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Observation and discussion with the Administrator and the Plant Engineer between 9 am and 2:30 pm on 10/13/2010 revealed that certain requirements stipulated in NFPA 101 were not met.

Interior finish for corridors and exitways, including exposed interior surfaces of buildings such as fixed or movable walls, partitions, columns, and ceilings has a flame spread rating of Class A or Class B. [NFPA 101, Life Safety Code, 2000: ? 19.3.3.2.]

Findings: This requirement was discussed and it was determined that the required documentation is not retained by the staff.

Observation and discussion with the Administrator and the Plant Engineer between 9 am and 2:30 pm on 10/13/2010 revealed that certain requirements stipulated in the State Licensing Rules were not met.

a. Level of Filtration

All central air handling systems serving patient care areas, including nursing unit corridors, shall be equipped with filters having efficiencies equal to, or greater than, those specified in Table 4 of ?133.169(d) of this title. ..... [Re: 25 TAC HLR 2007: ? 133.162(d)(3)(D)(ii).]

Findings: During the survey, it was noted that secondary filter banks were not installed on the units serving the imaging procedure rooms. The facility shall assess the status of these units regarding whether or not they serve more than one room, and if so, they must meet the requirement for multiple filters.

b. Draft Gauges

A manometer or draft gauge shall be installed across each filter bed having a required efficiency of 75% or more including hoods requiring high efficiency particulate air (HEPA) filters [Re: 25 TAC HLR 2007: ?133.162(d)(3)(D)(ii)(V).]

Findings: If item [a] above requires the installation of secondary filters, the required draft gauges must be installed.

c. Ventilation Requirements

All rooms and areas in the hospital listed in Table 3 of ? 133.169[c] shall have provision for positive ventilation [Re: 25 TAC HLR 2007: ? 133.162(d)(3)(D)(i).]

Findings: The referenced table requires a toilet room to be pressurized negatively, and this is accomplished by an exhaust fan operating continuously. During the survey, it was noted that toilet room fans were switchable with the overhead light which is not permitted.

Observation and discussion with the Administrator and the Plant Engineer between 9 am and 2:30 pm on 10/13/2010 revealed that certain requirements stipulated in NFPA 101 were not met.

Draperies, curtains, including cubicle curtains, and other loosely hanging fabrics and films serving as furnishings or decorations in ambulatory health care occupancies shall be in accordance with 10.3.1 [Re: NFPA 101, Life Safety Code. 2000: ? 21.7.5.1.]

Findings: This requirement was discussed and it was determined that the required documentation is not retained by the staff.

Observation and discussion with the Administrator and the Plant Engineer between 9 am and 2:30 pm on 10/13/2010 revealed that certain requirements stipulated in NFPA 99 were not met.

Locations for central supply systems and the storage of medical gases shall meet the following requirements: .... (7) Be provided with racks, chains, or other fastenings to individually secure all cylinders, whether connected, unconnected, full, or empty from falling [Re: NFPA 99, Health Care Facilities, 2002: ?5.1.3.3.2(7).]

Findings: The medical gas cylinders were restrained collectively as opposed to individually.

Observation and discussion with the Administrator and the Plant Engineer between 9 am and 2:30 pm on 10/13/2010 revealed that certain requirements stipulated in the state licensing regulations and NFPA 99 were not met.

a. Disaster Drills

A report for Disaster Drills held on a semi-annual basis must be provided [Re: NFPA 99, Health Care Facilities, 2002: ? 11 - 5.3.9.]

Findings: These required drills were not held on a semi-annual basis as stipulated.

b. Use of PVC

Soil stacks, drains, vents, waste lines, and leaders installed above ground within buildings shall be drain-waster-vent (DWV) weight or heavier and shall be: copper pipe, copper tube, cast iron pipe, or galvanized iron pipe [Re: 25 TAC, HLR, 2007: ? 133.162(d)(4)(A)(viii)(I).]

Findings: PVC piping was installed as condensate drain lines for the HVAC units in the imaging procedure rooms. This is not permitted.

Observation and discussion with the Administrator and the Plant Engineer between 9 am and 2:30 pm on 10/13/2010 revealed that certain requirements stipulated in NFPA 110 were not met.

a. Under Full Load.

The generator must be tested under full load for 30 minutes 12 times per year with testing intervals not less that 20 days or exceeding 40 days [Re: NFPA 110, Standard for Emergency and Standby Power Systems, 2002: ? 8-4.1.1.]

