HospitalInspections.org

Door Inspections:

Fire-rated door assemblies and certain other doors in the means of egress shall be tested annually or per an accepted performance-based evaluation schedule approved by the AHJ per NFPA 80, 2010, Ch. 5.2. A written record of the inspections and testing shall be signed and kept for inspection by the AHJ. NFPA101, 7.2.1.15

Based on observation the facility failed to provide adequate door inspections.

The inspector observed, while accompanied by the Facility Director during the hours of the inspection from 9:00 am to 11:30 am on 09/09/22 that there was not an annual door inspection that was signed by a facility representative.

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Based on observation the facility failed to provide self-closing devices that allowed the door to latch into the frame at smoke and fire barriers.

The inspector observed, while accompanied by the Facility Director on 09/09/22 from 9:00am to 11:30am that door closers needed to be installed or adjusted at smoke or fire barriers.

The Facility Director stated on 09/09/22 at 10:55am that the facility would make required revisions.







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Smoke Barrier Fire Walls:

"Penetrations for cables, cable trays, conduits, pipes, tubes, combustion vents and exhaust vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a fire barrier shall be protected by a firestop system or device." - NFPA 101, 2012, 8.3.5.1.

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

The inspector observed, while accompanied by the Facility Director during the hours of the inspection from 9:00 am to 11:30 am on 09/09/22 that there were penetrations in many locations all along smoke and fire barriers. It must be checked and repaired on both side along the entire length.

Based on observation the facility failed to provide adequate hazardous areas.

The inspector observed, while accompanied by the Facility Director during the hours of the inspection from 9:00 am to 11:30 am on 09/09/22 that there were doors that were not self closing, i.e. close on their own and latch, such as storage rooms over 100 square feet, soiled linen and biohazard waste.

Based on observation the facility failed to provide a fully exhaust system throughout the facility, as required by:

Department of State Health Services, Facility Licensing Group, Title 25, Texas Administrative Code, Chapter 133, Hospital Licensing State Regulations
§133.162. New Construction Requirements.
(d)(3)(D) Heating, ventilating and air conditioning (HVAC) systems. All HVAC systems shall comply with and shall be installed in accordance with the requirements of National Fire Protection Association 90A, Standard for the Installation of Air Conditioning and Ventilating Systems, 2002 edition, (NFPA 90A), NFPA 99, Chapter 6, the requirements contained in this subparagraph, and the specific requirements for a particular unit in accordance with §133.163 of this title.

(i) General ventilation requirements. All rooms and areas in the hospital listed in Table 3 of §133.169(c) of this title shall have provision for positive ventilation. Fans serving exhaust systems shall be located at the discharge end and shall be conveniently accessible for service. Exhaust systems may be combined, unless otherwise noted, for efficient use of recovery devices required for energy conservation. The ventilation rates shown in Table 3 of §133.169(c) of this title shall be used only as minimum requirements since they do not preclude the use of higher rates that may be appropriate. Supply air to the building and exhaust air from the building shall be regulated to provide a positive pressure within the building with respect to the exterior.

(VII) Areas requiring fully ducted systems. Fully ducted supply, return and exhaust air for HVAC systems shall be provided for all critical care areas, sensitive care areas, all patient care areas, all areas requiring a sterile regimen, storage rooms, food preparation areas, and where required for fire safety purposes. Combination systems, utilizing both ducts and plenums for movement of air in these areas shall not be permitted.

(I) If the toilet is for patient use, an additional hand washing fixture shall be provided in each room at the entrance of the room. If the modular toilet/hand washing unit is for patient use, provision shall be made for patient privacy and odor control. The toilet room exhaust shall be in accordance with Table 3 of §133.169(c) of this title.

(C) The isolation room exhaust shall be a dedicated system which exhausts all air continuously to the exterior in accordance with Table 3 of §133.169(c) of this title. Multiple isolation rooms may be interconnected to the same exhaust system.

(viii) The isolation exhaust system shall be connected to the emergency essential electrical system.

The inspector observed, while accompanied by the Facility Director on 09/09/22 from 9:00am to 11:30am that the negative air at the exhaust grille would not hold a tissue in place when tested at several required locations.

The Facility Director stated on 09/09/22 at 10:10am that the facility would make required revisions.
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Emergency Water and Fuel:

As a component of emergency preparedness, the facility shall provide letters indicating preferred customers status in case of emergency situation for water and fuel source. - Federal Register, 81 FR 63859

Based on observation the facility failed to provide adequate preferred customer status for water and fuel.

The inspector observed, while accompanied by the Facility Director during the hours of the inspection from 9:00 am to 11:30 am on 09/09/22 that there were no letters from water or fuel vendors indicating a preferred customers status in case of emergency situation for water and fuel.

Based on observation the facility failed to provide an adequate risk analysis.

The inspector observed, while accompanied by the Facility Director during the hours of the inspection from 9:00 am to 11:30 am on 09/09/22 that there was not a risk analysis done for the facility that follows NFPA 99, 2012.