HospitalInspections.org

Based on observation the facility failed to provide proper labeling for rated walls. Facility to verify all rated walls based on the latest Life Safety Plan and make sure all rated walls are properly marked (stenciling)
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 at the time of inspection, the facility failed to provide proper directional signage to a required exit. At the point of intersection at corridors, exit signs shall direct to the 2 means of egress exits. At the time of the inspection, only one directional chevron was active.
Directional Exit Signs, A sign complying with 7.10.3 with a directional indicator showing the direction of travel shall be placed in every location where the direction of travel to reach the nearest exit is not apparent. - NFPA 101, 2012 7.10.1.2.2

Based on observation at the time of inspection, the facility failed to provide an updated Life Safety Plan.

Based on observation at the time of inspection, the facility failed to provide a proper distance from the outside air intake of an existing rooftop unit to an existing exhaust fan.


Based on observation at the time of inspection, a flex conduit was noticed installed on electrical panel CLB-B. This is a critical panel; only hard conduit is allowed.
Mechanical protection of the emergency system. The wiring of the emergency system shall be mechanically protected by installation in nonflexible metal raceways by NFPA 70, 517.30(C)(3).


Based on observation at the time of inspection, the facility failed to provide proper labeling to the rated wall. The rated walls shall be stenciled to denote the rating of the wall.

Based on observation at the time of inspection, the facility failed to provide proper documentation identifying the Merv rating on the filters being replaced.




Based on observation at the time of inspection, the facility failed to provide proper access in various locations to fire extinguishers and a fire pull located in the mechanical room.

Based on observation at the time of inspection, the facility failed to comply with the State requirements under 133.166 (c) (1) (2)
(c) Common elements.

(1) Site requirements.

(A) Sites shall have a level concrete or asphalt pad and be designed for the structural loads of the unit.

(B) The sites shall provide hazard-free drop-off zones and adequate parking for patients. The site and location of the unit shall not restrict access to fire or emergency vehicles.

(C) Each site shall provide access to the unit for the handicapped, and wheelchair and stretcher patients.

(D) When a mobile, transportable, or relocatable unit is not physically attached to the hospital and provides inpatient services, a covered walkway or enclosure from the hospital to the unit shall be provided to ensure patient safety from the outside elements.

(E) The location of the unit shall be such that engine exhaust fumes from the unit are kept away from any fresh air intake of the hospital.

(F) When a mobile, transportable, or relocatable unit is permanently connected appropriately for the climate to the hospital or the unit does not move on a regular basis, i.e. every 90 days or less, the units shall be provided with the following equipment and systems connected to the hospital:

(i) fire alarm system.

(ii) sprinkler system.

(iii) electrical system and the essential electrical system.

(iv) water and wastewater system.

(v) medical gas systems; and

(vi) nurses calling systems.

(2) Support services. Support services shall meet the requirements of this chapter for new construction. These support services and areas shall be provided either within the mobile, transportable, or relocatable unit or located within the hospital adjacent to the unit served.

(3) Details and finishes. Details and finishes shall be in accordance with §133.162(d)(2) of this title.

(4) Mechanical requirements. Mechanical requirements shall be in accordance with §133.162(d)(3) of this title.

(5) Piping systems and plumbing fixtures. Piping systems and plumbing fixtures shall be in accordance with §133.162(d)(4) of this title.

(6) Electrical requirements. Electrical requirements shall be in accordance with §133.162(d)(5) of this title.


Based on observation at the time of inspection, the facility failed to comply with the State requirements under 133.161 (a) (2) (B)
Installation, alteration, or extension approval. No new system of mechanical, electrical, plumbing, fire protection, or piped medical gas system may be installed or any such existing system may be replaced, materially altered, or extended in an existing building licensed as a hospital, until complete plans and specifications for the replacement, installation, alteration, or extension have been submitted to the department, reviewed and approved in accordance with §133.167 of this title (relating to Preparation, Submittal, Review, and Approval of Plans, and Retention of Records).

Based on observation at the time of inspection, the facility failed to provide properly updated directories to the essential electrical panels.
Panel directories shall be labeled to legibly identify the purpose or use of each circuit - NFPA 70, 2002: 408.4.
Based on observation at the time of inspection, the facility failed to provide proper labeling to the existing disconnect. All disconnects associated with the essential system must be properly labeled.
NFPA 70, 2011, 110.22 Identification of Disconnecting Means. (A) General. Each disconnecting means shall be legibly marked to indicate its purpose unless located and arranged so the purpose is evident. The marking shall be of sufficient durability to withstand the environment involved.

Based on observation at the time of inspection, the facility failed to provide proper documentation identifying tests and associated repairs to patent care receptacles.

Based on observation at the time of inspection, the facility failed to provide proper documentation identifying transfer switches testing during monthly testing reports.

Based on observation at the time of inspection, the facility failed to provide proper protections for sprinkler heads located inside freezers/coolers.
6.2.8? Guards. Sprinklers subject to mechanical injury shall be protected with listed guards.