HospitalInspections.org

The inspector observed, while accompanied by the Plant Manager on 05/11/2021 that the door to CEO's office did not meet minimum door leaf requirements and ADA accessible front approach requirement.

Door leaves to rooms subject to occupancy shall not be less than 36 inches wide." - H.L.R, 2007: 133.162(d)(2)(A)(xi).
NFPA 101 2012
7.2.1.2.3.2? Door openings in means of egress shall be not less than 32 in. (810 mm) in clear width, except under any of the following conditions:
(1)?Where a pair of door leaves is provided, one door leaf shall provide not less than a 32 in. (810 mm) clear width opening.

The inspector observed, while accompanied by the Plant Manager on 05/12/2021 that Storage room adjacent to surgical suite not shown on Life Safety Plan.

Occupancy. The purpose for which a building or other structure, or part thereof, is used or intended to be used. [ASCE/SEI 7:1.2]



The inspector observed, while accompanied by the Plant Manager on 05/12/2021 that unaccounted for Storage room wall that used to be an exterior wall must be verified to be of 1 hr rating. Verification of impact on the existing smoke compartment must be researched. Storage space divided with fencing and lockable gate. This condition prevents a clear unobstructed path to an exit. Only one exit from the space. Travel distance over 100'. Also, no fire extinguisher was noted during the inspection.

4.5.3.2? Unobstructed Egress. In every occupied building or structure, means of egress from all parts of the building shall be maintained free and unobstructed. Means of egress shall be accessible to the extent necessary to ensure reasonable safety for occupants having impaired mobility.



The inspector observed, while accompanied by the Plant Manager on 05/12/2021 that MRI control room used as storage.

Occupancy. The purpose for which a building or other structure, or part thereof, is used or intended to be used. [ASCE/SEI 7:1.2]

The inspector observed, while accompanied by the Plant Manager on 05/12/2021 that signage for all rooms on second floor shall be verified.
A physical environment that protects the health and safety of patients, personnel, and the public shall be provided in each hospital. The physical premises of the hospital and those areas of the hospital's physical structure that are used by the patients (including all stairwells, corridors, and passageways) shall meet the local building and fire safety codes and Subchapters H and I of this chapter - HLR 2007, 133.162 (d)(1)(A).


The inspector observed, while accompanied by the Plant Manager on 05/12/2021 that a condensate pipe is protruding from ceiling of clean utility room. Line must be caped and relocated.

A physical environment that protects the health and safety of patients, personnel, and the public shall be provided in each hospital. The physical premises of the hospital and those areas of the hospital's physical structure that are used by the patients (including all stairwells, corridors, and passageways) shall meet the local building and fire safety codes and Subchapters H and I of this chapter - HLR 2007, 133.162 (d)(1)(A).

The inspector observed, while accompanied by the Plant Manager on 05/12/2021 that smoke detector needed at electrical room (2nd Floor)

Protection of Fire Alarm Control Unit(s). In areas that are not continuously occupied, automatic smoke detection shall be provided at the location of each fire alarm control unit(s) to provide notification of fire at that location - NFPA 72, 2002, 4.4.5.

The inspector observed, while accompanied by the Plant Manager on 05/11/21 that the required clear and unobstructed path of travel from any point in the building was not maintained throughout the building where plastic barriers were maintained. Specifically, stations 4 and 5 ( covid ward ) where 15 covid patients resided at the time of the survey. These plastic barriers not only impeded a clear and unobstructed path to an exit but also impacted clear and full view to an exit sign. Plastic barriers also pose the potential for fumes and smoke in case of fire.
4.5.3.2 Unobstructed Egress. In every occupied building or structure, means of egress from all parts of the building shall be maintained free and unobstructed. Means of egress shall be accessible to the extent necessary to ensure reasonable safety for occupants having impaired mobility.

The inspector observed, while accompanied by the Plant Manager on 05/12/2021 that positive latch was missing for the soiled utility room 2nd floor.

The inspector observed, while accompanied by the Plant Manager on 05/13/2021 that a fire exit sign needed on ea. Side of double egress main corridor door.

