HospitalInspections.org

Spare Sprinkler Heads:

"A supply of at least six spare sprinklers (never fewer than six) shall be maintained on the premises so that any sprinklers that have operated or been damaged in any way can be promptly replaced." - NFPA 13, 2010, 6.2.9.1* ("A minimum of two sprinklers of each type and temperature rating should be provided." A.6.2.9.1)
"One sprinkler wrench as specified by the sprinkler manufacturer shall be provided in the cabinet for each type of sprinkler installed to be used for the removal and installation of sprinklers in the system." - NFPA 13, 2010, 6.2.9.6

Based on observation the facility failed to provide adequate fire protection.

The inspector observed, while accompanied by the Assistant Chief Executive Officer (ACEO), Director Plant Operations (DPO), Director of Surgery and the Maintenance Technician during the hours of the inspection from 9:00 am to 6:00 pm on 6/19/2019 that there were 3 spare sprinkler head units in the red box in the riser room. There shall be 6 spares sprinkler heads in the box.


Fire Doors:

Doors in a 1 hour fire rated barrier shall be 45 minute rated fire door assemblies - NFPA 101, 2003: Table 8.3.4.2.

Fire doors shall be self-closing or automatic-closing. - NFPA 101, 2012, 8.3.3.3 & 7.2.1.8.

"Only labeled door frames shall be used." - NFPA 80, 2010, 6.3.1.1

Based on observation the facility failed to provide adequate fire protection.

The inspector observed, while accompanied by the Assistant Chief Executive Officer (ACEO), Director Plant Operations (DPO), Director of Surgery and the Maintenance Technician during the hours of the inspection from 9:00 am to 6:00 pm on 6/19/2019 that there were:

1. All the 1-hr rated Electrical rooms had door that were not rated and door frames that had UL rating stamp number that the
inspector could not verify if the frame met the 45 minutes rating. Provide evidence to show that the UL stamped number is
equivalent to or greater than 45 minutes fire rating.
2. The door leaf in the 1-hr rated electrical room was rated 20 minutes. It shall be rated 45 minutes. Verify UL door frame.
3. The 1-hr rated electrical room for the ER had a door and door frame that were not rated.

Firestops:

"Firestop Systems and Devices Required. 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. The firestop system or device shall be tested in accordance with ASTM E 814, Standard Test Method for Fire Tests of Through Penetration Fire Stops, or ANSI/UL 1479, Standard for Fire Tests of Through- Penetration Firestops, at a minimum positive pressure differential of 0.01 in. water column (2.5 N/m 2 between the exposed and the unexposed surface of the test assembly." NFPA 101, 2012, 8.3.5.1*

Based on observation the facility failed to provide adequate fire protection.

The inspector observed, while accompanied by the Assistant Chief Executive Officer (ACEO), Director Plant Operations (DPO), Director of Surgery and the Maintenance Technician during the hours of the inspection from 9:00 am to 6:00 pm on 6/19/2019 that all the fire rated electrical room had milky colored caulking material used between at the intersection of the wall and the roof. Verify that the correct firestops were used.


Protection from Hazards.

Hazardous Areas
NFPA 101, 2012: 18.3.2.1* Hazardous Areas. Any hazardous areas shall be protected in accordance with Section 8.7, and the areas described in Table 18.3.2.1 shall be protected as indicated.
Note: the table below assumes all areas are sprinklered.
Table 18.3.2.1? Hazardous Area Protection
Hazardous Area Description Protection/
Separation +
Boiler and fuel-fired heater rooms 1 hour
Central/bulk laundries larger than
100 ft2 (9.3 m2) 1 hour
Laboratories employing flammable or
combustible materials in quantities
less than those that would be considered a severe hazard See 18.3.6.3.11.
Closer
Laboratories that use hazardous
materials that would be classified as a
severe hazard in accordance with
NFPA 99, Standard for Health Care Facilities 1 hour
Paint shops employing hazardous
substances and materials in quantities
less than those that would be classified as a severe hazard 1 hour
Physical plant maintenance shops 1 hour
Rooms with soiled linen in volume
exceeding 64 gal (242 L) 1 hour
Storage rooms larger than 50 ft2
(4.6 m2) but not exceeding
100 ft2 (9.3 m2) and storing
combustible material See 18.3.6.3.11.
Closer
Storage rooms larger than 100 ft2
(9.3 m2) and storing combustible
material 1 hour
Rooms with collected trash in volume
exceeding 64 gal (242 L) 1 hour
+Minimum fire resistance rating.


Based on observation the facility failed to provide adequate wall separation.

