1. Do I need to submit drawings with the Seismic Evaluation Report?
The submittal requirements for the seismic evaluation can be found in 2019 California Administrative Code, Chapter 6, Section 1.3, Seismic Evaluation and all subsections which follow. These provisions stipulate that certain drawings and plans are an integral part of the Seismic Evaluation Report. The evaluator shall use drawings, diagrams, and details to accurately present the information necessary to communicate evaluated conditions and details of the subject existing building system.
The graphical information can be presented and incorporated in the evaluation report.
2. Which Acute Care Hospitals are designated as rural and small hospitals in Seismic Zone 3?
Rural & Small Hospitals in Seismic Zone 3
|Hospital Facility Name||Notes|
|Alta District Hospital||Peer Group 5|
|Barton Memorial Hospital|
|Biggs-Gridley Memorial Hospital|
|Bloss Memorial District Hospital|
|Central Valley General Hospital||Federal Designation|
|Chowchilla District Memorial Hospital|
|Colusa Community Hospital|
|Corcoran District Hospital|
|Del Puerto Hospital|
|Dos Palos Memorial Hospital|
|Eastern Plumas District Hospital|
|Glenn General Hospital|
|Hanford Community Hospital|
|Indian Valley Hospital|
|John C. Fremont Hospital|
|Kingsburg District Hospital||Peer Group 5|
|Lassen Community Hospital|
|Lindsay Hospital Medical Center|
|Mark Twain St. Joseph′s Hospital|
|Mayers Memorial Hospital|
|Memorial Hospital, Exeter||Peer Group 7|
|Mercy Medical Center, Mt. Shasta|
|Modoc Medical Center|
|Needles-Desert Community Hospital|
|Oak Valley District Hospital||Peer Group 5|
|Palo Verde Hospital|
|Plumas District Hospital|
|Sanger Hospital||Peer Group 5|
|Selma District Hospital|
|Seneca District Hospital|
|Sierra Nevada Memorial Hospital||Federal Designation/
Peer Group 5
|Sierra Valley Community Hospital|
|Sierra-Kings District Hospital||Peer Group 5|
|Siskiyou General Hospital|
|Sonora Community Hospital||Peer Group 5|
|St. Elizabeth Community Hospital|
|Surprise Valley Community Hospital|
|Sutter Amador Hospital|
|Tahoe Forest Hospital|
|Tuolumne General Hospital|
3. Can a different format be used for the “Compliance Plan Schedule” than the one specified in the regulations if we add a space for the governing codes and the year of construction?
2019 California Administrative Code, Chapter 6, Section 22.214.171.124 specifies the items required for a complete “Compliance Plan Schedule” and Section 126.96.36.199 specifies the information required for the “Existing and Planned Buildings Matrix”. An augmented version of these documents is acceptable only if all the required items are included in the modified document.
4. We are doing a major SB1953 retrofit on a hospital building. Will this trigger compliance with accessibility for disabled persons? Does the answer change if functional service areas are remodeled? Any range on cost to do accessibility changes?
Where the total cost of a retrofit, or remodel, exceeds the current valuation threshold discussed below, and the Office determines that the cost of full compliance is an unreasonable hardship, compliance shall be provided to the greatest extent possible; but in no case shall be cost of compliance be less than 20 percent of the cost of the alterations, structural repairs or addition. Where the total construction cost of a retrofit or remodel project does not exceed the most current valuation threshold and the cost of compliance with the accessibility requirements is disproportionate (i.e. exceeds 20% of the total project cost) without the required accessibility features, an “unreasonable hardship” may also exist. The Office will use the most current valuation threshold in determining if a retrofit or remodel project would create an “unreasonable hardship”. The 2021 valuation threshold is $172,418.00 and OSH-FD-800 application can be used when applicable.
The latest enforceable accessibility requirements for persons with disabilities contained in CBC Section 11B-202.4, Part 2, Title 24 (referenced from California Existing Building Code Section 305A.1) apply to any project submitted to the Office for hospital building retrofit or remodel, pursuant to SB 1953 regulations. OSHPD does not have the authority to enforce federal (ADA) accessibility requirements for disabled persons. If functional service areas are remodeled, the remodeled area will also need to comply with any accessible elements and path-of-travel requirements associated with the specific area of remodel. For additional information refer to Code Application Notice (CAN) 2-11B.
5. Can a conforming hospital building (SPC 3, 4, 4D or 5) be supplied with utilities emanating from a SPC 1 hospital building?
A SPC 1 hospital building will cease operation as a general acute care hospital building at the end of the maximum extension granted to that building. Refer to California Existing Building Code Section 307A.1.1.1 for additions, alternations and remodels of conforming hospital buildings.
6. Clarify as to which buildings fall under SB 1953 especially in those cases where the building contains more than one licensed category of service.
Though a hospital building may provide different categories of services, HCAI is not aware of any hospital buildings which are licensed under multiple licensure categories. 2019 California Administrative Code, Chapter 6, Section 1.2, Definitions, has the term “General Acute Care Hospital” which specifies the types of buildings included under the auspices of SB 1953. This definition states in part that
- “…a hospital building as defined in Section 129725 of the Health and Safety Code and also licensed pursuant to Section 1250 (a) of the Health and Safety Code…It also precludes hospital buildings that may be licensed under the above mentioned code sections, but provide skilled nursing services only.”
Hospital owners have various options under SB 1953 provisions for the continued use of noncompliant buildings. As part of the compliance plan, hospital owners may choose to remove all acute care services from selected buildings subject to the approval of the Department of Health Services Licensing and Certification Division (L&C).