The inspector observed, while accompanied by the Plant Manager on 05/12/2021 that pull chords for toilet rooms 207,208 touching floor.

All patient toilet rooms and bathrooms shall be provided with a nurse's emergency calling station including a pull cord. Bottom of cord shall be within a minimum of 6 inches from finish floor in the toilet rooms - H.L.R, 2007: §133.162(d)(5)(L)(ii) and §133.169(g), Table 7.


The inspector observed, while accompanied by the Plant Manager on 05/12/2021 that riser room at first floor (dry) had penetrations that needed to be sealed.

"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.


The inspector observed, while accompanied by the Plant Manager on 05/12/2021 that a smoke detector needed above FACP panel.

Protection of Fire Alarm Control Unit(s). In areas that are not continuously occupied, automatic smoke detection shall be provided at the location of each fire alarm control unit(s) to provide notification of fire at that location - NFPA 72, 2002, 4.4.5.

The inspector observed, while accompanied by the Plant Manager on 05/13/2021 that the door from interior corridor leading to lobby in case of fire access control device must disengage and door can be opened manually.

"Door-locking arrangements shall be permitted where the clinical needs of patients require specialized security measure or where patients pose a security threat, provided that staff can readily unlock doors at all times in accordance with 18.2.2.2.6." - NFPA 101, 2012, 18.2.2.2.5.1.

"Access-Controlled Egress Door Assemblies. Where permitted in Chapter 11 through Chapter 43, doors in the means of egress shall be permitted to be equipped with electrical lock hardware that prevents egress, provided that all of the following criteria are met:
(1) A sensor shall be provided on the egress side, arranged to unlock the door leaf in the direction of egress upon detection of an approaching occupant.
(2) Door leaves shall automaticically unlock in the direction of egress upon loss of power to the sensor or to the part of the access control system that locks the door leaves.
(3) Door locks shall be arranged to unlock in the direction of egress from a manual release device complying with all of the following criteria: (a) The manual release device shall be located on the egress side, 40 to 48 inches vertically above the floor, and within 60 inches of the secured door openings. (b) The manual release device shall be readily accessible and clearly identified by a sign that reads as follows: PUSH TO EXIT. (c) When operated, the manual release device shall result in direct interruption of power to the lock - independent of the locking system electronics - and the lock shall remain unlocked for not less than 30 seconds.
(4) Activation of the building fire-protective signaling system, if provided, shall automatically unlock the door leaves in the direction of egress,, and the door leaves shall remain unlocked until the fire-protective signaling system has been manually reset.
(5) The activation of manual fire alarm boxes that activate the building fire protective signaling system specified in 7.2.1.6.2(4) shall not be required to unlock the door leaves.
(6) Activation of the building automatic sprinkler or fire detection system, if provided, shall automatically unlock the door leaves in the direction of egress, and the door leaves shall remain unlocked until the fie-protective signaling system has been manually reset.
(7) The egress side of access-controlled egress doors, other than existing access-controlled egress doors, shall be provided with emergency lighting in accordance with Section 7.9." - NFPA 101, 2012, 7.2.1.6.2

The inspector observed, while accompanied by the Plant Manager on 05/13/2021 that a fire pull is needed on lobby entry doors.

K500
NFPA-101 7.13.1.2
The inspector observed, while accompanied by the Plant Manager on 05/11/21 that mechanical room being used as storage.

7.13.1.2?Building service equipment support areas shall not contain fuel-fired equipment or be used for the storage of combustibles.


H.L.R., 2007: §133.163(t)(5)(B).

The inspector observed, while accompanied by the Plant Manager on 05/11/21 that facility had three types of nurse call system. Nurse call system not fully functional in station 4 and station 5. Nurse call system upgrade shall be a state project and shall be inspected by state.

The nurse call shall be in accordance with 133.162(d)(5)(L) and Table 7 of 133.169(g) of this title - H.L.R., 2007: §133.163(t)(5)(B).



The inspector observed, while accompanied by the Plant Manager on 05/11/21 that filter logs for each air handler not properly kept.

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.


