Project Review and Construction Inspection

Project Review

Download the Submission for Project Review SNF61466 (PDF)

SNF 61466 is a fillable Adobe pdf document for a Submission for Project Review to Life Safety and Construction.  Type or print to complete the form and email the completed form, drawings and any supplemental information to lsc@nd.gov 

Memorandum Fees for Construction Plans Review and Onsite Construction Visits to Health Care Facilities subject to Licensure by the Division of Health Facilities

To:                            Hospital, Nursing Facility, and Basic Care Facility Administrators 

From:                       Dave L. Nelson, Division Director, Life Safety & Construction 

Effective Date         June 1, 2020

Subject:                  Fees for Construction Plans Review and Onsite Construction Visits to Health Care Facilities subject to Licensure by the Division of Health Facilities

The Department of Health has the authority to charge a reasonable fee for the review of plans for construction, remodeling, and installation projects in health care facilities licensed by the Division of Health Facilities. This includes licensed hospitals, nursing facilities, basic care facilities, and inpatient hospice facilities.

The intent is that partial cost of plan review and onsite construction visits would be based on fees collected from the licensed providers for plans review. The fee schedule is adjusted periodically based on the revenue generated from fees and/or increased costs of the program. At this time, there is a need to adjust the fee schedule based on legislative action in the recent 2019 session. The revised fee schedule will typically be based on the estimated cost of the project.

Upon receipt of the construction plans and the estimated cost of the project, the fee will be determined by our office. A request for payment of this fee will be sent to the licensed provider. Plans will be reviewed in the order received; however, department approval of plans will not be given until the fees for plans review have been received. An exception to the sequence and fees related to plans review may occur at the discretion of the department when plans are submitted in response to a Life Safety Code (LSC) survey deficiency. In addition, recent law changes now require the department to make an initial determination on those projects of $1,000,000 or less within 60 days of receipt.

If plans are submitted in phases, each phase or package will be considered as a new submission. A new fee will be allocated, and the plans will be considered separately in the timing of review.

Changes to plans previously submitted will not be charged an additional fee for review and approval.

State licensing rules require our office to review and approve plans and specifications for all construction, remodeling, and installations prior to the start of construction. For hospitals this rule is found in North Dakota Administrative Code 33-07-02.1-02, for nursing facilities it is found in NDAC 33-07-04.2-08, and for basic care facilities in NDAC 33-03-24.1-03. If there are changes to the plans that have been approved, the changes are required to be submitted to the department and approved prior to implementation.

Routine maintenance does not require the submission of plans and specifications. Routine maintenance is the repair or replacement of existing equipment, room finishes and furnishings, and similar activities. If you have questions whether your planned construction or remodeling activities are subject to review, please contact our office.

If you have questions regarding this information, please contact the Director, Division of Life Safety and Construction, North Dakota Department of Health at 701-328-2352.

Procedure for Construction or Renovation Plans Review for Facilities Subject to Licensure by the Division of Health Facilities

Effective June 1, 2020

Procedure:

  1. The health care facility subject to licensure by the Division of Health Facilities submits directly, or through an architect or engineer, construction or renovation project plans for review by the Department. The estimated cost of the project is to accompany the submission of the project plans. The submission form used to submit a project for review can be found on the department’s website.
  2. Based on the estimated cost of the project, a letter is sent to the facility administrator or designee indicating the plans review fee that needs to be submitted.
  3. Effective August 1, 2019, the current fee schedule is:

    Plan Review Fee Scale Based on Size and Project Cost:

    Small (Project Cost $0 - $50,000) 
    Minimum $500

    Medium (PC $50,001 - $4,000,000)
    Range - $500 - $40,250 ($500 + 1.0% PC $50,001- $4,000,000)

    Large (PC > $4,000,000)
    Range – Over$40,250 ($40,250 + 0.25%PC> $4,000,000)
     
  4. Review of the fee schedule is completed annually and adjusted as necessary.
  5. If plans are submitted in phases, each phase is considered as a separate project, and fees are charged consistent with the above fee schedule.
  6. A copy of the letter from the department and fee to be remitted is to be sent from the facility administrator or designee to:

North Dakota Department of Health and Human Services
Life Safety & Construction 
1720 Burlington Drive, Suite A
Bismarck, ND 58504-7736

