doh 8.17 commentsProject Comment Form
August 17, 2022
Project Information:
CRS# 61189204
76th Professional Commons
Chapter 246-330 WAC Ambulatory Surgery Facility
Project Title: New ASC
Project 21911 76th Ave W
Location: Edmonds, WA 98026
Local Permit #:
Washington State Department of
1 * Hea l th
Construction Review Services
PO Box 47852
111 Israel Rd. SE.
Tumwater, WA. 98501
www.doh.wa. og v/crs
tel. 360-236-2944
fax.360-236-2321
Electronic Submittal. Plans will be delivered to:
Name: Kent Gregory
Email: kgregory@tgbarchitects.com
Phone #: 425-599-4469
Key Contacts:
Company
Name
Phone
Email
DOH Reviewer
Matthew Canpbell
Facility Contact:
TGB Architects
Kent Gregory
425-599-4469
kgregory@tgbarchitects.com
Facility Admin.:
Transform Weight Loss
Josiah Billing
425-305-5182
jbilling@transformweightloss.com
Arch./Eng.:
TGB Architects
Kent Gregory
425-599-4469
kgregory@tgbarchitccts.com
Other:
DOH
Noam Platt
318 272 7963
noam.platt@doh.wa.gov
Other:
DOH
Ann Cho -Hunt
360 819 7594
ann.cho-hunt@doh.wa.gov
Other:
Other:
Local AHJ:
City of Edmonds
Leif Bjorback
425-771-0220
lci£bjorback@edmondswa.gov
Addt'l Copies To:
® L&I Electrical Section
❑ L&I Factory Assembled Structures ❑ Local
Electrical AHJ
Project Status:
-Authorized to Begin Construction -
Comments are NOT APPROVED
The Construction Documents have been reviewed and found acceptable. All plan review comments have not been
approved. Construction can begin, subject to construction permitting from the local building official. See page two
for important next steps.
A2BC
Preliminary
Initial
Issued
All
Licensing
Approved
Conference
Plan Review
Construction
Comments Closeout
Inspection
to Use
Completed
Completed
Begins
Approved Completed
Required
Space
Yes
Yes
Yes
No No
Yes
No ;
r
Page 1 of 16 Plan Review Comments for Project 61189204
76th Professional Commons
Chapter 246-330 WAC Ambulatory Surgery Facility
To avoid delays it is important you follow these Next Steps:
Respond to Comments:
• Revise project documents to be compliant with applicable rules and the review comments attached to
this form.
• Respond, in writing, to the comments attached to this form.
• Submit revised plans and responses to comments to the Construction Review Services.
During Construction
• Maintain a copy of the A2BC drawing set on the project site.
• Submit any changes to the A2BC set to CRS for review and approval prior to executing the work.
If you have any questions, please contact Construction Review Services (360) 236-2944. You can monitor project
status and history at www.doh.wa.gov/crs.
Page 2 of 16 Plan Review Comments for Project 61189204
76th Professional Commons
Chapter 246-330 WAC Ambulatory Surgery Facility
Project Details (for internal use only)
Occupancy Type
Construction Type
Fed Code:
IBC: B IBC: IBC:
IBC: 2-13 IBC: IBC:
Building Code: 2018 IBC
NFPA 101:
NFPA 101: NFPA 101:
Licensing Code: FGI 2006
Number of Beds Added: n/a Removed: n/a
CON Required? ❑ Yes ® No CON Approved ❑ Yes ❑ No
Req'd
Provided
Type/category
Are Hospital inpatients seen at this
location? ❑ Yes ® No
Automatic Fire Sprinkler System:
No
Yes
13
Are planned residents/patients incapable
of self preservation? ® Yes ❑ No
Automatic Fire Alarm System:
Yes
Yes
If yes, how many? <4
Emergency Power System:
Yes
Yes
Type 1 EES
Is sedation provided? ® Yes ❑ No
If yes, max. planned level?
Medical Gas System:
Yes
Yes
Category 1
General Anesthesia
Smoke Compartmentation:
No
No
Is space Medicare certified?
