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DOH Letter.doc Letter of Transmittal June 29, 2017 Construction Review Services 111 Israel Rd. SE Tumwater, WA 98501 PO Box 47852 Olympia, Washington 98504-7852 www.doh.wa.gov/crs tel. 360-236-2944 fax. 360-236-2321 Project Info: CRS# 60332787 Project 21601 76th Ave W Swedish Edmondslocation: Edmonds, WA 98026 Chapter 246-320 WAC Hospitals New Ambulatory Care Center Local Permit #: Key People: Assigned DOH Kevin A. Scarlett, RA, ASHRAE HFDP Reviewer: kevin.scarlett@doh.wa.gov Facility Swedish Edmonds Facility Contact: Providence Health & Services Administrator: Sarah Zabel Jim Grafton th 21601 76 Ave W 600 Broadway Suite 304 Edmonds, WA 98026 Seattle, WA 98122 (425) 640-4005 x. 206-215-3531 x. sarah.zabel@swedish.org James.Grafton@providence.org Architect / NBBJ Local AHJ: City of Edmonds Engineer: Chuck Kolb Leif Bjorback 223 Yale Avenue North 121 5th Avenue N. Seattle, WA 98109 Edmonds, WA 98020 (206) 223-5009 x. (425) 771-0220 x. ckolb@nbbj.com bjorback@ci.edmonds.wa.us Consultant: KPFF (Civil) Consultant: Sparling (Electrical) Scott Meurn Maureen Jackson thth 1601 5 Ave Ste 1600 4100 194 St SW Seattle, WA 98101 Lynnwood, WA 98036 (206) 622-5822 x. (206) 667-0553 x. scott.meurn@kpff.com mjackson@sparling.com Contact: KPFF (Structural) Contact: CDi Engineers ( Mechanical & Plumbing) Tom Hudgings Finn Jakobsen th 1601 5th Ave Ste 1600 19203 36 Ave W Ste 200 Seattle, WA 98101 Lynnwood, WA 98036 (206) 622-5822 x. (425) 672-1071 x. tom.hudgings@kpff.com fjakobsen@cdiengineers.com Copies To: of Edmonds DOH Child Birth Center Licensing Local AHJ: City DOH Office of Accommodations & Res. Care Survey Architect / Engineer: NBBJ DOH Office of Investigations & Inspections (Civil) Consultant: KPFF DSHS, , Div. Of Alcohol & Substance Abuse (Electrical) Consultant: Sparling DSHS, , Aging & Adult Services Admin. (Structural) Contact: KPFF L&I, Bill Eckroth, Electrical Section Engineers ( Mechanical & Plumbing) Contact: CDi L&I, John Harvey, Factory Assembled Structures CRS File Page 1 of 17 Plan Review Comments for Project #60332787 Facility Data Certificate: Facility Name: Swedish Edmonds Licensee UBI#: 602997735 Site Address: 21601 76th Ave W Critical Access Facility: Yes No Edmonds, WA 98026 Estimated Date of Occupancy: Sept 2015 Occupancy I-2 Construction 1-A Applicable Code: 2000 NFPA 101 Group: Type: 2009 IBC 2010 FGI Guidelines ALL FACILITY TYPES Number of Current: N/A Added: N/A Removed: N/A Total: N/A Beds: Automatic Fire Sprinkler System: Yes No Type 13 Automatic Fire Alarm System: Yes No Compartmentation req’d: Yes No Smoke Control System Provided: Yes No Special Delayed Egress Control: Yes No Location: Certificate of Need Required: Yes No CON Approval Granted: Yes No CON Number : Number of units: Private occupancy: Two person occupancy: RESIDENTIAL CARE FACILITIES ONLY Based on size of rooms used for sleeping Residents Based on size of common rooms Residents Maximum allowable licensable beds: Qualifies for Assisted Living Funding Program Yes No Number of qualifying units: 2-story addition to existing hospital to house Emergency Department, Urgent Care, and Imaging Department. At this time, Urgent Care area will NOT be under the hospital license. Existing Emergency Department will be renovated in Phase II to house Observation area. NOTES nd 2 floor will be a shelled space with a skybridge to the existing building. The building will have the potential to add rd a 3 story in the future. Clynn Wilkinson performed initial review. -kas The data above is based on the information presented to CRS. Any change in the facility or facility program that causes the above information to be incorrect is subject to review by CRS. Approval for construction is not approval for licensure. A copy of the facility data certificate will be sent to the licensing agency. Page 2 of 17 Plan Review Comments for Project #60332787 : Project Status - Authorized to Begin Construction – - Comments Not Approved – As of 11/5/15 Phase II (in its entirety) is approved for use. -kas not approved This project is for use or licensure. The construction documents have been reviewed and construction This project will not be approved until can begin, subject to construction permitting from the local building official. the comments labeled as “not approved” have been resolved by providing a written response to each of the comments. When referencing drawings or attached materials, provide sheet or page #, revision # and date as applicable. Additional comments may follow based on design team response and site inspections may be required to verify compliance. Please note the following: The stamped “Authorization to Begin Construction” drawings will be delivered to the Facility Administrator.  