HospitalInspections.org

Door Inspections:

Fire-rated door assemblies and certain other doors in the means of egress shall be tested annually or per an accepted performance-based evaluation schedule approved by the AHJ per NFPA 80, 2010, Ch. 5.2. A written record of the inspections and testing shall be signed and kept for inspection by the AHJ. NFPA101, 7.2.1.15.

Based on observation the facility failed to maintain properly all the doors along the means of egress.

The inspector observed, while accompanied by the Facilities Director, Market Facilities Compliance Officer, Associate Vice President (AVP) Regulatory and Maintenance Officer during the hours of the inspection from 9:00 am to 2:00 pm on 9/20/2022 that fire rated doors along the means of egress were inspected annually however, there was no record of repairs performed on the doors identified as defective during inspections.

Illumination of Means of Egress.
7.8.1.4* Required illumination shall be arranged so that the failure of any single lighting unit does not result in an illumination level of less than 0.2 ft-candle (2.2 lux) in any designated area.

Based on observation the facility failed to provide adequate illumination at exit landing.

The inspector observed, while accompanied by the Facilities Director, Market Facilities Compliance Officer, Associate Vice President (AVP) Regulatory and Maintenance Officer during the hours of the inspection from 9:00 am to 2:00 pm on 9/20/2022 that in the exit landing were missing two points of lights.

Based on observation the facility failed to provide adequate smoke barrier doors.

The inspector observed, while accompanied by the Facilities Director, Market Facilities Compliance Officer, Associate Vice President (AVP) Regulatory and Maintenance Officer during the hours of the inspection from 9:00 am to 2:00 pm on 9/20/2022 that there were many double egress doors without astragal. Provide astragals on these doors for optimal smoke infiltration protection.

Final filters and Frames:
Final filters and filter frames should be visually inspected for pressure drop and for bypass monthly. Filters should be replaced based on pressure drop or maintenance schedule with filters that provide the efficiencies specified. (ASHRAE 170, Informative Appendix A, Operations and Maintenance Procedures.) A log of filter replacements should be maintained for each air handler.


Based on observation the facility failed to provide adequate monthly pressure drop records.

The inspector observed, while accompanied by the Facilities Director, Market Facilities Compliance Officer, Associate Vice President (AVP) Regulatory and Maintenance Officer during the hours of the inspection from 9:00 am to 2:00 pm on 9/20/2022 that there was no record or logs of each air handler showing dates when the final filters, pre-filters have been replaced with the pressure differential across the filter before and after replacement where differential pressure monitors are required.

Medical gas tank farm outside- NFPA 99, 2012

8.3 Tanks must have permanent signage that states:

OXYGEN
NO SMOKING
NO OPEN FLAMES

8.4 Access to tanks should be controlled or locked.

NFPA, 99: 2012: 5.1.3.3.2*- Locations for central supply systems and the storage of positive-pressure gases shall meet the following requirements:

(1) They shall be constructed with access to move cylinders, equipment, and so forth, in and out of the
location on hand trucks complying with 11.4.3.1.1.
(2) They shall be secured with lockable doors or gates or otherwise secured.
(3) If outdoors, they shall be provided with an enclosure (wall or fencing) constructed of noncombustible
materials with a minimum of two entries/exits.

Based on observation the facility failed to provide adequate signage for gas storages outside and provide a procedure to ensure that the second exit is always open when somebody is the tank farm.

The inspector observed, while accompanied by the Facilities Director, Market Facilities Compliance Officer, Associate Vice President (AVP) Regulatory and Maintenance Officer during the hours of the inspection from 9:00 am to 2:00 pm on 9/20/2022 that the facility failed to provide adequate signage for gas storages outside and provide a procedure to ensure that the second exit is always open when somebody is the tank farm for safety reasons.


Medical Bulk Storage clearance

"The minimum distance from any bulk oxygen system to any public sidewalk or parked vehicle shall be 10 ft." - NFPA 50, 2001, 2.2.12.

"The minimum distance from any bulk oxygen system to any line of adjoining property that can be built upon shall be 5 ft." - NFPA 50, 2001, 2.2.13.

"The minimum distance from any bulk oxygen system to any opening in walls of adjacent structures shall be 10 ft." - NFPA 50, 2001, 2.2.3


Based on observation, the facility failed to provide adequate clearance between the sidewalk or road bulk gas storage area.

