HospitalInspections.org

Observation and discussion with the Director of Performance Improvement and Risk Management, and the Director of Plant Operations between 11 am and 2:45 pm on 2/1/2011 revealed that certain requirements stipulated in NFPA 101 were not met.

Interior finish for corridors and exitways, including exposed interior surfaces of buildings such as fixed or movable walls, partitions, columns, and ceilings has a flame spread rating of Class A or Class B. [NFPA 101, Life Safety Code, 2000: ? 19.3.3.2.]

Findings: This requirement was discussed and it was determined that the required documentation is not retained by the staff.

Observation and discussion with the Director of Performance Improvement and Risk Management, and the Director of Plant Operations between 11 am and 2:45 pm on 2/1/2011 revealed that certain requirements stipulated in NFPA 101 were not met.

Smoke Passage Resisted

Corridor walls shall form a barrier to limit the transfer of smoke [Re: NFPA 101, Life Safety Code, 2000: ? 19.3.6.2.2.]

Findings: The corridor wall above the monolithic ceiling, above the double doors, near Room 45 exhibited at least one penetration that must be sealed to protect the integrity of the rated wall. The facility shall affirm that all penetrations in rated walls have been caulked properly.

Observation and discussion with the Director of Performance Improvement and Risk Management, and the Director of Plant Operations between 11 am and 2:45 pm on 2/1/2011 revealed that certain requirements stipulated in NFPA 90A were not met.

a. Service Openings

A service opening shall be provided in air ducts adjacent to each fire damper, smoke damper, and smoke detector. The opening shall be large enough to permit maintenance and resetting of the device within [Re: NFPA 90A, Installation of Air Conditioning and Ventilating Systems, 1999: ? 2-3.4.1.]

Findings: During the survey, at least one damper [above the double doors near Room 45] did not have an access panel installed in the duct and therefore the damper cannot be serviced as required. The facility shall ensure that this requirement is satisfied at all required location.

b. Access Panel Labels

Service openings shall be identified with letters having a minimum height of ? in. [1.27 cm] to indicate the location of the fire protection device[s] within [Re: NFPA 90A, Installation of Air Conditioning and Ventilating Systems, 1999: ? 2-3.4.2.]

Findings: During the survey, access panel labels were not noted. All locations affected by a) above must be labeled according to this requirement. The facility shall ensure that this requirement is satisfied.

Observation and discussion with the Director of Performance Improvement and Risk Management, and the Director of Plant Operations between 11 am and 2:45 pm on 2/1/2011 revealed that certain requirements stipulated in NFPA 10 and state licensing rules were not met.

a. Placard

Provide a placard placed conspicuously near the Class K fire extinguisher after June 30, 1998. Placard to read " fire protection system shall be activated prior of using fire extinguisher " [Re: NFPA 10, Standard for Portable Fire Extinguishers, 1998: ? 4.3.2.2.]

Findings: During the survey, this required feature was not noted, although the extinguisher was noted. The facility shall ensure that this requirement is satisfied.

b. Illuminated Switch

Exhaust hoods shall have an indicator light indicating that the exhaust fan is in operation [Re: 25 TAC PPH & CSU LR, 2004: ? 134.123(d)(5)(A).]

Findings: During the survey, the kitchen hood on/off switch was observed and an illuminated feature was not installed. The facility shall ensure that this requirement is satisfied.

Observation and discussion with the Director of Performance Improvement and Risk Management, and the Director of Plant Operations between 11 am and 2:45 pm on 2/1/2011 revealed that certain requirements stipulated in NFPA 101 were not met.

Draperies, curtains, including cubicle curtains, and other loosely hanging fabrics and films serving as furnishings or decorations in ambulatory health care occupancies shall be in accordance with 10.3.1 [Re: NFPA 101, Life Safety Code. 2000: ? 19.7.5.1.]

Findings: This requirement was discussed and it was determined that the required documentation is not retained by the staff.

Observation and discussion with the Director of Performance Improvement and Risk Management, and the Director of Plant Operations between 11 am and 2:45 pm on 2/1/2011 revealed that certain requirements stipulated in NFPA 99 and certain requirements stipulated in the state licensing regulations were not met.

a. Disaster Drills

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

Findings: The most recent Disaster Drill was conducted more than 6 months ago. They must be held on a semi-annual basis and must be documented.

b. After Action Reports

Documentation of rehearsals for the last three years shall be retained [Re: 25 TAC PPH & CSU LR, 2004: ? 134.102(b)(4).]