❑ Yes ® No
Building Department contacted? No
Estimated construction completion:
New ASF not seeking reivew for CMS certification (licensed and certified ambulatory surgery facility (2007-2017)
W
license permitted to lapse) Services provided: Upper Endoscopies as part of the pre -surgical screening as well as post-
F"
O
surgical if indicated, Laparoscopic Gastric Sleeve procedures and hiatal hernia repair.
Certificate of Need not required: DOR #22-10
WElectrical
distribution reviewed under L&I EPR# 2-55847. Required alterations include: adding load bank and temp
portable gen set connections, creating an equipmetn branch of the EES, recircuiting of 8 receptacles in the OR to
provide a minimum of 12 receptacles served by the normal power branch of the EES, recircuiting of lights in the OR to
the critical branch of the EES, conducting a coordination study, .
For Assisted Living Facilities Only
Total Sleeping rooms
Minimum required area of day rooms/areas
Total Approved beds
A
Total area provided in day rooms/areas
Total Contract beds
W
C4
O
O
F
w
F
O
Page 3 of 16 Plan Review Comments for Project 61189204
76th Professional Commons
Chapter 246-330 WAC Ambulatory Surgery Facility
Preliminary Comments:
Q
0
U
Preliminary Conference-7/2/21
Steve Lickar
Josiah Billing
Kent Gregory
Matthew Campbell
Transform Weight loss
- Transform Weight loss
- TGBA
- Department of Health
T1 Contact General John Hilger, john.hilgergdoh.wa.gov or (360-236-2929).
• With general questions regarding ambulatory surgeries licensed under Chapter 246-330 WAC,
and,
• Specifically, regarding the process for re -licensing / restoring the license for this facility.
T2 There are four supporting programs within the Department of Health which support state licensed
ambulatory surgery facilities. These are:
• Certificate of Need
o Contact FSLCONkdoh.wa.gov (360) 236-2955
• Facility Licensing
o Contact Crissa Hanson Crissa.HansonkDOH.WA.GOV at (360) 236-4985
• Construction Review
o Application information: CRS(kdoh.wa.gov and (360) 236-2944
o Plan review: Matthew Campbell matthew.campbellkdoh.wa.gov at (360) 236-2954
• Facility Licensing Survey
o Contact Rosie Tillotson: rosie.tillotson(kdoh.wa.gov and (360) 236-4681
T3 Basis of review: building construction, life safety, and means of egress.
• Alterations must meet the applicable provisions of the International Existing Building Code
(IEBC) and referenced codes and standards as adopted and amended by the state building code
council and the City of Edmonds.
o State amendments to the IBC and IEBC Chapter 51-50 WAC:
o Scope of work to be determined
T4 Basis of review: building systems supporting surgical services:
Page 4 of 16 Plan Review Comments for Project 61189204
76th Professional Commons
Chapter 246-330 WAC Ambulatory Surgery Facility
The existing medical gas and vacuum, electrical, and mechanical HVAC systems are vested in the
original review and approval for the stated services and methods (types of surgieries and types and
levels of anesthetization). These systems must be reviewed to the current design and construction
requirements appropriate to any the planned services, procedures, delivery of care and/or
anesthetization methods and any altered, renovated, or modernized portions of these systems must
meet the applicalbe provisions of the respective codes and standards:
0 2018 Uniform PlumbingCode ode (iqpmo.org) with reference to NFPA 99: 2015 as adopted
and amended under Chapter 51-56 WAC:
o The NEC (NFPA 70) with reference to NFPA 99: 2018 as adoped and amended by WA
State L&I Electrical Laws, Rules & Policies (wa.gov) and
o The 2018 International Mechanical Code (IMC) with reference to the 2017 Edition of
ASHRAE 170 for the ventilation of ambulatory surgery faclities.
Recommend third party inspection / certification of the medical gas and vacuum systems to identify any
elements not in strict compliance with 2015 NFPA 99 to identify any conditions of the design, installation,
or maintenance which may present a distinct hazard to life. Recommend similar inspection of the
essential electrical system to the requirements of the 2020 NEC by a consulting engineer. 2018 NFPA 99:
6.1.3 identifies electrical system requirements for new and existing health care facilities.
