HospitalInspections.org

Based on observations made during the survey of the facility between the hours of 11:00 am and 4:30 pm, while accompanied by the CFO, Chief Nursing Officer, Director of Quality/Risk Mgmt., and Environmental Svcs. Mgr. it was observed that the construction/maintenance for the required 1 hour fire/smoke-rated SMOKE BARRIER WALLS was found to be typically not in compliance with the requirements for rated construction. Due to the quantity and multiple types of non-compliant occurrences found and observed during this inspection the facility will need to provide a complete assessment of non-compliant construction for all fire-rated separations throughout the facility, and address their repair/correction in the PLAN OF CORRECTION.
Types of non-compliant conditions (primarily above ceiling) include the following:
A. Unsealed openings and penetrations (both sides of partitions).
B. Incomplete drywall construction with unsealed gypsum board joints having no tape embedment (both sides of partitions).
C. Unsealed where top of walls transition to bottom of roof deck is required to be continuously sealed along entire length of all walls (both sides of partitions).

Based on observations made during the survey of the facility between the hours of 11:00 am and 4:30 pm, while accompanied by the CFO, Chief Nursing Officer, Director of Quality/Risk Mgmt., and Environmental Svcs. Mgr. it was observed that the facility failed to maintain the required fire rating for the various HAZARD AREAS as well as OCCUPANCY SEPARATION between non-licensed CLINIC FACILITY and the HOSPITAL. Due to the quantity and multiple types of non-compliant occurrences found and observed during this inspection the facility will need to provide a complete assessment of non-compliant construction for all fire-rated separations throughout the facility, and address their repair/correction in the PLAN OF CORRECTION.
Types of non-compliant conditions (primarily above ceiling) include the following:
A. Unsealed openings and penetrations (both sides of partitions).
B. Incomplete drywall construction with unsealed gypsum board joints having no tape embedment (both sides of partitions).
C. Unsealed where top of walls transition to bottom of roof deck is required to be continuously sealed along entire length of all walls (both sides of partitions).

Based on observations made during the survey of the facility between the hours of 11:00 am and 4:30 pm, while accompanied by the CFO, Chief Nursing Officer, Director of Quality/Risk Mgmt., and Environmental Svcs. Mgr. it was observed that the facility failed to provide a log indicating compliance with requirement for monthly testing by staff of the fire alarm system and its automatic signal response.

Based on observations made during the survey of the facility between the hours of 11:00 am and 4:30 pm, while accompanied by the CFO, Chief Nursing Officer, Director of Quality/Risk Mgmt., and Environmental Svcs. Mgr. it was observed that while it appears the facility had accomplished some of the requirements, the facility failed to record in their logs any information to show " who / what / when / where " types of information that would help in indicating consistent, systematic compliance on the following issues and items:

1. Air filter change log.
2. Electrical equipment inspections - Biomedical.
Critical Areas: Semi-annually.
General Areas: Annually
3. Electrical power and distribution and grounding systems - Effectiveness.
Critical Areas: Semi-annually.
General Areas: Annually

Based on observations made during the survey of the facility between the hours of 11:00 am and 4:30 pm, while accompanied by the CFO, Chief Nursing Officer, Director of Quality/Risk Mgmt., and Environmental Svcs. Mgr. it was observed that while it appears the facility had accomplished some of the requirements, the facility failed to provide an Emergency Generator log indicating consistent, systematic compliance on the following issues and items:

1. Weekly inspections.
2. Monthly load tests.

Based on observations made during the survey of the facility between the hours of 11:00 am and 4:30 pm, while accompanied by the CFO, Chief Nursing Officer, Director of Quality/Risk Mgmt., and Environmental Svcs. Mgr. it was observed that the construction/maintenance for the required 1 hour fire/smoke-rated SMOKE BARRIER WALLS was found to be typically not in compliance with the requirements for rated construction. Due to the quantity and multiple types of non-compliant occurrences found and observed during this inspection the facility will need to provide a complete assessment of non-compliant construction for all fire-rated separations throughout the facility, and address their repair/correction in the PLAN OF CORRECTION.
Types of non-compliant conditions (primarily above ceiling) include the following:
A. Unsealed openings and penetrations (both sides of partitions).
B. Incomplete drywall construction with unsealed gypsum board joints having no tape embedment (both sides of partitions).
C. Unsealed where top of walls transition to bottom of roof deck is required to be continuously sealed along entire length of all walls (both sides of partitions).

Based on observations made during the survey of the facility between the hours of 11:00 am and 4:30 pm, while accompanied by the CFO, Chief Nursing Officer, Director of Quality/Risk Mgmt., and Environmental Svcs. Mgr. it was observed that the facility failed to maintain the required fire rating for the various HAZARD AREAS as well as OCCUPANCY SEPARATION between non-licensed CLINIC FACILITY and the HOSPITAL. Due to the quantity and multiple types of non-compliant occurrences found and observed during this inspection the facility will need to provide a complete assessment of non-compliant construction for all fire-rated separations throughout the facility, and address their repair/correction in the PLAN OF CORRECTION.
Types of non-compliant conditions (primarily above ceiling) include the following:
A. Unsealed openings and penetrations (both sides of partitions).
B. Incomplete drywall construction with unsealed gypsum board joints having no tape embedment (both sides of partitions).
C. Unsealed where top of walls transition to bottom of roof deck is required to be continuously sealed along entire length of all walls (both sides of partitions).

Based on observations made during the survey of the facility between the hours of 11:00 am and 4:30 pm, while accompanied by the CFO, Chief Nursing Officer, Director of Quality/Risk Mgmt., and Environmental Svcs. Mgr. it was observed that the facility failed to provide a log indicating compliance with requirement for monthly testing by staff of the fire alarm system and its automatic signal response.

Based on observations made during the survey of the facility between the hours of 11:00 am and 4:30 pm, while accompanied by the CFO, Chief Nursing Officer, Director of Quality/Risk Mgmt., and Environmental Svcs. Mgr. it was observed that while it appears the facility had accomplished some of the requirements, the facility failed to record in their logs any information to show " who / what / when / where " types of information that would help in indicating consistent, systematic compliance on the following issues and items:

1. Air filter change log.
2. Electrical equipment inspections - Biomedical.
Critical Areas: Semi-annually.
General Areas: Annually
3. Electrical power and distribution and grounding systems - Effectiveness.
Critical Areas: Semi-annually.
General Areas: Annually

Based on observations made during the survey of the facility between the hours of 11:00 am and 4:30 pm, while accompanied by the CFO, Chief Nursing Officer, Director of Quality/Risk Mgmt., and Environmental Svcs. Mgr. it was observed that while it appears the facility had accomplished some of the requirements, the facility failed to provide an Emergency Generator log indicating consistent, systematic compliance on the following issues and items:

1. Weekly inspections.
2. Monthly load tests.