Findings: Documentation of past drills was not available for review.

c. Use of PVC

Soil stacks, drains, vents, waste lines, and leaders installed above ground within buildings shall be drain-waste-vent (DWV) weight or heavier and shall be: copper pipe, copper tube, cast iron pipe, or galvanized iron pipe [Re: 25 TAC, PPH & CSU LR, 2004: ? 134.122(d)(4)(A)(v)(I).]

Findings: PVC piping was installed extensively in the dietary suite, eg, on the dishwasher, the three compartment sink and in the food prep area. This is not permitted.

d. Letters of Preference

The hospital is required to have letters of preference from providers of fuel and potable water in order to provide continuous service in the event of an emergency [Re: NFPA 99, Health Care Facilities, 1999: 11-5.3.2.]

Findings: The staff could not present these letters verifying that this requirement was met.

Observation and discussion with the Director of Performance Improvement and Risk Management, and the Director of Plant Operations between 11 am and 2:45 pm on 2/1/2011 revealed that certain requirements stipulated in NFPA 70 and certain requirements stipulated in the state licensing regulations were not met.

a. Requirement

A Type I essential electrical system shall be provided in each facility in accordance with requirements of NFPA 99, NFPA 101, and NFPA 110 ... ... [Re: 25 TAC PPH & CSU LR, 2004: ? 134.122(d)(5)(L).]

Findings: This topic was discussed during the survey and it was not possible to determine if a Type I system is present. During the survey, no Life Safety components were observed. One panelboard was hand-labeled " critical " . The facility shall affirm that a Type I system is installed as required. ]. However, it is departmental policy to permit an electrical system to be configured with a normal branch and an emergency branch provided the hospital was built before 1981 and deliveries and surgeries are not performed, and life support systems are not employed. This facility meets these conditions.

b. GenSet Life Safety Features

A battery powered light where the battery is charged by the life safety branch and a receptacle powered by the life safety branch is required [Re: NFPA 70, National Electrical Code, 2002: ? 517.32[E].]

Findings: This topic was discussed during the survey and when the generator was observed, it was obvious that this requirement was not met. The facility shall make the necessary changes to meet this requirement.

c. Functional Allocation

Specific requirements exist identifying the functions as they must be allocated to the critical branch [NFPA 70, National Electrical Code, 2002, ?517.33], life safety branch [NFPA 70, National Electrical Code, 2002, ?517.32], and the equipment system [NFPA 70, National Electrical Code, 2002, ?517.34.]

Findings: During the survey, it was difficult to determine which electrical component was powered by a particular branch of the electrical system. The facility shall develop a one-line diagram and identify each component of the electrical system

d. Equipment Labels

All boxes and enclosures (including transfer switches, transformers, distribution panels, and panelboards) for emergency circuits shall be permanently marked so they will be readily identified as a component of an emergency circuit or system [Re: NFPA 70, National Electrical Code, 2002: 700.9(A).] The above listed components shall be labeled with the words " LIFE SAFETY " , " CRITICAL " AND " EQUIPMENT " to be readily identifiable as part of the Essential Electrical System.

Findings: During the survey, the electrical components were not labeled and it could not be determined which branch powered the electrical components. The components must be labeled appropriately. If the hospital chooses to retain an " emergency " and " normal " configuration, it may do so.

f. Circuit Directory

All circuits and circuit modifications shall be legibly identified as to purpose or use on a circuit directory located on the face or inside of the panel door in the case of a panelboard, and at each switch on a switchboard [Re: NFPA 70, National Electrical Code, 2002: ? 408.4.]

Findings: All circuit directories must be updated to be legible and meaningful.


g. Specific Power Sources

Specific Loads must be powered by certain branches according to national codes [Re: NFPA 70, National Electrical Code, 2002: ? 517.30.] These codes were not followed in the facility and should be observed.

Findings:

1. In Room 140B, a fire alarm component was powered by what appeared to be a normal panelboard; this is not permitted.

2. It could not be ascertained that the fire/smoke damper observed above the double doors near Room 45 was powered by the equipment branch as required.

h. Junction Box

All branch circuits serving patient care areas shall be provided with a ground path for fault current by installation in a metal raceway system ..... [Re: NFPA 70, National Electrical Code, 2002: ? 517.13.]

Findings: Loose wiring was observed above the double doors near Room 45. These must be enclosed in a junction box so this requirement is met.

