HospitalInspections.org

Observation between 1:15 and 2:45 on 1/5/2011 revealed 2000 NFPA 8.3.1 and 8.3.2 were not being met.
Smoke barriers shall be provided to subdivide building spaces for the purpose of restricting the movement of smoke. Smoke barriers shall be continuous from an outside wall to an outside wall, from a floor to floor and from a smoke barrier to a smoke barrier or a combination there of.. such barriers shall be continuous throught all concealed spaces, such as those found above a ceiling, including interstitial spaces.
Findings: Gaps were observed, no sealant was observed, at the top of the wall at the 1-hour rated separation wall/smoke barrier between the main lobby and adjacent wing of the hospital.

Observation and review of inspection logs between 1:15 and 2:45 on 1/5/2011 revealed NFPA 72: 7-3.2.1 was not being met.
Detectors sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After 2 years of sensitivity testing and detector falls in to the prescribed sensitivity range the testing can be extended up to 5 years.
Finsings: The paperwork did not indicated any testing of the duct mounted smoke detectors during the annual alarm inspection.

Observation of inspection logs between 1:00pm and 1:30. NFPA 96: 11.2.1. Inspecting and servicing of the fire extinguishing system is required every 6 months by a properly trained and qualified person.
Findings: Records indicated the fire extinguisher system for the kitchen is only being tested on a yearly basis.

A. Observation and discussion between 1:15 and 2:45 on 1/5/2011 revealed 1999 NFPA 13, 3-2.9.1 thru 3-2.9.3 was not being met.
A supply of at least six spare sprinklers shall be maintained on the premises so that any sprinklers that have been operated or damaged in any way can be replaced promptly. A minimum of two sprinklers of each type and temperature rating should be provided. For protected facilities having 300 to 1000 sprinklers, no fewer than 12 sprinklers shall be provided, and for over 1000 sprinklers, no fewer than 24 sprinklers. One sprinkler wrench shall be kept in the cabinet for each sprinkler type.
Findings: The sprinkler storage box contained fusible link type sprinkler heads but not quick response type heads that were installed in the facility.
B. Review of records between 1:15 and 2:45 on 1/5/2011 revealed NFPA 99: 11-5.3.2 was not being met.
When designated by the emergency preparedness management plan to provide continuous service in a disaster or emergency, healthcare facilities shall establish contingency plans for the continuity of essential building systems.
Findings: Letters of agreement to with a provider to provide for emergency water and fuel provisions were not available at the time of inspection.
C. Observation and discussion between 1:15 and 2:45 on 1/5/2011 revealed 2000 NFPA 101, 19.3.2.1 was not being met.
Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistive rating or shall be provided with an automatic extinguishing system. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors.
Findings: 1. The back wall of the dirty linen room had gaps between the wall and ceiling joint. 2. A scuttle hole between the General Stores storage room was open to the interstitial space above the adjacent office

Observation and discussion between 1:15 and 2:45 on 1/5/2011 revealed 1999 NFPA 99, 4-3.2.2.8 (a) and 4-3.1.2.2 (b)2 were not being met.
To ensure continuous responsible observation of the vacuum system, the master alarm signal panels shall be located in two separate warning locations. One shall be in the office or principal working area of the person responsible for the maintenance of the system and a seconds at a continuously staffed location.
Findings: No med gas alarms for medical gas or vacuum systems were located in the maintenance office. On set of alarms were located in the located in the ER nurses station.

A. Observation and discussion between 1:15 and 2:45 on 1/5/2011 revealed 1999 NFPA 99: 3-3.2.1.2 (d)2 and Survey and Certification Letter S&C-03-21, requiring facilities to meet the 2000 Life Safety code were not being met.
The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords. A minimum of one emergency receptacle is required for each patient room per Hospital Licensing Rules Chapter 133.163 (t)(5)(iii).
Findings: No emergency receptacles were located in the patient rooms. It was stated the facility had a contingency plan to implement use of extension cords of emergency power is required for the individual patient rooms.
B. Observation between 1:15 and 2:45 on 1/5/2011 revealed 1999 NFPA 70, 370-28(C)was not being met.
All pull boxes, junction boxes (j-boxes) and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use.
Findings: J-box in the interstitial space above the main lobby ceiling was not covered.

