1. Tennessee Department of Health Bureau of Health Licensure and Regulations Division of Health Care Facilities

2. Fire Safety Supervisor (615)306-8424 East Stuart Hurwitz
Facilities Construction Director
(615)
Bill Harmon
Nelson Rodriguez
Fire Safety Supervisor
(615)
East
Stuart Hurwitz
Fire Safety Specialist 2
(865)
Dustin Phillips
Fire Safety Specialist 1
(865)
Larry Stafford
(615)
Jim McCall
(865)
Middle
Jendy Avens
(615)806-
Colby Henson
(615)
Donald Tate
(615)
Alexander Warner
(615)
West
Ricky Gore
(731)
Wanda Browning
(731)
Brandon Maness
(731)
(731)
Vacant

3. Topics Rules and Regulations Progress and Final Inspections
Top 5 Deficiencies for Hospitals

4. Rules and Regulations Hospitals
Tennessee Department of Health (June 2015)
Nation Fire Protection Association (NFPA) 101 Life Safety Code (2000 Ed) and the referenced publications per chapter 2. (CMS)
Nation Fire Protection Association (NFPA) 101 Life Safety Code (2012 Ed) and the referenced publications per chapter 2.
International Building Code (IBC) 2012 Ed

5. (CMS-2786R) 5

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

7. Fire Dampers

8. Hospitals Top 5 Deficiencies (5)
K-130 Miscellaneous List 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.

9. Penetrations

10. Penetrations

13. Penetrations

14. Hospitals Top 5 Deficiencies (4)
K-77
Piped in medical gas systems comply with NFPA 99, Chapter 4.

15. NH Top 10 Deficiencies (3) K-147
Electrical wiring and equipment is in accordance with NFPA 70, National Electrical Code
Broken outlet covers
Power strips (back to back)
Exposed electrical junction boxes
Electrical panels blocked with equipment

16. Power Strips in Patient Care Areas
S&C: LSC DATE: September 26, 2014
SUBJECT: Categorical Waiver for Power Strips Use in Patient Care Areas

19. Hospitals Top 5 Deficiencies (2)
K-29
One hour fire rated construction (with ¾ hour fire-rated doors) or an approved automatic fire extinguishing system in accordance with and/or 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

20. 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

21. 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, , NFPA 13, and NFPA 25.
No quarterly
No annuals
Obstructions
Corroded sprinklers

22. Sprinklers

23. Sprinklers

24. Sprinklers

25. Sprinklers

26. Other Deficiencies

33. Questions?

34. Health Care Facilities Offices
Thank You
Health Care Facilities Offices
ETRO: (865) : Knoxville
WTRO: (731) : Jackson
Central Office Nashville (615)
Plans Review Office (615)