Observation and discussion with the Director of Performance Improvement and Risk Management, and the Director of Plant Operations between 11 am and 2:45 pm on 2/1/2011 revealed that certain requirements stipulated in NFPA 101 were not met.

Interior finish for corridors and exitways, including exposed interior surfaces of buildings such as fixed or movable walls, partitions, columns, and ceilings has a flame spread rating of Class A or Class B. [NFPA 101, Life Safety Code, 2000: ? 19.3.3.2.]

Findings: This requirement was discussed and it was determined that the required documentation is not retained by the staff.

Observation and discussion with the Director of Performance Improvement and Risk Management, and the Director of Plant Operations between 11 am and 2:45 pm on 2/1/2011 revealed that certain requirements stipulated in NFPA 101 were not met.

Smoke Passage Resisted

Corridor walls shall form a barrier to limit the transfer of smoke [Re: NFPA 101, Life Safety Code, 2000: ? 19.3.6.2.2.]

Findings: The corridor wall above the monolithic ceiling, above the double doors, near Room 45 exhibited at least one penetration that must be sealed to protect the integrity of the rated wall. The facility shall affirm that all penetrations in rated walls have been caulked properly.

Observation and discussion with the Director of Performance Improvement and Risk Management, and the Director of Plant Operations between 11 am and 2:45 pm on 2/1/2011 revealed that certain requirements stipulated in NFPA 90A were not met.

a. Service Openings

A service opening shall be provided in air ducts adjacent to each fire damper, smoke damper, and smoke detector. The opening shall be large enough to permit maintenance and resetting of the device within [Re: NFPA 90A, Installation of Air Conditioning and Ventilating Systems, 1999: ? 2-3.4.1.]

Findings: During the survey, at least one damper [above the double doors near Room 45] did not have an access panel installed in the duct and therefore the damper cannot be serviced as required. The facility shall ensure that this requirement is satisfied at all required location.

b. Access Panel Labels

Service openings shall be identified with letters having a minimum height of ? in. [1.27 cm] to indicate the location of the fire protection device[s] within [Re: NFPA 90A, Installation of Air Conditioning and Ventilating Systems, 1999: ? 2-3.4.2.]

Findings: During the survey, access panel labels were not noted. All locations affected by a) above must be labeled according to this requirement. The facility shall ensure that this requirement is satisfied.

Observation and discussion with the Director of Performance Improvement and Risk Management, and the Director of Plant Operations between 11 am and 2:45 pm on 2/1/2011 revealed that certain requirements stipulated in NFPA 10 and state licensing rules were not met.

a. Placard

Provide a placard placed conspicuously near the Class K fire extinguisher after June 30, 1998. Placard to read " fire protection system shall be activated prior of using fire extinguisher " [Re: NFPA 10, Standard for Portable Fire Extinguishers, 1998: ? 4.3.2.2.]

Findings: During the survey, this required feature was not noted, although the extinguisher was noted. The facility shall ensure that this requirement is satisfied.

b. Illuminated Switch

Exhaust hoods shall have an indicator light indicating that the exhaust fan is in operation [Re: 25 TAC PPH & CSU LR, 2004: ? 134.123(d)(5)(A).]

Findings: During the survey, the kitchen hood on/off switch was observed and an illuminated feature was not installed. The facility shall ensure that this requirement is satisfied.

Observation and discussion with the Director of Performance Improvement and Risk Management, and the Director of Plant Operations between 11 am and 2:45 pm on 2/1/2011 revealed that certain requirements stipulated in NFPA 101 were not met.

Draperies, curtains, including cubicle curtains, and other loosely hanging fabrics and films serving as furnishings or decorations in ambulatory health care occupancies shall be in accordance with 10.3.1 [Re: NFPA 101, Life Safety Code. 2000: ? 19.7.5.1.]

Findings: This requirement was discussed and it was determined that the required documentation is not retained by the staff.

Observation and discussion with the Director of Performance Improvement and Risk Management, and the Director of Plant Operations between 11 am and 2:45 pm on 2/1/2011 revealed that certain requirements stipulated in NFPA 99 and certain requirements stipulated in the state licensing regulations were not met.

a. Disaster Drills

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

Findings: The most recent Disaster Drill was conducted more than 6 months ago. They must be held on a semi-annual basis and must be documented.

b. After Action Reports

Documentation of rehearsals for the last three years shall be retained [Re: 25 TAC PPH & CSU LR, 2004: ? 134.102(b)(4).]