  1. Plans are reviewed in the order received. If plans are received in phases, each project phase is considered separately and reviewed in the order received along with the other plans received by our office.
  2. The fee for plans review must be received by the department prior to approval of plans.
  3. An exception to the sequence of plans review may occur at the discretion of the department, when plans are submitted in response to a Life Safety Code (LSC) certification survey citation. If the plans review related to deficiency citations meets the small project criteria, no fee will be charged. If the plans are submitted prior to the LSC survey or are larger than a small review, the fee schedule is applied.
  4. An exception to the sequence of plans review may also occur if the submitted project cost is $1,000,000 or less. In this instance, state law requires an initial determination of compliance within 60 days of the date of the completed submission.
  5. Changes to plans previously submitted and reviewed are not charged an additional fee for review.
  6. A health care facility may choose to utilize individuals and/or entities, with an approved contract with the State of North Dakota, to perform reviews of construction documents for proposed construction in health care facilities in North Dakota. The owner will be responsible for the repayment of review services directly to the reviewing contractor. The North Dakota Department of Health will receive a separate review fee based on the Plan Review Fee Scale Based on Size and Project Cost (PC) X 25%. This fee will be assessed for project administration, over-sight review and construction inspection.

Memorandum regarding Compliance Review by Venders of Construction Documents

To:                            Hospital, Nursing Facility, and Basic Care Facility Administrators 

From:                      David L. Nelson, Division Director, Life Safety & Construction 

Effective Date:       June 1, 2020

Subject:                Compliance Review by Venders of Construction Documents

The Department of Health (DOH), Division of Life Safety & Construction (State) has contracted with multiple vendors, and/or entities, to assist in the performance of compliance reviews, of construction documents, for health care construction projects in North Dakota. Documents will be reviewed for compliance with state construction standards as identified in the North Dakota General Standards of Construction and Equipment for Hospitals, Chapter 33-07-02.1, North Dakota General Standards of Construction and Equipment for Nursing Facilities, Chapter 33-07-04.2, the North Dakota General Standards of Construction and Equipment for Basic Care Facilities, Chapter 33-03-24.2 and identify areas of noncompliance with utilizing these standards.

The intent is to give licensed providers the option to directly contract the review of construction documents with venders, from an approved list, selected by the State. It is the expectation of the DOH that a separate agreement will be entered into between the vendor and the licensed provider. The DOH will not be responsible for payments of independent compliance reviews.

The scope of the compliance review will encompass the project from initial review, including all applicable construction contract modifications submitted at any point of the project, to the point of completion. The goal of this project is to assist the DOH in completing reviews of construction documents in a timely manner.

The DOH will receive a separate review fee from the licensed provider, based on the Plan Review Fee Scale Based on Size and Project Cost (PC) X 25%, to provide project administration, over-sight review and construction inspection.

If you have questions regarding this information, please contact the Director, Division of Life Safety and Construction, North Dakota Department of Health at 701-328-2352

