HomeMy WebLinkAbout402.001 - Ambulatory Health Care Centers Requiring HHS Licensing
FIRE PREVENTION MANUAL
ADMINISTRATIVE REQUIREMENTS
402.001 AMBULATORY HEALTH-CARE CENTERS
REQUIRING HHS LICENSING
EFFECTIVE: JUNE 2008
Current Revision Date: 07/22/2021 Next Revision Date: 07/22/24
Author’s Name/Rank:
Darla Scott,
Supervising Fire Prevention Inspector Review Level: 1
Administrative Support:
Noemi E. Rodriguez,
Management Analyst II ADA
PURPOSE
The purpose of this policy is to clarify the requirements of “other agencies” for outpatient
(ambulatory) surgery centers that receive federal funding and require licensing by the
United States Department of Health and Human Services (HHS).
APPLICATION
This policy applies to anyone who is in the process of starting an outpatient (ambulatory)
surgery center and is seeking to receive federal funding and a license by HHS.
OPERATIONAL POLICY
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OPERATIONAL GUIDELINE
Ambulatory surgery centers treat patients receiving outpatient medical care that may
render the patient incapable of unassisted, self-preservation in the event of a fire or other
emergency. Such patients do not stay in the facility overnight. When an ambulatory
health-care (outpatient surgery) center has six (6) or more such patients, it is classified as
a Group I2.1 occupancy per the California Code of Regulations, Title 24. The
requirements of Title 24 for a Group I2.1 occupancy must meet most, but not all, licensing
requirements for an outpatient surgery center licensed by HHS.
Outpatient surgery centers with an occupant load of five (5) or less are classified as a
Group B occupancy per Title 24 and have additional requirements in the California Building
Code (CBC) and the California Fire Code (CFC) for fire sprinkler and fire alarm systems.
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When the facility plans on receiving federal funding from HHS, it is mandated the
facility also comply with Section 20.6 or 21.6 of the Life and Safety Code (NFPA 101),
regardless of occupant load. Therefore, both the Group B and Group I2.1 facilities
seeking federal funding must meet the HHS licensing requirements.
PROCESS
The following requirements are mandated by the current CBC and the current Life and
Safety Code (NFPA 101). The specific requirements for ambulatory surgery centers are
determined by the number of patients, the type of surgery conducted, and if the facility is
licensed by the federal government. The number of such patients requiring assistance
during exiting is generally based on one (1) patient in preparation, one (1) in surgery, and
one (1) in recovery. Typically, a facility with two (2) surgery units would have a patient
occupant load of six (6). If more than one (1) recovery or preparation bed per surgery unit
is proposed, the occupant load is increased accordingly.
Plans for ambulatory health-care (surgery) centers must be submitted to the City of Fresno
Planning and Development Department for plan review. A separate submittal directly to
the City of Fresno Fire Department (FFD or Department) for fire sprinkler and fire alarm
systems is also required for facilities to be HHS licensed.
The California State Department of Public Health Services (CDPH) office works under a
contract with the federal government to conduct inspections mandated by the HHS. They
will only conduct such an inspection after a facility is constructed; however, they will
complete a courtesy review of the submittal for compliance with NFPA 101. The applicant
must contact the local CDPH, Licensing and Certification office.
INFORMATION
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DEFINITIONS
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CROSS REFERENCES
HHS Form CMS-2786U (07/2018) contains a complete list of federal requirements that
must be met for a building to be approved as a federal funded, HHS approved Ambulatory
Surgery Center. A copy of HHS form CMS-2786U (07/2018) for a new ambulatory surgery
center is available on their website at the following address.
https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/CMS-Forms-Items/CMS009395
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