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Seismic Hazard Mitigation Program for Hospitals Eligibility

Appeal Brief Appeal Letter Appeal Analysis

Appeal Brief

DisasterFEMA-1008-DR
ApplicantBarlow Repiratory Hospital
Appeal TypeSecond
PA ID#037-90316
PW ID#76709 ,76710
Date Signed1999-02-08T05:00:00

Citation: Second Appeal by Barlow Hospital for inclusion of their Main Hospital Building into the Seismic Hazard Mitigation Program for Hospitals (SHMPH).

Cross-Reference: Subject: Section 406 Hazard Mitigation (SHMPH): FEMA Record: DSR #76709 & 76710.

Summary: Barlow Respiratory Hospital requests entrance into the SHMPH on the basis that they have been licensed as an Acute Care General Hospital, and grandfathered on the requirement that they have all of the required services. They currently have limited surgical facilities on site and contract for surgical and anesthesiology services with neighboring institutions. One of the criteria for SHMPH eligibility is that the all of the services required by section 1250 of the State Health and Safety Code be located in the eligible hospital complex. Barlow does have surgical services appropriate to the patient profile for which the hospital is used, and the patients served do require a higher level of acute care and intensive care than those usually found in an ordinary hospital.

Issues: Must Barlow Hospital conform to the letter of the SHMPH entrance criteria, including the criteria cited in footnote #7 in section I.C of the Program Description?Is it sufficient to make a finding that these rules are satisfied by a finding that the hospital is capable of (1) providing emergency acute care services for individuals from the general population following a disaster with the facilities it does have, (2) that the normal in-patient population would be put at significant risk in the event a disaster caused the closure of the building, and (3) there is sufficient evidence that the acute care services required by the law are sufficiently available on site to justify a determination that the intentions behind the SHMPH rules are met?

Findings: That Barlow Respiratory Hospital is a singular special case where the on-site provision of limited, rather than complete, anesthesiology and surgery services, together with their nearby off-site full provision, does meet the purpose of the SHMPH and the intentions behind the entrance criteria. This finding is supported by the fact that the hospital's specialization on respiratory diseases has resulted in a concentration of patients requiring a particularly high level of constant care not provided by other area hospitals, and that the services necessary for these patients are provided on site. In addition, the absence of full surgical facilities does not prevent the facility from being used for full post disaster triage and emergency care should the need arise.

Rationale: The SHMPH Program is intended to provide immediate occupancy level upgrading only for acute care inpatient hospital facilities, not for facilities requiring a lower level of care. Barlow has established proof that it does service only severely ill patients, and is thus equally justified in being included into the SHMPH as the other hospitals in the Program.

Appeal Letter

February 8, 1999

D.A. Christian
Governor's Authorized Representative
Governor's Office of Emergency Services
Post Office Box 419023
Rancho Cordova, California 95741-9023

Dear Mr. Christian:

This letter is in response to Gilbert Najera's letter of February 4, 1998 forwarding the Second Appeal of Damage Survey Report (DSR) #76709 & 76710 submitted by Barlow Respiratory Hospital to OES on December 22, 1997. The applicant has requested their main hospital building and Dietary services building be determined to be eligible for SHMPH funding.

As explained in the attached analysis, FEMA has concluded that the facilities contained in the Barlow Hospital Building are sufficiently complete to service their specialized acute care patients. Thus their lack of general surgical facilities on their campus should not be a reason to deny entrance into the SHMPH for this facility.

Accordingly, the applicant's appeal is approved. The amount of the funding is dependent on the review and approval of the individual building units based on the Program Description criteria applied to all hospital buildings admitted into the Program.

Please inform the applicant of this determination. In accordance with the appeal procdure governing appeal decisions made on or after May 8, 1998, my decision constitutes the final decision on this matter. The current appeal procedure was published as a final rule in the Federal Register on April 8, 1998. It amends 44 CFR 206.206.

Sincerely,

/S/

Lacy E. Suiter
Executive Associate Director
Response and Recovery Directorate

Enclosure

cc: Martha Z. Whetstone
Regional Director
FEMA Region IX

Appeal Analysis

BACKGROUND
Barlow Respiratory Hospital is licensed as a General Acute Care Hospital. Like a number of hospitals in the Los Angeles Area which were originally constructed as Tuberculosis sanitariums, Barlow Respiratory Hospital has evolved into a more general hospital from an earlier disease-specific use. The surgical facilities in the present hospital facility are limited to special procedure rooms related to the kind of surgical procedures necessary to treat the respiratory ailments in which the hospital specializes. To meet the General Acute Care license requirements, Barlow has contracted with other nearby hospitals to provide general surgical services, should they be necessary. This off-site contracted service is permitted as an alternative under Section 1250 of the California Health and Safety Code. Because it meets (1) the license requirement, (2) the damage, and (3) the construction date criteria for admission into the Seismic Hazard Mitigation Program for Hospitals (SHMPH) cited in the SHMPH Program Description , Barlow would like to be reconsidered for inclusion in the SHMPH.