Observation between 1:15 and 2:45 on 1/5/2011 revealed 2000 NFPA 8.3.1 and 8.3.2 were not being met.
Smoke barriers shall be provided to subdivide building spaces for the purpose of restricting the movement of smoke. Smoke barriers shall be continuous from an outside wall to an outside wall, from a floor to floor and from a smoke barrier to a smoke barrier or a combination there of.. such barriers shall be continuous throught all concealed spaces, such as those found above a ceiling, including interstitial spaces.
Findings: Gaps were observed, no sealant was observed, at the top of the wall at the 1-hour rated separation wall/smoke barrier between the main lobby and adjacent wing of the hospital.

Observation and review of inspection logs between 1:15 and 2:45 on 1/5/2011 revealed NFPA 72: 7-3.2.1 was not being met.
Detectors sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After 2 years of sensitivity testing and detector falls in to the prescribed sensitivity range the testing can be extended up to 5 years.
Finsings: The paperwork did not indicated any testing of the duct mounted smoke detectors during the annual alarm inspection.

Observation of inspection logs between 1:00pm and 1:30. NFPA 96: 11.2.1. Inspecting and servicing of the fire extinguishing system is required every 6 months by a properly trained and qualified person.
Findings: Records indicated the fire extinguisher system for the kitchen is only being tested on a yearly basis.

A. Observation and discussion between 1:15 and 2:45 on 1/5/2011 revealed 1999 NFPA 13, 3-2.9.1 thru 3-2.9.3 was not being met.
A supply of at least six spare sprinklers shall be maintained on the premises so that any sprinklers that have been operated or damaged in any way can be replaced promptly. A minimum of two sprinklers of each type and temperature rating should be provided. For protected facilities having 300 to 1000 sprinklers, no fewer than 12 sprinklers shall be provided, and for over 1000 sprinklers, no fewer than 24 sprinklers. One sprinkler wrench shall be kept in the cabinet for each sprinkler type.
Findings: The sprinkler storage box contained fusible link type sprinkler heads but not quick response type heads that were installed in the facility.
B. Review of records between 1:15 and 2:45 on 1/5/2011 revealed NFPA 99: 11-5.3.2 was not being met.
When designated by the emergency preparedness management plan to provide continuous service in a disaster or emergency, healthcare facilities shall establish contingency plans for the continuity of essential building systems.
Findings: Letters of agreement to with a provider to provide for emergency water and fuel provisions were not available at the time of inspection.
C. Observation and discussion between 1:15 and 2:45 on 1/5/2011 revealed 2000 NFPA 101, 19.3.2.1 was not being met.
Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistive rating or shall be provided with an automatic extinguishing system. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors.
Findings: 1. The back wall of the dirty linen room had gaps between the wall and ceiling joint. 2. A scuttle hole between the General Stores storage room was open to the interstitial space above the adjacent office

Observation and discussion between 1:15 and 2:45 on 1/5/2011 revealed 1999 NFPA 99, 4-3.2.2.8 (a) and 4-3.1.2.2 (b)2 were not being met.
To ensure continuous responsible observation of the vacuum system, the master alarm signal panels shall be located in two separate warning locations. One shall be in the office or principal working area of the person responsible for the maintenance of the system and a seconds at a continuously staffed location.
Findings: No med gas alarms for medical gas or vacuum systems were located in the maintenance office. On set of alarms were located in the located in the ER nurses station.

A. Observation and discussion between 1:15 and 2:45 on 1/5/2011 revealed 1999 NFPA 99: 3-3.2.1.2 (d)2 and Survey and Certification Letter S&C-03-21, requiring facilities to meet the 2000 Life Safety code were not being met.
The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords. A minimum of one emergency receptacle is required for each patient room per Hospital Licensing Rules Chapter 133.163 (t)(5)(iii).
Findings: No emergency receptacles were located in the patient rooms. It was stated the facility had a contingency plan to implement use of extension cords of emergency power is required for the individual patient rooms.
B. Observation between 1:15 and 2:45 on 1/5/2011 revealed 1999 NFPA 70, 370-28(C)was not being met.
All pull boxes, junction boxes (j-boxes) and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use.
Findings: J-box in the interstitial space above the main lobby ceiling was not covered.