The inspector observed, while accompanied by the Facilities Director, Market Facilities Compliance Officer, Associate Vice President (AVP) Regulatory and Maintenance Officer during the hours of the inspection from 9:00 am to 2:00 pm on 9/20/2022 that the facility failed to provide adequate clearance between the sidewalk or vehicular roadway and the bulk medical gas storage area.

Based on observation the facility failed to provide a risk assessment for the medical gas system.

The inspector observed, while accompanied by the Facilities Director, Market Facilities Compliance Officer, Associate Vice President (AVP) Regulatory and Maintenance Officer during the hours of the inspection from 9:00 am to 2:00 pm on 9/20/2022 that the facility had not done a risk assessment to determine the procedures and schedule for testing the medical gas system.

Panel directory:
"Circuit Directory or Circuit Identification. Every circuit and circuit modification shall be legibly identified as to its clear, evident, and specific purpose or use. The identification shall include sufficient detail to allow each circuit to be distinguished from all others. Spare positions that contain unused overcurrent devices or switches shall be described accordingly. The identification shall be included in a circuit directory that is located on the face or inside of the panel door in the case of a panelboard and located at each switch or circuit breaker in a switchboard. No circuit shall be described in a manner that depends on transient conditions of occupancy." - NFPA 70, 2011, 408.4 (A) Note: Labeling includes all disconnecting means, see 110.22.

Based on observation the facility failed to provide adequate Essential Electrical System (EES).

The inspector observed, while accompanied by the Facilities Director, Market Facilities Compliance Officer, Associate Vice President (AVP) Regulatory and Maintenance Officer during the hours of the inspection from 9:00 am to 2:00 pm on 9/20/2022 that the EES Life Safety directories had wrong circuits in the life Safety panel. Panel directories shall be correct and shall be legible.



Essential Electrical System Segregation (Life Safety):
"The essential electrical system shall be divided into the following three branches: (1) Life safety, (2) Critical, (3) Equipment." NFPA 99, 2012, 6.4.2.2.1.1.

6.4.2.2.3 Life Safety Branch.
6.4.2.2.3.1 The life safety branch shall be limited to circuits essential to life safety.

6.4.2.2.3.2 "The life safety branch shall supply power for lighting, receptacles, and equipment as follows:
(1) Illumination of means of egress in accordance with 101, Life Safety Code,
(2) Exit signs and exit directional signs in accordance with NFPA 101, Life Safety Code,
(3) Hospital communications systems, where used for issuing instruction during emergency conditions,
(4) Generator set locations as follows:
(a) Task illumination,
(b) Battery charger for emergency battery-powered lighting unit(s),
(c) Select receptacles at the generator set location and essential electrical system transfer switch locations,
(5) Elevator cab lighting, control, communications, and signal systems,
(6) Electrically powered doors used for building egress,
(7) Fire alarms and auxiliary functions of fire alarm combination systems complying with NFPA 72, National Fire Alarm and Signaling Code."

6.4.2.2.3.3 "Alarm and alerting systems (other than fire alarm systems) shall be connected to the life safety branch or critical branch."

6.4.2.2.3.4 "Loads dedicated to a specific generator, including the fuel transfer pump(s), ventilation fans, electrically operated louvers, controls, cooling system, and other generator accessories essential for generator operation, shall be connected to the life safety branch or the output terminals of the generator with overcurrent protective devices."

6.4.2.2.3.5 "No functions other than those in 6.4.2.2.3.2, 6.4.2.2.3.3, and 6.4.2.2.3.4 shall be connected to the life safety branch, except as specifically permitted in 6.4.2.2.3."


Based on observation the facility had incorrect circuits connected in the essential electrical system.

The inspector observed, while accompanied by the Facilities Director, Market Facilities Compliance Officer, Associate Vice President (AVP) Regulatory and Maintenance Officer during the hours of the inspection from 9:00 am to 2:00 pm on 9/20/2022 that the select receptacle at Generator and ATS locations could not be verified to be connected to Life Safety branch/panel.

