HospitalInspections.org

Based on observations during the survey walk of the facility on the afternoon of 9/29/2016, accompanied by the Director of maintanave and Regional Enginner, the facility failed to provide and exit sign pointing left on the 1st floor by the Pharmacy directors office and the elevator banks.

Based on observations during the survey walk of the facility on the morning of 9/29/2016, accompanied by the Director of plant maintanance and the Regional enginner, the facility failed to provide proper markings on rated or smoke walls.
All fire walls, fire barriers, fire partitions, smoke barriers, and smoke partitions shall be effectively and permanently identified with signs or stenciling per IBC 2012 section 703.7.



Based on observation the facility failed to provide a history of records for receptacle testing per NFPA 99: 3-3.3.3. in patient care areas.
Receptacle Testing in Patient Care Areas - NFFA 99, 1999, 3-3.3.3

(a) The physical integrity of each receptacle shall be confirmed by visual inspection.
(b) The continuity of the grounding circuit in each electrical receptacle shall be verified.
(c) Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.
(d) The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz).

Based on observation the facility failed to provide a history of records for Line Isolation Monitor testing per NFPA 99, 1999, 3-3.3.4.2

Line Isolation Monitor Tests.
"The proper functioning of each line isolation monitor (LIM) circuit shall be ensured by the following:
(a) The LIM circuit shall be tested after installation, and prior to being placed in service, by successively grounding each line of the energized distribution system through a resistor of 200 V ohms, where V = measured line voltage. The visual and audible alarms [see 3-3.2.2.3(b)] shall be activated.
(b) The LIM circuit shall be tested at intervals of not more than 1 month by actuating the LIM test switch [see 3-3.2.2.3(f)]. For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months. Actuation of the test switch shall activate both visual and audible alarm indicators.
(c) After any repair or renovation to an electrical distribution system and at intervals of not more than 6 months, the LIM circuit shall be tested in accordance with paragraph (a) above and only when the circuit is not otherwise in use. For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months. " - N.F.P.A. 99, 1999, 3-3.3.4.2


Based on observation the facility failed to provide a history of records for Biomedical Testing per NFPA 99, 1999, 7-6.2.1.2.

All appliances used in patient care areas shall be tested in accordance with 7-5.1.3 or 7-5.2.2.1 before being put into service for the first time and after repair or modification. Patient-care-related electrical appliances shall be retested at intervals determined by their normal location or area of normal use, but not exceeding the intervals listed below:

General care areas - 12 months
Critical care areas - 6 months
Wet locations - 6 months

Based on observations during the survey walk of the facility on the afternoon of 9/29/2016, accompanied by the Director of maintanave and Regional Enginner, the facility failed to provide and exit sign pointing left on the 1st floor by the Pharmacy directors office and the elevator banks.

Based on observations during the survey walk of the facility on the morning of 9/29/2016, accompanied by the Director of plant maintanance and the Regional enginner, the facility failed to provide proper markings on rated or smoke walls.
All fire walls, fire barriers, fire partitions, smoke barriers, and smoke partitions shall be effectively and permanently identified with signs or stenciling per IBC 2012 section 703.7.



Based on observation the facility failed to provide a history of records for receptacle testing per NFPA 99: 3-3.3.3. in patient care areas.
Receptacle Testing in Patient Care Areas - NFFA 99, 1999, 3-3.3.3

(a) The physical integrity of each receptacle shall be confirmed by visual inspection.
(b) The continuity of the grounding circuit in each electrical receptacle shall be verified.
(c) Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.
(d) The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz).

Based on observation the facility failed to provide a history of records for Line Isolation Monitor testing per NFPA 99, 1999, 3-3.3.4.2

Line Isolation Monitor Tests.
"The proper functioning of each line isolation monitor (LIM) circuit shall be ensured by the following:
(a) The LIM circuit shall be tested after installation, and prior to being placed in service, by successively grounding each line of the energized distribution system through a resistor of 200 V ohms, where V = measured line voltage. The visual and audible alarms [see 3-3.2.2.3(b)] shall be activated.
(b) The LIM circuit shall be tested at intervals of not more than 1 month by actuating the LIM test switch [see 3-3.2.2.3(f)]. For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months. Actuation of the test switch shall activate both visual and audible alarm indicators.
(c) After any repair or renovation to an electrical distribution system and at intervals of not more than 6 months, the LIM circuit shall be tested in accordance with paragraph (a) above and only when the circuit is not otherwise in use. For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months. " - N.F.P.A. 99, 1999, 3-3.3.4.2


Based on observation the facility failed to provide a history of records for Biomedical Testing per NFPA 99, 1999, 7-6.2.1.2.

All appliances used in patient care areas shall be tested in accordance with 7-5.1.3 or 7-5.2.2.1 before being put into service for the first time and after repair or modification. Patient-care-related electrical appliances shall be retested at intervals determined by their normal location or area of normal use, but not exceeding the intervals listed below:

General care areas - 12 months
Critical care areas - 6 months
Wet locations - 6 months