Frequently Asked Questions

Q. How should the facility submit the documentation identified on the EDC to the Regional Office? (Hard Copy, Disc, Jump Drive?)

  • A. Data can be accepted using various manners, such as pdf files. Submitting information electronically is often helpful since drawings can be enlarged electronically. Tablets used by surveyors may no longer read CDs. Please check with your Regional Office staff for a preferred method.

Q. Who should be present at the on-site inspection?

  • A. The facility should have available (either in person or via phone) facility personnel and/or consultants who are able to provide answers to any architectural/engineering questions that are raised. At a minimum, a facility representative assigned to the project and the architect of record should be present. Exceptions can be made on a case by case basis.

Q. I have a small project involving conversion of a small office building to Article 28 space. No work was done to the existing ventilation system, which is believed to be in compliance with applicable standards. Is HVAC Balance Report still required?

  • A. Yes, this is still needed to show that the HVAC system is in compliance with the 2010 FGI Guidelines. If no work was done to the system and a recent report is available showing compliance, then that report may be used.

Q. I am required to have a construction safety plan for my project. What should the plan consist of?

  • A. The construction safety plan shall, at a minimum, include:
    1. A detailed Life Safety Plan that explains how the facility shall ensure compliance with all of the requirements found in NFPA 101 (2000 edition) Life Safety Code Sections 18.7.9/19.7.9 and 4.6.10 and with NFPA 241 (1996 edition), Standard for Safeguarding Construction, Alteration, and Demolition Operations.
      • *You may also need to consult the following NFPA standards when preparing your Construction Safety Plan:
        • NFPA 601, Standard for Security Services in Fire Loss Prevention,
        • NFPA 51B, Standard for Fire Prevention During Welding, Cutting, and Other Hot Work,
        • NFPA 58, Liquefied Petroleum Gas Code,
        • NFPA 30, Flammable and Combustible Liquids Code,
        • NFPA 701, Standard Methods of Fire Tests for Flame Propagation of Textiles and Films,
        • NFPA 600, Standard on Industrial Fire Brigades,
        • NFPA 80, Standard for Fire Doors and Windows,
        • NFPA 14, Standard for the Installation of Standpipe, Private Hydrant, and Hose Systems, and
        • NFPA 495, Explosive Materials Code
      • *The Life Safety Plan should include copies of all forms/log sheets that are to be used (for example, log sheets for fire watches/guards, hot work permits and daily means of egress inspection rounds).
    2. An Infection Control Risk Assessment (ICRA) detailing procedures to be followed to ensure patient safety during construction.
      For more information, please consult the CDC Guidelines for Environmental Infection Control in Health-Care Facilities.
    3. A detailed description on what, if any, impact the construction project would have on patients (such as disruption of normal services).
    4. A detailed description of the scope of the project and a breakdown of phase planning (details of each phase, estimated date of completion of construction for each phase) for multi-phase construction projects.
    5. You are also required by NFPA 241 to contact your local fire department to let them know about your construction/renovation project and to develop a pre-fire plan with them.