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The inspector observed, while accompanied by the Director of the facility operational, the executive Director of Risk Management, and the Maintenance Supervisor during the hours of the inspection 1:00 PM to 5:30 PM on 11/19/2014 that there were the following issues. They were:

The facility fail to provide fire rated caulk for the penetration located at the smoke barriers walls at the following locations:
1) On the Admin Building, above the ceiling of the smoke barrier cross corridor doors near the ECT Room.
2) On the Module A building, above the ceiling of the smoke barrier cross corridor doors near the Break Room.
3) On the Module B building, above the ceiling of the smoke barrier cross corridor doors near the Group Therapy Room, the Hall storage room, Kitchen Room.
3) On the Module C building, above the ceiling of the smoke barrier cross corridor doors near the Quiet Room, the Office/Mech Room.

Reference: NFPA 101, 2000: 19.3.7.3 and 8.3.6.

The inspector observed, while accompanied by the Director of the facility operational, the executive Director of Risk Management, and the Maintenance Supervisor during the hours of the inspection 1:00 PM to 5:30 PM on 11/19/2014 that there were the following issues. They were:

A) The sprinkler escutcheon plate was missing at the following locations:
1) At the Module A Building, located at the Room 201 and 204.
2) At the PES Building, located at the Nurse station and the vestibule.



Reference: NFPA 101, 2000: 19.3.5 and NFPA 13.
Escutcheons are part of the listed assembly per 1999 NFPA 13 §3-2.7.2.

Based on observation the facility failed to provide the log showing dates of HVAC filter changes, and the log of grounding system test inpatient areas on TDSHS form. This is required of all hospitals.

The inspector observed, while accompanied by the Director of the facility operational, the executive Director of Risk Management, and the Maintenance Supervisor during the hours of the inspection 1:00 PM to 5:30 PM on 11/19/2014 that there were the following issues. They were:


1) The Facility failed to provide the log showing dates of HVAC filter changes on TDSHS form. This is required of all hospitals.
2) The Facility failed to provide the log of grounding system test inpatient areas on TDSHS form. This is required of all hospitals.

Facility failed to maintain essential electrical system wiring in accordance with the 1999 edition of the Standard for Health Care, NFPA 99. Findings included the following:

The inspector observed, while accompanied by the Director of the facility operational, the executive Director of Risk Management, and the Maintenance Supervisor during the hours of the inspection 1:00 PM to 5:30 PM on 11/19/2014 that there were the following issues. They were:


1) The facility failed to provide receptacles powered from critical branch for the crash cart located at the ECT Room.
2) The crash cart located at the Module B nurse station was plugged into the extension cord which is not allowed.

Reference: NFPA 99, 1999: 3-4.2.2.2 (a) Life Safety Branch.

The inspector observed, while accompanied by the Director of the facility operational, the executive Director of Risk Management, and the Maintenance Supervisor during the hours of the inspection 1:00 PM to 5:30 PM on 11/19/2014 that there were the following issues. They were:

The facility fail to provide fire rated caulk for the penetration located at the smoke barriers walls at the following locations:
1) On the Admin Building, above the ceiling of the smoke barrier cross corridor doors near the ECT Room.
2) On the Module A building, above the ceiling of the smoke barrier cross corridor doors near the Break Room.
3) On the Module B building, above the ceiling of the smoke barrier cross corridor doors near the Group Therapy Room, the Hall storage room, Kitchen Room.
3) On the Module C building, above the ceiling of the smoke barrier cross corridor doors near the Quiet Room, the Office/Mech Room.

Reference: NFPA 101, 2000: 19.3.7.3 and 8.3.6.

The inspector observed, while accompanied by the Director of the facility operational, the executive Director of Risk Management, and the Maintenance Supervisor during the hours of the inspection 1:00 PM to 5:30 PM on 11/19/2014 that there were the following issues. They were:

A) The sprinkler escutcheon plate was missing at the following locations:
1) At the Module A Building, located at the Room 201 and 204.
2) At the PES Building, located at the Nurse station and the vestibule.



Reference: NFPA 101, 2000: 19.3.5 and NFPA 13.
Escutcheons are part of the listed assembly per 1999 NFPA 13 §3-2.7.2.

Based on observation the facility failed to provide the log showing dates of HVAC filter changes, and the log of grounding system test inpatient areas on TDSHS form. This is required of all hospitals.

The inspector observed, while accompanied by the Director of the facility operational, the executive Director of Risk Management, and the Maintenance Supervisor during the hours of the inspection 1:00 PM to 5:30 PM on 11/19/2014 that there were the following issues. They were:


1) The Facility failed to provide the log showing dates of HVAC filter changes on TDSHS form. This is required of all hospitals.
2) The Facility failed to provide the log of grounding system test inpatient areas on TDSHS form. This is required of all hospitals.

Facility failed to maintain essential electrical system wiring in accordance with the 1999 edition of the Standard for Health Care, NFPA 99. Findings included the following:

The inspector observed, while accompanied by the Director of the facility operational, the executive Director of Risk Management, and the Maintenance Supervisor during the hours of the inspection 1:00 PM to 5:30 PM on 11/19/2014 that there were the following issues. They were:


1) The facility failed to provide receptacles powered from critical branch for the crash cart located at the ECT Room.
2) The crash cart located at the Module B nurse station was plugged into the extension cord which is not allowed.

Reference: NFPA 99, 1999: 3-4.2.2.2 (a) Life Safety Branch.