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Based on observations made during the survey of the facility between the hours of 9:00 am and 1:00 pm, while accompanied by the Hospital's Chief Nursing Officer it was observed that the facility failed to provide the following requirements:

"Permanent Record Documents/Drawings" for the Hospital Facility's Architectural Floor Plan layout and its Life Safety Floor Plan layout ".
The 2 above-mentioned Permanent Record Documents/Drawings were requested by the Inspector/Surveyor for Survey-use during the on-site Survey visit, but these could not made available to the Inspector/Surveyor at the time of the SURVEY even after that request had been made.

The Hospital does appear to be operating without these required Documents and the Compliance Requirements Information Records that they would contain.

The ARCHITECTURAL and LIFE SAFETY FLOOR PLAN DRAWING(s) are required to contain accurate, current, and up-to-date documentation & information for the Licensed Hospital Facility's use for maintaining COMPLIANCE throughout the Facility (for the life of the Facility) as well as for its use during Regulatory Compliance Inspections and Surveys.

The design for "LIFE SAFETY PROTECTION" shall comply with all applicable Regulatory Requirements contained within applicable CODES, STANDARDS and HOSPITAL LICENSING RULES.
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HLR 2007: §133.167 (h)(1) As built drawings. Upon occupancy of the building or portion thereof, the owner shall retain as part of the hospital's permanent records, a complete set of legible architectural plans of each building level, fire safety plans as described in subsection (f)(2)(B) of this section for each floor reflecting fire safety requirements, and all single line diagrams described in subsection (f)(2)(F)(v) of this section, drawings for fixed equipment, and mechanical and electrical systems, as installed or built.

Based on observations made during the survey of the facility between the hours of 9:00 am and 1:00 pm, while accompanied by the Hospital's CEO it was observed that the facility failed to provide the following requirements:

There was NO PROJECT APPLICATION SUBMITTAL from the Facility requesting HHSC-ARU REVIEW & APPROVAL PROCESS regarding the facility's recent and newly completed DESIGN and CONSTRUCTION work. The time of the "construction completion" appeared to be just prior to the 04/26/2023 date of this CMS - LIFE SAFETY CODE RESURVEY visit.

Following is a list of the recently completed construction SCOPE OF WORK items:
1. A new single 18,000 GALLON WATER RESERVOIR.
2. Two new pad-mounted CHILLERS installed for the Hospital's HVAC SYSTEM.
3. One new PUMP HOUSE BUILDING.
4. One new EMERGENCY GENERATOR.
5. One new ELECTRICAL BUILDING containing all new SWITCH GEAR EQUIPMENT.

The recent construction/installation work (items 1 thru 5 as listed above) was started and completed by the facility without any opportunity for HHSC-ARU to provide the following:
A. Required Review & Approval for: The project's proposed SCOPE OF WORK to proceed forward.
B. Required Review & Approval for: The project's proposed DESIGN to proceed forward.
C. Required Review & Approval for: The project's START OF CONSTRUCTION prior to actually starting the construction work.
D. Required Construction Inspection(s) by HHSC-ARU to AUTHORIZE the Facility's use of the completed work.

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HLR 2007: §133.167. Preparation, Submittal, Review and Approval of Plans, and Retention of Records.
(a) General.
(1) Hospital owners/operators may not begin construction of a new building, additions to or renovations or conversions of existing buildings until the department approves final construction documents.

(2) Plans and specifications describing the construction of new buildings and additions to or renovations and conversions of existing buildings shall be prepared by registered architects and/or licensed professional engineers and meet the requirements of this subchapter.

(b) Submission of projects and assignment of application number.
(1) The hospital owner/operator or representative shall submit the following items to the department in care of the mailing or overnight delivery address that appears on the Application for Plan Review:
(A) a completed and signed Application for Plan Review. The Application for Plan Review may be obtained by calling the department's Architectural Review Group, telephone (512) 834-6649;
(B) the applicable plan review fee in accordance with §133.26 of this title (relating to Fees);
(C) a functional program narrative in accordance with subsection (d) of this section; and
(D) final construction documents in accordance with subsection (f) of this section.

(2) The cost of submitting documents/plans and specifications shall be borne by the sender.