7. If a Static Nonlinear (Pushover) design approach is used, can the hospital utilize the same engineering specialist that assists with the analysis to provide the peer review functions?
No, see 2019 California Building Code Section 1617A.1.41, Part 2, Title 24.
8. How do I add building projects to a hospital inventory or complete the certifying process for SPC5/NPC4 for a new building?
To add a building to our hospital inventory or complete the process of certifying SPC5/NPC4 for a new building, submit an SER project to the Seismic Compliance Unit with the following information:
- Form FD-121 on our website – first 4 pages of the form are sufficient. For “Project Type”, select “Seismic Retrofit Program” and write in “Add Building”.
- Evaluation of the building per 2019 California Administrative Code (CAC), Chapter 6. If new HCAI approved construction – letter stating building is conforming per 2019 CAC, Article 2.0.1 (Item 2.1) and Article 11.01.2.2 will suffice.
2019 CAC, Article 2.0.1, Item 2.1
2.1. A conforming building as defined in Article 1, Section 1.2, may be placed into SPC 5 in accordance with Table 2.5.3 under the following circumstances:
- The building was designed and constructed to the 1989 or later edition of Part 2, Title 24, and
- If any portion of the structure, except for the penthouse, is of steel moment resisting frame construction (Building, Type 3, or Building Type 4 or 6 with dual lateral system, as defined in Section 2.2.3) and the building permit was issued after October 25, 1994.
2019 CAC, Article 11.01.2, Item 2
2. The building is designated “NPC 4” in conformance with Table 11.1 “Nonstructural Performance Categories” and provided:
- The building was designed and constructed under a building permit issued by HCAI;
- All subsequent repairs, remodels, additions and alterations were performed under a permit issued by HCAI, and
- Fire sprinkler systems have been retrofitted in conformance with Table 11.1, “Nonstructural Performance Categories.”
Per Table 11.1, Fire sprinkler systems shall comply with the bracing and anchorage requirements of NFPA 13, 1994 edition, or subsequent applicable standards.
- Matrix of Construction per 2019 CAC, Chapter 6, Section 1.3.4, Item 6,Page 86.
- Amended or revised site plan showing location of buildings. Recommend including approved drawings for this building, PDFs are OK. This will speed up the review as it takes time to retrieve the drawings from archives.
- Matrix of Construction per 2019 CAC, Chapter 6, Section 1.3.4, Item 6,Page 86.
The Seismic Compliance Unit will assign SPC 5/NPC 4 to the building if the project under which the building was built is closed in compliance.
9. How do I remove Acute Care Services from a hospital building?
This is a 2-step process:
- Step 1 – Submit a Removal of Acute Care Services project
Submit a project (commonly referred to as a RACS, Removal of Acute Care Services project) to the appropriate region of the Building Safety Section of HCAI/FDD that demonstrates that the building qualifies to have acute care services removed and is eligible to be handed to either the local jurisdiction or remain in HCAI jurisdiction as a non-hospital building (may include Acute Psychiatric or Skilled Nursing uses).
See 2019 California Existing Building Code, Section 309A for the requirements for such a project. Also see CAN 1-6-188.8.131.52.4 for examples on this issue even though this CAN has superseded by the 2019 California Building Code.
For further information, talk to the supervisor of the appropriate region of the Building Safety Section of HCAI/FDD where the building is located.
- Step 2 – Submit a SER project
After RACS project from Step 1 has been completed and closed in compliance, submit an SER project to the Seismic Compliance Unit of HCAI/FDD with the following information:
- Form FD-121 on our website – first 4 pages of the form are sufficient. For “Project Type”, select “Removal of Acute Care Services” and select one of the choices therein.
- Where HCAI jurisdiction is requested, provide the RACS project number and approval letter.
- Where Local jurisdiction is requested, provide the letter written by the supervisor of the appropriate region that hands the jurisdiction of the building to local authorities.
- Amended or revised site plan showing location of remaining buildings that remain in HCAI jurisdiction.
Recommend including approved drawings for the RACS project, PDFs are OK. This will speed up the review as it takes time to retrieve the drawings from archives.
The Seismic Compliance Unit will then remove the building from the list of buildings that need to comply with Senate Bill 1953 and reclassified as OSHPD 1R. Where the building is being handed to local jurisdictions, the building is removed from the list of hospital buildings all together.
10. How are demolished buildings removed from the Seismic Compliance Unit list of hospital buildings?
When buildings are demolished, provide a SER project application to the Seismic Compliance Unit for each of the buildings with the following information:
- Form OSH-FD-121 on our website – first 4 pages of the form are sufficient. For “Project Type”, select “Seismic Retrofit Program” and write in “Demolition of Building”
- Amended or revised site plan showing location of remaining buildings.
- Relevant sheets of permit drawings under which building was demolished (PDFs OK).
- Field staff report showing start or completion of demolition or demolition progress photographs.
The Seismic Compliance Unit will then remove the building from the list of hospital buildings.
11. What is the process for the Detailed Frame Joint Evaluation Procedure for Pre-Northridge Moment Frame Buildings after an earthquake?
The three step process is as follows:
- Step 1: Submit a CJP (Complete Joint Penetration) Joint Inspection Program
Submit a CJP Joint inspection program to Seismic Compliance Unit per 2019 California Administrative Code, Chapter 6, Section 184.108.40.206 to the Seismic Compliance Unit where buildings have exceeded the ground motion specified in 2019 CAC Chapter 6, Section 220.127.116.11.
