HospitalInspections.org

Based on observation at the time of inspection, the facility failed to provide the proper identification of rated walls.
All fire walls, fire barriers, fire partitions, smoke barriers, and smoke partitions shall be effectively and permanently identified with signs or stenciling per IBC 2012 section 703.7.

Based on observation at the time of inspection, the facility failed to provide the proper required building separation. The hospital currently has a contractual agreement for 5 (five) hospice beds. This space is not currently separated by a 2 hr separation from the hospital footprint.
Separate buildings. Portions of a building divided horizontally with two-hour fire rated walls which are continuous (without offsets) from the foundation to above the roof shall be considered as a separate building. Communicating openings in the two-hour wall shall be limited to public spaces such as lobbies and corridors. All such openings shall be protected with self-closing one and one-half hour, Class B fire door assemblies. 133.162 (d)(C)

Based on observation at the time of inspection, the facility failed to provide the proper required building separation. After reviewing the provided life safety plans, it was noticed that the Medical Office Building did not meet the required 2hr separation from the hospital. The hospital is to also verify that the mechanical and electrical systems of the hospital are not shared with the Medical Office Building.

Major remodeling or alterations. Plans shall be submitted in accordance with §133.167 of this title for all major remodeling or alterations. All remodeling or alterations which involve alterations to load bearing members or partitions, change functional operation, affect fire safety (e.g. modifications to the fire, smoke, and corridor walls), or add beds or services over those for which the hospital is licensed are considered as major remodeling and alterations. Chapter 133, 133.161 (a) (2) (D)

Based on observation at the time of inspection, the facility failed to provide the proper directional indicator. Remove the two chevrons located at the lobby entrance to LND.
A sign complying with 7.10.3 with a directional indicator showing the direction of travel shall be placed in every location where the direction of travel to reach the nearest exit is not apparent. - NFPA 101, 2012 7.10.2.

Based on observation at the time of inspection, the facility failed to provide the proper protection for a rated wall. Conduit penetration was not caulked at double doors by storage room 1187.
"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 at the time of inspection, the facility failed to provide proper documentation identifying the Merv rating on the filters being replaced.





Based on observation at the time of inspection, the facility failed to provide secured low voltage wires throughout the facility.
Communications circuits and equipment shall be installed in a neat and workmanlike manner. Cables installed exposed on the surface of ceilings and sidewalls shall be supported by the building structure in such a manner that the cable will not be damaged by normal building use. Such cables shall be secured by hardware, including straps, staples, cable ties, hangers, or similar fittings designed and installed so as not to damage the cable.
NFPA-70 800.24 Mechanical Execution of Work.

Based on observation at the time of inspection, the facility failed to provide proper labeling to the existing disconnect. All disconnects associated with the essential system must be properly labeled.
General. Each disconnecting means shall be legibly marked to indicate its purpose unless located and arranged so the purpose is evident. The marking shall be of sufficient durability to withstand the environment involved. NFPA-70 110.22 Identification of Disconnecting Means.
Identification. All boxes and enclosures (including transfer switches, generators, and power panels) for emergency circuits shall be permanently marked so they will be readily identified as a component of an emergency circuit or system. NFPA-70 700.10 Wiring, Emergency System.




Based on observation at the time of inspection, the facility failed to provide proper identification of required bonding between the normal and critical panels. Hospital to verify.
The equipment grounding terminal buses of the normal and essential branch-circuits panelboards serving the same individual patient vicinity shall be connected together with an insulated continuous copper conductor not smaller than # 10 AWG." - NFPA 70, 2011: 517-14.

K914
Based on observation at the time of inspection, the facility failed to provide proper documentation identifying tests and associated repairs to patient care receptacles.

Based on observation at the time of inspection, the facility failed to provide proper marking for essential power receptacles at the laboratory. Properly identify all critical plugs.
All boxes and enclosures (including transfer switches, generators, and power panels) for emergency circuits shall be permanently marked so they will be readily identified as a component of an emergency circuit or system - NFPA 70, 2002: 700.9(A).