HospitalInspections.org

STANDARD is not met as evidenced by: During the review of the facility records, with staff, documentation was not available to confirm that the facility had a kitchen-hood-exhaust-system cleaning schedule as required by NFPA 96, (Chapter 8, Section 8-3). This deficient practice could affect all residents, and staff should a fire occur due to grease build-up in the exhaust system and fail to operate effectively due to non-code compliant cleaning and maintenance. This was evidence by the following;

No documentation was available to confirm that the facility had the kitchen-hood-exhaust-system cleaned, or schedule as required by NFPA 96.

NFPA 96, Chapter 8, Section 8-3.1 Hoods, grease removal devices, fans, ducts and other appurtenances shall be cleaned to bare metal at frequent intervals prior to surface becoming heavily contaminated with grease or oily sludge. After the exhaust system is cleaned to bare metal, it shall not be coated with powder or other substance. The entire system shall be inspected by a properly trained, qualified and certified company or person(s) acceptable to the authority having jurisdiction in accordance with Table 8-3.1.

The Maintenance Director acknowledge the lack of documentation for the cleaning of the Kitchen Hood System.

STANDARD is not met as evidenced by: Based on record review during the survey, it was determined that the facility failed to conduct fire drills in accordance with the Life Safety Code, Section 19.7.1.2 and 4.7. This deficient practice could affect residents when staff are not trained in the emergency actions required during unusual condition that can occur in an actual emergency. This was evidenced by the following:

Fire drills are required to be conducted on each shift quarterly, the facility failed to conduct fire drills on the first shift in the first quarter, second shift all quarters between 2022 and 2023.

Life Safety Code, Section 19.7.1.2 requires, in part, that fire drills be conducted quarterly on each shift to familiarize personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 pm and 6:00 am, a coded announcement shall be permitted to be used instead of audible alarms. Section 4.7.5 requires that drills be held unexpected times and under varying conditions to simulate the unusual conditions that can occur in an actual emergency.

The Director of Maintenance acknowledge the conditions of fire drills deficiency during record review of the facility.

STANDARD not met: Based on record review and documentation of inspection and testing of the non-hospital grade electrical outlets in patient care areas as required by sections 6.3.4.1.3 and 6.3.4.2.1.1 of NFPA 99, Health Care Facilities Code. This deficient practice could affect all residents, staff and visitors throughout the facility if the continuity of the grounding circuit, polarity of hot and neutral connections, and retention force of the grounding blade were to fail due to lack of testing.

No written test records of the continuity of the grounding circuit, polarity of hot and neutral connections, and retention force of the grounding blade in patients care areas was conducted annually.

NFPA Standard: NFPA 99 Health Care Facilities Code (2012)
6.3.3.2 Receptacle Testing in Patient Care Rooms.
6.3.3.2.1 The physical integrity of each receptacle shall be confirmed by visual inspection.
6.3.3.2.2 The continuity of the grounding circuit in each electrical receptacle shall be verified.
6.3.3.2.3 Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.
6.3.3.2.4 The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz).
6.3.4.1 Maintenance and Testing of Electrical System.
6.3.4.1.3 Receptacles not listed as hospital-grade, at patient bed locations and in locations where deep sedation or
general anesthesia is administered, shall be tested at intervals not exceeding 12 months.
6.3.4.2 Record Keeping.
6.3.4.2.1* General.
6.3.4.2.1.1 A record shall be maintained of the tests required by this chapter and associated repairs or modification.
6.3.4.2.1.2 At a minimum, the record shall contain the date, the rooms or areas tested, and an indication of which items have met, or have failed to meet, the performance requirements of this chapter.

The non-hospital grade electrical outlets testing at patient's care areas deficiency was discussed with the Director of Maintenance during the survey and again during the exit conference with the CEO.

STANDARD not met. Based on record review and staff interview during the course of the survey, it was determined that the facility failed to maintain emergency power systems in accordance with Section 9.1.3 of the Life Safety Code and NFPA 110, Standard for Emergency and Standby Power Systems Chapter 8. This deficient practice has the potential to affect all residents, staff and visitors in the event of power loss.


1)At the time of the survey no records were available to verify testing and recording of battery
conductance testing in connection with the emergency power supply system (Emergency Generator)
monthly.

2)No records to indicate the generator transfer time during monthly load bank testing.

3)The facility failed to provide documentation at the time of the survey to reflect that the emergency generator was exercised under load at 30 % of the EPS nameplate KW rating in the past 12 months.

4)Diesel annual fuel quality test not conducted as annually using applicable ASTM Standards in the past year.


NFPA 110-8.4 Operational Inspection and Testing.
8.4.1* EPSSs, including all appurtenant components, shall be inspected weekly and exercised under load at least monthly.

The emergency power system deficiency were discussed with the Maintenance Director during the survey and again during the exit conference with the CEO.