THE DAMAGE
Because it is not central to the case, the Appeals package has little information about the damage. An A&E DSR was prepared for $5,360 for the preparation of a structural evaluation. The inspection date is March 11, 1994, and the identified damages include (1) "cracking on all the interior walls," (2) "Broken Windows" (3) "Damaged Chimney and fireplace." The package includes little about whether the buildings were structurally damaged, so satisfaction of that criterion is not reviewed here.

If Barlow Hospital is included into the SHMPH, the existence of structural damage, as well as the conformance with the other building unit criteria, would have to be affirmed for each of the "Building Units" which make up the acute care hospital complex. The Barlow property contains many buildings, most of which are the small wood frame cottages which were used by patients at the time that the facility was a Tuberculosis Sanitarium. Now all of the patient care takes place in the main hospital complex, which has been modified and upgraded to hospital use for acute care with some intensive care units.

The main hospital complex is made up of (1) an original central hospital facility constructed in 1927, (2) a series of extensions and wings on both ends and the rear of that facility constructed in 1974, and major addition to the north, constructed as two separate building units in 1980. The Dietary services building, containing the kitchens and cafeteria, is a 1902 timber frame building to the south of the main hospital. Because it contains one of the services required by the Health and Safety Act for General Acute Care Hospitals, this one original timber frame building is included as part of the Hospital complex for the purposes of this appeal.

DSRs WRITTEN:

DSRs FOR BARLOW RESPIRATORY HOSPITAL

DSR #

Papped Date

CAT

Scope

Net Eligible

76706

4/25/94

B

Hospital Grounds:

Repairs to fires sprinkler main pipe below ground & /life support equip.

13,574

76707

4/25/94

E

Williams Hall:

Replace brick fireplace in 85 yr old historical building

10,576

76708

4/25/94

E

Library:

Structural Evaluation of 72 yr old bldg. Crack of wall-ceiling joint / chimney destroyed

1,140

76709

4/25/94

E

Cafeteria & Offices:

Misc. repairs of 92-year-old bldg. Crack patching & paint.

4,436

76710

4/25/94

E

Hospital: Const. 1927. Patch and Paint / Replace cracked concrete floor.

16,080

76711

4/25/94

E

Admin. Bldg.

: Bldg. const. 1961 (in Historical Area). Patch and Paint / Carpet replace.

1,858

76712

4/25/94

E

Birge Hall:

Structural Evaluation (A&E) of 1919 bldg. Flexible Bldg. Broken Windows / damaged chimney

5,360

76713

4/25/94

E

Physician's Residence

: Const. 1932. Repair stucco cracks.

2,612

76714

4/25/94

E

Physician's Residence:

Const. 1936 (discrepancy with above). Patch and paint interior plaster damage.

4,038

85120

11/13/96

E

Optimist Library:

Repair plaster cracks / replace chimney / realign south wall & anchor to roof.

39,251

45391

6/21/97

E

Library:

Seismic upgrade (406 HMP). Plywood diaphragm / blocking and steel roof connectors / plywood shear wall.

47,720

13698

6/30/97

E

Birge Hall:

Repair (determined ineligible because unoccupied at time of earthquakeLIALIGN="RIGHT">0

16741

10/17/97

E

Williams Hall:

Additional costs to complete scope in DSR 76707 - fireplace and chimney.

9,945

16742

10/17/97

B

Hospital Grounds:

Additional costs to complete scope in DSR #76706

3,876

16760

10/17/97

E

Optimist Library:

Additional costs to complete A&E scope in DSR 76708.

3,651

16858

2/17/98

E

Optimist Library:

Earthquake damage repair in addition to #85120 & 45391 ($86,971)

5,235

  y y

NET TOTAL FUNDING

$169,352

Only the DSRs outlined in bold pertain to buildings in this appeal. The subgrantee reports that supplemental DSRs for structural damage had not been pursued pending approval of application for the SHMPH.

SECOND APPEAL REQUEST:

NOTE: This appeal was submitted by Barlow Hospital as a first appeal, but elevated to the level of a second appeal by Chris Lopez, FCO in an undated memorandum to Lacy Suiter. This memo explained that the claim had been denied by the DFO on January 21, 1997, and, following a request for reconsideration by Barlow, it had been denied again on October 1, 1997. Since the reconsideration was also handled at the DFO level, this appeal has been forwarded by the DFO to Headquarters as a Second Appeal.