- Step 2: Submit a project for the joint inspection
After the CJP Joint inspection is approved, submit a project for the joint inspection to the appropriate region of the Building Safety Section or the Field Compliance Unit. Here the full application (OSH-FD-121 or application in eServices) is required. Obtain a building permit and perform the joint inspection.
- Step 3: Submit the results of the joint inspection to the Seismic Compliance Unit
Submit the results of the joint inspection to the Seismic Compliance Unit . Use application form OSH-FD-121 (first 4 pages are sufficient). If there is no damage, the Seismic Compliance Unit will concur with the results of the joint inspection and close SCU projects. Perform additional joint inspections depending on a damage index based on the results of field joint inspection where required. If some damage is found, the Seismic Compliance Unit will discuss possible repair projects with the responsible design professionals.
- The joint inspections for affected buildings should be completed within six months after the earthquake.
- The joint inspection project should be left open until the Seismic Compliance Unit concurs with the results.
- Include notes on the process for inspection (2013 processforinspections.doc) with the joint inspection project.
- The joint inspection project will be reviewed by a fire marshal to verify replacement in kind of the fire proofing removed for the joint inspection.
- 2019 California Administrative Code, Chapter 6
4.2 Steel moment frames. Welded steel moment frames may be subject to detailed frame joint evaluation requirements, as outlined in this section. The purpose of this joint evaluation is to determine if the building has experienced joint damage in strong ground shaking.
18.104.22.168 Preliminary screening. All welded steel moment frame structures shall undergo a detailed frame joint evaluation if the building is located at a site that has experienced the following:
- An earthquake of magnitude greater than or equal to 6.5 that produced ground motion in excess of 0.20 g; or
- An earthquake that generated ground motion in excess of 0.30g.
The ground motion estimates shall be based on actual instrumental recordings in the vicinity of the building. When such ground motion records are not available, ground motion estimates may be based on empirical or analytical techniques. All ground motion estimates shall reflect the site-specific soil conditions.
22.214.171.124 Additional indicators. A detailed frame joint evaluation of the building shall be performed if any of the following apply:
- Significant structural damage is observed in one or more welded steel moment frame structures located within 1 km of the building on sites with similar, or more firm, soil properties;
- An earthquake having a magnitude of 6.5 or greater, where the structure is located within 5 km of the trace of a surface rupture or within the vertical projection of the rupture area when no surface rupture has occurred;
- Significant architectural or structural damage has been observed in the building following an earthquake; or
- Entry to the building has been limited by the building official because of earthquake damage, regardless of the type or nature of the damage.
126.96.36.199 Connection inspections. Detailed frame joint evaluations shall be performed in accordance with the procedures in the Interim Guidelines: Evaluation, Repair, Modification and Design of Welded Steel Moment Frame Structures, FEMA 267, August 1995.
- Accessibility requirements for Detailed Frame Joint Evaluation Procedure for Pre-Northridge Moment Frame Buildings
The detailed frame joint evaluation procedure for pre-Northridge moment frame buildings involves a visual, ultrasonic or magnetic particle inspection of moment frame joints in an existing building. As the inspections of the joint by itself does not constitute a “building alteration, structural repair or addition”, accessibility requirements of Chapter 11B of 2019 California Building Code do not apply. Spray-on-fireproofing or other fireproofing materials removed from the moment frame joint for the purposes of the inspection also do not constitute a “building alteration, structural repair or addition” where they are replaced in kind soon after the inspection (may be subject to special inspection under Section 1705A.14 Sprayed Fire-resistant materials). Where non-structural framing, finishes and/or ceiling systems are removed or altered temporarily to gain access to the joint, and then replaced in kind, the accessibility requirements apply only when the work performed exceeds an amount that would normally be required to gain access to the moment frame joint – a rule of thumb used in such cases is accessibility requirements apply when more than 25% of the ceiling in a room is temporarily removed/altered. Any repair, removal or alteration and replacement of structural systems such as beams, bearing and/or shear walls, will trigger accessibility requirements of Chapter 11B of the 2019 California Building Code, see examples in CAN 2-11B.
12. Do buried tunnels have SPC or NPC ratings?
• Buried tunnels connecting hospital buildings that are not used for public egress (such as utility tunnels with just service personnel access) receive NPC ratings only.
• Buried Tunnels for public use (such as tunnels linking the basements of multiple hospital buildings) are required to have SPC and NPC ratings.
The actual use of the tunnels may be verified by HCAI field staff.
Seismic Performance Category (SPC)
1. Can I submit a letter declaring the seismic performance category of a hospital building instead of a detailed Seismic Evaluation Report?
Per 2019 California Administrative Code, Sections 188.8.131.52 (SPC) and 11.01.2 (NPC) list the specific conditions where a hospital facility owner can submit a written declaration and be exempt from submitting either a structural or nonstructural evaluation report. However, the matrix of construction information specified in Section 184.108.40.206 shall be submitted pursuant to the requirements of Section 1.3.1. There are no other provisions for exemption from the Seismic Evaluation Report.
2. What if I don′t have any existing drawings?
When performing the structural evaluation for a hospital building without existing drawings or sufficient construction documents, as-built drawings as required by 2019 CAC, Chapter 6, Sections 220.127.116.11.1 and 18.104.22.168.2 shall be rendered to determine the SPC category of the specified hospital building. Refer to Sections 22.214.171.124, Item (d); 11.2.2, Item (e) and 11.2.3, Item (e), when performing the nonstructural evaluation to determine the NPC category of a hospital building without existing drawings or sufficient construction documents.