These shall be kept available on site for inspection during construction and post occupancy survey. Any changes/deviations (incl. change orders or addenda) from the approved documents must be submitted to  the Department for review and approval. Beginning construction prior to resolving the attached comments will constitute facility acknowledgement that  you are proceeding at your own risk. Please include your CRS number on all communications to Construction Review Services.  PROJECT CLOSE-OUT REQUIREMENTS You must notify the department when construction is complete by completing the following steps: Verify that you have resolved all of the comments on this form and have submitted any revisions  Complete the Notification of Construction Completed at:  http://www.doh.wa.gov/NotificationofCompletion.aspx Email a copy of the approval from the local building department (final permit approval or  crs-closeout@doh.wa.gov certificate of occupancy) to: crs-closeout@doh.wa.gov Email a floor plan showing the scope of work to:  Once your construction project is complete, you may contact the DOH Office of Customer Service (360) 236-4700 for help with adjusting or amending your license to add this project. You can monitor project status www.doh.wa.gov/crs by visiting our website at or simply by pressing Ctrl+Click on the following link...... https://fortress.wa.gov/doh/constructionreviewsearch/ Page 3 of 17 Plan Review Comments for Project #60332787 – Department of Health – Department of Health Preliminary Comments ent ID # Comm Preliminary Conference – 1/27/14 Attendees: Mina Zarelli - Department of Health (mina.zarelli@doh.wa.gov) John Williams - Department of Health (john.williams@doh.wa.gov) Sarah Zabel - Swedish Edmonds Nancy Wood - Swedish Edmonds Mark Nunes - Swedish Edmonds Lyle Hansen - Swedish Edmonds Tyler Howren - Swedish Edmonds Bryan Hall - Swedish Edmonds Bobbi Ragland - Swedish Edmonds Heather Nye - Swedish Edmonds Chuck Kolb - NBBJ Janet Dugan - NBBJ Maureen Jackson - Sparling Comments made during this preliminary conference, both oral and written, represent guidance provided by the Department of Health, Construction Review Services, for your facility to meet the licensing requirements of Chapter 246-320 Washington State Administrative Code. These preliminary comments should not be considered as an exemption or alternate from the requirements of any federal, state or local authority who may have jurisdiction. In the event of conflicts between other jurisdictions and these comments, please contact this office immediately. Items Received: Functional program & floor plans (design development stage) T1 If this project will be completed in multiple phases, provide a phasing plan, and phased ICRA and ILSM. T2 Clarify the construction type of the existing building and the new addition. T3 Clarify in the functional program if the Urgent Care department will be under the hospital license. Regardless, the Urgent Care department will be reviewed for its life safety impacts on the hospital. T4 The East ED suite (gridlines E&C) is required to have not less than two exit access doors remotely located from each other per NFPA 101: 18.2.5.3. Provide at least one door from the suite that leads directly to a corridor. CRS will allow the second exit access door to travel through the adjacent suite to a corridor, if remotely located. Page 4 of 17 Plan Review Comments for Project #60332787 ent ID # Comm T5 Identify the location of the fire wall between the existing building and new addition. Clarify if the addition is a separate building. Provide details to show how the wall meets all requirements of IBC 706. Fire walls shall be designed to restrict the spread of fire and extend continuously from the foundation to or through the roof with sufficient structural stability under fire conditions to allow collapse of construction on either side without collapse of the wall. T6 Blanket warmers are ok if located