (E) Reporting conclusions, recommendations, and actions of the Safety Committee at least quarterly to administration; and

       6. (F) Ensuring each department or service shall have a safety policy and procedure manual within their own area that:

          1. (i) Is a part of the overall facility safety manual; and
          2. (ii) Establishes safety policies and procedures specific to each area.

    6. (6)

       1. (A) Fire extinguishers shall be:

          1. (i) Provided in adequate numbers;
          2. (ii) Of the correct type; and
          3. (iii) Properly located and installed in accordance with NFPA 10: Standard for Portable Fire Extinguishers.

       2. (B)

          1. (i) Personnel shall be trained in the proper use of fire extinguishers and equipment.
          2. (ii) Personnel shall follow procedures in fire containment and evacuating patients in case of fire or explosion.
       3. (C) There shall be an annual check of all fire extinguishers by qualified persons in accordance with NFPA 10: Standard for Portable Fire Extinguishers.

       4. (D) The date the check was made and the initials of the inspector shall be recorded on:

          1. (i) The fire extinguisher; or
          2. (ii) A tag attached to the extinguisher.

    7. (7)

       1. (A) A plan shall be available for the protection of patients, visitors, and employees for evacuation in the event of an emergency.
       2. (B) Any fire or disaster event at the facility shall be reported immediately to the Department of Health by telephone 501-661-2201 during regular working hours or to 1-800-554-5738 or 501-661-2136 after normal working hours, holidays, and weekends.

    8. (8)

       1. (A) There shall be policies and procedures to address usage of tobacco.

       2. (B) "No Smoking" signs or the international symbol for no smoking shall be posted in any:

          1. (i) Room or compartment where flammable liquids, combustible gases, or oxygen is used or stored; and
          2. (ii) Other hazardous locations.
    9. (9) There shall be rules governing the routine methods of handling and storing flammable and explosive agents.

    10. (10)

        1. (A) There shall be keys available to ensure prompt access to all locked areas.

        2. (B)

           1. (i) All doors shall be devised so they can be opened from the inside of the locked area.
           2. (ii) Special door locking devices are acceptable in limited areas.
        3. (C) Usage is subject to all codes and regulations.
    11. (11) All required exit doors shall remain unlocked in accordance with NFPA 101: Life Safety Code.
    12. (12) A list of material safety data sheets for solutions, cleaning compounds, disinfectants, vermin control chemicals, and other potentially hazardous substances used in connection with the facility shall be readily available onsite.

Codification Notes: “NFPA” means National Fire Protection Association.