Additionally, the Seismic Evaluation Report and Compliance Plan/Schedule submittal process does not require original construction documents, only the information specified in Sections 1.3 and 1.4 and their respective subdivisions.
3. Is HCAI′s expectation that a SPC 2 upgrade provides a “Life Safety” level of performance?
The various levels of structural seismic performance established by SB 1953 include potential collapse hazard (SPC 1) to immediate occupancy (SPC 5) after a seismic event. The SPC 2 may not be repairable or functional after the event and, therefore; unable to provide general acute care hospital services. Buildings reclassified to SPC-2 on the basis of their collapse probability assessment (HAZUS) have a calculated probability of collapse which increases with the presence of significant structural deficiencies in the building.
4. Is HCAI′s expectation that a SPC 5 upgrade provides an “Immediate Occupancy” level of performance?
The various levels of seismic performance established by SB 1953 include potential collapse hazard (SPC 1) to immediate occupancy after a seismic event (SPC 5). The SPC 5 subgradation is currently the highest level of seismic structural performance. After a seismic event, it is anticipated that a SPC 5 facility will survive; suffering only very limited structural damage and will be able to provide full general acute care patient services (i.e. immediate occupancy).
5. What is the HCAI/FDD process for Material Testing and Condition Assessment for SPC-4D projects?
The following steps explain the process for Material Testing and Condition Assessment. However, the steps described below apply to any type of material testing projects (i.e. same for material testing required by SPC-2 “Usual Level” or SPC 4D “Comprehensive Level”).
Step 1: Submit an Application and Material Testing and Condition Assessment Program (MTCAP) Documents
- Submit an application (do not use the eServices Portal (eSP)) to the Seismic Compliance Unit with complete MTCAP documents. Material Testing Program (MTP) and Condition Assessment Program (CAP) applications/programs can be submitted separately. Applications and programs may be submitted electronically via email or a FTP service. NOTE: Seismic Compliance Unit projects start with the letters SER (e.g. SER-2016-00035).
- Seismic Compliance Unit reviews the structural scope of the MTCAP, the detail drawings and specifications. After getting approval for the program from the Seismic Compliance Unit, the SER project gets closed. The Seismic Compliance Unit typically stamps the cover page of the report and electronically delivers the approved MTCAP report.
Step 2: Submit an Application to the HCAI/FDD Region
- Submit an application (eServices Portal may be used here) to the appropriate HCAI/FDD region including the following documentation: (These projects may be processed in accordance with the FREER Manual as a Field Review project).
- Approved MTCAP report and approval letter.
- Construction documents, which shall include all of the following:
An overall building floor plan showing the proposed locations of inspection;
Emergency procedures for construction workers;
Details and requirements for restoration of finishes and/or fire rated assemblies;
When inspection impacts means-of-egress, a temporary exiting plan;
Plans and details for temporary construction barriers;
Fire watch procedures: When it is not possible to maintain fire-resistive assemblies, fire-resistive construction and/or the means of egress, temporary construction barriers and/or a fire watch shall be provided in accordance with HCAI FDD PIN 14.
- TIO form
OSHPD/FDD region review includes architectural, structural, fire/life safety. Electrical or mechanical review are typically not required.
After the HCAI/FDD region approves the project and issues a permit for the MTCAP project, construction phase (i.e. testing) starts.
During the Conditions Assessment, fire-resistive assemblies, fire-resistive construction and the means of egress shall be maintained in accordance with Chapters 7 and 33 of the California Fire Code. These plans and procedures shall be reviewed and approved by the HCAI field staff (Compliance Officer, Fire and Life Safety Officer and District Structural Engineer) and the local fire authority (as applicable) in accordance with Section 3301 of the 2019 California Fire Code. Compliance with the provisions of Chapter 33 of the 2019 California Fire Code are in addition to any additional regulations or requirements pertaining to dust control, noise control and asbestos abatement enforced by agencies other than HCAI FDD.
When demolition, inspection and reconstruction is continuous, no hot work is involved and inspectors and construction workers are in constant attendance, enforcement of temporary construction barrier and / or fire watch requirements may be deferred. Under these conditions, appropriate procedures shall be established in the event of a fire or other emergency.
During sampling stage, if any deviation from the MTCAP report occurs, such as sampling location, number of samples etc., Seismic Compliance Unit shall be notified immediately via email with a brief description of the change, a photo and any additional supporting documentation. To prevent any construction delays, Seismic Compliance Unit will respond back via email as soon as possible (Keep track of these responses, as these communications will be required in the MTCAR report).
Where changes are extensive, an amended construction document may be required at the discretion of the District Structural Engineer in consultation with the Seismic Compliance Unit.
Seismic Compliance Unit recommends that the project remain open (within time limitations per 2019 CAC 7-129) until the results are accepted by the Seismic Compliance Unit just in case additional testing or inspection is required.
Step 3: Submit an Application to the Seismic Compliance Unit with a complete Material Testing and Condition Assessment Report (MTCAR)
- Submit an application (do not use the eServices Portal) to the Seismic Compliance Unit with complete MTCAR reports, include all deviations, and corresponding Seismic Compliance Unit (SCU) approval emails. Applications and documents may be submitted electronically via email or a FTP service.
- SCU issues MTCAR approval letter, and closes SER project.
- Close the construction project.
