HospitalInspections.org

Based on observations made during the survey of the facility between the hours of 9:00 am and 12:00 pm, while accompanied by the Acting Administrator, Safety Officer, Maintenance Director it was observed that the facility failed to provide a log showing a past "history" (for years 2014 and 2015) of consistent, systematic compliance with requirement for quarterly fire drills on each shift. While it was documented that the facility had accomplished fire drills for the current year, their overall documentation was incomplete due to not maintaining historical records for agency review.

Based on observations made during the survey of the facility between the hours of 9:00 am and 12:00 pm, while accompanied by the Acting Administrator, Safety Officer, Maintenance Director it was observed that the facility failed to provide a log indicating compliance with requirement for monthly testing/validation by staff of the fire alarm dial-out system and the receipt of its automatic signal to a designated 3rd party monitoring vendor.

Based on observations made during the survey of the facility between the hours of 9:00 am and 12:00 pm, while accompanied by the Acting Administrator, Safety Officer, Maintenance Director it was observed that while it appears the facility had accomplished some of the requirements, the facility failed to provide logs indicating consistent, systematic compliance on the following issues and items:

1. Air filter change log.
2. Electrical equipment inspections - Biomedical.
Critical Areas: Semi-annually.
General Areas: Annually
3. Electrical power and distribution and grounding systems - Effectiveness.
Critical Areas: Semi-annually.
General Areas: Annually

ADDITIONALLY:
4. The building's ROOF/CEILING construction assembly appeared to be a rated assembly. The gypsum board membrane installed horizontally along the bottom of the roof's structural members was not firestopped, and is not in compliance with fire-resistive construction regulatory requirements. The lack of compliance was observed in multiple locations. The facility shall make a full assessment of the building's ROOF/CEILING construction assembly and provide TDSHS with a written report of the findings and proposed resolution(s).

Based on observations made during the survey of the facility between the hours of 9:00 am and 12:00 pm, while accompanied by the Acting Administrator, Safety Officer, Maintenance Director it was observed that the facility failed to provide a log documenting consistent, systematic records on the facility's weekly observances on the Generator equipment system. Log records should include information on TIME/DATE/PERSONELL, as well as records regarding checks on OPERATIONAL/MAINTENANCE issues such as:
Fluid levels_belts_hoses_battery(s)_emergency shut-off(s)_fuel supply level(s)_leaks_etc.

Based on observations made during the survey of the facility between the hours of 9:00 am and 12:00 pm, while accompanied by the Acting Administrator, Safety Officer, Maintenance Director it was observed that the facility failed to provide a log showing a past "history" (for years 2014 and 2015) of consistent, systematic compliance with requirement for quarterly fire drills on each shift. While it was documented that the facility had accomplished fire drills for the current year, their overall documentation was incomplete due to not maintaining historical records for agency review.

Based on observations made during the survey of the facility between the hours of 9:00 am and 12:00 pm, while accompanied by the Acting Administrator, Safety Officer, Maintenance Director it was observed that the facility failed to provide a log indicating compliance with requirement for monthly testing/validation by staff of the fire alarm dial-out system and the receipt of its automatic signal to a designated 3rd party monitoring vendor.

Based on observations made during the survey of the facility between the hours of 9:00 am and 12:00 pm, while accompanied by the Acting Administrator, Safety Officer, Maintenance Director it was observed that while it appears the facility had accomplished some of the requirements, the facility failed to provide logs indicating consistent, systematic compliance on the following issues and items:

1. Air filter change log.
2. Electrical equipment inspections - Biomedical.
Critical Areas: Semi-annually.
General Areas: Annually
3. Electrical power and distribution and grounding systems - Effectiveness.
Critical Areas: Semi-annually.
General Areas: Annually

ADDITIONALLY:
4. The building's ROOF/CEILING construction assembly appeared to be a rated assembly. The gypsum board membrane installed horizontally along the bottom of the roof's structural members was not firestopped, and is not in compliance with fire-resistive construction regulatory requirements. The lack of compliance was observed in multiple locations. The facility shall make a full assessment of the building's ROOF/CEILING construction assembly and provide TDSHS with a written report of the findings and proposed resolution(s).

Based on observations made during the survey of the facility between the hours of 9:00 am and 12:00 pm, while accompanied by the Acting Administrator, Safety Officer, Maintenance Director it was observed that the facility failed to provide a log documenting consistent, systematic records on the facility's weekly observances on the Generator equipment system. Log records should include information on TIME/DATE/PERSONELL, as well as records regarding checks on OPERATIONAL/MAINTENANCE issues such as:
Fluid levels_belts_hoses_battery(s)_emergency shut-off(s)_fuel supply level(s)_leaks_etc.