T5 Basis of review: design and operational licensing requirements:
• All facilties must meet the minimum health and safety requirements for the licensing, operation,
maintenance, and construction of WAC 246-330 (Chapter 246-330 WAC:) including,
• Alterations, including changes to the physical environment, additions, functional change, or
modification to the facility must meet the provisions of the 2006 Guidelines for the Design and
Construction of Hospital and Outpatient Facilities (FGI) Facility Guidelines logo v2
(fg_iguidelineLgrgr),
T6 Include a life safety plan in any documents provided for review. Ensure the facility's fire safety plan is
current and maintained on site. IFC Chapter 43.3
T7 Recommend review FGI Section 1.2 Environment of Care regarding requirements for the functional
program. Ensure patient, staff and material circulation patterns support operational infection prevention
and design supports this effort by clearly identifying semi -restricted and restricted areas.
T8 Operating rooms in which general anesthesia is administered and post -anesthesia recovery areas are
designated as Category 1 areas and require:
o A Category 1 piped medical gas and vacuum system
■ Generally including provision for waste anesthesia gas disposal, and
o A Type 1 essential electrical system,
■ Powered by a Type 10, Class X, Level 1 classified generator meeting the requirements of
NFPA 99: 6.4, NFPA 110, NFPA 70
o A mechanical ventilation which maintains room ventilation and pressurization upon loss of
electrical power.
■ Reference ASHRAE 170: 6.1 and 8.4.1, and FGI 3.1-7.2.3
Page 5 of 16 Plan Review Comments for Project 61189204
76th Professional Commons
Chapter 246-330 WAC Ambulatory Surgery Facility
■ Requirement for OR's only
T9 Recommend creating a dedicated patient changing area. FGI 3.7-2.7
T10 Review general requirements of FGI:
• Chapter 1.6 Common (building) Requirements
• Chapter 3.7 Outpatient Surgical Facilities
o Sections 1 through 5 of Chapter 3.1: Common requirements for (all) Outpatient Facilities
Recommend line by line review of Chapter 3.7 to identify elements and adjacencies specific to outpatient
surgical facilities then line by line review of common requirements for all outpatient facilities.
Tl l Note retroactive provisions of the International Fire Code, Uniform Plumbing Code, National Electrical
Code and NFPA 99 for medical gas supply and distribution, electrical wiring and protection for patient
care areas, and essential electrical systems.
Preliminary comments based on material received 2/3/22 and 2/28/22 and conference 2/28/22:
Robert Cronk, Leo Maya, Nicole Olaes, Kent Gregory, Matthew Campbell
T12 Status: Certificate of Need (CN):
Application to, and evaluation by, the DOH Certificate of Need (CN) program under DOR22-10 identifies
the services to be provided at this location to include bariatric, endoscopic, and laparoscopic surgeries and
procedures. The functional program identifies endoscopic, laparoscopic, and the full scope of aesthetic
cosmetic plastic surgery procedures. Revise application to CN or functional program for consistency.
Revisions to the functional program / scope of services expected.
T13 Revise the functional program to identify the procedures and level(s) of sedation planned for Minor
Procedure room / Endoscopy procedure room 110 and revise architectural design as appropriate to the
intended use. The room shown does not meet the requirements for a Class A procedure room or an
endoscopy procedure room or provide additional space to accommodate conscious sedation. FGI 3.7-
2.3.1.1 and FGI 3.9-2.3.1.1
Revisions to the functional program /scope of services expected. Surgical services provided in
the OR only. Evaluate Room I10 for PACUfunction.
T14 Provide an overall licensing narrative and architectural plan to show how the facility design and
operations address the requirements of FGI 3.1, 3.7, 3.8, and 3.9, as applicable to the services offered.