in the suite and installed per the manufacturer’s instructions. T7 A fireplace may be installed in the elevator lobby area open to the corridor system. Provide fireplace details and cut sheets to determine if this makes the lobby a “hazardous area” not allowed by NFPA 101:18.3.6.1 T8 Gift shops may be open to the corridor if they are less than 500 sf. NFPA 101:18.3.2.5 T9 If seating is provided on the second floor (near the sky bridge), provide separate floor finish or other to keep the minimum required corridor width clear and unobstructed. T10 Identify the “anesthetizing locations” throughout the emergency department. NFPA 99 T11 Identify the location and quantity of med gas cylinders that will be stored throughout the project area (including Urgent Care). T12 Provide information in the functional program to clarify what level of patient care will be provided at chairs (1-7) located in the “Internal Lobby”. These may be reviewed similar to Phase 2 cubicles (50 sf) if no patient treatment will occur per FGI 2.2-3.3.3.4. If patient care is provided, the chair spaces may be reviewed as a multiple bed treatment room (80 sf) per FGI 2.2-3.1.3.6(3) Depending on functional program, additional hand washing stations may be required. T13 Provide information in the functional program to clarify what is meant by “swing rooms”. Are these secure hold rooms? FGI 2.2-3.1.4.4 T14 Doors from secure hold rooms should swing out or be provided with rescue hardware. FGI 2.2-3.1.4.4(3)(d) T15 Doors to patient toilets should swing out or be provided with rescue hardware. Page 5 of 17 Plan Review Comments for Project #60332787 ent ID # Comm T16 Identify the location for storage of special pediatric and OBGYN equipment. T17 Emergency department facilities should consider designated rooms for treating sexual trauma patients. Rooms used for pelvic exams shall allow for the foot of the exam table to face away from the door. FGI 2.2-3.1.3.6(1)(b) T18 Provide information in the functional program to address the bariatric needs at this location. What are the weight limits for patient lifts, equipment, plumbing fixtures and staff handling? T19 Clarify what areas of the new addition will be used for Emergency Department waiting and triage. These areas are required to have 12 total ach and be fully exhausted per FGI Table 7- Provide a floor plan showing the seating areas that is coordinated with the HVAC plan and the functional program. The proposed plan shows ED waiting areas that are open to other circulation spaces (Main Lobby 101 and Urgent Care Waiting 102). It will be important to show how the air in these areas are “separated” with the HVAC system design if not all treated as ED waiting areas. How do you ensure that you are getting the air changes? T20 Consider “back doors” from the AII rooms so that patients can be brought directly to these rooms without entering the corridor. (Recommendation only). T21 Consult with the Snohomish County Health Department for review of the Bistro. This will depend on who operates the bistro. T22 Clarify in the functional program if the patients located in the Observation Unit will stay greater than 24 hours. The proposed unit does not meet Med-surge standards and will require revision for patient stays greater than 24 hours. Page 6 of 17 Plan Review Comments for Project #60332787 Swedish Edmonds Chapter 246-320 WAC Hospitals New Ambulatory Care Center Plan Review Comments: ID # Not Approved Approved Comment Initial review 06/26/2014. Family of Codes Used for this review  2000 Life Safety Code – NFPA 101  1999 Standard for the Installation of Sprinkler Systems – NFPA 13  1999 National Fire Alarm Code Handbook – NFPA 72  1999 Standard for Installation of Air-conditioning and Ventilation Systems NFPA – 90A  1999 Standard for Emergency and Standby Power Systems NFPA - 110  Hospital Washington State Administrative Code - WAC 246-320  2012 International Building Code (IBC)  2012 Washington State amendments (WAC 51-50)  2012 International Mechanical Code (IMC)  2012 International fuel & Gas Code (IFGC)  2012 Uniform Plumbing Code (UPC)  2008 National Electric code (NEC) NFPA 70  2010 Guidelines for Design and Construction of Health Care Facilities (FGI) WAC 246-320-500 Building Code Issues 1  Two complete plans and specifications for the fire alarm system installation or prior modification