Nonstructural Performance Category (NPC)
1. The continuous operation issue is to be addressed for hospitals that are to remain in existence beyond the 2030 deadline. Since the 2008 milestone relates to life safety performance, why does the Nonstructural Performance Category (NPC) 3 category require components that are part of continuous operation systems to be anchored and braced, when located in critical care areas and other support areas critical to patient care?
The NPC′s were developed with the intent of establishing various levels of seismic performance for nonstructural equipment, components and systems critical to patient care. The critical distinction between any two NPC′s is not merely the survivability of the facility, but its level of functionality after a seismic event. Nonstructural components and systems have a lower threshold to seismic forces than structural elements and systems.
Buildings in the NPC 3 category are expected to maintain their inpatient population following a moderate earthquake, as well as provide a full array of emergency services to the public. To enable a NPC 3 hospital building to provide these level of services (i.e. beyond mere survivability and be able to provide a minimal amount of medical care in specific areas) it is necessary to provide the bracing and anchorage specified in California Administrative Code, Chapter 6, Table 11.1, Nonstructural Performance Categories.
2. Do critical care areas such as Emergency Rooms which are not part of the required Basic Services have to meet with the requirements of NPC?
In Section 1.2, Definitions, the term “Critical Care Area” is defined as “those special care units…in which patients are intended to be subjected to invasive procedures and connected to line-operated, electromedical devices.” Within this definition, “emergency rooms” is listed as a type of critical care area. The California Administrative Code, Chapter 6, Table 11.1 lists “Critical Care Areas” in NPC 3 as an area where specified components/equipment/systems must meet the bracing and anchorage requirements of Part 2, Title 24. Therefore, “emergency rooms” must meet the requirements as specified in the NPC 3.
3. Would a Neurocare Ward (not ICU) with patients hooked up to a ventilator fall under the definition of “critical care”? Also, would a telemetry unit be considered “critical care” area?
A neurocare ward would be considered a “critical care” area due to the nature of the treatment for the patients placed in them or the type of service provided (e.g. postoperative from brain surgery, etc.). A telemetry unit need only be considered for evaluation purposes if it supports a critical care area. In this context, a “telemetry unit” is defined as a group of patient beds with remote monitoring.
4. Regarding Exhaust Fans – does that mean ALL fans in the system or only those above a certain threshold value? And if so, what is that threshold value?
ASCE 7, Section 13.6 specifies the requirements for seismic bracing of mechanical and electrical equipment suspended from the structure. In addition Article 11 requires that mechanical, electrical systems, components and equipment shall meet the anchorage and bracing requirements of Part 2, Title 24.
5. One of our hospital buildings does not have fire sprinklers now. If this building is seismically retrofitted to SB 1953, SPC 2 level, will this require us to install a fire sprinkler system? What about SPC 5 level?
Sprinkler systems fall under the Nonstructural Performance Categories (NPC′s) and not under the Structural Performance Category (SPC) requirements. Compliance with SB1953 does not require that fire sprinkler systems be installed where none existed before, even for SPC 5 conformance. However, hospital buildings with existing fire sprinkler systems must meet the anchorage and bracing requirements of NPC 3 and NPC 4.
6. Are there areas within a typical hospital where the Nonstructural Evaluation requirements of SB 1953 do not apply?
The answer to this question depends on the desired NPC level of performance. Table 11.1, Nonstructural Performance Categories, determines the applicability of the nonstructural evaluation requirements for a hospital. If the desired performance level is NPC 4 or 5 (for acute care operation beyond 2030) then all areas of the hospital are subject to the requirements as listed in California Administrative Code, Chapter 6, Table 11.1. However, NPCs 2 and 3 primarily impact critical care areas of a hospital, with adjacent non-critical care areas affected by presence of specific systems (e.g. communications, emergency power, means of egress, fire alarm and med-gas) as delineated in California Administrative Code, Chapter 6, Table 11.1.
7. Are single line diagrams required for the location of certain hospital areas?
The Nonstructural Evaluation Report (see 2019 California Administrative Code, Chapter 6, Article 1, Section 1.3.4, Item 2.1) must include single line diagrams for the location of the following:
Central supply areas
Clinical laboratory service spaces
Critical care areas
Pharmaceutical service spaces
Radiological service spaces
Sterile supply areas
There are no provisions requiring single line diagrams for other hospital areas.
8. What is meant by “description…where deficiencies are identified” in Section 1.3.4, Item 2.2 of Article 1?
Nonstructural elements and systems which do not meet the requirements of Article 11 should be reported as deficiencies. These deficient systems/elements should be described in the nonstructural evaluation either in narrative or diagrammatic format as specified in 2019 California Administrative Code, Chapter 6, Article 1, Section 1.3.4, Item 2.2.
The essential aspects of this description shall include identification and location of deficiencies within specific building systems including but not limited to the mechanical, plumbing, and electrical systems of the building and their respective components which fall within the scope of the nonstructural evaluation.
9. Often in hospital corridors the ceiling space is filled with pipes and conduits. Is it acceptable to create a secondary frame to “catch” the pipes to protect the exiting corridors instead of bracing all the pipes?
Though catching the pipes is important, it is not the primary issue. In addition to the potential as a falling hazard that the pipes may represent, it is also important to prevent escape of the pipes′ contents should the pipes break. Proper anchorage and bracing will reduce movement and shearing of pipes, and thus reduce the possibility of the escape of the contents. Therefore, the anchorage and bracing of pipes and conduits must meet the requirements of Chapter 16A, Part 2, 2019 California Building Code. Secondary framing is an option available for pipe bracing, but is dependent on site conditions.
