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This STANDARD is not met as evidence by: Based on observations during the survey, on the morning of 05/07/2014, the required door closer was not present at the door to the Soiled Linen Room of the newest patient wing.

Receptacle Testing in Patient Care Areas - NFPA 99, 2002, 4.3.3.2.1, 4.3.3.2.2, 4.3.3.2.3 & 4.3.3.2.4:

4.3.3.2.1 The physical integrity of each receptacle shall be confirmed by visual inspection.

4.3.3.2.2 The continuity of the grounding circuit in each electrical receptacle shall be verified.

4.3.3.2.3 Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.

4.3.3.2.4 The retention force of the grounding blade of each electrical receptacle (except for locking-type receptacles) shall be not less than 115g (4 oz).

NFPA 99, 2002, 4.3.4.1 states that testing shall be performed after initial installation, replacement or servicing of a device, and that additional testing shall be performed at intervals defined by documented performance data. Since data is not typically available from the manufacturer, the facility may document the failure rates of the receptacles and provide a testing schedule that will safeguard their patients. This shall be done by the Safety Committee, approved by the Governing Board, and written into the safety policies and procedures. Title 25, Texas Administrative Code, Chapter 135 ASC Licensing Rules. Until this assessment has been done, receptacle testing shall be performed in all general care areas every 12 months and in critical care areas every 6 months. (NFPA 99, 1984).

Based on observation the facility failed to provide documentation for receptacle testing per NFPA 99: 4.3.4.1 in patient care areas.



Continuity of Essential Building Systems - NFPA 99, 2002, 12.3.3.2:

12.3.3.2 When designated by the emergency management plan to provide continuous service in a disaster or emergency, health care facilities shall establish contingency plans for the continuity of essential building systems, as applicable: (1) Electricity, (2) Water, (3) Ventiliation, (4) Fire protection systems, (5) Fuel sources, (6) Medical gas and vacuum systems (if applicable), (7) Communications systems.

Based on observation the facility failed to provide letters indicating preferred customer status in case of emergency for water and fuel.

This STANDARD is not met as evidence by: Based on observations during the survey, on the morning of 05/07/2014, the required door closer was not present at the door to the Soiled Linen Room of the newest patient wing.

Receptacle Testing in Patient Care Areas - NFPA 99, 2002, 4.3.3.2.1, 4.3.3.2.2, 4.3.3.2.3 & 4.3.3.2.4:

4.3.3.2.1 The physical integrity of each receptacle shall be confirmed by visual inspection.

4.3.3.2.2 The continuity of the grounding circuit in each electrical receptacle shall be verified.

4.3.3.2.3 Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.

4.3.3.2.4 The retention force of the grounding blade of each electrical receptacle (except for locking-type receptacles) shall be not less than 115g (4 oz).

NFPA 99, 2002, 4.3.4.1 states that testing shall be performed after initial installation, replacement or servicing of a device, and that additional testing shall be performed at intervals defined by documented performance data. Since data is not typically available from the manufacturer, the facility may document the failure rates of the receptacles and provide a testing schedule that will safeguard their patients. This shall be done by the Safety Committee, approved by the Governing Board, and written into the safety policies and procedures. Title 25, Texas Administrative Code, Chapter 135 ASC Licensing Rules. Until this assessment has been done, receptacle testing shall be performed in all general care areas every 12 months and in critical care areas every 6 months. (NFPA 99, 1984).

Based on observation the facility failed to provide documentation for receptacle testing per NFPA 99: 4.3.4.1 in patient care areas.



Continuity of Essential Building Systems - NFPA 99, 2002, 12.3.3.2:

12.3.3.2 When designated by the emergency management plan to provide continuous service in a disaster or emergency, health care facilities shall establish contingency plans for the continuity of essential building systems, as applicable: (1) Electricity, (2) Water, (3) Ventiliation, (4) Fire protection systems, (5) Fuel sources, (6) Medical gas and vacuum systems (if applicable), (7) Communications systems.

Based on observation the facility failed to provide letters indicating preferred customer status in case of emergency for water and fuel.