shall be submitted for review and approval to system installation. The department reserves the right to defer plan review and inspections to the local authority having jurisdiction (AHJ). Plans and specifications shall include, but not be limited to, a floor plan; location of all alarm-initiating and alarm-signaling devices; alarm-control and trouble-signaling equipment; annunciation; power connection; battery calculations; conductor type and sizes; voltage drop calculations; name, address, and phone number of the agency receiving off-premises transmission of alarm; and the manufacturer, model numbers, and listing information for all equipment, devices, and Incomplete plans and specifications will be returned without review materials. . Plans and specifications may be submitted separately from construction documents during the construction of the project. Section 907.1, International Fire Code Response received - 10/16/2014 – Fire alarm plans and specs will be submitted as a deferred submittal. Deferred – 10/31/2014 – Page 7 of 17 Plan Review Comments for Project # 60332787 Swedish Edmonds Chapter 246-320 WAC Hospitals New Ambulatory Care Center Deemed 10/14/15 – based on documents received 9-24-15, indication of Local AHJ Review and Approval satisfies this requirement. Refer also to added comment # 31 below. –kas 2  Two sets of sprinkler system working plans shall be submitted for review and approval before any equipment is installed or remodeled. The department reserves the right to defer plan review and inspections to the local authority having jurisdiction (AHJ). Deviation from approved plans will require permission. Plans and specifications, including hydraulic calculations, that are incomplete or are not stamped by a Washington State Licensed Fire Sprinkler Contractor, will be returned without review. Plans and specifications may be submitted separately from construction documents during the construction of the project. Section 903.1, International Fire Code Response received - 10/16/2014 – Sprinkler system plans and specs will be submitted as a deferred submittal. Deferred – 10/31/2014 – Deemed 10/14/15 – based on documents received 9-24-15, indication of Local AHJ Review and Approval satisfies this requirement. –kas 3  Provide a damper for the 10 inch diameter duct near grid B, near room 102.012, as it crosses the Smoke Barrier on sheet M4.01.B. Otherwise, provide the rationale why a damper would not be needed. IBC 709.8 and 717 Response received - 10/16/2014 – Revised - refer 10 attached sheet M4. 01 B . Approved – 10/31/2014 – As per the response, above, and the provided documents the requirement has been met. 4  Provide a damper for the 10 inch diameter duct near grid B, near room 102.012, as it crosses the Smoke Barrier on sheet M4.01.B. Otherwise, provide the rationale why a damper would not be needed. IBC 709.8 and 717 Response received - 10/16/2014 – Revised - refer 10 attached sheet M4. 01 B . Approved – 10/31/2014 – As per the response, above, and the provided documents the requirement has been met. Page 8 of 17 Plan Review Comments for Project # 60332787 Swedish Edmonds Chapter 246-320 WAC Hospitals New Ambulatory Care Center 5  Provide dampers for the large duct as it crosses the Smoke Barrier on sheet M4.01.5C near grids E and H. Otherwise, provide the rationale why a damper would not be needed. IBC 709.8 and 717 Response received - 10/16/2014 – Revised - refer to attached sheet M4.01.5C. Approved – 10/31/2014 – As per the response, above, and the provided documents the requirement has been met. 6  Explain the conflict between the large 38” x 20” duct that is shown on top of the Smoke Barrier. The duct is shown on sheet M4.01C between grid E and F and near 3. Relate how the continuity requirements for the Smoke Barrier are preserved. IBC 709.4 Response received - 10/16/2014 – Revised - refer to attached sheet M4.01.5C. Approved – 10/31/2014 – As per the response, above, and the provided documents the requirement has been met. 7  Provide dampers for the 22” x 10” duct as it crosses the Smoke Barrier above the door between grids E & F and 1 & 2 near rooms 103.49 and 013.48 on sheet M4.01C near grids E and H. Otherwise, provide the rationale why a damper would not be needed. IBC 709.8 and 717 Response received - 10/16/2014 – Revised - refer to attached sheet M4. 