The inspector observed, while accompanied by the Assistant Chief Executive Officer (ACEO), Director Plant Operations (DPO), Director of Surgery and the Maintenance Technician during the hours of the inspection from 9:00 am to 6:00 pm on 6/19/2019 that the area adjacent to the ICU, on the floor plan labelled suite 3.4a is currently empty and larger than 100 square ft. This area is not separated from the rest of the hospital by a 1-hr wall per the code above. Per NFPA 101, 2012 , this area is considered a hazardous area and shall be enclosed by 1-hr wall. See bolded.

Based on observation the facility failed to provide adequate testing and maintenance.

The inspector observed, while accompanied by the Assistant Chief Executive officer (ACEO), Director Plant Operations (DPO), Director of Surgery and the Maintenance Technician during the hours of the inspection from 9:00 am to 6:00 pm on 6/19/2019 that did not have any record of monthly fire testing record performed.

Final filters and Frames:

Final filters and filter frames should be visually inspected for pressure drop and for bypass monthly. Filters should be replaced based on pressure drop or maintenance schedule with filters that provide the efficiencies specified. (ASHRAE 170, Informative Appendix A, Operations and Maintenance Procedures.) A log of filter replacements should be maintained for each air handler.


Based on observation the facility failed to provide adequate monthly pressure drop records.

The inspector observed, while accompanied by the Assistant Chief Executive Officer (ACEO), Director Plant Operations (DPO), Director of Surgery and the Maintenance Technician during the hours of the inspection from 9:00 am to 6:00 pm on 6/19/2019 that there was no record of the monthly pressure drops across the filters in the air handling units.

Screens on Pressure Relief Outlets:

"Relief Valves. All pressure relief valves shall meet the following requirements: ...They shall have the discharge terminal turned down and screened to prevent the entry of rain, snow, or vermin." - NFPA 99, 2012, 5.1.3.5.6.1(8).


Based on observation the facility failed to provide adequate screen on the pressure relief outlet.

The inspector observed, while accompanied by the Assistant Chief Executive Officer (ACEO), Director Plant Operations (DPO), Director of Surgery and the Maintenance Technician during the hours of the inspection from 9:00 am to 6:00 pm on 6/19/2019 that they were:
1. The inspector could not verify the existence of a vent line on the medigas system and a screen on the pressure relief
outlets. Verify that a vent exist with a screen.
2. The vacuum vent line was disconnected and the vent line on the roof could not be verify to have a screen over outlet.


Design and Construction:

NFPA, 99: 2012: 5.1.3.3.2*- Locations for central supply systems and the storage of positive-pressure gases shall meet the following requirements:

(1) They shall be constructed with access to move cylinders, equipment, and so forth, in and out of the
location on hand trucks complying with 11.4.3.1.1.
(2) They shall be secured with lockable doors or gates or otherwise secured.
(3) If outdoors, they shall be provided with an enclosure (wall or fencing) constructed of noncombustible
materials with a minimum of two entries/exits.

Based on observation the facility failed to provide adequate medical gas storage location.

The inspector observed, while accompanied by the Assistant Chief Executive Officer (ACEO), Director Plant Operations (DPO), Director of Surgery and the Maintenance Technician during the hours of the inspection from 9:00 am to 6:00 pm on 6/19/2019 that the Medical gas enclosure did not have two entries/exits. Medical gas enclosure outdoors shall have two entries/exits.

Zone Valve Location:

NFPA 99, 2012: 5.1.4.8?:
Zone Valves: All station outlets/inlets shall be supplied through a zone valve as follows:
(1)?The zone valve shall be placed such that a wall intervenes between the valve and outlets/inlets that it controls.
(2)?The zone valve shall serve only outlets/inlets located on that same story.
(3)?The zone valve shall not be located in a room with station outlets/inlets that it controls.


Based on observation the facility failed to provide a safe medical gas zone valve location.

The inspector observed, while accompanied by the Assistant Chief Executive Officer (ACEO), Director Plant Operations (DPO), Director of Surgery and the Maintenance Technician during the hours of the inspection from 9:00 am to 6:00 pm on 6/19/2019 that the zone valve is visible from medical gas port in Pre-Ops room # 19. There shall be an intervening wall.

No Storage Allowed in EPS Equipment (Generator) Room:

"The room in which the EPS equipment is located shall not be used for other purposes that are not directly related to the EPS. Parts tools, and manuals for routine maintenance and repair shall be permitted to be stored in the EPS room." - NFPA 110, 2010: 7.11.1.

Based on observation, the facility failed to provide a safe EPS generator location.

The inspector observed, while accompanied by the Assistant Chief Executive Officer (ACEO), Director Plant Operations (DPO), Director of Surgery and the Maintenance Technician during the hours of the inspection from 9:00 am to 6:00 pm on 6/19/2019 that there were 3 plastic drums stored in the generator room. Remove these combustible drums.
Essential Electrical System Segregation (Life Safety):

"The essential electrical system shall be divided into the following three branches: (1) Life safety, (2) Critical, (3) Equipment." NFPA 99, 2012, 6.4.2.2.1.1.

