30A-032 (54) -offt-
ow
JOINT. COMMISSION ON ACCREDITATION OF HEALTHCARE ORGANIZATIONS
OUTPATIENT STATEMENT OF CONSTRUCTION
Tri-County Youth Programs, Inc. (413) 586-6210
Name of .Facility/Program (Area Code) Telephone Number
320 Riverside Drive
Central Administrative Offices
. StreetAddress Identification
Northampton, MA 01060
City, State and Zip Code
STATEMENT OF CONSTRUCTION AND FIRE PROTECTION
1. Contents of, this document shall be verified byl one of the following
individuals: .a fire protection engineer, a certified safety professional, a
qualified representative of a," fire insurance rating - organization, a
registered professional engineer, a registered' aichiiect or the state fire
marshall. Equi�oint
alent individuals- are requested •tol describe on the next
page*, for the Commission • review, the ' tr-aining, education, and;or
experience which qualifies .them to verify the contents .of 'this• document.
2. Complete a Statement of Const,ruction and Fire Protection for every building
in which patients/residents receive treatment in Psychiatric Facilities. The
statement must also.'be completed for all major additions to these buildings
which have different structural fire protection -characteristics.
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3. A rough sketch must be completed for each Statement of Construction.
4. All questions mlust,be answered. Indicate "Y" for yes, "N" for no, "NA" where
not applicable,..unless other specified.
5. List' on the next. **
page ,, all "eq I uivalenciesgranted; by the .authority having
jurisdiction, aind append copies of supporting documents.
STATEMENT VERIFIED BY
i
, Name (Type or Print) . Title Profession
Organization Registration Number State License Number
(where applicable) (where applicable)
Street Address, ,City, State, . Zip Code Telephone Number
Signature Date
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tY � ,
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*Training, educat•ion7, and experience
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**Equivalencies (Intent of Life Safety Code ,is met, but not necessarily exactly as
specified in Life Safety Code
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STATEMENT OF CONSTRUCTION AND: FIRE PROTECTION
OUTPATIENT CLINICS
Informational Data-
1. Give a sketch of the entire building showing -exits (X) and 2-Hour fire
separations` by //////////j/, Also show 'the location of the clinic using
shading if the building is shared by other occupants.
Plan View: - -
- Please see attached building sketch.
Elevation:
The offices are all located on the first floor with a minor variation
'of gradiCconnected' by a handicap accessible ramp.
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Exits are arranged so- that'.a common path of 'travel (dead end) does not exceed
75 feet: (NFPA '101, 1988 26-2.5.3,,-27-2.5.3)
Yes
Some are not (ex;plain & specify`the _distance of common path),,
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No (explain & specify the distance of, common path
8. The travel`distance from' any point in �thd'�clihid `Eo the nearest exit•-is less
than 200 feet. -(NFPA 101, 1988 26-2.6, 27-2.6)
--- '.f — - -- _�
Yes X
Some are not (explain & specify the maximum distance) _
"._ svGCn 2 - -_- -
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---•,.._._.ivy..__,:"- _ _ ._ --... _.. -. .. - - - .,
No .(explain & specific the maximum distance)
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9. All ..corridors o k passageways- serving, as, a means. of- travel _to or from ,a
required exit for the clinical are at least 44 inches in`clear width. (NFPA
101, - 1988 26-2.3.2, 27-2:3.2)
„Yes �
Some are not (explain) One exit way is 36 1/2 inches wide. All other
exits exceed 44 inches.
No (explain)
L. .
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2. State the use of -,this building used as Tri-County's .central administrative
offices, case management,' and' ::-house'clinical -offices.
3. State:
. _-----a.---The- maximum' allowed aucnbe.r of ✓occupants in
the building
— - (approximate---if nevessary)—=_ __._�.___,___..:._._.___..�__._._ ..._. . - 45jtaff
--------- b.----The-maximum-allowed-number-of-occupants- in-the"building
above or below grade level ' _
(approximate if necessary) N/A
4. State the year of construction 1901 (original)
a.. If not know, was the building. cons_tiucted. before- 1/1/88 ,.
Yes X c -17-� � _
No
5. Indicate: --- --
-----a. -The-total-,number"of `sto�ries�above "ground- Y - one
-----b.--Those- stories--used-by-the-clinic—`--�--_-. grg,mri fioo
Life Safetv Code- Comoliance--
Please-refer to the--1988-NFPA- Life-Safety: Code:,' Chap ter'-26`(`d'esigried"after '88)
when- answering or Chapter 27 (designed prior to 188) the following questions.