Findings: Documentation of past drills was not available for review.

c. Use of PVC

Soil stacks, drains, vents, waste lines, and leaders installed above ground within buildings shall be drain-waste-vent (DWV) weight or heavier and shall be: copper pipe, copper tube, cast iron pipe, or galvanized iron pipe [Re: 25 TAC, PPH & CSU LR, 2004: ? 134.122(d)(4)(A)(v)(I).]

Findings: PVC piping was installed extensively in the dietary suite, eg, on the dishwasher, the three compartment sink and in the food prep area. This is not permitted.

d. Letters of Preference

The hospital is required to have letters of preference from providers of fuel and potable water in order to provide continuous service in the event of an emergency [Re: NFPA 99, Health Care Facilities, 1999: 11-5.3.2.]

Findings: The staff could not present these letters verifying that this requirement was met.

Observation and discussion with the Director of Performance Improvement and Risk Management, and the Director of Plant Operations between 11 am and 2:45 pm on 2/1/2011 revealed that certain requirements stipulated in NFPA 70 and certain requirements stipulated in the state licensing regulations were not met.

a. Requirement

A Type I essential electrical system shall be provided in each facility in accordance with requirements of NFPA 99, NFPA 101, and NFPA 110 ... ... [Re: 25 TAC PPH & CSU LR, 2004: ? 134.122(d)(5)(L).]

Findings: This topic was discussed during the survey and it was not possible to determine if a Type I system is present. During the survey, no Life Safety components were observed. One panelboard was hand-labeled " critical " . The facility shall affirm that a Type I system is installed as required. ]. However, it is departmental policy to permit an electrical system to be configured with a normal branch and an emergency branch provided the hospital was built before 1981 and deliveries and surgeries are not performed, and life support systems are not employed. This facility meets these conditions.

b. GenSet Life Safety Features

A battery powered light where the battery is charged by the life safety branch and a receptacle powered by the life safety branch is required [Re: NFPA 70, National Electrical Code, 2002: ? 517.32[E].]

Findings: This topic was discussed during the survey and when the generator was observed, it was obvious that this requirement was not met. The facility shall make the necessary changes to meet this requirement.

c. Functional Allocation

Specific requirements exist identifying the functions as they must be allocated to the critical branch [NFPA 70, National Electrical Code, 2002, ?517.33], life safety branch [NFPA 70, National Electrical Code, 2002, ?517.32], and the equipment system [NFPA 70, National Electrical Code, 2002, ?517.34.]

Findings: During the survey, it was difficult to determine which electrical component was powered by a particular branch of the electrical system. The facility shall develop a one-line diagram and identify each component of the electrical system

d. Equipment Labels

All boxes and enclosures (including transfer switches, transformers, distribution panels, and panelboards) for emergency circuits shall be permanently marked so they will be readily identified as a component of an emergency circuit or system [Re: NFPA 70, National Electrical Code, 2002: 700.9(A).] The above listed components shall be labeled with the words " LIFE SAFETY " , " CRITICAL " AND " EQUIPMENT " to be readily identifiable as part of the Essential Electrical System.

Findings: During the survey, the electrical components were not labeled and it could not be determined which branch powered the electrical components. The components must be labeled appropriately. If the hospital chooses to retain an " emergency " and " normal " configuration, it may do so.

f. Circuit Directory

All circuits and circuit modifications shall be legibly identified as to purpose or use on a circuit directory located on the face or inside of the panel door in the case of a panelboard, and at each switch on a switchboard [Re: NFPA 70, National Electrical Code, 2002: ? 408.4.]

Findings: All circuit directories must be updated to be legible and meaningful.


g. Specific Power Sources

Specific Loads must be powered by certain branches according to national codes [Re: NFPA 70, National Electrical Code, 2002: ? 517.30.] These codes were not followed in the facility and should be observed.

Findings:

1. In Room 140B, a fire alarm component was powered by what appeared to be a normal panelboard; this is not permitted.

2. It could not be ascertained that the fire/smoke damper observed above the double doors near Room 45 was powered by the equipment branch as required.

h. Junction Box

All branch circuits serving patient care areas shall be provided with a ground path for fault current by installation in a metal raceway system ..... [Re: NFPA 70, National Electrical Code, 2002: ? 517.13.]

Findings: Loose wiring was observed above the double doors near Room 45. These must be enclosed in a junction box so this requirement is met.