10. Regarding air handlers that are functionally inadequate and have to be braced, do I have to replace them?
No, all that is required is that the air handlers be braced and anchored, not replaced.
11. If the intent of SB 1953 NPC 3 is to prevent loss of water from pipes in critical care areas, do we have to brace pipes from the central plant to the critical care areas? We infer the intent to prevent water loss from the valving option permitted. Can we only valve the pipes at the boundaries of critical care?
Pipes from the central plant supplying or passing through the areas specified in the NPC 3 category do not need to be braced outside the boundaries of those areas. However, equipment anywhere in the physical plant that services the NPC 3 specified areas shall be anchored and braced.
NPC 3 Exception 1 permits piping systems not be anchored and braced until 2030 provided that “an approved method of preventing release of the contents of the piping system in the event of a break is provided.” Valving the piping system is an acceptable method of preventing the escape of the pipe systems contents in the event of pipe breakage or shearing. The configuration of the valving layout depends on the layout of the piping within the NPC 3 specified areas. It should be noted that valving the pipes only at the boundaries may or may not prevent the release of pipe contents in those areas.
12. Could a policy be established which would clearly delineate the equipment within a hospital that would be affected by SB 1953?
No. As medical and other types of equipment vary from hospital to hospital, it is impractical to establish a policy with a definitive list of equipment which would be affected by SB 1953. The evaluation procedures and evaluation (appendix) questions delineate the conditions, equipment, systems, and components which fall under the general scope of the seismic evaluation.
13. In Article 11, the NPC process involves first a complete survey, then determining whether an HCAI permit exists, then making a NPC designation. This infers that in a code compliant structure, we have to do the whole survey even though it was built with full inspection. We cannot rely on an HCAI permit and inspection to designate the structure as compliant. Isn′t this backwards? We intended to look for permits first, and then survey the non-compliant areas.
The evaluator is free to perform the nonstructural evaluation in any manner desired. Hospital buildings constructed under a permit issued by HCAI are deemed to comply with the anchorage and bracing requirements of Title 24, with the exception of the fire sprinklers. For other types of buildings, a review of the available drawings to determine the extent of the nonstructural bracing prior to conducting the site visit is very prudent. Aside from establishing the level of anchorage and bracing required to be expected, it will allow the evaluator to inventory components appearing on the drawings that should be braced. As a rule all major components that require bracing should be shown on the drawings. It is important to note that the evaluation is limited to those systems and components listed in the 1995 CBC, Part 2, Title 24, Table 16A-O.
All compliant buildings are not the same. Between 1973 and 1983, the enforcement of the code requirements for nonstructural elements, components and systems was inconsistent. The level of attention given to nonstructural bracing varied tremendously. This is substantiated by the nonstructural failures that occurred in various post-1973 hospitals as a result of the Northridge Earthquake.
In the late 1970′s and 1980′s some pre-1973 buildings had extensive remodels. The scope of these remodels can vary extensively, from cosmetic alterations to a complete gutting of the space, with reconstruction to current standards. It is not unusual to find braced and unbraced components next to each other in the same space. If the component or system was not modified during the remodel, then it was probably not seismically retrofitted. Only by inventorying the systems can the extent of the seismic bracing be definitively established.
14. Do hospital facilities need to meet the requirements of NPC-5 now?
No. The milestone date for NPC-5 compliance is January 1, 2030 per 2019 California Administrative Code, Chapter 6, Table 11.1.
However, if a new seismically separate general acute care hospital building greater than 4000 square feet is constructed, it is required to be NPC-5 compliant per Section 1616A.1.40 of the 2019 California Building Code. Only the new building is required to be NPC-5 compliant and not the entire facility.
15. Is NPC-5 a campus-wide designation (like NPC-2) or a seismically separate building designation?
NPC-5 is a campus-wide designation with compliance expected in 2030, but new seismically separate buildings constructed to the 2010 or later California Building Codes are required to be NPC-5 compliant now. HCAI recommends planning to comply on a campus-wide basis with a phased approach to get NPC-5 compliance for a new building before it’s occupancy.
16. Is a hospital facility required to have storage tanks for 72 hours of water and sewage and liquid waste? The required tanks are too big and our site does not have the room for placement of such tanks.
NPC-5 refers to the ability of a hospital facility to support 72 hours of emergency operations. The California Plumbing Code has exceptions (see Sections 615.4 and 727.0 of the 2019 California Plumbing Code) that allow much smaller holding tanks where alternate arrangements have been made for delivery of water or transportable means for sewage and liquid waste disposal. Where such exceptions are used, the arrangements require approval by HCAI and the California Department of Public Health.
17. Does the NPC-5 requirement of 72 hours of water refer to potable water only? Is industrial water or (process) water to operate hospital utilities included in this storage requirement?
NPC-5 requirement refers to both potable water as well as industrial/process water to operate hospital utilities to support 72 hours of emergency operations:
For a seismically separate building that has licensed patient beds, a minimum of 150 gallons of potable water shall be provided (Section 615.4,2019 California Plumbing Code) with additional industrial/process water to support 72 hours of emergency operation of the subject building. Also see exception in California Plumbing Code Section 615.4.1. For a seismic separate building that has no licensed patient beds, potable water and industrial/process water to support 72 hours of emergency operation of the subject building. A new Central Utility Plant must provide water for 72 hours of emergency operation for itself, any other new buildings but not for the existing buildings on the campus (The existing buildings will need to comply by 2030).