01 C . Approved – 10/31/2014 – As per the response, above, and the provided documents the requirement has been met. 8  Provide dampers duct at patient toilet room 103.039 as it crosses the Smoke Barrier on sheet M4.01D. Otherwise, provide the rationale why a damper would not be needed. IBC 709.8 and 717 Response received - 10/16/2014 – Revised-refer to attached sheet M4.01D . Approved – 10/31/2014 – As per the response, above, and the provided documents the requirement has been met. Page 9 of 17 Plan Review Comments for Project # 60332787 Swedish Edmonds Chapter 246-320 WAC Hospitals New Ambulatory Care Center 9  Explain the conflict between the 16” diameter duct that is shown on top of the Smoke Barrier. The duct is shown on sheet M4.01D near grid H near the public toilet room number 103.064. Relate how the continuity requirements for the Smoke Barrier are preserved. IBC 709.4 Response received - 10/16/2014 – Revised-refer to attached sheet M4.01D . Approved – 10/31/2014 – As per the response, above, and the provided documents the requirement has been met. 10  Provide dampers duct at public toilet room 103.064 as it crosses the Smoke Barrier on sheet M4.01D. Otherwise, provide the rationale why a damper would not be needed. IBC 709.8 and 717 Response received - 10/16/2014 – Revised-refer to attached sheet M4.01D . Approved – 10/31/2014 – As per the response, above, and the provided documents the requirement has been met. 11  Provide a damper for 22” x 10” duct at office 101.004 as it crosses the Smoke Barrier on sheet M4.01D. Otherwise, provide the rationale why a damper would not be needed. IBC 709.8 and 717 Response received - 10/16/2014 – Revised-refer to attached sheet M4.01D . Approved – 10/31/2014 – As per the response, above, and the provided documents the requirement has been met. 12  Indicate that the Fire Alarm strobes are less than 55 feet apart are synchronized. NFPA 72 4-4.4.2.3 Response received - 10/16/2014 – Fire Alarm plans and specs will be submitted as a deferred submittal . Deferred – 10/31/2014 – Page 10 of 17 Plan Review Comments for Project # 60332787 Swedish Edmonds Chapter 246-320 WAC Hospitals New Ambulatory Care Center Not Approved – this comment to be field verified by CRS reviewer and GC along with clear documentation provided at the inspection. –kas Approved 11/24/15 – based on site inspection performed by DOH/Kevin A. Scarlett on 11-5-15 in conjunction with on site verification/inspection by City Fire Inspector Kevin Zweber. –kas 13  Provide CO detectors. IBC 908.7 Response received - 10/16/2014 – Refer to sheet M1O.O1B. CO detector has been located in the Lobby above the fire place, which has been reviewed by the City of Edmonds Fire Marshal for IBC compliance . Approved – 10/31/2014 – As per the response, above, and the provided documents the requirement has been met. FGI Issues 14  Clarify if the curtains on the windows are “smooth and easy to clean” of the ISO rooms. FGI 2.1-2.4.2.4 (2)(a) Response received - 10/16/2014 – Yes, all window shades are specified to be easy to wipe down and clean. MechoShade has been used as a basis of design. At the ISO rooms, there will be a dual-shade system provided. One will be a PVC-free black-out shade made with polyester yarn with opaque acrylic backing that is easily cleaned with a damp cloth. The other shade will be PVC-free 100% thermoplastic olefin at a (max. 5% openness) also easy to clean and contains anti-fungal properties . Approved – 10/31/2014 – As per the response, above, and the provided documents the requirement has been met. 15  Clarify if the privacy curtains in the ISO rooms are “washable” or preferably “wipe able.” FGI 2.1-2.4.2.4 (2)(c) Response received - 10/16/2014 – Yes, the privacy curtains in the ISO rooms are washable. Knoll Textiles cubicle curtains have been specified. The cleaning code for the specified curtain is W-S (water/solvent compatible ). Page 11 of 17 Plan Review Comments for Project # 60332787 Swedish Edmonds Chapter 246-320 WAC Hospitals New Ambulatory Care Center Approved – 10/31/2014 – As per the response, above, and the provided documents the requirement has been met. 16  Clarify which room will be used for pediatric care. FGI 2.2-3.1.6 (4) Response received - 10/16/2014 – Per the functional program, pediatric care can be delivered in any exam room. Special provisions include a pediatric crash