The inspector observed, while accompanied by the Plant Manager on 05/11/21 that condensate line was protruding from ceiling tiles at 3-bathroom locations. These lines were located directly above a sink, in all cases. In two cases plastic piping is visible.

A physical environment that protects the health and safety of patients, personnel, and the public shall be provided in each hospital. The physical premises of the hospital and those areas of the hospital's physical structure that are used by the patients (including all stairwells, corridors, and passageways) shall meet the local building and fire safety codes and Subchapters H and I of this chapter - HLR 2007, 133.162 (d)(1)(A).

The inspector observed, while accompanied by the Plant Manager on 05/12/2021 that housekeeping room at first floor missing light and light switch.

A physical environment that protects the health and safety of patients, personnel, and the public shall be provided in each hospital. The physical premises of the hospital and those areas of the hospital's physical structure that are used by the patients (including all stairwells, corridors, and passageways) shall meet the local building and fire safety codes and Subchapters H and I of this chapter - HLR 2007, 133.162 (d)(1)(A).



The inspector observed, while accompanied by the Plant Manager on 05/12/2021 that hardware is missing to CT control door.

A physical environment that protects the health and safety of patients, personnel, and the public shall be provided in each hospital. The physical premises of the hospital and those areas of the hospital's physical structure that are used by the patients (including all stairwells, corridors, and passageways) shall meet the local building and fire safety codes and Subchapters H and I of this chapter - HLR 2007, 133.162 (d)(1)(A).




The inspector observed, while accompanied by the Plant Manager on 05/12/2021 that laundry room did not have return grille.

A physical environment that protects the health and safety of patients, personnel, and the public shall be provided in each hospital. The physical premises of the hospital and those areas of the hospital's physical structure that are used by the patients (including all stairwells, corridors, and passageways) shall meet the local building and fire safety codes and Subchapters H and I of this chapter - HLR 2007, 133.162 (d)(1)(A).

The inspector observed, while accompanied by the Plant Manager on 05/13/2021 that facility is to verify that emergency lighting from facility to exterior exits is present and part of the life safety branch of the essential system.

"Emergency lighting systems shall include all required means of egress lighting, illuminated exit signs, and all other lights specified as necessary to provide required illumination. Emergency lighting systems shall be designed and installed so that the failure of any individual lighting element, such as the burning out of a light bulb, cannot leave in total darkness any space that requires emergency illumination." - NFPA 70, 2002, 700.16.


The inspector observed, while accompanied by the Plant Manager on 05/13/2021 that outside air intake for AHU on roof is located below 3'-0" above finish roof line.

ASHRAE, 2003, Applications Handbook - Hospital Facilities - "Outside Air Intakes. These intakes should be located as far as practical (on directionally different exposures whenever possible), bout not less than 25 ft, from combustion equipment stack exhaust outlets, ventilation exhaust outlets from the hospital or adjoining buildings, medical-surgical vacuum system, cooling towers, plumbing vent stacks, smoke control exhaust outlets, and areas that may collect vehicular exhaust and other noxious fumes. The bottom of the outside air intakes serving central systems should be located as high as practical (12 ft recommended) but not less that 6 ft above ground level or, if installed above the roof, 3 ft above the roof level."


The inspector observed, while accompanied by the Plant Manager on 05/13/2021 that the nurse call system did not meet state requirements. It was apparent that the current system was installed after the state inspection had occurred. The new system in place needs to be inspected by the state. The facility shall apply for a minor inspection for the current operating nurse call system.

The inspector observed, while accompanied by the Plant Manager on 05/11/21 fire drills record not well kept.

The inspector observed, while accompanied by the Plant Manager on 05/12/2021 that improvement on record keeping for fire drills is needed.

The inspector observed, while accompanied by the Plant Manager on 05/11/2021 that facility failed to keep test log of smoke evacuation system.

"Nondedicated Systems, at Least Annually. Operate the smoke-control system for each control sequence in the current design criteria and observe the operation of the correct output for each given input. Tests should also be conducted under standby power, if applicable." - NFPA 92A, 2000, 5.4.3.2.