Construction Inspection

Typical Findings of Noncompliance During Construction Visits

  1. Common wall with a nonconforming building:
    1. Air ducts through a two-hour fire-rated wall were not equipped with a fire damper.
    2. Air duct, electrical, and pipe penetrations were not sealed with fire-rated material.
    3. Doors were not equipped with the correct latching hardware.
    4. Rating of door and frames (2 hour).
  2. Building Construction:
    1. Gypsum board fasteners were not protected with two coats of joint compound.
    2. Gypsum board seams were not sealed with tape and/or two coats of joint compound.
    3. Penetrations in load-bearing walls were not sealed with fire-rated material.
    4. Steel beams and columns were not protected with fire-proofing or gypsum board.
    5. Roof/ceiling assembly and floor/ceiling assembly penetrations (pipes, electrical conduits, air ducts, and low voltage wiring) were not sealed with fire-rated assemblies.
  3. Interior finishes for corridors and exit ways:
    1. No fire rating documentation for suspended ceiling systems (class A rating).
  4. Interior finishes for rooms and spaces:
    1. No fire rating documentation for suspended ceiling systems (class A rating).
  5. Corridor openings:
    1. Doors did not latch into the frame.
    2. Door hardware was missing.
    3. Doors were missing.
    4. Door glazing was missing (door windows were not installed).
    5. Window openings (windows were not installed).
  6. Marking of exit access:
    1. Exit signage was not provided.
    2. Adequate exit signage was not provided in the exit system and at cross-corridor doors.
    3. Exit signage was not illuminated.
  7. Stair enclosure:
    1. Doors did not have the required fire-rating.
    2. Doors were not equipped with self-closing devices.
    3. Doors were not equipped with fire-rated smoke gaskets.
    4. Doors were not equipped with intumescent gaskets.
    5. Doors were not equipped with latching hardware.
    6. Doors did not automatically latch into the frame.
    7. Door glazing was not fire rated.
  1. Fire-resistance rating of exits:
    1. Walls did not extend to the floor/ceiling deck.
    2. Walls did not extend to the roof deck.
    3. Gypsum board fasteners were not protected with two coats of joint compound.
    4. Gypsum board seams were not sealed with tape and/or two coats of joint compound.
    5. Head-of-wall was not sealed with a UL fire-rated assembly.
    6. Edges of walls were not sealed with a UL fire-rated assembly.
  2. One-hour fire resistance rating of smoke barriers:
    1. Walls did not extend to the floor/ceiling deck.
    2. Walls did not extend to the roof deck.
    3. Gypsum board fasteners were not protected with two coats of joint compound.
    4. Gypsum board seams were not sealed with tape and/or two coats of joint compound.
    5. Head-of-wall was not sealed with a UL fire-rated assembly.
    6. Head-of-wall assembly did not provide adequate deflection capabilities for movement of the floor/ceiling or roof deck.
    7. Edges of walls were not sealed with a UL fire-rated assembly.
    8. Through-wall penetrations (pipes, electrical conduits, air ducts, low voltage wiring, etc.) were not sealed with fire-rated assemblies.
  3. Openings in smoke barriers:
    1. Doors did not self-close.
    2. Door glazing was not fire-rated.
  4. Hazardous areas of one-hour fire resistance rated construction with 3/4-hour fire-rated doors:
    1. Doors were not 3/4-hour fire resistance rated assembly.
    2. Doors were not equipped with self-closing devices.
    3. Doors were not equipped with fire rated smoke gaskets.
    4. Doors were not equipped with intumescent gaskets.
    5. Doors were not equipped with correct latching hardware.
    6. Walls did not extend to the floor/ceiling deck.
    7. Walls did not extend to the roof deck.
    8. Gypsum board fasteners were not protected with two coats of joint compound.
    9. Gypsum board seams were not sealed with tape and/or two coats of joint compound.
    10. Head-of-wall was not sealed with a UL fire-rated assembly.
    11. Head-of-wall assembly did not provide adequate deflection capabilities for movement of the floor/ceiling or roof deck.
    12. Edges of walls were not sealed with a UL fire-rated assembly.
    13. Through-wall penetrations (pipes, electrical conduits, air ducts, low voltage wiring, etc.) were not sealed with fire-rated assemblies.
  5. Exit access arranged so that exits are readily accessible at all times:
    1. Multiple latching/locking devices must open with a single operation.
    2. Delayed locking devices must release in fifteen seconds, during loss of power, and during activation of the fire alarm.
  1. Delayed locking devices on doors must be properly signed. Illumination of means of egress, including exit discharge and to public way, arranged so that failure of any single lighting fixture (bulb) will not leave the area in darkness:
    1. Exterior exit lighting has single light fixture with single bulb.
    2. Long life (1500 hour) single bulb fixture is accepted only if the fixture is equipped with a quick strike feature.
  2. Exit and directional signs continuously illuminated and served by the emergency lighting system:
    1. Emergency exit illumination was not provided throughout the exit system.
    2. Emergency exit illumination of one foot-candle was not provided at floor level throughout the exit system.
    3. Emergency exit illumination was controlled by light switches.
  3. The fire alarm system installed according to NFPA 72, National Fire Alarm Code:
    1. No fire alarm test results.
    2. Fire alarm test results were not complete (missing some of the initiating or signaling devices).
  4. All required smoke detectors, including those activating door hold-open devices, in accordance with the manufacturer's specifications:
    1. Smoke detector dust covers were not removed.
    2. No smoke detector above the fire alarm panel.
    3. Some of the smoke detectors were installed at the wrong elevation and/or the wrong spacing.
    4. Smoke detection was not installed near doors where magnetic hold-open devices were being utilized.
  5. Health care facilities protected throughout by an approved, supervised automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems:
    1. The sprinkler system must be equipped with water flow and tamper switches that are electrically interconnected to the building fire alarm.
    2. Sprinkler coverage is not complete because rooms, closets, and/or combustible overhangs were not sprinklered.
    3. Sprinkler coverage was obstructed by light fixtures, air ducts, pipes, and structural members.
    4. Sprinklers were the wrong temperature rating for the areas they were installed.
    5. Sprinklers were not installed beneath air ducts over four feet in width.
    6. No covers on the fire department connection.
    7. The inspector test discharge was not equipped with a smooth bore orifice.
    8. No underground pipe test documentation was available.
    9. No above ground pipe test documentation was available.
    10. No initial fire sprinkler test documentation was available.
    11. The sprinkler riser specification plate was not installed.
    12. Inadequate number of spare sprinklers (representative number of each design)
    13. No spare sprinkler cabinet.
    14. No sprinkler wrench.
    15. Sprinklers not installed under garage door when open.
    16. Dry system requirements.
    17. Sprinklers installed less than 6'0" from each other.
  6. Portable fire extinguishers provided in accordance with NFPA 10, Standard for Portable Fire Extinguishers:
    1. Excessive travel distance to the fire extinguisher.
    2. No pin seals.
    3. Empty extinguisher cabinets.
    4. No K-extinguisher or extinguisher usage signage in the kitchen.
    5. Extinguisher sitting on the floor rather than properly mounted on the wall.
    6. Not mounted at the proper height.
  7. Heating, ventilating, and air conditioning installed in accordance with the manufacturer's specifications and NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems:
    1. No air balancing results were available.
  8. Cooking facilities protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations:
    1. No design installation test results.
    2. Fire suppression system was not supervised by the fire alarm.
    3. The gas and electrical equipment located under the fire protection equipment was not equipped with automatic shut-offs.
    4. No initial hood system test result.
    5. Cooking equipment not under hood system must meet UL 197.
  9. Draperies, curtains (including cubicle curtains), and other loosely hanging fabrics and films serving as furnishings or decorations must be flame resistant as demonstrated by testing in accordance with NFPA 701, Standard Methods of Fire Tests for Flame Propagation of Textiles and Films:
    1. No flame resistance documentation for curtains and window treatments.
    2. No flame resistance documentation for cubicle curtains.
  10. Medical gas storage and administration areas protected in accordance with NFPA 99, Standard for Health Care Facilities:
    1. Rooms were not properly signed as oxygen storage areas.
  11. Piped-in medical gas systems comply with NFPA 99, Standard for Health Care Facilities:
    1. Medical gas piping certification was not available.
    2. Medical gas pipe shut-offs were not labeled.
    3. The medical gas manifold room was not separated by a fire-rated assembly from the rest of the building:
      • Doors were not a 3/4-hour fire resistance rated assembly.
      • Doors were not equipped with self-closing devices.
      • Doors were not equipped with fire-rated smoke gaskets.
      • Doors were not equipped with intumescent gaskets.
      • Doors were not equipped with correct latching hardware.
      • Walls did not extend to the floor/ceiling deck.
      • Walls did not extend to the roof deck.
      • Gypsum board fasteners were not protected with two coats of joint compound.
      • Gypsum board seams were not sealed with tape and/or two coats of joint compound.
      • Head-of-wall was not sealed with a UL fire-rated assembly
      • Edges of walls were not sealed with a UL fire-rated assembly.
      • Through wall penetrations (pipes, electrical conduits, air ducts, low-voltage wiring, etc.) were not sealed with fire-rated assemblies.
  1. An alternate source of power separated and independent from the normal source that will be effective for minimum 1 ½-hour after loss of the normal source. NFPA 99, Standard for Health Care Facilities:
    1. Emergency generator performance test certification was not available.
    2. Generator did not operate during test (within 10 sec).
    3. Transfer switch did not operate during test.
    4. Nurses' station lighting was not on the emergency circuit.
    5. Medication rooms were not on the emergency circuit.
    6. Exterior lighting was not on the emergency circuit.
    7. Battery-powered lighting was not provided in the generator room.

