HospitalInspections.org

At the time of the inspection, multiple maintence documents were request for review it was found the facility was not maintaining required documentation, or documentation was behind or inadequate for the required survey period. Missing included, All Electrical and Emergency EES weekly and monthly inspections and documentation, Basic Life Safety Facility Plan and updated Evacuation Routes, ALL Heating, Cooling Ventilation and Process Systems maintenance records, Risk Assessment by Building System Categories, All Medical Gas System Testing and Documentation.

Upon inspection at the time of the survey, the Two Hour Fire Wall Separation between the Hospital and the Rehab Clinic was not intact, and not constructed to meet NFPA-101 8.2.1.3

NFPA-101 8.2.1.3 Where the building or facility includes additions or connected structures of different construction types, the rating and classification of the structure shall be based on one of the following:
(1) Separate buildings, if a 2-hour or greater vertically aligned fire barrier wall in accordance with NFPA 221, Standard for High Challenge Fire Walls, Fire Walls, and Fire Barrier Walls, exists between the portions of the building

At the time of the survey, the facility was unable to produce a Life Safety Plan denoting wall rating, location of Smoke Barrier Walls, and egress routes.

At the time of the survey, the inspector found Smoke Barriers and Rated Wall Assemblies had applied ("Scabbed-On") sheetrock not installed per ASTM/UL rated assembly in multiple locations. NFPA-101 19.3.7.3.? Smoke Barrier Walls had opening which were not sealed.

NFPA-101 19.3.7.3? Any required smoke barrier shall be constructed in accordance with Section 8.5 and shall have a minimum ½-hour fire resistance rating, unless otherwise permitted by one of the following:
(1)?This requirement shall not apply where an atrium is used, and both of the following criteria also shall apply:
(a)?Smoke barriers shall be permitted to terminate at an atrium wall constructed in accordance with 8.6.7(1)(c).
(b)?Not less than two separate smoke compartments shall be provided on each floor,
(2)*Smoke dampers shall not be required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air-conditioning systems where an approved, supervised automatic sprinkler system in accordance with 19.3.5.8 has been provided for smoke compartments adjacent to the smoke barrier.

At the time of the survery and upon physical inspection, the inspector was unable to identify Flame Spread and Smoke Development rating on Cubical Curtains and Furnishings. Hospital does not have a purchasing policy regarding FF&E.

NFPA- 101 10.3.1* Where required by the applicable provisions of this Code, draperies, curtains, and other similar loosely hanging furnishings and decorations shall meet the flame propagation performance criteria contained in NFPA 701, Standard Methods of Fire Tests for Flame Propagation of Textiles and Films.

NFPA-101 19.7.5.1* Draperies, curtains, and other loosely hanging fabrics and films serving as furnishings or decorations in health care occupancies shall be in accordance with the provisions of 10.3.1 (see 19.3.5.11), and the following also shall apply:
(1)?Such curtains shall include cubicle curtains.

At the time of the inspection, the inspetor was unable to identify Flame Spread and Smoke Development rating on Furnishings. Hospital does not have a purchasing policy regarding FF&E.
NFPA-101 19.7.5.2? Newly introduced upholstered furniture within health care occupancies shall comply with one of the following provisions, unless otherwise provided in 19.7.5.3:

At the time of the inspection, the inspector noted that Medical Gas Cylinders where not labeled (In-Use, Empty, etc), or chained to prevent falling within the Medical Gas Room.

NFPA-99 5.1.3.3.2(7)?They shall be provided with racks, chains, or other fastenings to secure all cylinders from falling, whether connected, unconnected, full, or empty.
K902


At the time of inspection, the inspector noted the medical gas storage room did not have proper ventilation (Mechanical or Natural Ventilation) per NFPA-99 Chapter 9.

NFPA-99 9.3.7.5? Indoor storage or manifold areas and storage or manifold buildings for medical gases and cryogenic fluids shall be provided with natural ventilation or mechanical exhaust ventilation in accordance with 9.3.7.5.1 through 9.3.7.8.
9.3.7.5.1* For the purposes of this section the volume of fluid (gas and liquid) to be used in determining the ventilation requirements shall be the volume of the stored fluid when expanded to standard temperature and pressure (STP) of either the largest single vessel in the enclosed space or of the entire volume of the connected vessels that are on a common manifold in the enclosed space, whichever is larger.

9.3.7.5.2? Natural Ventilation.
9.3.7.5.2.1? Natural ventilation shall consist of two nonclosable louvered openings, each having an aggregate free opening area of at least 155 cm2/35 L (24 in.2/1000 ft3) of the fluid designed to be stored in the space and in no case less than 465 cm2 (72 in.2).
9.3.7.5.2.2? One opening shall be located within 30 cm (1 ft) of the floor, and one shall be located within 30 cm (1 ft) of the ceiling.
9.3.7.5.2.3? The openings shall be located to ensure cross ventilation.
9.3.7.5.2.4? Natural ventilation openings shall be directly to the outside atmosphere without ductwork.
9.3.7.5.2.5? Mechanical ventilation shall be provided if natural ventilation requirements cannot be met.