The inspector observed, while accompanied by the Plant Manager on 05/11/2021 that facility failed to keep test log of smoke evacuation system.
"Nondedicated Systems, at Least Annually. Operate the smoke-control system for each control sequence in the current design criteria and observe the operation of the correct output for each given input. Tests should also be conducted under standby power, if applicable." - NFPA 92A, 2000, 5.4.3.2.

The inspector observed, while accompanied by the Plant Manager on 05/12/2021 that facility not keeping test log of smoke evacuation system.

NFPA 99 5.1.3.7.7.
The inspector observed, while accompanied by the Plant Manager on 05/12/2021 that med gas exhaust at roof not properly screened.

5.1.3.7.7.3?The end of the exhaust shall be turned down and screened or otherwise be protected against the entry of vermin, debris, or precipitation by screening fabricated or composed of a noncorroding material.

The inspector observed, while accompanied by the Plant Manager on 05/13/2021 that nurse call system did not meet state requirements. Facility shall follow up with state for an inspection.



(L) Nurses calling systems. Three different types of nurses calling systems are required to be installed in a hospital: a nurses regular calling system; a nurses emergency calling system; and a staff emergency assistance calling system. The hospital shall comply with the requirements of this subparagraph in addition to any specific requirements for nurses calling systems for the particular unit of the hospital in accordance with §133.163 and Table 7 of §133.169(g) of this title. Where required in this subparagraph, a distinct visible signal is provided when a colored dome light lamp, or particular combination of colored lamps is used for only one type of call. Different flash rates do not meet this requirement.

(i) A nurses regular calling system is intended for routine communication between each patient and the nursing staff. Activation of the system at a patient's regular calling station will sound a repeating (every 20 seconds or less) distinct audible signal at the nurse station, indicate type and location of call on the system monitor, and activate a distinct visible signal in the corridor at the patient suites door. In multi-corridor nursing units, additional visible signals shall be installed at corridor intersections. The audible signal shall be canceled and two-way voice communication between the patient room and the nursing staff shall be established at the unit's nursing station when the call is answered by the nursing staff. The visible signal(s) in the corridor shall be canceled upon termination of the call. Calls shall activate visible signals in accordance with Table 7 of §133.169(g) of this title. An alarm shall activate at the nurses station when the call cable is unplugged.

(ii) A nurses emergency calling system shall be installed in all toilets used by patients to summon nursing staff in an emergency. Activation of the system shall sound a repeating (every 5 seconds or less) a distinct audible signal at the nurse station, indicate type and location of call on the system monitor, and activate a distinct visible signal in the corridor at the patient suites door. In multi-corridor nursing units, additional visible signals shall be installed at corridor intersections. The visible and audible signals shall be cancelable only at the patient calling station. Calls shall activate visible signals in accordance with Table 7 of §133.169(g) of this title. When conveniently located and accessible from both the bathing and toilet fixtures, one emergency call station may serve one bathroom. A nurses emergency call system shall be accessible to a collapsed patient lying on the floor. Inclusion of a pull cord extending to within six inches of the floor will satisfy this requirement.

(iii) A staff emergency assistance calling system (code blue) is intended to be used by staff to summon additional help in an emergency. In open suites, an emergency assistant call system device shall be located at the head of each bed and in each individual room. The emergency assistance calling device can be shared between two beds if conveniently located. Activation of the system will sound a distinct audible signal at the nursing unit's nurses station or at a staffed control station of a suite, department or unit, indicate type and location of call on the system monitor and activate a distinct visible signal in the corridor at the patient suites door. In multi-corridor nursing units, additional visible signals shall be installed at corridor intersections. Calls shall activate audible and visible signals in accordance with Table 7 of §133.169(g) of this title. A visible system shall clearly define the alarm location to a continuously staffed back up area (other than the nurse station or an administrative center) from which assistance can be summoned. Alternatively, back up may be provided via automatic annunciation from the staff emergency assistance calling system through wireless phones or pagers. The system shall have voice communication capability so that the type of emergency or help required may be specified between the point of alarm and the unit's nurse station.

NFPA-99 - 5.3.6.21.11, 5.3.6.21.12, 5.3.6.21.13, 5.3.6.21.14
The inspector observed, while accompanied by the Plant Manager on 05/11/21 that nitrous oxide manifold not properly working.

