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Observation and discussion with the Maintenance Director and the EMS/Safety Director between 1:30 pm and 4:00 pm on 2/22/2012 revealed that certain requirements stipulated in NFPA 101 were not met.

Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1/2 hour [Re: NFPA 101, Life Safety Code, 2000: ? 19.3.7.3.]

Findings: The walls above the double egress doors had holes in the wall and could not be considered properly sealed.

Observation and discussion with the Maintenance Director and the EMS/Safety Director between 1:30 pm and 4:00 pm on 2/22/2012 revealed that certain requirements stipulated in NFPA 101 were not met.

Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms [Re: NFPA 101, Life Safety Code, 2000: ? 19.7.1.2.]

Findings: The required log indicating that this testing is performed was not observed.

Observation and discussion with the Maintenance Director and the EMS/Safety Director between 1:30 pm and 4:00 pm on 2/22/2012 revealed that certain requirements stipulated in NFPA 72 were not met.

The testing frequencies associated with system components are specified [Re: NFPA 52, National Fire Alarm Code, 1999: ? Table 7-3.2, Testing Frequencies.] The system must be tested monthly and serviced every six months by a licensed contractor.

Findings: This requirement was discussed with the staff during the survey, and it was noted that this requirement was not satisfied.

Observation and discussion with the Maintenance Director and the EMS/Safety Director between 1:30 pm and 4:00 pm on 2/22/2012 revealed that certain requirements stipulated in NFPA 99 and the State Licensing Rules were not met.

a. Disaster Drills

Each organizational entity shall implement one or more specific responses of the emergency preparedness plan at least semi-annually. At least one semi-annual drill shall rehearse mass casualty response for health care facilities with emergency services, disaster receiving stations, or both. At least one annual " after action report " shall be retained [Re: NFPA 99, Health Care Facilities, 1999: ? 11-5.3.9.]

The State Licensing Rules require that the documentation for these Disaster Drills be retained for three years [Re: 25 TAC HLR, 2007: ? 133.142(c)(3).]

Findings: Documentation was not available indicating that these requirements were satisfied.

b. Use of PVC

Soil stacks, drains, vents, waste lines, and leaders installed above ground within buildings shall be drain-waster-vent (DWV) weight or heavier and shall be: copper pipe, copper tube, cast iron pipe, or galvanized iron pipe [Re: 25 TAC, HLR, 2007: ? 133.162(d)(4)(A)(viii)(I).]

Findings: PVC drain pipes were installed in the dirty dish room underneath the triple hopper sink; this is not code compliant.

Observation and discussion with the Maintenance Director and the EMS/Safety Director between 1:30 pm and 4:00 pm on 2/22/2012 revealed that certain requirements stipulated in NFPA 70 and the State Licensing Rules were not met.


a. Mechanical Protection

The wiring of the emergency system of a hospital shall be mechanically protected by installation in nonflexible metal raceways, or shall be wired with Type MI cable. Where installed as branch circuit conductors serving patient care areas, the installation shall comply with the requirements of Section 517-13 [Re: NFPA 70, National Electrical Code, 1999: 517-30[c](3).]

Findings: A flex conduit was observed connected between Panelboard D2 and an unknown load. This must be replaced by EMT conduit and the load shall be identified.

b. Receptacles to be Labeled

All critical care area receptacles shall be identified. The face plate for the receptacle(s) shall have a nonremovable label or be engraved indicating the panel and circuit number [Re: 25 TAC HLR 2007: ? 133.162(d)(5)(h)(vi).]

Findings: The normal receptacles in the ED did not have this required labeling affixed to the cover plates.


c. Ice Machine Power

The State requires at least one ice machine to be located within reasonable proximity to every patient and powered by the critical branch in order that patients are served appropriately.

Findings: The ice machine identified as providing ice to patients was not powered by the critical branch as required.


d. Junction Box Covers

All pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction .... [Re: NFPA 70, National Electrical Code, 2002: ? 314.28[C].]

Findings: At least one junction box was observed without a cover as required above the double egress doors. The facility shall ensure all junction boxes are provided with covers.

