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Based on observation the facility failed to provide adequate smoke barrier.

The inspector observed, while accompanied by The CEO, The CFO, The plant operator, and The Plant operations Technician during the hours of the inspection from 4:30 PM to 6:45 PM on 06/02/2015 that there was the following issues:

A.)There was missing fire rated sealant/ caulking missing at the above ceiling of the fire rate and smoke barrier partitions and the two hours occupancy separation partitions.

B) While performing the fire alarm testing the cross corridor door located at the smoke barrier partition were not fully closed.

Based on observation the facility failed to provide adequate medical gas system storage requirement.

The inspector observed, while accompanied by The CEO, The CFO, The plant operator, and The Plant operations Technician during the hours of the inspection from 4:30 PM to 6:45 PM on 06/02/2015 that there was the following issues:


A.) There was no signage provided at the medical gas bulk storage tank area. Provide the following signage:

Re. NFPA 99, 2002: 5.1.3.1.5. The door shall have the following label:

CAUTION
Medical Gases
NO Smoking or Open Flame

The inspector observed, while accompanied by The CEO, The CFO, The plant operator, and The Plant operations Technician during the hours of the inspection from 4:30 PM to 6:45 PM on 06/02/2015 that there was the following issues:



1) The Biomedical electrical semi-annual and annual inspection were overdue.
2) The Grounding system testing at inpatient areas on TDSHS form were not performed.
3) Line isolation monitor - Grounding system testing on TDSHS form were not performed.
4) The letters indicating preferred customer status report in case of emergency situation for water and fuel source was not available.
5) The boiler inspection was overdue.
6) The HVAC filter change logs provided did not have adequate history.

The inspector observed, while accompanied by The CEO, The CFO, The plant operator, and The Plant operations Technician during the hours of the inspection from 4:30 PM to 6:45 PM on 06/02/2015 that there was the following issues:

A.) At the essential transfer switch location there was a missing electrical outlet powered from the life safety branch and a missing battery power operated light fixture.
B.) The electrical connection between the panel/breaker and the FACP was not cross referenced correctly. Please provide label on the outside of the FACP panel as required.
C.) The FCAP breaker was not identified as fire alarm control circuit control. Please provide label next to the FACP breaker.
D.) The generator was not operational at the time of the inspection.

" The emergency generator location shall have task illumination, battery charger for emergency battery powered lighting unit(s), and selected receptacles at the generator set location and essential transfer switch location " - NFPA 99, 1999: 3-4.2.2.2.(b)5.

The essential electrical panels were not clearly identified. Emergency panels shall be distinctively marked so that they are readily identifiable as a component of the essential electrical system - NFPA 70, 1999 700-9(a). They shall be labeled "LIFE SAFETY", "CRITICAL", or "EQUIPMENT" as applicable.

The electrical connection between the panel/breaker and the FACP must be cross referenced correctly. " The circuit breaker at the electrical panel board for the fire alarm shall have a red marking, shall be accessible only to authorized personnel, and shall be identified as "FIRE ALARM CIRCUIT CONTROL" " - NFPA 72, 2002: 4.4.1.4.2.2. " The location of the circuit disconnecting means shall be permanently identified at the fire alarm control unit. " - NFPA 72, 2002: 4.4.1.4.2.3.