6.4.2.2.3 Life Safety Branch.
6.4.2.2.3.1 The life safety branch shall be limited to circuits essential to life safety.

6.4.2.2.3.2 "The life safety branch shall supply power for lighting, receptacles, and equipment as follows:
(1) Illumination of means of egress in accordance with 101, Life Safety Code,
(2) Exit signs and exit directional signs in accordance with NFPA 101, Life Safety Code,
(3) Hospital communications systems, where used for issuing instruction during emergency conditions,
(4) Generator set locations as follows:
(a) Task illumination,
(b) Battery charger for emergency battery-powered lighting unit(s),
(c) Select receptacles at the generator set location and essential electrical system transfer switch locations,
(5) Elevator cab lighting, control, communications, and signal systems,
(6) Electrically powered doors used for building egress,
(7) Fire alarms and auxiliary functions of fire alarm combination systems complying with NFPA 72, National Fire Alarm and Signaling Code."

6.4.2.2.3.3 "Alarm and alerting systems (other than fire alarm systems) shall be connected to the life safety branch or critical branch."

6.4.2.2.3.4 "Loads dedicated to a specific generator, including the fuel transfer pump(s), ventilation fans, electrically operated louvers, controls, cooling system, and other generator accessories essential for generator operation, shall be connected to the life safety branch or the output terminals of the generator with overcurrent protective devices."

6.4.2.2.3.5 "No functions other than those in 6.4.2.2.3.2, 6.4.2.2.3.3, and 6.4.2.2.3.4 shall be connected to the life safety branch, except as specifically permitted in 6.4.2.2.3."


Based on observation the facility failed to provide adequate essential electrical system.


The inspector observed, while accompanied by the Assistant Chief Executive Officer (ACEO), Director Plant Operations (DPO), Director of Surgery and the Maintenance Technician during the hours of the inspection from 9:00 am to 6:00 pm on 6/19/2019 that there were the following issues. They were:
1. In the electrical room/Phone clo room, the life safety panel had Ahus control and master clock in Maint, nurse call and
music &page in Maint circuits connected ton it.
2. In the main Electrical room, Life Safety Panel had nurse call, PBX blood ann, and receptacle janitor etc on it.
3. Remove these circuits from life safety panel per the code above.

Essential Electrical System Segregation (Critical):

6.4.2.2.4.2 The critical branch shall supply power for task illumination, fixed equipment, select receptacles, and select power circuits serving the following areas and functions related to patient care:

(1) Critical care areas that utilize anesthetizing gases, task illumination, select receptacles, and fixed equipment
(2) Isolated power systems in special environments
(3) Task illumination and select receptacles in the following:
(a) Patient care rooms, including infant nurseries, selected acute nursing areas, psychiatric bed areas (omit receptacles), and
ward treatment rooms
(b) Medication preparation areas
(c) Pharmacy dispensing areas
(d) Nurses' stations (unless adequately lighted by corridor luminaires)
(4) Additional specialized patient care task illumination and receptacles, where needed
(5) Nurse call systems
(6) Blood, bone, and tissue banks
(7) Telephone equipment rooms and closets
(8) Task illumination, select receptacles, and select power circuits for the following areas:
(a) General care beds with at least one duplex receptacles per patient bedroom, and task illumination as required by the
governing body of the health care facility
(b) Angiographic labs
(c) Cardiac catheterization labs
(d) Coronary care units
(e) Hemodialysis rooms or areas
(f) Emergency room treatment areas (select)
(g) Human physiology labs
(h) Intensive care units
(i) Postoperative recovery rooms (select)
(9) Additional task illumination, receptacles, and select power circuits needed for effective facility operation, including single-
phase fractional horsepower motors, which are permitted to be connected to the critical branch


Based on observation the facility had incorrect circuit connected to the essential electrical system.

The inspector observed, while accompanied by the Assistant Chief Executive Officer (ACEO), Director Plant Operations (DPO), Director of Surgery and the Maintenance Technician during the hours of the inspection from 9:00 am to 6:00 pm on 6/19/2019 that the critical panel had so many unrelated circuits connected to it. Re-wire the critical panel to include only the items listed above per the code.


Panel directory:

"Circuit Directory or Circuit Identification. Every circuit and circuit modification shall be legibly identified as to its clear, evident, and specific purpose or use. The identification shall include sufficient detail to allow each circuit to be distinguished from all others. Spare positions that contain unused overcurrent devices or switches shall be described accordingly. The identification shall be included in a circuit directory that is located on the face or inside of the panel door in the case of a panelboard, and located at each switch or circuit breaker in a switchboard. No circuit shall be described in a manner that depends on transient conditions of occupancy." - NFPA 70, 2011, 408.4 (A) Note: Labeling includes all disconnecting means, see 110.22.