cart parked in Exam (Trauma) Room #17 and a portable infant scale parked in an alcove at Hallway 0103.033A . Approved – 10/31/2014 – As per the response, above, and the provided documents the requirement has been met. 17  Designate which rooms will be used for the treatment of Bariatric patents. Ensure that the all components in the room meet the load requirements. Make certain, that room has all the proper clearances. FGI 2.2-3.1.3.6 (5) Response received - 10/16/2014 – (Please note that FGI reference should read FGI 2.2-3.1.3.6 (5).) Exam Room #18 meets the criteria for bariatric patients, with the exception of a wall-mounted hand- wash sink in lieu of floor-mounted. The Functional criteria for this sink includes exposed foot pedals than are standardized throughout the department. The Owner requests DOH consider the use of alcohol-based hand gel and/or sani-wipes for bariatric patient hand-washing when the need arises . Not Approved – 11/03/2014 – Provide a sink that has the ability to support the 100lb load. Approved 10/14/15 – based on documents received 9-8-15, the Architect indicates that this lav was revised in ASI-08 (November 2014) to a type BN piece of cabinetry: solid surface countertop with integral bowl supported by wall brackets (sketches are attached). See also, the previous response to comment # 18 for bracket capacity information. –kas 18  Designate which toilet rooms will met the requirements for Bariatric patients. Provide details, notes, and/or specifications that demonstrate that load requirements are ,et FGI 2.2-3.1.6 (5) Response received - 10/16/2014 – Per discussion with CRS Reviewer Clynn Wilkinson, Toilet Rooms 0103.039 and 0103.046 have been adjusted as follows: Page 12 of 17 Plan Review Comments for Project # 60332787 Swedish Edmonds Chapter 246-320 WAC Hospitals New Ambulatory Care Center Wall hung lavatories to meet at least 300lbs leaning weight. Refer to detail 1 'BN - Solid Surface Countertop with Integral Sink' on sheet A9.41 and the attached Rakks product information sheet. Water closets relocated to allow 24 "from centerline to wall. Approved – 10/31/2014 – As per the response, above, and the provided documents the requirement has been met. The bracket has a capacity of 450#. When two brackets are used the counter/sink could support a 900# force placed in the center. This, the 900# would be the design capacity and not the failure capacity; therefore it meets the 1000# requirement of the FGI. Misc Issues 19  Notify the department when construction begins. WAC 246-320-505 (2)(d) Response received - 10/16/2014 – Construction is scheduled to commence on October 20, 2014. Approved – 10/31/2014 – As per the response, above, the requirement has been met. 20  Provide a detailed phasing plan. Explain how work will be completed in the existing building. Provide a written narrative, plans show the temporary construction barriers, information how the fire alarm and fire sprinkler system will be addressed, and so forth. WAC Response received - 10/16/2014 – See attached phasing plans and PICRA prepared by Contractor and Owner. . Approved – 10/31/2014 – As per the response, above, and the provided documents the requirement has been met. 21  Notify the CRS plan reviewer for the following on site inspections: 1) Prior to the placement of the gypsum wall board. 2) Prior to placement of all the ceiling tiles so that fire and smoke barriers maybe seen for continuity. 3) Prior to final inspection by the local building official. WAC-246-320-505 (2)(i) and IBC 110 Provide a 1 week lead time to coordinate schedules. Page 13 of 17 Plan Review Comments for Project # 60332787 Swedish Edmonds Chapter 246-320 WAC Hospitals New Ambulatory Care Center Response received - 10/16/2014 – Confirmed. The above list has been shared with the Contractor for appropriate scheduling . Deferred – 10/31/2014 – Note: this comment will not be “Approved” until inspections have been completed or an agreed resolution to a meeting has been met. Deferred – 11/24/15 – Note: this comment will not be “Approved” until inspections have been completed for Phase III (final phase) of the project. Background; Phase I-Parking Garage; Phase II- Main ACC; Phase III Imaging and Observation. -kas 22  Provide documentation that verifies that the generator will meet the increase load. IBC 107.3 Response received - 10/16/2014 – Yes, there is capacity in the existing generators to serve the addition. See the attached generator load analyses Sheets E1 0. 