(3) Once the department has determined that the submission required in paragraph (1) of this subsection is complete, the department will assign an application number to the project that must be referenced on all documents and correspondence related to the project. Final construction documents will be reviewed in the chronological order received.

(4) All deficiencies noted in the final plan review shall be satisfactorily resolved before approval of project for construction will be granted.

(5) Construction shall not begin until the hospital owner/operator of the facility receives written notification from the department that the final construction documents have been approved.

HLR 2007: §133.167. Preparation, Submittal, Review and Approval of Plans, and Retention of Records.
(d) Functional program narrative. The hospital owner/operator shall submit a functional program narrative to the department with each new project in accordance with subsection (b)(1)(C) of this section. The functional program narrative shall be presented on facility letterhead, signed by hospital administration, include the functional description ...

HLR 2007: §133.168. Construction, Inspections, and Approval of Project.
(a) Construction.
(1) Major construction. Construction, of other than minor alterations, shall not commence until the final plan review deficiencies have been satisfactorily resolved, the appropriate plan review fee according to the plan review schedule in §133.26 of this title (relating to Fees) has been paid, and the department has issued a letter granting approval to begin construction. Such authorization does not constitute release from the requirements contained in this chapter. If the construction takes place in or near occupied areas, adequate provision shall be made for the safety and comfort of occupants.
(2) Construction commencement notification. The architect of record or the hospital owner/operator shall provide written notification to the department when construction will commence. The department shall be notified in writing of any change in the completion schedules.
(3) Completion. Construction shall be completed in compliance with the construction documents including all addenda or modifications approved for the project.

(b) Construction inspections. All hospitals including those which maintain certification under Title XVIII of the Social Security Act (42 United States Code, §1395 et seq), and those which maintain accreditation by a Centers for Medicare and Medicaid Services-approved organization are subject to construction inspections.

(c) Approval of project. Patients and staff shall not occupy a new structure or remodeled or renovated space until approval has been received from the local building and fire authorities and the department.
(1) Documentation requirements. The hospital owner/operator shall submit the following documents to the department before the project will be approved:
(A) written approval of the project by the fire authority;
(B) a certificate of occupancy for the project issued by the local building authority;

(F) a copy of the test and a letter from the electrical contractor certifying that the electrical system was tested and complies with the standards of NFPA 99, Health Care Facilities, 2002 edition, § 4.3.2.2.8 (Special Grounding) and §4.3.3.1 (Grounding System Testing), if applicable to the project;

(I) a written plan of correction signed by the hospital owner/operator for any deficiencies noted during the final inspection;
(J) a Final Construction Approval form signed by the hospital owner/operator; and
(K) any other documentation or information required or requested due to the type of the project.

(3) Final approval. Upon its receipt and acceptance of the documents required in paragraph (1) of this subsection, the department will issue written final approval of the project.

Based on observations made during the survey of the facility between the hours of 9:00 am and 1:00 pm, while accompanied by the Hospital's CEO it was observed that the facility failed to provide compliance with the following requirements:

1. WHEN REQUESTED THE FACILITY DID NOT HAVE THE REQUIRED DOCUMENTED MAINTENANCE PROGRAM FOR OUTDOOR MED GAS CYLINDER & MANIFOLD EQUIPMENT AREA.

2. SURVEYOR OBSERVED THAT THE OUTDOOR MED GAS MANIFOLD "EQUIPMENT" (INCLUDING PRESSURE GAUGES) APPEARS TO BE ABANDONED IN PLACE AND NON-WORKING.

It did not appear as though the outdoor MANIFOLD EQUIPMENT is being maintained and the current condition of the installation appeared to be in a visibly old, shabby condition indicating the maintenance of the MANIFOLD EQUIPMENT is not being well managed. Regarding the current operational status of the MANIFOLD EQUIPMENT - it appeared to be non- functional (as though it had been abandoned in place). It was not currently providing a means for taking pressure readings of the cylinders. On-site discussions could not verify a methodology for how the facility is ensuring that all of the OUTDOOR MED GAS CYLINDER STORAGE is being effectively and systematically monitored and maintained.
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NFPA 99, 2012: Chapter 5 Gas and Vacuum Systems