These include, but are not limited to:
Examination room(s) or equivalent areas for thorough patient pre -procedure examination
Recovery areas:
o Requirements determined by the level of sedation
Support areas for surgical services, including
o Nurse / control station in observation of the operatory
o Scrub facilities
o Drug distribution facilities with a refrigerator and handwash sink
Page 6 of 16 Plan Review Comments for Project 61189204
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Chapter 246-330 WAC Ambulatory Surgery Facility
o Soiled workroom with a clinical sink or equivalent flushing -type fixture, a work counter,
a handwashing station, and waste receptacle(s), appropriate to the facility program
o Sterilization facilities
■ Including a soiled workroom (may be same as above) and a physically separate
clean/assembly workroom with a handwashing station and equipment for
terminal sterilization of instruments
o Fluid waste disposal facilities
o Storage for clean and sterile supplies
o Soiled holding for items processed off -site
o Equipment supply and storage
o Housekeeping room
• Support areas for surgical staff
o Staff clothing changing areas
o Staff shower
• Support areas for patients
o Changing areas, including lockers, toilet facilities, and clothing changing areas, space for
administration of medication, and provisions for securing patients' belongings
• General support areas for outpatient facilities, including
o A general housekeeping room
o Equipment rooms for building system components
o Waste collection facilities
• And administrative and public areas including:
o Reception
o Waiting room and supporting toilet facilities
o Access to a public telephone
o Provisions for drinking water
o Wheelchair storage
o Interview areas
o Individual office(s)
o Provisions for medical records and clerical supplies
These elements are drawn generally from Sections 3.7 and 3.8 for surgical facilities and the broader
requirements of Section 3.1 which apply to all outpatient facilities. Section 3.1-5 provides design and
construction standards for outpatient facilities in addition to the those of the building code.
T15 Provide information to demonstrate the mechanical HVAC system meets the general requirements of FGI
3.1-7.2 and ASHRAE 170 Parts 6 and 7.
T16 Revise design and/or relocate the med gas zone valve box serving the open pre / post -operative recovery
bays such that a wall intervenes between the valve and outlets/inlets it controls and the valve is not located
in the room with the station outlets/inlets that is controls. UPC 1311.6
T17 Provide engineered evaluation of existing conditions, and construction documents for proposed alterations
to the mechanical HVAC and electrical systems towards the design of a single FGI Class C / Category 1
operatory.
T 18 Provide information to demonstrate circuiting, identification, number of receptacles, and grounding of the
electrical system for the Category I operating room and post -anesthesia recovery areas meet the
Page 7 of 16 Plan Review Comments for Project 61189204
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Chapter 246-330 WAC Ambulatory Surgery Facility
requirements of NEC 517.19, 517.31 and 517.63. Specify (re)testing and acceptance of the essential
electrical system to the requirements of NEC 700 and NFPA 110
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 applicable
licensing requirements for this project. These comments are provided as information and for use in
preparing the construction documents. They may be revised and/or additional preliminary comments may
be made during subsequent submissions.
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 and they do not guarantee compliance or
approval by these authorities. In the event of conflicts between other jurisdictions and these comments,
please contact this office immediately.
Supplemental Notes based on review of select original construction documents:
2003 UPC
IAPMO UPC (2003): Uniform Plumbing Code: International Association of Plumbing and Mechanical
Officials : Free Download, Borrow, and Streaming : Internet Archive with reference to standard 2002
NFPA 99 and 2002 NFPA 99C
Page 8 of 16 Plan Review Comments for Project 61189204
76th Professional Commons
Chapter 246-330 WAC Ambulatory Surgery Facility
Plan Review Comments:
Q
b
o P
z
1 p Provide as -built installation drawings, as available, and the most recent copy of the inspection
and testing record for the building fire alarm system. NFPA 72: 14.6
Response 07/15/22 — Find attached Fire Alarm As-builts & 2019 Annual Guardian
Fire alarm & sprinkler report.
Approved 08/16/22 — Based on Guardian FA report dated 11/06/19
rovide the most recent documentation of inspection and testing of the building fire sprinkler
ystem to the requirements of NFPA 25. NFPA 13: 27
Response 07/15/22 — Find attached sprinkler deficiency report dated 12110121
(Mastgech LLC WSPRK 12.10.2021. Find attached Correction quote dated (3116122)
(Mastgech LLC SPK Deficiency Quote 03.16.2022)
.pproved 08/16/22 — Based on Comment response and Guardian ITS report dated
2/10/2021
rovide a copy of the written plan for the protection of all persons in the event of fire, for their
vacuation to areas of refuge, and for their evacuation from the building when necessary. IFC
01, 403.3.1 through 403.3 and 404 through 406, and WAC 246-330-230(2)(d) and (3)
Response 07/15/22 — Find attached Fire Evacuation Policy dated 6111122
.pproved 08/16/22 — Based on fire evacuation policy and procedures dated 06/07/22
rovide/confirm illumination of the means of egress during loss of normal power to the two
;quired exits from the building. (lighting within Lobby not shown) IBC 1008.3 / IFC 1104.5
Response 07/15/22 — See sheet E3.1 indicting photometrics of exist path. Exit signs
are indicated. Exist lighting is powered by battery packs.
