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Section i: Functional Program

Reference: FGI Guidelines 2018 Hospitals Edition, Section 1.2-1, 1.2-2, 1.2-3; and 2018 Outpatient Facilities Edition, Sections 1.2-1, 1.2-2, 1.2-3

This section pertains to: 1) new construction, 2) major renovations, and 3) projects that change the functional use of any facility space. It is not required for activities such as equipment replacement, fire safety upgrades, or minor renovations that will not change the facility’s function or character.

Project Name/FDC#Proposed LocationDepartment ContactAdministratorSubmission Date/Phase

A. FUNCTIONAL PROGRAM EXECUTIVE SUMMARY.

Describe the purpose of the project. Include services to be provided, expanded or eliminated by the proposed project. Include a description of proposed new or existing occupancy(ies). (A separate document may be attached)

Indicate the type of health care facility (i.e., hospital, outpatient).

Indicate project location and size in square footage.

Indicate the department(s) affected by the project. Include details on operational relationships and required adjacencies of clinical and support areas.

Describe the services required for the completed project to function as intended. Describe changes in circulation patterns.

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B. PROGRAM OF REQUIREMENTS

Complete a Program of Requirements for your project with the assistance of Planning Design and Construction. Indicate the name and quantity of each type of space. The names for spaces and departments shall be consistent with those used in the FGI. Attach completed Program of Requirements to this document.

C. BUILDING SYSTEMS EVALUATION

Complete an evaluation of engineering and building construction type for all projects.

Date of Report

D. PROJECT NARRATIVE

Complete Project Narrative for submission to PA DOH for all Hospital-based projects and include completed form with this document.

Date Approved by DOH

E. Documentation Required

Check all forms that are required

ICRA (Infection Control Risk Assessment) ILSM (Interim Life Safety Measures)

PCRA (Pre-Construction Risk Assessment) Complete SRA Package

*Refer to NFPA 101 (2012 Edition) Section 43.2.2.1 Categories of Rehabilitation Work.

Team Members for this project:

Administrator

Nurse/Clinical Manager

Falls Prevention Expert

Infection Control Expert

Medication Safety Expert

PHAMA Expert

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Security Expert

PDC PM

Architect/Engineer

Director, Planning Design and Construction

Chair, SRA Multidisciplinary Committee

F:\ SRA Functional Program Revised 08.20.2018

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Section 1: INFECTION CONTROL RISK ASSESSMENT

Reference: FGI Guidelines 2018 Hospitals Edition, Sections 1.2-4.2; Table 1.2-2 (inclusive) and 2018 Outpatient Facilities Edition, Sections 1.2-4.2 and Table 1.2-2 (inclusive).

This section pertains to: 1) new construction and 2) all renovations. It affects all areas. Per 1.2-3.2.1.1 ICRA requirement “For a health care facility project to support safe designs, HVAC/plumbing systems, and surface and furnishing material selections.”

Project Name/FDC#Project LocationProject Square FeetSubmission Date/Phase

A. EVALUATION AND ASSESSMENT/DESIGN ELEMENTS

Describe patient population’s requirement for airborne infection isolation (AII) or protective environment (PE)rooms:

Indicate number of AII rooms required in projectIndicate number of PE rooms required in project

Are any services located within the project area that require special HVAC? (i.e. surgical suites, AII/PE rooms, laboratories, pharmacies, areas with local exhaust systems for hazardous agents). If so, list room types.

A/E provide documentation of temperature/pressure/humidity/air change/filtration parameters as part of design documentation and review:

Water and Plumbing Systems. Describe any specialty plumbing systems in the area (i.e., dialysis, RO/DI water, drain arrangements).

A/E provide documentation of design solutions for plumbing specialty plumbing systems for review:

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Requirements for fixtures and systems

Is this Required

Note Quantity and Location

Yes NoHand washing stations – CorridorsHand washing stations – Patient RoomsHand washing stations – Support SpacesHand sanitation dispensersScrub SinkClinical SinkShower/Bathing Emergency eyewash/shower (provide specifics on caustic materials and justification)Drainage systems/condensate /floor drainsIce MachinesDialysis MachinesRO/DI

Requirements for Cleaning/ Sterilization

Is this Required

Describe process and equipment used.

Yes NoScope ProcessingInstrument ProcessingFlash SterilizationETOSteamOther

Requirements for Cleaning/ Sterilization

Provide design solution.

Scope ProcessingInstrument ProcessingFlash SterilizationETOSteamOther

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Assess risk from transmissible waterborne pathogens. Ensure that existing or new plumbing systems do not result in dead-end conditions.