Findings: This requirement was discussed and it was determined that a log was not maintained confirming that this test was conducted as required. The facility shall perform this test as required and maintain a log.

b. Load Tests.

The generator must be tested under full load for 4 hrs every 36 to 48 months [Re: NFPA 110, Standard for Emergency and Standby Power Systems, 2002: ? 8-4.8.]

Findings: This requirement was discussed and it was determined that this test has not been run, and it is not scheduled. The facility shall perform this test as required.

Observation and discussion with the Administrator and the plant Engineer between 9 am and 2:30 pm on 10/13/2010 revealed that certain requirements stipulated in NFPA 70, NFPA 99, and the State Licensing Regulations were not met.

a. GenSet Life Safety Features

A battery powered light where the battery is charged by the life safety branch and a receptacle powered by the life safety branch is required [Re: NFPA 70, National Electrical Code, 2002: ? 517.32[E].]

Findings: This topic was discussed during the survey and when the generator was observed, it was obvious that this requirement was not met. The facility shall make the necessary changes to meet this requirement.

b. Functional Allocation

Specific requirements exist identifying the functions as they must be allocated to the critical branch [NFPA 70, National Electrical Code, 2002, ?517.33], life safety branch [NFPA 70, National Electrical Code, 2002, ?517.32], and the equipment system [NFPA 70, National Electrical Code, 2002, ?517.34]. It is departmental policy to permit an electrical system to be configured with a normal branch and an emergency branch provided the hospital was built before 1981 and deliveries and surgeries are not performed, and life support systems are not employed. This facility meets these conditions.

Findings: During the survey, it was difficult to determine which electrical component was powered by a particular branch of the electrical system. The facility shall develop a one-line diagram and identify each component of the electrical system

c. Equipment Labels

All boxes and enclosures (including transfer switches, transformers, distribution panels, and panelboards) for emergency circuits shall be permanently marked so they will be readily identified as a component of an emergency circuit or system [Re: NFPA 70, National Electrical Code, 2002: 700.9(A).] The above listed components shall be labeled with the words " LIFE SAFETY " , " CRITICAL " AND " EQUIPMENT " to be readily identifiable as part of the Essential Electrical System. In this case, the components should be labeled " Emergency " as appropriate.

Findings: During the survey, the electrical components were not labeled and it could not be determined whether they were " Emergency " or " Normal. " The " Emergency " components must be labeled appropriately

d. Flex Conduit

The wiring of the emergency system of a hospital shall be mechanically protected by installation in nonflexible metal raceways, or shall be wired with Type MI cable [Re: NFPA 70, National Electrical Code, 2002: ? 517.30[C](3).]

Findings: Flexible conduit was installed on the panelboard that provided the power for the Fire Alarm Control Panel [FACP]. If this is " emergency " power as it should be, flex conduit is not permitted. This must be replaced with nonflexible metal installations.

e. Circuit Directory

All circuits and circuit modifications shall be legibly identified as to purpose or use on a circuit directory located on the face or inside of the panel door in the case of a panelboard, and at each switch on a switchboard [Re: NFPA 70, National Electrical Code, 2002: ? 408.4.]

Findings: All circuit directories must be updated to be legible and meaningful.

f. Blood Bank

The critical branch of the emergency system shall supply power for task illumination, fixed equipment, selected receptacles, and selected power circuits serving the following areas and functions related to patient care: .... (6) Blood, bone and tissue banks .... [Re: NFPA 70, National Electrical Code, 2002: ? 517.33 (6) ......]

Findings: The blood bank was powered by a receptacle without a red marking as required. The facility shall ensure that this power source is an emergency source and mark the receptacle accordingly.

g. Label Red Receptacles

The cover plates for the electrical receptacles or the electrical receptacles themselves supplied from the emergency system shall have a distinctive color or marking so as to be readily identifiable [Re: NFPA 99, 3.4.2.2.4(b)2.] [Re: NFPA 70, National Electric Code, 2002: ? 517.30(E).] Acting as the state-level Authority Having Jurisdiction [AHJ], the Department requires the facility to have the circuit number and the panelboard identification labeled on the receptacle in a permanent fashion if the receptacle is in a critical care area [ie, surgical suite, recovery suite, etc.]

Findings: All receptacles in the critical care areas were not marked as required. The facility shall ensure that this requirement is met in critical care areas.