07 and E1 0.08. Most of the new addition loads will hit the two generators in the CUP (analysis on E10.08). The added loads in Observation and other existing building areas will hit Generator #3 (analysis on E10.07). Approved – 10/31/2014 – As per the response, above, and the provided documents the requirement has been met. The following comments result from an initial site visit by CRS Reviewer Kevin A. Scarlett on 6/9/15 23  Decontamination Area 0103.052: The floor drain flows directly into the sewer system and is not captured or detained. CRS Reviewer Kevin A. Scarlett will coordinate with the City about the connection and if there are any special needs for the hospital and City to communicate regarding hazardous materials being released into the sanitary sewer system. The expectation is that there will be a requirement for written procedures that the hospital will follow to notify the City when decontamination procedures are necessary. -kas Deferred – 10/14/15 – Note: this comment will not be “Approved” until inspections have been completed; however, based on documents received 9-8-15, the Facility has coordinated with the City and will provide signage directing users to appropriate steps to be taken upon use/release. -kas Approved 11/24/15 – based on site inspection performed by DOH/Kevin A. Scarlett on 11-5-15. –kas Page 14 of 17 Plan Review Comments for Project # 60332787 Swedish Edmonds Chapter 246-320 WAC Hospitals New Ambulatory Care Center 24  Lobby 0101.002E: The fireplace will obtain combustion air from a vent below the raised hearth and will vent through the Level 2 roof north of the skylight. A power vent cap is provided at the flue. CRS Reviewer Kevin A. Scarlett will revisit this issue at the next site visit. The intent will be to review proposed location/s & proposed spacing for Carbon monoxide detectors. Using combination smoke-CO detectors is anticipated. Lee Brei may have a plan. If so, this should be brought to the next site meeting. Also, Lee has concerns about whether smoke detectors are required in each skylight bay between the furred-down beams. This issue can be resolved at the next site visit. -kas Not Approved 10/14/15 – this item must be coordinated with City Fire Marshal and field inspected by CRS reviewer. –kas Approved 11/24/15 – based on site inspection performed by DOH/Kevin A. Scarlett on 11-5-15. –kas 25  Spray-applied Fire-proofing: CRS Reviewer Kevin A. Scarlett indicated that the patching must follow regulated application procedures. Mark Bucek, the Sellen superintendent, noted that the application of both the initial spray and the patching are being observed and tested by Mayes Testing. He will have that information available for final and process inspections. -kas Not Approved 10/14/15 – this item must be coordinated with the GC at the next inspection site visit. -kas Approved 11/24/15 – based on site inspection performed by DOH/Kevin A. Scarlett on 11-5-15. –kas 26  Floor Level 1 Normal Power Electrical Room 0198.000 Exiting and doors: only one exit is required from this room. It must be the active leaf of the door pair on the north wall. The east wall (single leaf) door violates required clearances to the switchgear. Panic hardware is required at the exit door (active leaf only). An exit light must be installed above the active leaf door (not centered). Only one ‘bug eye’ emergency light pack is required. Architect will confirm owners direction for all issues and submit ASI for DOH CRS Review and Approval. -kas Deferred – 10/14/15 – Note: this comment will not be “Approved” until inspections have been completed, however, based on documents received 9-8-15, the revised exit light plans submitted satisfy the exit light requirement. –kas Approved 11/24/15 – based on site inspection performed by DOH/Kevin A. Scarlett on 11-5-15. –kas Page 15 of 17 Plan Review Comments for Project # 60332787 Swedish Edmonds Chapter 246-320 WAC Hospitals New Ambulatory Care Center 27  Floor Level 2 Emergency Power Electrical Room 0298.000 Exiting and doors: both doors are required for exiting from this room. Both require panic hardware and exit lights above. The exit light at the door pair must be located over the active leaf door (not centered). Only