.pproved 08/16/22 — Based on comment response and E3.1
rovide/confirm exit signage from the proposed ambulatory surgery facility to the two
;quired exits from the building. IBC 1013 / IFC 1104.1
Response 07/15/22 — See Sheet T2.14B indicating exit signage and travel path for (2)
exit pathways. (TWL Architectural Drawing 042022 rev 071422)
.pproved 08/16/22 — Based on comment response and T2.14B
Page 9 of 16 Plan Review Comments for Project 61189204
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Chapter 246-330 WAC Ambulatory Surgery Facility
px Provide a site plan/revise T1.10 to show the path from the ASF exit discharge to the staging
location of emergency transportation. IBC 1028, FGI 1.3-2.1, and WAC 246-330-230
Response 07/15/22 — See sheet A].00 Site Plan
Approved 08/16/22 — Approved 08/16/22 — Based on comment response and A1.00
xp Provide/confirm the facility has a written and signed transfer agreement with one or more local
hospitals that has been approved by the facility's medical staff. WAC 246-330-225(1)(b)
Response 07/15/22 — Transfer Agreement with Evergreen Medical Center pending.
Both Surgeons presently admitting privileges at Evergreen Medical Center.
Deferred 08/17/22
❑x Provide, and identify on plan(s), at least one exam room, ensuring both visual and acoustical
privacy, for examination and testing of patients prior to surgery. This room must have a
handwash-station and may be used for patient changing, treatment, consultation, interviews,
and similar functions. FGI 3.7-2.2, 3.1-2.1.1, and 3.1-2.1.3
Response 07/15/22 — See Sheet T2.14B, Minor Procedure S130 used for exam and
testing. (TWL Architectural Drawing 042022 rev 071422)
Approved 08/16/22 — Approved based on comment response
px Provide, and identify on plan(s), drug distribution station equipped with a work counter, sink,
refrigerator, and locked storage for biologicals and drugs. FGI 3.1-2.1.7.2
Response 07/15/22 — See Sheet T2.14B drug distribution station at North end of
Nurse Station S138 with required refrigerator S03, Locked Storage S10, and work
counter. Sink S-1 located at south side of Nurse station. (TWL Architectural Drawing
042022 rev 071422)
Approved 08/16/22 — Based on drawings and comment response.
10 1 ❑x I i Provide, and identify on plan(s), wheelchair storage 3.1-2.1.7.6
11 1 19
Response 07/15/22 — See Sheet T2.14B, Waiting S100 for Wheelchair storage. (TWL
Architectural Drawing 042022 rev 071422)
Approved 08/16/22 — Approved based on T2.14B
Provide/confirm door hardware selection for Patient Toilet Rooms S 140 and S 141 will permit
staff emergency access. FGI 3.7-5.2.1.4
Response 07/15/22 — Doors at Patient Toilets S141 & S146 have exterior key access
to privacy lock. See attached Patient Toilet Door photo.
Not Approved 08/16/22 — Inward swinging toilet room doors need to need equipped with
hardware that permits access from the outside in emergencies. The issue is someone
Page 10 of 16 Plan Review Comments for Project 61189204
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Chapter 246-330 WAC Ambulatory Surgery Facility
_J collapsing in front of an inward swinging door, there are specialized hinges that can be
installed to allow for removal of the door from the frame in this scenario. FGI 3.7-5.2.1.4
12 ❑x Provide access to public telephone(s) and provisions for drinking water in the waiting area of
the proposed facility. FGI 3.1-4.1.3
Response 07/15/22 — See Sheet T1.10 and Public Drinking Fountain Photo for access
to drinking water. Public Phones have not been provided in Public Building in this
century
Not Approved 08/16/22 — Confirm there is public internet access for patients and family
members in this facility.