9.3.7.5.3? Mechanical Ventilation.
9.3.7.5.3.1? Mechanical exhaust to maintain a negative pressure in the space shall be provided continuously, unless an alternative design is approved by the authority having jurisdiction.
9.3.7.5.3.2? Mechanical exhaust shall be at a rate of 1 L/sec of airflow for each 300 L (1 cfm per 5 ft3 of fluid) designed to be stored in the space and not less than 24 L/sec (50 cfm) nor more than 235 L/sec (500 cfm).
9.3.7.5.3.3? Mechanical exhaust inlets shall be unobstructed and shall draw air from within 300 mm (1 ft) of the floor and adjacent to the cylinder or containers.
9.3.7.5.3.4? Mechanical exhaust air fans shall be supplied with electrical power from the essential electrical system.
9.3.7.5.3.5? Dedicated exhaust systems shall not be required, provided that the system does not connect to spaces that contain combustible or flammable materials.
9.3.7.5.3.6? The exhaust duct material shall be noncombustible.
9.3.7.5.3.7? A means of make-up air shall be provided according to one of the following:
(1) Air shall be permitted via noncombustible ductwork to be transferred from adjacent spaces, from outside the building, or from spaces that do not contain combustible or flammable materials
(2) Air shall be permitted to be transferred from a corridor under the door up to the greater of 24 L/sec (50 cfm) or 15 percent of the room exhaust in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems.
(3) Supply air shall be permitted to be provided from any building ventilation system that does not contain flammable or combustible vapors.

At the time of the inspection and upon request, the facility could not provide a "Risk Assessment" of the Medical Gas System per NFPA-99

NFPA-99 4.1* Building System Categories. Building systems in health care facilities shall be designed to meet system Category 1 through Category 4 requirements as detailed in this code.

At the time of the inspection, the inspector found no warning or information signs where at the Medical Gas Storage Room.

NFPA-99 5.1.3.1.8? Locations containing positive pressure gases other than oxygen and medical air shall have their door(s) labeled as follows:
Positive Pressure Gases
NO Smoking or Open Flame
Room May Have Insufficient Oxygen
Open Door and Allow Room to
Ventilate Before Entering
5.1.3.1.9? Locations containing central supply systems or cylinders containing only oxygen or medical air shall have their door(s) labeled as follows:
Medical Gases
NO Smoking or Open Flame

At the time of inspection, and upon request the facility was unable to provide maintenance documents to verify maintenance and required testing of the Medical Gas System.

NFPA-99 5.1.14.2.1* General. Health care facilities with installed medical gas, vacuum, WAGD, or medical support gas systems, or combinations thereof, shall develop and document periodic maintenance programs for these systems and their subcomponents as appropriate to the equipment installed.
5.1.14.2.2? Maintenance Programs.
5.1.14.2.2.1? Inventories. Inventories of medical gas, vacuum, WAGD, and medical support gas systems shall include at least all source subsystems, control valves, alarms, manufactured assemblies containing patient gases, and outlets.
5.1.14.2.2.2* Inspection Schedules. Scheduled inspections for equipment and procedures shall be established through the risk assessment of the facility and developed with consideration of the original equipment manufacturer recommendations and other recommendations as required by the authority having jurisdiction.
5.1.14.2.2.3? Inspection Procedures. The facility shall be permitted to use any inspection procedure(s) or testing methods established through its own risk assessment.
5.1.14.2.2.4? Maintenance Schedules. Scheduled maintenance for equipment and procedures shall be established through the risk assessment of the facility and developed with consideration of the original equipment manufacturer recommendations and other recommendations as required by the authority having jurisdiction.

At the time of inspection the facility was unable to provide testing documentation for review for the Medical Gas Systems.