The amount of water required is determined from the facility’s emergency operations plan and an associated Water Conservation/Water Rationing Plan to provide for 72 hours of operation. The water conservation/water rationing plan must also be accepted by the California Department of Public Health licensing division. Whereas, there is a minimum volume of potable water per licensed bed, there is no minimum volume for industrial/process water in the California Plumbing Code. This volume is dependent on which utilities and systems the hospital facility intends to operate during an emergency. The Water Conservation/Water Rationing Plan must account for losses in the process water for closed loop heating and cooling systems.
See a planning guide titled “Emergency Water Supply Planning Guide for Hospitals and Health Care Facilities” published by DHHS, CDC and AWWA.
HCAI review of NPC-5 will be based on the volume of water required by the facility’s Water Conservation/Water Rationing Plan (as part of the facility’s emergency operations plan) with a minimum of 150 gallons of potable water per licensed bed as required by the California Plumbing Code.
18. Does the facility have to comply with Section 615.4.2 of the 2019 California Plumbing Code even when using the exception in Section 615.4.1?
Section 615.4.2 of the 2019 California Plumbing Code requires the emergency supply of water be provided with sufficient pressure using gravity, pressure tanks or booster pumps. If booster pumps are provided, they are required to be connected to the emergency power supply system.
Section 615.4.2 applies even when the exception of Section 615.4.1 of the California Plumbing Code is used, to ensure that the emergency supply of water is delivered to the end point of usage at sufficient pressure from the storage tank. The ability to dispense water to portable containers from the storage tank required in the exception of Section 615.4.1 of the California Plumbing Code is to be considered a measure of last resort.
19. Per Section 727, of the 2019 California Plumbing Code, can the facility store the sewage and liquid waste in a 5,000-gallon tank? Does this tank need to be connected to a sewage line?
Yes, holding tanks are required; however, there is no minimum size for the holding tank provided in Section 727,2019 California Plumbing Code. The capacity shall be based on the Water Conservation/Water Rationing Plan required in Section 615.4.1.
The purpose of the holding tank is to permit 72 hours of continuing operation if the external sewer connection is severed. Thus, HCAI does not have any requirements for connection of the holding tank to the existing sewer line; however, such connections should be made with sufficient valves to isolate the external sewer lines.
20. Can we use bladder tanks to store sewage and waste water in the parking lot?
The exception to Section 727,2019 California Plumbing Code permits use of leak-proof bags where adequate storage for such bags is provided where they comply with the appropriate local health and environmental authorities’ requirements, California Department of Public Health requirements for medical waste management AND requirement for location as well as enclosure.
HCAI takes no objection for use of the parking lot or any other location for storing these bags, IF the storage location complies with the requirements of a lockable screen enclosure, floor, curb, drain connected to a sewer and supply of water as enumerated in this exception.
21. Is the fuel storage requirement based on 96 hours or 72 hours? Are the fuel storage requirements based on fuel consumption of the generators at rated capacity or the actual load for the facility?
HCAI enforces a minimum of 72 hours of fuel storage for the new NPC-5 building and not the 96 hours required by NFPA 101. However, NFPA 110 requires the main fuel tank(s) to have a minimum capacity of at least 133% of the quantity required by 2019 CEC 700.12 (B) (2) Exception 1 or 2. For NPC 5 buildings, the minimum capacity requirement is 133% of 72 hour fuel supply.
The fuel consumption for the NPC-5 building should be based on the actual load (“full-demand” on the Essential Electrical System per 2019 California Electrical Code Sections 517.25 and 700.12 (B)) from the facility for its emergency operations. The fuel consumption of the generators may be interpolated from literature provided by the generator manufacturer for the actual load expected during emergency operations.
22. NPC 3 upgrade requirements for GAC buildings that do not contain critical care spaces noted in 2019 California Administrative Code, Chapter 6, Article 11, Table 11.1
The facility needs to submit a formal request for NPC 3 upgrade when a building does not contain any of the critical care spaces noted in the NPC 3 description. The NPC 3 upgrade request needs to provide a functional layout for all the areas in the building showing what the various areas are used for. Also, if equipment serving the critical care areas in other buildings is in the building in question, then a full NPC 3 upgrade would be required.
Skilled Nursing Facility (SNF)/Acute Psychiatric Facility
1. Do Skilled Nursing Facility buildings have to meet the requirements of SB 1953?
Skilled Nursing Facility buildings (SNFs) which are licensed under 1250 (c) of the Health and Safety Code do not have to meet the requirements of SB 1953. Also precluded are hospital buildings that are licensed under Section 1250 (a), General Acute Care, but provide skilled nursing services only. For additional information, refer to the response to Question #3 below.
2. My Skilled Nursing Facility (SNF) is on the third floor of one of my General Acute Care (GAC) buildings. What are the requirements of SB 1953 for this arrangement?
The entire building is subject to the SPC requirements. With respect to the NPC requirements, the SNF area would not be considered “critical care area” under the NPC 3 category for compliance, but it will be subject to the NPC 4 requirements for compliance.
3. My SNF building is under GAC license but it is a separate building on the campus. Does SB 1953 require this building to be evaluated?
The Seismic Evaluation Procedures and Compliance Plan Regulations were developed by HCAI specifically for implementation by GAC licensed hospital buildings in furtherance of the Alfred E. Alquist of Hospital Facilities Seismic Safety Act of 1983. These regulations require GAC licensed hospitals to perform seismic evaluations on their respective facilities and for mitigation of substandard structural and nonstructural conditions by the seismic retrofit (compliance) plan.
