HospitalInspections.org

Based on observations made during the survey of the facility while accompanied by the Dir. Plant Ops it was observed that the facility was not in compliance with the following:
Initiation of the fire alarm system is by manual means and by any required sprinkler system alarm, detection device, or detection system. Manual alarm boxes are provided in the path of egress near each required exit. Manual alarm boxes in patient sleeping areas shall not be required at exits if manual alarm boxes are located at all nurse's stations or other continuously attended staff location, provided alarm boxes are visible, continuously accessible, and 200' travel distance is not exceeded.
18.3.4.2.1, 18.3.4.2.2, 19.3.4.2.1, 19.3.4.2.2, 9.6.2.5
REMARKS:
" Multiple duct detectors for the RETURN-SIDE DUCTS and for the SUPPLY-SIDE DUCTS at the air handling units for the HVAC SYSTEM are improperly located and installed such that they are not "Readily Viewable". This is not in compliance.

Based on observations made during the survey of the facility while accompanied by the Dir. Plant Ops it was observed that the facility was not in compliance with the following:

REMARKS:
NOTE: There are 8 roof top HVAC SYSTEM air handling units that were observed by the surveyor for this Hospital site.
" The Surveyor observed and noted that the both the PRE-FILTER BEDS and the FINAL FILTER BEDS were missing some of the required filter units.
" Additionally, it was observed that filter units are placed within the filter beds in such a way that the individual filter units separate and have gaps between them allowing unfiltered air to pass-thru the filter bed area.