A/E describe design solutions for identified risks.

Indicate requirements for infection prevention related to surfaces and finishes.

Flooring (specify requirement by room type)Work surface – staff and support areasWork surface – patient roomSinks – staff and support areasSinks – patient room Wall finish (paint, wall covering, wall protection, monolithic walls)Upholstery fabrics – public areasUpholstery fabrics – staff and support areasUpholstery fabrics – patient roomOther

B. CONSTRUCTION ELEMENTS

Complete Pre-Construction Risk Assessment Form Date:

Complete ICRA Permit Date:

Complete ILSM Form Date:

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Section 2: Patient Handling and Movement Needs Assessment (PHAMA) and Patient Immobility

Reference: FGI Guidelines 2018 Hospitals Edition, Section 1.2-4.3 and 1.2-4.7; and 2018 Outpatient Facilities Edition, Section 1.2-4.3 (note: Patient Immobility assessment is not included in Outpatient Facilities)

This section pertains to: 1) new construction, 2) major renovation and renovations changing the functional use of space, and 3) minor and minimal renovations where patient handling occurs. It affects inpatient, outpatient and ancillary spaces where patient handling, transport, transfer and movement occur.


A. EVALUATION AND ASSESSMENT

Patient Dependency Levels: Describe the Patient Populations’ Characteristics and Ambulatory Abilities.

Bariatric Design: Describe size and weight of patient population.

Does this patient population require bariatric design? Yes / No

What is the weight requirement for bariatric lift considerations? #

What percentage of the population generally requires these considerations? %

Patient Handling, Movement and Mobility Tasks: Describe the frequency of tasks for the high risk populations that exhibits Total Dependency/Extensive Assistance.

Task Frequent Daily1-2X

Rarely

Vertical Transfers (to or from bed, chair, commode toilet, wheelchair)

Positioning or Repositioning in bed (side to side, up to head, raise/lower feet)

Positioning or Repositioning in chair

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Lateral Transfers (to or from bed, stretcher, gurney)

Bathing/Showering requiring extensive or total assistance from staff (i.e., bed bath)Bathing/Showering requiring minimal or no staff assistance (i.e., patient shower in bathroom)Lifting limbs

Patient Transport

Ambulation Assistance

Patient Weights using standing scales

Describe immobility risk to this patient population. Include information on bed alarms and other items that may add to sedentary patient treatment and behavior.

B. REQUIREMENTS FOR PHAMA IN DESIGN

Patient Lifts and Equipment

Type Qty Capacity To/From Destinations Installation Requirements Storage SF/Type

Portable lift, manual floor model

Fixed lift, floor model

Fixed lift, ceiling mountedSlings

Ambulation Assist (wheel chair/ walker)Other

Design Considerations: Based on the preceding Evaluation and Assessment.

Structural

Mechanical/Electrical

Maneuvering Space (within work and

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storage areas)Storage Space (non-fixed equipment and accessories)Door Opening Sizes (patient room, toilet room and ancillary spaces)Flooring Surfaces

Flooring Transitions

Impact on or Conflict with Building SystemsImpact on Aesthetics

ICRA Implications

Other

Describe designs solutions for mitigating contributing factors for sedentary patient treatment and behavior.

F:\FDC\SRA Documents\2018 PHAMA Revised 08.20.2018

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Section 3: Fall Prevention

Reference: FGI Guidelines 2018 Hospitals Edition, Sections 1.2-4.4 and 2018 Outpatient Facilities Edition Section 1.2-4.4

This section pertains to: 1) new construction, 2) major renovations and renovations changing the functional use of space, and 3) minor and minimal renovations where patient falls may occur. It affects any area to which a patient or family member has access.



Describe the Patient Populations’ Characteristics and Ambulatory Abilities.

Describe any requirements for this patient population that call for protective measures in addition to the standard.

B. REQUIREMENTS FOR PATIENT FALLS PREVENTION IN DESIGN

Design Considerations DescriptionCorridor WidthDoor Opening WidthDoor Operator (i.e., sliding, automatic assist)Door HardwareGrab BarsHandrails - CorridorsFloor Surfaces – Treatment AreasFloor Surfaces – Toilet RoomsFloor Surfaces – Specialty Spaces

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Other Considerations

C. REQUIREMENTS FOR PATIENT FALL PREVENTION DURING CONSTRUCTION

Complete Pre-Construction Risk Assessment Form Date

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Section 4: Medication Safety

Reference: FGI Guidelines 2018 Hospitals Edition, Sections 1.2-4.5 and 2.1-2.8.8; and 2018 Outpatient Facilities Section 2.1-3.8.8.