In the 2019 California Administrative Code, Chapter 6, Section 1.2, Definitions, the term “General Acute Care Hospital” is defined. It states in part the following:
“…a hospital building as defined in Section 129725 of the Health and Safety Code and also licensed pursuant to Section 1250 (a) of the Health and Safety Code…(but) It also precludes hospital buildings that may be licensed under the above mentioned code sections, but provide skilled nursing services only.”
Therefore, a building which contains no GAC licensed beds or services but is used only for SNF beds and services is not subject to the requirements of SB 1953 even though it is under the GAC license. However, the building must be “freestanding and separate” in accordance with the conditions set forth in HCAI Policy Intent Notice #HSC-129725, revised August 20, 1996. For additional information, refer to Question #4 below.
4. If all the general acute care beds are moved into one building and all the SNF beds are moved into and/or remain in the other building, is this other building subject to the requirements of SB 1953?
No. Even if the SNF beds are listed on the general acute care license, this building is not subject to SB 1953. It is not a hospital building within the meaning of Section 130005 (k) of the Health and Safety Code. See also 2019 California Administrative Code, Chapter 6, Part 1, Article 1, Section 1.2, Definitions – General Acute Care Hospital. This section explicitly excludes hospital buildings that provide skilled nursing services only. However, this building must be physically separate from the building housing GAC services or be separated by a seismic joint. This answer also applies to existing, separate buildings listed on the general acute care license that exclusively contain SNF beds.
Facilities should be aware of the possible Medi-Cal reimbursement consequences of a general acute care hospital providing SNF services in a separate building. Reference should be made to Health and Safety Code Sections 1250.8 and 1254 relating to separate licenses for “separate freestanding facilities” providing SNF services.
Facilities should also be aware that Department of Health Services licensing approval is required before beds or space approved for one use may be used for or converted to another use.
If a new, separate SNF license is required, facilities should consult with HCAI and the Department of Health Care Services licensing to discuss the means by which they will demonstrate compliance with Title 24 requirements (including structural) for SNF′s. The facility, of course, may request the utilization of alternate means and methods found in Chapter 1, Part 2, Title 24.
Facilities should also be aware of §72202 of Title 22 which requires that “…the licensee shall maintain the skilled nursing facility in a safe structural condition…” and that the Department of Health Care Services may require an evaluation of the structural condition of the building if necessary.
5. Are acute psychiatric (or skilled nursing) facilities exempt from seismic retrofit requirements?
Seismic retrofit requirements apply to General Acute Care Hospital buildings (as defined in the 2019 California Administrative Code Chapter 6), therefore, buildings, including SPC and/or free-standing buildings, providing only skilled nursing or acute psychiatric services are exempt.
Conversion of General Acute Care Hospital buildings for acute psychiatric or skilled nursing uses can be complex especially if the subject building is located in a facility that also provides general acute care services in other buildings at the same site. It is recommended that a meeting with the regional supervisor of the Building Safety Section of HCAI/FDD be arranged to discuss all possible issues related to the conversion.
GENERAL ACUTE CARE HOSPITAL as defined in Chapter 6 of the 2019 California Administrative Code
GENERAL ACUTE CARE HOSPITAL as used in Chapter 6, Part 1 means a hospital building as defined in Section 129725 of the Health and Safety Code and that is also licensed pursuant to subdivision (a) of Section 1250 of the Health and Safety Code, but does not include these buildings if the beds licensed pursuant to subdivision (a) of Section 1250 of the Health and Safety Code, as of January 1, 1995, comprise 10 percent or less of the total licensed beds of the total physical plant, and does not include facilities owned or operated, or both, by the Department of Corrections. It also precludes hospital buildings that may be licensed under the above mentioned code sections, but provide skilled nursing or acute psychiatric services only.
AB 2190 Attestation
1. What is an AB 2190 Attestation statement?
A hospital owner or operator who has a facility with one or more buildings with a structural performance rating of less than SPC-3 or whose non-structural performance rating is less than NPC-5 must submit a statement to HCAI attesting that its board of directors is aware of that their hospital buildings are required to meet the January 1, 2030 deadline for substantial compliance. (H&S Code Section 130066)
2. What does HCAI require to be included in the attestation?
The attestation is a written statement that the board of directors is aware of its 2030 requirements.
3. Does the owner or operator of the facility need to disclose its compliance plan in its attestation?
No. H&S Code 130066 only requires an attestation of the awareness of the board of directors of its obligation to meet seismic safety deadlines.
4. When are attestations due to HCAI?
Attestations must be received by HCAI prior to January 1, 2020
5. What will HCAI do with the attestation statement?
Attestations are public records due to their mandate in law. Attestation letters will be publicly available on the Facility Detail page on the HCAI Facilities Development Division web site for each responding facility. The Facility Detail page is here.
6. What will happen if our facility does not submit an attestation statement?
Facilities required to submit attestations that do not do so will be listed on HCAI’s website and included in FDD’s periodic report to the legislature regarding statewide progress toward compliance with the Hospital Facilities Seismic Safety Act as amended by SB 1953 and AB 2190.
7. Can an attestation letter be for more than one facility?
If a healthcare system wants to submit one letter for all the hospitals for which they are the governing authority, they need to specify which hospitals and which building(s) at each hospital that are not in substantial compliance, the letter is intended to cover. HCAI will duplicate and apply to each campus that is detailed in the letter.