Construction Standards

Download the Request for Waiver of Licensing Rule or Construction Standard SNF19751 (PDF)

SNF 19751 is a fillable Adobe pdf form for a Request for Waiver of Licensing Rule or Construction Standard.  omplete one form for each waiver you are requesting. Additional documentation may be attached to this form. The Department reserves the right to deny or terminate a waiver. The granting of a waiver does not mean the requirement has been met. Your facility will be considered deficient until the requirement has been met. 

Send the completed form to:
North Dakota Department of Health and Human Services 
Life Safety & Construction Unit
1720 Burlington Dr, Ste A 
Bismarck ND 58504-7736 
 

Basic Care Waiver Request

Download the Basic Care Waiver Request Form SNF61649 (PDF)

SNF 61649 is a Basic Care Waiver Request for a Waiver to all or a portion of Licensure Standard.  Complete one form for each waiver you are requesting.  Additional documentation may be attached to this form.  The Department reserves the right to deny or terminate a waiver.  The granting of a waiver does not mean the requirement has been met.  Your facility will be considered deficient until the requirement has been met. 

Send the completed form to:
North Dakota Department of Health and Human Services 
Health Facilities and Life Safety & Construction Unit
1720 Burlington Dr, Ste A 
Bismarck ND 58504-7736 

Innovative Waiver Request

Download Innovative Waiver Request Form SNF61666 (PDF)

SNF61666 is the Innovative Construction, Renovation or Construction and Renovation Project Waiver Request Form.  Complete one form for each waiver you are requesting. All questions require a response to be deemed complete. Additional documentation may be attached to this form. The Department reserves the right to deny or terminate a waiver. You are responsible for ensuring compliance with other state laws, federal certification requirements or accrediting standards and assume any risk associated with lack of compliance that may be caused by the granting of the waiver. 

Send the completed form to:
North Dakota Department of Health and Human Services 
Life Safety & Construction Unit
1720 Burlington Dr, Ste A 
Bismarck ND 58504-7736 

Contact Life Safety and Construction