Barlow Respiratory Hospital requests to be included into the SHMPH. The basis for the appeal is the claim that (1) the Hospital qualifies as a licensed Acute Care Hospital under section 1250(a) of the California Health and Safety Code, as mandated by the SHMPH Program Description I.C.2, and (2) the fact that the surgical facilities are not on-site should not be a reason to disqualify the facility because it is allowed under the provisions of the Health and Safety Code cited in the SHMPH qualifying criteria.

The appeal does not refer to any specific building within the complex, but requests that the Hospital be included. At the site visit, it was determined that the appeal relates to the hospital complex as described above under "Damage," which consists of the Main Hospital, with its wings, and the Dietary Building only. Since the SHMPH is based on "Qualifying Hospital Buildings," not entire hospital institutions, upon acceptance into the SHMPH, the normal vetting and quantity take-off procedure, which has been carried out at all other SHMPH hospitals, would have to be undertaken. Only upon completion of this procedure can the amount of the SHMPH funding be determined. Since the appeal issue does not pertain to the inclusion of one building or another, but of the institution as a whole, the approval for inclusion of the individual buildings does not have to be conducted as part of the appeal. It can follow the standard procedures at the Northridge Area Long-Term Recovery Office (NALTRO).

DISCUSSION
The SHMPH has several criteria that must be met for entry into the Program. These criteria are specified in the Program Description. Three of these criteria are at issue in this appeal: (1) Sect I.C.2: a hospital building unit.must be an integral part of a complex which.meets the definition of Section 15026(a)(1).the Alquist Act AND section 1250 of Chapter 2, Division 2 of the California Health and Safety Code subsection (a), (2) Sect I.C.6(a) .a building must.provid[e] [as required by Sect 1250 (a) of the Health and Safety Code] "24 hour in-patient care, including the following basic services [for the in-patients]: medical, nursing, surgical, anesthesia, laboratory, radiology, pharmacy, and dietary services" and (3) Sect I.C.3.footnote #7: " the [eligible] building unit forms an integral part of the complex which does contain all of the required basic services." In this appeal, Barlow Hospital requests that the licensing requirement as stated in the Program Description section I.C.2 be treated as sufficient evidence that the further mandate described in Footnote #7 has been complied with. Barlow Hospital does acknowledge that the facilities for general surgery and anesthesiology are located off-site under contract at other hospitals, but they make the case that, because of their specialization, the limited surgical facilities necessary and pertinent to that specialty are provided for within the complex.

The issue thus reduces down to the question of whether, in the absence of the letter of the rule in footnote #7 being met, does the fact that the hospital serves a specialized group of patients under its General Acute Care license mean that the intent of the SHMPH rule has been met? In other words, are the same governmental interests met by upgrading this hospital to immediate occupancy standards as are being met by the other facilities already accepted into the Program?

To make a finding in favor of the Barlow Hospital claim, two questions must be able to be answered in the affirmative:

  1. Does the facility as presently constituted provide the kinds of services required of a General Acute Care in-patient hospital such that it can serve as an emergency hospital following a major disaster for a broad range of medical problems (beyond the scope of respiratory related problems alone)?
  2. Would the existing pre-disaster patients commonly in the facility be at risk if they were dislocated or evacuated as a result of short and long-term damage to the structure of the hospital, perhaps even causing a crisis in the ability of the nearby hospitals to adequately serve their needs in such an emergency?

The FEMA review of this appeal included a visit to Barlow Respiratory Hospital on October 21, 1998. In this review, the physical layout, the patient rooms and medical activities of the Hospital were inspected. As a result of this inspection it has been determined that much evidence does exist to support an affirmative answer to these questions.

In answer to question #1, Barlow submitted evidence of its participation in the Emergency Disaster Preparedness System of the County of Los Angeles since 1995, and described its provision of emergency services to the nearby general population following the Northridge Earthquake in 1994. In a letter from Barlow to OES dated April 9, 1997, Margaret Crane, Chief Executive Officer of Barlow Hospital states that "Maintains at all times a detailed disaster plan.which is integrated with, and is an integral part of, the Disaster Plan of the County. Pursuant to such plans, the Hospital is prepared at all times to take external casualties from its geographic area, which encompasses potential areas of high population density during and/or after a disaster, including Dodger Stadium [ysiariodic training exercises include, for example, emergency medical records systems, triage procedures, and provision of emergency care." It is clearly evident that the medical staff and equipment at Barlow is the same as that found in other General Acute Care Hospitals, and thus the provision of emergency services would not have to be limited to respiratory illnesses only.