This section pertains to: 1) new construction, 2) major renovations and renovations changing the functional use of space, and 3) minor or minimal renovations where medication preparation, processing and distribution occur. It affects all areas that contain medication safety zones.



Describe the Patient Populations’ general medication requirements including the number and type of patients that will be treated in this location.

Number of Adult Patients: Number of Pediatric Patients/Neonates:Describe the most frequent medication errors on this unit and how errors might be prevented.

Medication Error Prevention Measure

B. REQUIREMENTS FOR MEDICATION SAFETY ZONES IN DESIGN

Design Considerations Description

Size and configuration of medication dispensing machines (Main and Aux)

Size and configuration of medication refrigerator

Adequate work surface for number of medication stations

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Number of EMR stations required in area

Hand washing sink of adequate sizeAdequate shelving for clean supplies related to dispensing medicationsNurse Call duty stationRoom visible by staffLocation of sharps disposal and wasted drug containersLocation of trash cansAdequate lighting for tasks performedLocking methodAppropriate air changes and pressure relationshipAre any medications compounded in this space? Is there a need for a hood?

If yes, attach description of USP-NF Guidelines that are applicable.

F:\FDC\SRA Documents\2018 MEDICATION SAFETY 08.20.2018

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Section 5: Behavioral and Mental Health

Reference: FGI Guidelines 2018 Hospital Edition, Section 1.2-4.6, 2.5-1.5.2, and 2.5-1.5.2.3; and 2018 Outpatient Facilities, Section 1.2-4.6

This section pertains to: 1) new construction, 2) major renovation and renovations changing functional use of space to include care of behavioral health patients, and 3) minor and minimal renovations where behavioral health patient treatment occurs. It affects any area where behavioral health patient care is provided.



Does this area provide behavioral health patient care? Yes NoDescribe the type of behavioral health patient care provided in this area.

Describe the typical precautions taken.

Describe additional precautions that should be taken into consideration during the design process.

B. REQUIREMENTS FOR BEHAVIORAL AND MENTAL HEALTH RISK IN DESIGN

Complete this section if “Yes” is checked in Section A.

Design Considerations Description

Perimeter security systemOpenings in perimeter Security (doors, windows, gates)Security cameras and other measuresSpecial considerations for injury and suicide

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preventionDuress AlarmsLocking ScheduleDoor hinges to minimize points of hangingDoor lever handlesFastenersImpact resistive window assemblies, frames and anchorageToilet/bathing facility hardware and accessoriesTamper-resistant fire sprinklersSecured ventilation grillsSecured light fixturesMonolithic ceilingsClothing rods or hooksWindow treatmentsTamper-resistant receptaclesDead End CorridorsBlind SpotsBarricadesWater Temperature Restrictions

F:\FDC\SRA Documents \2018 BEHAVIORAL-MENTAL HEALTH Revised 08.20.2018

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Section 6: SECURITY RISK ASSESSMENT

Reference: FGI Guidelines 2018 Hospital Edition, Sections 1.2-4.8 and 2018 Outpatient Facilities Edition Section 1.2-4.7

This section pertains to: 1) new construction and 2) all renovations. It affects all areas.


A. EVALUATION AND ASSESSMENT/DESIGN ELEMENTS

Describe the population that will use this space. Does the population or location present special security risks?

Does this space have an entrance at street level accessible to the general public? If so, describe the entrance plans.

Is this program in leased, off-campus space? If so, describe building security.

Describe existing security measures. Check boxes that apply. Include additional information here.

Cameras: Tied to Security Secured Entry Doors

Cameras: Local to area, not recorded Secured Stair TowersAir Phones (camera/intercom) Duress Alarms (panic buttons)HUGS (Infant Abduction) Card Swipes

Other:

Describe any special emergency management considerations for this program.

B. DESIGN ELEMENTS

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Describe entrance at street level.

Describe security measures desired in new space. Include additional information here.

Cameras: Tied to Security

Cameras: Local to area, not recordedAir Phones (camera/intercom)

HUGS (Infant Abduction)Secured Entry Doors

Secured Stair Towers

Duress Alarms (panic buttons)Card SwipesOther:

Describe design solution for special emergency management considerations.

C. CONSTRUCTION ELEMENTS

Complete Pre-Construction Risk Assessment Form Date:

Complete ILSM Form Date:

F:\FDC\SRA Documents\SRA SECURITY Revised 09.28.2017

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