one ‘bug eye’ emergency light pack is required. Architect will confirm owners direction for all issues and submit ASI for DOH CRS Review and Approval. - kas Deferred – 10/14/15 – Note: this comment will not be “Approved” until inspections have been completed, however, based on documents received 9-8-15, the revised exit light plans submitted satisfy the exit light requirement. –kas Approved 11/24/15 – based on site inspection performed by DOH/Kevin A. Scarlett on 11-5-15. –kas 28  Leif Bjorback (City of Edmonds Building Official) has accepted the CSA International testing and listing of the fireplace in lieu of a UL rating. DOH CRS (kas) accepts/approves as of 6/25/15. -kas The following two comments resulted from the DOH site inspection on 7/30/15. -kas 29  Based on the KAS Site Inspection on 7/30/15 and the confirming (24ga min duct thickness) email FW’d by Rex on 7-30-15, all Smoke Dampers are approved as installed. –kas 30  Note the following damper issues yet to be resolved: a) (2) fire dampers in shell space on east side L1; why they were added and verify they will be omitted. rdnd b) (2) added 90 min FSD’s from 3 to 2 floor; photos of completed installation with install instructions. -kas Approved 10/14/15 – based on site inspection by kas on 9-22-15, CRS reviewer verified appropriate installation of items referenced in ‘b’ in this comment. Also, dampers referenced in ‘a’ above were no longer present as-of this site inspection. These dampers were not required and were appropriately removed. -kas The following two comments resulted from the DOH site inspection on 9/22/15. -kas 31  Additional Smoke Detection and FA notification devices may be required in the Lobby area. Verify/confirm with the City (local AHJ). 2012 IFC 907.1 Approved 11/24/15 – based on site inspection performed by DOH/Kevin A. Scarlett Page 16 of 17 Plan Review Comments for Project # 60332787 Swedish Edmonds Chapter 246-320 WAC Hospitals New Ambulatory Care Center on 11-5-15 in conjunction with on site verification/inspection (along with a two day follow-up inspection) by City Fire Inspector Kevin Zweber. –kas 32  Verify the following items within the Behavioral Health Area; a) Anti ligature hardware on exam room doors. b) Access panels have standard screwdriver operation latches; tamper resistant. c) hardware on the public side of the Exam room nurse server doors. d) Remove the plumbing box for the washer in Soiled Utility 0103.062. e) Pressure differential monitors in Isolation Exam Rooms, 0103.15 and 0103.16. f) Ice Machines, 1” air gap at filler trays and indirect waste. These items must be field verified/inspected for approval. –kas Approved 11/24/15 – based on site inspection performed by DOH/Kevin A. Scarlett on 11-5-15. –kas The following comments address the revision/submittal of the portion of Phase 3 of the ACC project relating to modification of the exit passageway portion of the project. -kas 33  This ‘exit passageway’ portion of the project has been reviewed and appears to be in compliance with all applicable codes and regulations with no additional comments. -kas The following comments address the submittal of the the cooling towers which were received on 5-23-16. -kas 34  Provide an RPBA on the domestic water feed for these two cooling towers. Provide Make & Model number (and product data cut sheets) for the RPBA device. Should an existing RPBA be present and intended for re-use, the Owner/Engineer can verify and reply to this comment with the existing Make & Model number and the statement of intent to re-use. 35  Other than comment #34 above, this cooling tower portion of the project has been reviewed and appears to be in compliance with all applicable codes and regulations with no additional comments. -kas Compliance with the comments above provided by the Department of Health Construction Review Services are necessary for this facility to meet the requirements of the applicable licensing regulations found in the Washington State Administrative Code and associated references. These comments do not relieve the facility from the responsibility to meet the requirements of any other applicable federal, state or local regulations. In the event of conflicts between other jurisdictions and these written comments, the most stringent shall apply. Page 17 of 17 Plan Review Comments for Project # 60332787