NFPA-99 5.1.14.2.3? Inspection and Testing Operations.
5.1.14.2.3.1? General. The elements in 5.1.14.2.2.2 through 5.1.15 shall be inspected or tested as part of the maintenance program as follows:
(1)*Medical air source, as follows:
(a)?Room temperature
(b)?Shaft seal condition
(c)?Filter condition
(d)?Presence of hydrocarbons
(e)?Room ventilation
(f)?Water quality, if so equipped
(g)?Intake location
(h)?Carbon monoxide monitor calibration
(i)?Air purity
(j)?Dew point
(2)*Medical vacuum source - exhaust location
(3)?WAGD source - exhaust location
(4)*Instrument air source - filter condition
(5)*Manifold sources (including systems complying with 5.1.3.5.10, 5.1.3.5.11, 5.1.3.5.12, and 5.1.3.5.13), as follows:
(a) Ventilation
(b)?Enclosure labeling
(6)?Bulk cryogenic liquid source inspected in accordance with NFPA 55, Compressed Gases and Cryogenic Fluids Code
(7)?Final line regulation for all positive pressure systems - delivery pressure
(8)*Valves - labeling
(9)*Alarms and warning systems - lamp and audio operation
(10)?Alarms and warning systems, as follows:
(a)?Master alarm signal operation
(b)?Area alarm signal operation
(c)?Local alarm signal operation
(11)*Station outlets/inlets, as follows:
(a)?Flow
(b)?Labeling
(c)?Latching/delatching
(d)?Leaks

At the time of the inspection, the facility could not provide a risk assesment or designation for Wet Procedure Locations conducted by the governing body.

NFPA-99 1.3.4.3? Wet Procedure Locations. It shall be the responsibility of the governing body of the health care organization to designate wet procedure locations.
6.3.2.2.8.4* Operating rooms shall be considered to be a wet procedure location, unless a risk assessment conducted by the health care governing body determines otherwise

At the time of the inspection, the Hospital could not document or provide testing information regarding Line Isolation Monitor or Receptacles within the Operating Rooms.

NFPA-99 6.3.4 6.3.4.1.4? The LIM circuit shall be tested at intervals of not more than 1 month by actuating the LIM test switch (see 6.3.2.6.3.6). 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.

At the time of this inspection, the Hospital failed to provide documentation regarding a "Risk Assessment" for the EES per NFPA-99

NFPA-99 4.1* Building System Categories. Building systems in health care facilities shall be designed to meet system Category 1 through Category 4 requirements as detailed in this code.

At the time of inspection, and upon request, the Hospital could not provide documentation, nor verify Monthly testing, or inspection of the EES inclusive of the Emergency Generator. (46 Month Load Bank test was conducted on 3/6/25)

NFPA-99 6.4.4.1? Maintenance and Testing of Essential Electrical System.
6.4.4.1.1? Maintenance and Testing of Alternate Power Source and Transfer Switches.
6.4.4.1.1.1? Maintenance of Alternate Power Source. The generator set or other alternate power source and associated equipment, including all appurtenance parts, shall be so maintained as to be capable of supplying service within the shortest time practicable and within the 10-second interval specified in 6.4.1.1.10 and 6.4.3.1.
6.4.4.1.1.2? The 10-second criterion shall not apply during the monthly testing of an essential electrical system. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm the capability of the life safety and critical branches to comply with 6.4.3.1.
6.4.4.1.1.3? Maintenance shall be performed in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 8.
6.4.4.1.1.4? Inspection and Testing. Criteria, conditions, and personnel requirements shall be in accordance with 6.4.4.1.1.4(A) through 6.4.4.1.1.4(C).
(A)* Test Criteria. Generator sets shall be tested 12 times a year, with testing intervals of not less than 20 days nor more than 40 days. Generator sets serving essential electrical systems shall be tested in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 8.
(B)? Test Conditions. The scheduled test under load conditions shall include a complete simulated cold start and appropriate automatic and manual transfer of all essential electrical system loads.
(C)? Test Personnel. The scheduled tests shall be conducted by competent personnel to keep the machines ready to function and, in addition, serve to detect causes of malfunction and to train personnel in operating procedures.
6.4.4.1.2? Maintenance and Testing of Circuitry.
$. Annual Circuit Breaker Testing
6.4.4.1.2.1* Circuit Breakers. Main and feeder circuit breakers shall be inspected annually, and a program for periodically exercising the components shall be established according to manufacturer's recommendations.

At the time of inspection, the facility could not provide documentation to indicate Fire Loss Prevention training, or case meetings prior to surgical procedures were completed.


NFPA-99 15.13.3.6? A preoperative "time out" period shall be conducted prior to the initiation of any surgical procedure using flammable liquid germicides or antiseptics to verify the following:
(1) Application site of flammable germicide or antiseptic is dry prior to draping and use of electrosurgery, cautery, or a laser.
(2) Pooling of solution has not occurred or has been corrected.
(3) Any solution-soaked materials have been removed from the operating room prior to draping and use of electrosurgery, cautery, or a laser.
15.13.3.7? Whenever flammable aerosols or antiseptics are employed, sufficient time shall be allowed to elapse between deposition and application of drapes to allow complete evaporation and dissipation of any flammable vehicle remaining.
15.13.3.8? Health care organizations shall establish policies and procedures outlining safety precautions related to the use of flammable liquid or aerosol germicides or antiseptics used in anesthetizing locations, as required in 15.14.1, whenever the use of electrosurgery, cautery, or a laser is contemplated.