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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 Administrator and Facility Director on 02/09/17 from 1:00pm to 3:30pm 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 02/09/17 at 2:10pm that the facility would make required revisions.
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Based on observation, the facility failed to provide GFCI receptacles within three feet of a wash basin or sink, as required by:

NFPA 70, §517.20 and §517.21, shall be GFCI protected regardless of the branch of the electrical system serving the receptacle.

HLR 2007: §133.162(d)(5)(J) .....GFCI receptacles shall be provided for all general use receptacles located within three feet of a wash basin or sink. When GFCI receptacles are used, they shall be connected to not affect other devices connected to the circuit in the event of a trip. Receptacles connected to the critical branch that may be used for equipment that should not be interrupted do not have to be GFCI protected. Receptacles in wet locations, as defined by NFPA 70, §517.20 and §517.21, shall be GFCI protected regardless of the branch of the electrical system serving the receptacle.

The inspector observed, while accompanied by the Administrator and Facility Director on 02/02/17 from 1:00pm to 2:30pm that the GFCI receptacles installed within three feet of a water source did not trip when tested.

The Facility Director stated on 02/02/17 at 1:40pm that the facility would make required revisions.
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Based on observation the facility failed to provide electrical receptacle cover plates supplied from the life safety and critical branches marked with a non-removable label or engraved indicating the panel and circuit number, as required by:

NFPA 99; 2002: 4.4.2.2.2.2 ... ...The life safety branch of the emergency system shall supply power for the following lighting, receptacles and equipment: 1. Illumination of means of egress as required in NFPA 101, Life Safety Code; 2. Exit signs and exit direction signs required in NFPA 101, Life safety Code; 3. Alarm and alerting systems including the following: a. Fire Alarms, b. Alarms required for systems used for the piping of nonflammable medical gases as specified in Chapter 4, "Gas and Vacuum Systems;" 4. (Hospital or ASC) communication systems, where used for issuing instruction during emergency conditions; 5. Task illumination, battery charger for emergency battery-powered lighting unit(s), and selected receptacles at the generator set location; 6. Elevator ... 7. Automatically opened doors used for building egress. No functions other than those listed above in items 1 through 7 shall be connected to the life safety branch.

NFPA 99: 2002; 4.4.2.2.4.2 ..... The electrical receptacles or the cover plates for the electrical receptacles supplied from the emergency system shall have a distinctive color or marking so as to be readily identifiable.

HLR 2007: §133.162(d)(5)(H)(vi) ..... All critical care area receptacles shall be identified. The face plate for the receptacle(s) shall have a nonremovable label or be engraved indicating the panel and circuit number.

The inspector observed, while accompanied by the Administrator and Facility Director on 02/09/17 from 1:00pm to 2:30pm that the red receptacles were marked with removeable tape or unmarked.

The Facility Director stated on 02/09/17 at 1:55pm that the facility would make required revisions.
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