5.3.6.21.11?The two banks of each medical gas source shall be manifolded so that either bank can supply its distribution piping system.
5.3.6.21.12?Where the source equipment is remote from a single treatment facility and an "in use" bank is unable to supply the system, the manifold shall automatically switch to the secondary bank.
5.3.6.21.13?Where the source equipment serves multiple treatment facilities and an "in use" bank is unable to supply the system, the manifold shall automatically switch to the secondary bank.
5.3.6.21.14?Where the source equipment is not remote and is accessible from a single treatment facility served and an "in use" bank is unable to supply the system, the manifold shall be manually (or automatically) switched to the secondary bank.

NFPA-99 - 5.1.12.3.13
The inspector observed, while accompanied by the Plant Manager on 05/11/21 that medical gas piping not properly labeled. Properly identify main and riser lines.
5.1.12.3.13?Labeling. The presence and correctness of labeling required by this code for all components (e.g., station outlets/inlets, shutoff valves, and alarm panels) shall be verified.

NFPA 70, 2012
The inspector observed, while accompanied by the Plant Manager on 05/11/21 that electrical room being used for storage.

"Dedicated Equipment Space: All switchboards, panelboards, distribution boards, and motor control centers shall be located in dedicated spaces and protected from damage." - NFPA 70, 2012, 110.26(E)


The inspector observed, while accompanied by the Plant Manager on 05/11/21 roof units were located on the critical branch of the essential system. RTU's should be moved to equipment brach of essential system.

"General. The equipment branch shall be connected to equipment described in 6.4.2.2.5.3 through 6.4.2.2.5.4.
6.4.2.2.5.4 Equipment for Delayed-Automatic or Manual Connection. The following equipment shall be permitted to be arranged for either delayed-automatic or manual connection to the alternate power source (also see A. 6.4.2.2.5.3): (1) Heating equipment used to provide heating for operating, delivery, labor, recovery, intensive care, coronary care, nurseries, infection/isolation rooms, emergency treatment spaces, and general patient rooms: and pressure maintenance (Jockey or make-up) pump(s) for water-based fire protection systems." - NFPA 99, 2012: 6.4.2.2.5.





The inspector observed, while accompanied by the Plant Manager on 05/11/21 that disconnect switches for RTU 's was not properly labeled.

"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, 2011, 700.10. They shall be labeled "LIFE SAFETY", "CRITICAL", or "EQUIPMENT" as applicable.



The inspector observed, while accompanied by the Plant Manager on 05/11/21 that the essential panels of the essential systems were not properly labeled.

"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, 2011, 700.10. They shall be labeled "LIFE SAFETY", "CRITICAL", or "EQUIPMENT" as applicable.


The inspector observed, while accompanied by the Plant Manager on 05/11/21 that disconnect switches for vacuum pumps not properly labeled.

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.


The inspector observed, while accompanied by the Plant Manager on 05/11/21 that disconnect switches for vacuum pumps not properly labeled.

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.

The inspector observed, while accompanied by the Plant Manager on 05/12/2021 that essential equipment and disconnect switches were not labeled. As a general comment, facility to verify that all essential equipment is properly labeled.

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.

The inspector observed, while accompanied by the Plant Manager on 05/13/2021 that disconnects for pump #1 and #2 were not properly labeled.

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.

K914,K918,K924,K771,K712

The inspector observed, while accompanied by the Plant Manager on 05/12/2021 that improvement on record keeping for essential system testing is needed.

The inspector observed, while accompanied by the Plant Manager on 05/13/2021 that line isolation monitors not tested monthly/yearly.

The inspector observed, while accompanied by the Plant Manager on 05/12/2021 that the plug at nourishment needs to be identified.


The inspector observed, while accompanied by the Plant Manager on 05/12/2021 that split system in IT room tied to essential system needs to be identified.

The inspector observed, while accompanied by the Plant Manager on 05/11/21 that transfer switches not properly identified at start of generator.


The inspector observed, while accompanied by the Plant Manager on 05/11/21 that improvement opportunities for facility record keeping were identified.