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Tag No.: K0500
Based on observations made during the survey of the facility between the hours of 8:30 am and 12:30 pm, while accompanied by the hospital's CEO, COO, and the Plant Ops Manager it was observed that the facility failed to provide the required filter change log for the pre-filter beds and final filter beds for all AHUs.
Tag No.: K0900
Based on observations made during the survey of the facility between the hours of 9:00 am and 1:00 pm, while accompanied by the hospital's CEO, COO, and the Plant Ops Manager it was observed that the facility failed to show the surveyor the required "duct detectors" for 8 AHUs. The dampers were there, and they appeared to be controlled by "something". However, we were not able to locate the duct detectors which normally are required to initiate emergency dampering of the supply and return air ducts.