Based on observation the facility failed to provide adequate panel board directories.


The inspector observed, while accompanied by the Assistant Chief Executive Officer (ACEO), Director Plant Operations (DPO), Director of Surgery and the Maintenance Technician during the hours of the inspection from 9:00 am to 6:00 pm on 6/19/2019 that there were panels with unreadable directories, Update Life Safety and Critical panels accordingly.


Receptacles & Isolated Power:

"Electrical outlets powered from the critical branch shall be provided in all patient care, procedure and treatment locations in accordance with NFPA 99, 4.4.2.2.2.3. At least one receptacle at each patient treatment or procedure location shall be powered from the normal power panel." - HLR, 133.162 (d)(5)(H)(ii).

"Critical Care Areas: Patient Bed Location Branch Circuits. Each patient bed location shall be supplied by at least two branch circuits, one or more from the emergency system and one or more circuits from the normal system. At least one branch circuit from the emergency system shall supply an outlet(s) only at that bed location. All branch circuits from the normal system shall be from a single panel board. Emergency System receptacles shall be identified and shall also indicate the panelboard and circuit number supplying them." NFPA 70, 2002, 517.19(A).

(Critical care areas are defined as special care units, intensive care units, coronary care units, angiography laboratories, cardiac catheterization laboratories, delivery rooms, operating rooms, post-anesthesia recovery rooms, emergency departments, and similar areas in which patients are intended to be subjected to invasive procedures and connected to line-operated, patient-care-related electrical appliances, re NFPA 99, 2002, 3.3.135.2.)

Electrical outlets powered from the critical branch shall be provided at all critical care areas that utilize anesthetizing gases, isolated power in special environments, general care beds, angiographic labs, cardiac catheterization labs, coronary care units, hemodialysis rooms or areas, emergency room treatment areas, human physiology labs, intensive care units, postoperative recovery rooms, and were needed for effective facility operation in accordance with NFPA 99, 2002, 4.4.2.2.2.3.

Based on observation the facility failed to provide adequate Essential Electrical System.

The inspector observed, while accompanied by the Assistant Chief Executive Officer (ACEO), Director Plant Operations (DPO), Director of Surgery and the Maintenance Technician during the hours of the inspection from 9:00 am to 6:00 pm on 6/19/2019 that there were no critical receptacles in the main Ultra sound room in the Imaging department. However, in the Ultra sound room B there were critical receptacles.


Panelboard Bonding:

"Panelboard Bonding. 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.

Based on observation the facility failed to provide adequate safety for Essential Electrical System.

The inspector observed, while accompanied by the Assistant Chief Executive Officer (ACEO), Director Plant Operations (DPO), Director of Surgery and the Maintenance Technician during the hours of the inspection from 9:00 am to 6:00 pm on 6/19/2019 that the facility could not demonstrate to the satisfaction of the inspector that the EPSS critical panel was bonded to the normal branch. Provide evidence that the EPSS critical panel is bonded to the Normal branch.

Based on observation the facility failed to provide adequate risk assessment for all the operating rooms.

The inspector observed, while accompanied by the Assistant Chief Executive Officer (ACEO), Director Plant Operations (DPO), Director of Surgery and the Maintenance Technician during the hours of the inspection from 9:00 am to 6:00 pm on 6/19/2019 that risk assessments were not performed by the governing body to determine if the Operating rooms were wet or dry locations. If determined to be wet, they must be protected by line isolation monitors or GFCIs.

Based on observation the facility failed to provide adequate maintenance and testing of Essential Electrical System.

The inspector observed, while accompanied by the Assistant Chief Executive Officer (ACEO), Director Plant Operations (DPO), Director of Surgery and the Maintenance Technician during the hours of the inspection from 9:00 am to 6:00 pm on 6/19/2019 that there were the following issues:

1. That additional testing was not being performed at intervals defined by documented performance data on all the patient care
receptacles.
2. Records of where, type of repairs performed and date of electrical maintenance and required tests performed in all the patient
care areas.

Based on observation the facility failed to provide adequate maintenance and testing of Essential Electrical System.

The inspector observed, while accompanied by the Assistant Chief Executive Officer (ACEO), Director Plant Operations (DPO), Director of Surgery and the Maintenance Technician during the hours of the inspection from 9:00 am to 6:00 pm on 6/19/2019 that there were:

1. The main and feeder circuit breakers were not being inspected annually and there was no program for periodically exercising
the components - Infra-red testing cannot subsist for the physical exercising the components.
2. There were no records of maintenance and testing maintained.