Observation and discussion with the Maintenance Director and the EMS/Safety Director between 1:30 pm and 4:00 pm on 2/22/2012 revealed that certain requirements stipulated in NFPA 101 were not met.

Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1/2 hour [Re: NFPA 101, Life Safety Code, 2000: ? 19.3.7.3.]

Findings: The walls above the double egress doors had holes in the wall and could not be considered properly sealed.

Observation and discussion with the Maintenance Director and the EMS/Safety Director between 1:30 pm and 4:00 pm on 2/22/2012 revealed that certain requirements stipulated in NFPA 101 were not met.

Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms [Re: NFPA 101, Life Safety Code, 2000: ? 19.7.1.2.]

Findings: The required log indicating that this testing is performed was not observed.

Observation and discussion with the Maintenance Director and the EMS/Safety Director between 1:30 pm and 4:00 pm on 2/22/2012 revealed that certain requirements stipulated in NFPA 72 were not met.

The testing frequencies associated with system components are specified [Re: NFPA 52, National Fire Alarm Code, 1999: ? Table 7-3.2, Testing Frequencies.] The system must be tested monthly and serviced every six months by a licensed contractor.

Findings: This requirement was discussed with the staff during the survey, and it was noted that this requirement was not satisfied.

Observation and discussion with the Maintenance Director and the EMS/Safety Director between 1:30 pm and 4:00 pm on 2/22/2012 revealed that certain requirements stipulated in NFPA 99 and the State Licensing Rules were not met.

a. Disaster Drills

Each organizational entity shall implement one or more specific responses of the emergency preparedness plan at least semi-annually. At least one semi-annual drill shall rehearse mass casualty response for health care facilities with emergency services, disaster receiving stations, or both. At least one annual " after action report " shall be retained [Re: NFPA 99, Health Care Facilities, 1999: ? 11-5.3.9.]

The State Licensing Rules require that the documentation for these Disaster Drills be retained for three years [Re: 25 TAC HLR, 2007: ? 133.142(c)(3).]

Findings: Documentation was not available indicating that these requirements were satisfied.

b. Use of PVC

Soil stacks, drains, vents, waste lines, and leaders installed above ground within buildings shall be drain-waster-vent (DWV) weight or heavier and shall be: copper pipe, copper tube, cast iron pipe, or galvanized iron pipe [Re: 25 TAC, HLR, 2007: ? 133.162(d)(4)(A)(viii)(I).]

Findings: PVC drain pipes were installed in the dirty dish room underneath the triple hopper sink; this is not code compliant.

Observation and discussion with the Maintenance Director and the EMS/Safety Director between 1:30 pm and 4:00 pm on 2/22/2012 revealed that certain requirements stipulated in NFPA 70 and the State Licensing Rules were not met.


a. Mechanical Protection

The wiring of the emergency system of a hospital shall be mechanically protected by installation in nonflexible metal raceways, or shall be wired with Type MI cable. Where installed as branch circuit conductors serving patient care areas, the installation shall comply with the requirements of Section 517-13 [Re: NFPA 70, National Electrical Code, 1999: 517-30[c](3).]

Findings: A flex conduit was observed connected between Panelboard D2 and an unknown load. This must be replaced by EMT conduit and the load shall be identified.

b. Receptacles to be Labeled

All critical care area receptacles shall be identified. The face plate for the receptacle(s) shall have a nonremovable label or be engraved indicating the panel and circuit number [Re: 25 TAC HLR 2007: ? 133.162(d)(5)(h)(vi).]

Findings: The normal receptacles in the ED did not have this required labeling affixed to the cover plates.


c. Ice Machine Power

The State requires at least one ice machine to be located within reasonable proximity to every patient and powered by the critical branch in order that patients are served appropriately.

Findings: The ice machine identified as providing ice to patients was not powered by the critical branch as required.


d. Junction Box Covers

All pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction .... [Re: NFPA 70, National Electrical Code, 2002: ? 314.28[C].]

Findings: At least one junction box was observed without a cover as required above the double egress doors. The facility shall ensure all junction boxes are provided with covers.