6. Are at least two exits provided_ on each floor of, this building- used by the.
clinic? (NFPA' 101, 1988, 26-2- -x;` 27-2.4.2) _
Yes X -
Some are not (explain) - -- -
.No (explain)
-.189 _
10. All exits are identified with exit signs that are:
,Yes`"
a. Illuminated x
b. ` Provide with letters at least 6"
in height iri� new construction
C. Provide with letters at least- 4 1/2"
in light in existing construction x .
(NFPA 101;_19'88 26-2.8) _.
(NFPA. 101, 1988 27-2.8)
11A. All designated e' it corridors, stairways, -
and exit passages are illuminated. x
11B. Is the source of illumination for the
following- supplied by- an emergency .
power system:!-.'
(Required for buildings two or more stories:.:
in height, 100 of more occupants above or =
below level of`. exit discharge, or a total of _
1000' or more occupants) .
a. Exit signs `
b. Exit across corridors
C. Stairways N/A.
d. Exit passageways
(NFPA 101, 1988 26-2.9).
(NEPA 101,. 1988 27-2-.9)
12. Doors used as exits are: . _
a. At least 28' inches' wide x. ;. .:
b. Always unlocked or
C. Locked with .panic -hardware x
(NFPA 101, 1988 26-2.2.1, 27-2.2.2.1)
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Yes No
13. The interior finish in all exits and
exit.-access corridors is at least:
a.7'-Class A (Flamespread 0-25)
b. Class B�(Flamespread 26-75) :.
C.- Class C (Flamespread 76-200). with
a .complete automatic fire
extinguishing system throughout
the clinic and exits x'
(NFPA 101, 1988 26-3.3)
(NFPA 101, 1988 27-3.3 6-5)
14: A1.1 stairs serving as a required means
of egress .have: .
a. , At least one handrail N/A
b. Handrails on both sidesE�_ . _ _.. .. . �
(required in buildings
designed after 1988) =: _ N/A-
(NFPA
/A.(NFPA 101, 1988 5-2.2.6)
15A. Hazardous areas, in or immediately
adjacent to the outpatient treatment
area are' separated by construction having .
a fire resistive rating of at least 1-hour-
with all openings equipped with self-closing
positive latching fire doors. x
(At least Class "C" 3/4 hour)
(NFPA 101, 1988 26-3.2)
(NFPA 101, 1988 27-3.2)
15B. If no, all hazardous areas are equipped
with approved automatic fire extinguishing
system.
(Note: hazardous areas include: general storage rooms, boiler or furnace
rooms, fuel. storage, maintenance shops, kitchens, etc. )
(NFPA 101, 1988 25-3.2.1)
(NFPA 101, 1988 27-3.2.1)
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Yes No
15C. High hazard areas are protected by both
fire rated construction and an approved._:
automatic extinguishing system. " X , : -
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(NFPA 101, 1988 26-3.2.2) - . _ : _....
(NFPA"1011 198827-3.2.2)
Note: Adjacent is taken to mean both above and:. :-_ --:
below-the clinic area and on the same
floor. If a two hour separation exists,
please state.) .
15D. Vertical openings, such as stairs,
elevator shafts,letc. , which connect
--`with ou`fpatient`clinical' areas, protected
by 1-hour construction, 1/2 hour construction
__._...�_.
1'n---e-xi's-t-i-n-g- buil'Idings.) ----
-'.-"(NFPA 101;1988 26-3�.1)
(NFPA 101, 1988 27-3.1)
16A: There is a .manual fire alarm installed
throughout this (building.
16B. If'ye`s, does i FT,transmit an alarm
directly to: . ._ _ . _ .
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1. The ,fire department
2. An approved central receiving station .-:.:-. : . _ X.
3. Other-Describe:
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(NFPA 101, 1988126-3.4, 27-3.4)
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Yes
17. An approved automatic fire •extinguishing'-L -- - -: -- • - - - _.
system is provided.
a. Throughout the building -f}
b. : Throughout that part of the building.
housing the clinic -�.: ..-.. .. _ . -X'r_ =_ r
C. Other (explain and state locations) : :-'. - - - _ -
(NFPA 101, 1988 26-3.2., 3.4, 3.5, 27-3.2, 3.4, 3.5)
18. , An approved automatic
a. Smoke detection system is proved
OR
• of=_...._ .._. :. <i-.._-:C.-._ .. _ 65vtic-• __ .0-^,. •
b. Fire detection system is provided
_
(Item 1-3.-.apply to both a s b above)
-- 1_ Throughout the building '
2`. Throughout that part of the
building .housing the clinic x•
3. Other (explain and state locations
NFPA 101, 1988 26-3.4, '27-3.4.1)
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