Essential Electrical System Segregation (Critical Branch)

"General Care Areas. Patient Bed Location. Each patient bed location shall be supplied by at least two branch circuits, one from the emergency system and one from the normal system all Branch circuits from the normal system shall originate in the same panelboard." NFPA 70, 2011, 517.18(A)

Patient Bed Location Receptacles. Each patient bed location shall be provided with a minimum of four receptacles. They shall be permitted to be of the single, duplex, or quadruplex type, or any combination of the three. All receptacles, whether four or more, shall be listed "hospital grade" and so identified. The grounding terminal of each receptacle shall be connected to an insulated copper equipment grounding conductor sized in accordance with Table 250.122.

Exception No. 1: The requirements of 517.18(B) shall not apply to psychiatric, substance abuse, and rehabilitation hospitals meeting the requirement of 517.18(B)(2).

Exception No. 2: Psychiatric security rooms shall not be required to have receptacle outlets installed in the room.

Informational Note: It is not intended that there be a total, immediate replacement of existing non-hospital grade receptacles. It is intended, however, that non-hospital grade receptacles be replaced with hospital grade receptacles upon modification of use, renovation, or as existing receptacles need replacement." NPFA 70, 2011, 517.18(B)

Based on observation the facility failed to provide lights from critical branch lights to all the patient care areas.

The inspector observed, while accompanied by the Facilities Director, Market Facilities Compliance Officer, Associate Vice President (AVP) Regulatory and Maintenance Officer during the hours of the inspection from 9:00 am to 2:00 pm on 9/20/2022 that were:
1. the facility did not provide lights to the patient care areas from the critical branch. Also, some patient care areas were missing receptacles from critical branch.
2. Remove all fire related systems from Critical branch panel to life safety panel.

Generator EPOS or Kill Switch:

"All installations shall have a remote manual stop station of a type to prevent inadvertent or unintentional operation located outside the room housing the prime mover, where so installed, or elsewhere on the premises where the prime mover is located outside the building" - NFPA 110, 2010.

Based on observation the facility had incorrectly installed the Generator kill switch in a locked location.

The inspector observed, while accompanied by the Facilities Director, Market Facilities Compliance Officer, Associate Vice President (AVP) Regulatory and Maintenance Officer during the hours of the inspection from 9:00 am to 2:00 pm on 9/20/2022 that the generator kill was installed outside the generator enclosure per the code but was in a LOCKED location. Access to the kill switch shall not be hindered.

Based on observation the facility failed to provide adequate risk assessment for all the operating rooms.

The inspector observed, while accompanied by the Facilities Director, Market Facilities Compliance Officer, Associate Vice President (AVP) Regulatory and Maintenance Officer during the hours of the inspection from 9:00 am to 2:00 pm on 9/20/2022 that risk assessments were not performed by the governing body to determine if the Operating rooms were wet or dry locations. If determined to be wet, they must be protected by line isolation monitors or GFCIs.

Based on observation the facility failed to provide adequate maintenance and testing of Essential Electrical System.

The inspector observed, while accompanied by the Facilities Director, Market Facilities Compliance Officer, Associate Vice President (AVP) Regulatory and Maintenance Officer during the hours of the inspection from 9:00 am to 2:00 pm on 9/20/2022 that there were the following issues:
1. That additional testing was not being performed correctly in terms of referencing each receptacle to the different tests performed on the particular receptacle in the patient care area at intervals defined by documented performance data on all the patient care receptacles. The testing record shall be such that each area and receptacles tested must be identified.
2. Records of where, type of repairs performed and date of electrical maintenance and required tests performed in all the patient care areas.

Based on observation the facility failed to provide adequate maintenance and testing of Essential Electrical System.

The inspector observed, while accompanied by the Facilities Director, Market Facilities Compliance Officer, Associate Vice President (AVP) Regulatory and Maintenance Officer during the hours of the inspection from 9:00 am to 2:00 pm on 9/20/2022 that there were the following issues:

1. The main and feeder circuit breakers were not being inspected annually and there was no program for periodically exercising the
components.
2. There were no records of maintenance and testing maintained.

Based on observation the facility failed to provide adequate medical gas equipment testing.

The inspector observed, while accompanied by the Facilities Director, Market Facilities Compliance Officer, Associate Vice President (AVP) Regulatory and Maintenance Officer during the hours of the inspection from 9:00 am to 2:00 pm on 9/20/2022 that the facility had no scheduled maintenance program for medical gas equipment.