In answer to question #2, Barlow houses approximately 45 acute care patients, a significant number of which are hooked up to ventilators and other intensive care equipment 100% of the time. In the event of a shutdown or evacuation of these patients, their lives could be placed at risk. Because of Barlow's specialization in respiratory illnesses, many of its patients are placed there from other hospitals because the other hospitals are not well enough equipped to deal with them. This fact supports the claim that a need to evacuate Barlow could cause more of a crisis than would be met with the evacuation of hospital with a less unique patient profile or high a concentration of intensive care and mechanically assisted life support.

Overall, Barlow Respiratory Hospital does meet the SHMPH requirement that it be licensed as an acute care hospital. It is no longer a rehabilitation clinic for tuberculosis patients living in small cottages, where the warm sun and dry air were used as a therapy in the early part of the 20th Century for patients. Despite the fact that it serves a specialized purpose (respiratory illnesses) it is not a "Specialty Hospital" as defined by the Health and Safety Act because it is not a Dental or Maternity Hospital, which are the two listed as "specialty Hospitals" as opposed to General Hospitals under its licensing provisions.

"Specialty Hospitals" are at a lower level of license than "General Acute Care." Barlow's acute care services are at too high a level to qualify for the less restrictive license. All of the Barlow patients are now housed in a hospital building, with many hooked up to mechanical ventilators, and under constant acute level care. Limited surgical requirements which are consistent with the needs of this specialty are in fact on site, and they do not, except in emergency situations (as they would following an earthquake - and did following the Northridge earthquake) take patients with other medical problems. Instead, the other regional hospitals transfer their respiratory patients requiring long-term in-hospital care to them. It is also important to recognize the fact that many other hospitals, regardless of the existence or absence of general anesthesiology or surgery facilities, would send certain patients with specialized needs to other institutions as required as well. Barlow is no different than other institutions in this respect.

The Program Description in footnote 7 on page 16 stipulates that a "qualifying building unit" must be "an integral part of" a complex which does possess all of the "required basic services." In this case, it seems fair to interpret this provision as being complied with, based on the finding that (1) limited surgical facilities commensurate with their specialized patient load are actually within the complex, and (2) surgical facilities of a more general and complete nature, as required under the provisions of section 1250 of the Health and Safety Code, are available as needed under their institutional administrative provisions (namely their contract with two nearby hospitals) rather than physically within the same complex. (For example, they exist administratively, rather than physically, within the same complex and are equally available, as they would be if they were physically located there).

There are no other instances in the Northridge Area where other licensed acute care hospitals lack facilities for general surgery because only a select few institutions in the State of California were "grandfathered" into the acute care licensed category without surgical facilities. Barlow was "grandfathered" because of the fact that Barlow provides such a high level of acute care to an otherwise underserved specialized group of acute care patients.

CONCLUSIONS
The evidence that the hospital serves a high level of specialized intensive care and acute care patients throughout its facility supports a finding in favor of granting the appeal. In all respects, the intent of the SHMPH is equally served by having a facility such as this continue uninterrupted, as it is by the protection of any other hospital facility already accepted into the Program.
The appeal is approved.

Eligible Building Units:
The SHMPH criterion also includes a definition of a building unit, and the requirement that each building unit meet the eligibility criteria. Since most hospital complexes contain separate structures of different dates, uses, and other characteristics, it is rare that an entire hospital facility is eligible for SHMPH funding. In the case of the Barlow Hospital building, the documents submitted indicate that it is composed of a total of 7 attached "building units" (the main hospital), and one detached building unit (the dietary services building). Of these building units, only the original 1927 two-story hospital building and the 1902 dietary services building, were constructed earlier than the SHMPH cut-off date of 1973.

While the final analysis for the determination of the eligibility of the individual building units is the responsibility of the NALTRO, the documents submitted with this appeal indicate that eligibility may be limited to only these two structures. The smaller 1974 additions to the main hospital may qualify under the "Dependency Analysis" methodology developed to cover situations involving small and dependent additions to principal hospital buildings. The criteria for judgement as to acceptance of a "dependency" as eligible includes (1) lack of independent exit pathways, functions and utilities, (2) small size (2 stories or less / 5,000SF or less), (3) small size in relationship to parent hospital building (< 15% of floor area of parent structure), (4) interference or lack of independent access for retrofit tasks. It is possible that some or all of the 1974 additions could be found to qualify under this analysis, but the 1980 additions do not appear to conform to these criteria.

The SHMPH inspectors and analysts at the NALTRO will be responsible for the final detailed determination of which of the seven building units within the hospital complex qualify as eligible for SHMPH funding based on the other criteria in the Program Description.