13 ❑x Provide drawings to demonstrate the OR has at least 2 oxygen and 3 vacuum station outlets.
FGI 3.7-6.1, 3.1-7.1, and Table 3.1-2
Response 07/15/22 — See Plumbing Sheet P2.2 indicating location of required
outlets.
Approved 08/16/22 — Based on P2.2
14 x❑ Provide design/construction drawings, prepared by the engineer of record, or equivalent
information, such as drawings and certification report (certified to 2005 NFPA 99 or a more
restrictive later code), for the medical gas and vacuum systems to demonstrate these systems
meet the requirements for 2005 NFPA 99 Category 1 systems supporting surgical procedures
under general anesthesia and post anesthesia recovery / critical care areas. 2005 NFPA 99
Chapter 5 (FGI 3.1-7.1.4.1)
New work and alterations, such as relocation of med gas zone valve box to provide a wall
intervening between the valve and station outlets served shown sheet P2.1, must meet current
2018 UPC Chapter 13 (with reference to 2015 NFPA 99) as indicated sheet P1.1.
Material provided for review does not include information about the `infrastructure of the
medical gas and vacuum system to permit complete review of the Category 1 system with
WAGD provided by the medical surgical vacuum. System elements include:
• Source
• Central supply location, quantity, and construction (NFPA 99: 5 and 11)
o Plans indicate vacuum pump in the manifold room
■ Co -location not permitted 2005 NFPA 99: 5.1.3.3.1
• Permitted locations
o As -built approved documents show medical surgical vacuum serving the
Decontamination instrument processing room. Not permitted 99: 5.1.3.5.2
• Source regulators and relief valves
• Local signals
• Headers
• Manifolds
• Medical surgical vacuum systems
o Source
o Location
Page 11 of 16 Plan Review Comments for Project 61189204
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Chapter 246-330 WAC Ambulatory Surgery Facility
15 1 1 a
E,
o Equipment
o Distribution
■ As -built drawings appears to serve non -patient care instrument
processing room. This is not permitted in the 1999 NFPA 99 or the
2012 NFPA 99; cannot locate language in the 2005 Edition.
o Valves
■ As -built drawings indicate the vacuum system is supplied through
zone valves as required 2005 NFPA 99: 5.1.4
o Alarms
o Power
o Exhaust
• WAGD
• Alarms
o Double check mix of nurse call and med gas alarms
2016 CMS survey indicated that this information was not provided / maintained
5/12/22 Conference: Design team plans to engage third party certifier to evaluate and
identify elements not compliant to 2005 NFPA 99 or more restrictive edition of the code.
Response 07/15/22 - See attached report from third party certification firm showing
specific defects and see Plumbing Sheets P2.0, P2.1, and P2.2 for resolution to all
defects cited. Please note that while N2O defects are cited, there will not be an N2O
manifold being installed and the N2O lines will be capped for future.
Not Approved 08/16/22 — This comment will be closed once final med gas verification
report is provided.
Provide the City of Edmonds permit number for proposed alterations to the medical gas and
vacuum system. WAC 246-320-510 and UPC 104.3.1
Response 07/15/22 — City of Edmonds Permit Number 2022-0392. Note: the City of
Edmonds will not allow work on medical gas and vacuum system until proposed
alternation are specifically approved by DOH.
Not Approved 08/16/22 — A2BC letter issued 08/17 sufficient for City of Edmonds to
allow work to begin. Provide permit.
pp Revise panel schedule E1.3 to remove OR, Crash Cart, and Server Room receptacles from the
Life Safety branch of the essential electrical system.
