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Tennessee Department of HealthBureau of Health Licensure and

RegulationsDivision of Health Care Facilities

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Topics

• Rules and Regulations• Progress and Final Inspections• Top 5 Deficiencies for Hospitals

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Rules and Regulations

Hospitals 1. Tennessee Department of Health 1200-08-01 (June 2015)2. Nation Fire Protection Association (NFPA) 101 Life Safety

Code (2000 Ed) and the referenced publications per chapter 2. (CMS)

3. Nation Fire Protection Association (NFPA) 101 Life Safety Code (2012 Ed) and the referenced publications per chapter 2.

4. International Building Code (IBC) 2012 Ed

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WWW.cms.gov (CMS-2786R)

Progress and Final Inspections• Phasing a project• UL systems• Fire Stop systems• Fire/Smoke Dampers • Med Gas • Sprinklers • Fire Alarm• Final Inspection

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Fire Dampers

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Hospitals Top 5 Deficiencies (5)

K-130MiscellaneousList in the REMARKS sections, any items that are

not listed previously, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.

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Penetrations

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Penetrations

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Penetrations

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Hospitals Top 5 Deficiencies (4)

K-77• Piped in medical gas systems comply with

NFPA 99, Chapter 4.

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K-147Electrical wiring and equipment is in accordance with NFPA 70, National Electrical Code.

9.1.2• Broken outlet covers• Power strips (back to back)• Exposed electrical junction boxes• Electrical panels blocked with equipment

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NH Top 10 Deficiencies (3)

Power Strips in Patient Care Areas

• S&C: 14-46-LSC DATE: September 26, 2014

• SUBJECT: Categorical Waiver for Power Strips Use in Patient Care Areas

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Hospitals Top 5 Deficiencies (2)K-29One hour fire rated construction (with ¾ hour fire-

rated doors) or an approved automatic fire extinguishing system in accordance with 8.4.1 and/or 19.3.5.4 protects hazardous areas. When the approved automatic fire extinguishing system option is used, the areas are separated from other spaces by smoke resisting partitions and doors. Doors are self-closing and non-rated or field-applied protective plates that do not exceed 48 inches from the bottom of the door are permitted. 19.3.2.1 19

K-29

• Penetrations in fire rated walls.• Door self-closing device removed.• Penetrations in fire doors• Improper gaps in fire doors• Damaged fire doors• Fire doors not latching

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NH Top 10 Deficiencies (1)K-62 Required automatic sprinkler systems are

continuously maintained in reliable operating condition and are inspected and tested periodically. NFPA 101, 19.7.5, NFPA 13, and NFPA 25.

• No quarterly• No annuals• Obstructions• Corroded sprinklers

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Sprinklers

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Sprinklers

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Sprinklers

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Sprinklers

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Other Deficiencies

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Questions?

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Thank You

Health Care Facilities OfficesETRO: (865) 594-9396: KnoxvilleWTRO: (731) 984-9684: JacksonCentral Office Nashville (615) 741-7221Plans Review Office (615) 741-6998

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