Response 07/15/22 —See E1.3 clouded revisions
Approved 08/16/22 — Based on revised E1.3
17 Eg Provide design/construction drawings, prepared by the engineer of record, or equivalent
information to demonstrate the essential electrical system is served by a Type 1 generator set:
• Which can restore power in 10 seconds or less (Type 10)
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Chapter 246-330 WAC Ambulatory Surgery Facility
With adequate on -site fuel supply as required by the services provided consistent with
facility emergency plans (Class X), with
Level 1 safety indicators and shutdown features (reference NFPA 110 Table 5.6.5.2)
And a battery powered, remote alarm annunciator located to be readily observed by
personnel at a regular workstation with visible signals and audible alarms as required
by 1999 NFPA 99: 3-41.1.15 (as referenced 2002 NFPA 70 / NEC)
Engineering narrative states the specified/installed gen set meets NFPA 110 for a Type 10,
Class X (18.9-hour run-time) with remote annunciator. Provide documentation of start up, and
function testing to document performance to the standard endorsed by the engineer of record.
Response 07/15/22 — Response to this item is deferred. Start up and testing of this
existing Cummins Gen Set is waiting for a replacement part. No ETA has been
defined. Once installed the systems will the load tested, followed by a performance
report
Deferred 08/17/22
18 ❑p Revise drawings to document or revise design to provide a mechanical HVAC system serving
the OR and PACU with:
19
x❑
• Individual temperature control (only in the OR),
• An air conditions system capable of maintaining temperatures between 68-73°F and
humidity between 30-60%,
• Ventilation providing at least 3 outside and 15 total air changes per hour (only OR),
• Supply air with a MERV 8 first filter upstream of conditioning equipment, and
• MERV 14 final filtration downstream of any fans or blowers with gaskets and seals to
provide a positive seal against air leakage, and with a manometer installed to permit
access for field testing.
o Identify location of final filter
FGI 3.1-7.2.3.1, Table 2.1-2, and 3.1-7.2.6
Response 07/15/22 — See Mechanical Sheets M2.1 and M2.2 for identification of all
requirements.
Approved 08/16/22 — Based on submitted drawings
Provide a plan of the area submitted for review for licensure showing the mechanical HVAC
supply, return, and exhaust elements for areas listed in FGI Table 2.1-2, and a table presenting
the room name, the supply, return, and/or exhaust CFM air total and outdoor air changes,
pressure relationship to adjacent spaces, and design temperature and humidity, for these spaces
to permit review to the requirement of FGI Table 2.1-2. FGI 3.7-6.2.1 and 3.1-7.2.2.2
Response 07/15/22 — See Sheet M-1.]for addition of the Air Balance Schedule,
showing all pressure balance relationships
Not Approved 08/16/22 — Provide narrative or other information on the schedule
showing pressure relationship of positive pressure spaces and the adjacent spaces [OR /
Substerile/ Clean Supply].
Page 13 of 16 Plan Review Comments for Project 61189204
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Chapter 246-330 WAC Ambulatory Surgery Facility
20 ❑x � Revise equipment plan to identify local exhaust for steam/moisture producing equipment in
instrument processing (or other) areas or show equipment on the mechanical ventilation plan.
(Autoclave and Steris System in Substerile S 145, Washer / Disinfector in Decontam S 142
Endo Processor in Soiled S129) FGI 3.7-6.2.1 and 3.1-7.2.2.2(4)
Response 07/15/22 — Autoclave has no steam emitting capability, and as such no vent
is provided. The Washer/Disinfector currently has a 4" vent in place as noted on
plans (see M2.2)
Approved 08/16/22 — Based on comment response
21 ❑x Clarify whether there is a plenum return element in Substerile S 145. Identify all areas with
plenum return elements within the proposed ASC. All return air ventilation in patient care
areas must be ducted. FGI 3.1-7.2.5
22 I ❑x
')'2 n
Response 07/15/22 — All plenum return elements in patient and back of house areas
have been converted to ducted return. See mechanical floor plan sheet M2.2 for
layout.
Approved 08/16/22 — Based on comment response and M2.2
Revise HVAC design such that fresh air intakes serving the proposed ASC are located at least
25' from exhaust outlets of ventilating systems, combustion equipment stacks, medical -
surgical vacuum systems, plumbing vents. FGI 3.7-6.2.1 and 3.1-7.2.5.4(1)
Response 07/15/22 — See new mechanical sheet M2.3 for roof plan showing fresh air
intake extension to meet 25' requirement
Approved 08/16/22 — Based on roof plan M2.3
Provide/confirm copper tubing for supply connections to the ice machine. FGI 1.6-2.1.3.4
Response 07/15/22 — Plans call out for copper tubing to be used for ice machine
supply. See note on P2.2.
Approved 08/16/22 — Based on P2.2
Provide information to demonstrate or otherwise confirm equipment shown T2.14B:
Autoclave and Steris System in Substerile S 145, Washer / Disinfector in Decontam S 142,
Endo Processor in Soiled S 129, Icemaker in Clean Supply S 137, and any other equipment with
direction connection to the building water supply or fixtures with threaded outlets, have
backflow prevention devices or internal air gaps and indirect drains consistent with UPC
Chapter 6 and 8 and FGI 3.1-7.1.2.2(3)
Response 07/15/22 — See plumbing floor plan sheet P2.2 for addition of vacuum
breakers where needed, and adjustments to indirect waste as required to meet code.
See Clean Supply, Decontamination, and Substerile for notes
Page 14 of 16 Plan Review Comments for Project 61189204
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Chapter 246-330 WAC Ambulatory Surgery Facility
27
01i
29
❑x
❑x
vot Approved 08/16/22 — Confirm Ice Machine has internal air gap or is installed with
)ackflow prevention.
�onfirm/provide general handwashing stations used by clinical staff have hands -free faucet
771xtures with single -lever or wrist blade handles of at least 4". FGI 1.6-2.1.3.2
Response 07/15/22 — All handwashing stations meet code with proper 4 " wrist
blades.
approved 08/16/22 — Based on comment response
?rovide/confirm the scrub sink is trimmed with foot, knee, or ultrasonic controls.
FGI 3.1-7.1.3.2
Response 07/15/22 — Existing scrub sink is equipped with foot controls.
Approved 08/16/22 — Based on comment response
Provide signed stamps on construction documents typically. WAC 246-320-505
Response 07/15/22 — All attached correction drawings are stamped and signed.
Approved 08/16/22 — Based on comment response
Provide third party med gas verification report for the medical gas and vacuum system. 1999
NFPA 99: 4-3.4.1.3 and UPC 1318.0
Response 07/15/22 — See attached 2022 Annual Medical Gas Inspection — Transform
Weight Loss Edmonds.
Not Approved 08/16/22 — Existing report noted, provide final verification report once
work has been completed.
xp Provide a final HVAC testing and balance report which includes reference drawings used by
the evaluator to demonstrate system performance and pressure differentials consistent with the
engineered design and applicable requirements. FGI 1.5-4, ASHRAE 170: 8, and IMC 304.
Deferred 08/17/22
30 1 p Project close out:
A (virtual) final inspection will be required at substantial completion. Contact plan
reviewer to discuss survey / inspection during construction to reduce the opportunity
for issues at final construction inspection and licensing survey. WAC 246-320-505
31 Drawings M1.1, MD2.1, M2.1, M3.1, P1.1, and P2.1 revision date 5/16/22 received 5/16/22.
Revise drawings to cloud or otherwise identify revisions and provide written responses to the
`not approved' comments in this form. .
Page 15 of 16 Plan Review Comments for Project 61189204
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Chapter 246-330 WAC Ambulatory Surgery Facility
Changes to the approved (A2BQ documents must be submitted to DOH/CRS with
revisions clouded or otherwise clearly identified to ensure review.
Discrepancies between the approved drawings and construction may delay licensur(
Respond, in writing, to the comments attached to this form.
Additional comments may follow based on receipt of revised construction document
design team response.
s and
Compliance with the comments above provided by the Department of Health, Construction Review Services, are necessary for this facility to meet the cited
requirements of the applicable licensing regulations found in the Washington State Administrative Code and associated references. These comments,
authorization to begin construction or final project approval do not relieve the facility from the responsibility to meet the requirements of any applicable
federal, state or local regulations. In the event of conflicts between other jurisdictions and these written comments, the most stringent shall apply. The
building owner or operator is ultimately responsible for safety and insuring the building is in compliance with all applicable laws.
Page 16 of 16 Plan Review Comments for Project 61189204