HospitalInspections.org

Door Inspections:

Fire-rated door assemblies and certain other doors in the means of egress shall be tested annually or per an accepted performance-based evaluation schedule approved by the AHJ per NFPA 80, 2010, Ch. 5.2. A written record of the inspections and testing shall be signed and kept for inspection by the AHJ. NFPA;101, 7.2.1.15.

Based on observation the facility failed to maintain properly all the doors along the means of egress.

The inspector observed, while accompanied by the Chief Nursing Officer (CNO) and Director of Plant Operations (DPO) during the hours of the inspection from 1:30 pm to 6:45 pm on 6-24-2020 that the facility had not performed the required inspection of all the doors along the means of egress to ascertain their level of functionality as required by the code.

Emergency Shutoff:

"Each air distribution system shall be provided with at least one manually operable means for stopping the operation of the supply, return, and exhaust fan(s) in an emergency. The means of manual operation shall be located at an approved location." NFPA 90A, 2012, 6.2.1 & 6.2.2. The emergency stops or kill switch is typically a red "mushroom" button at a nurse station. There may be one switch for each air handler or one switch that shuts down multiple the air handlers.

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

The inspector observed, while accompanied by the Chief Nursing Officer (CNO) and Director of Plant Operations (DPO) during the hours of the inspection from 1:30 pm to 6:45 pm on 6-24-2020 that some RTUs serving the facility had no emergency shutoff switches.

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 Chief Nursing Officer (CNO) and Director of Plant Operations (DPO) during the hours of the inspection from 1:30 pm to 6:45 pm on 6-24-2020 that there was no record or logs of each air handler showing dates when the final filters, pre-filters have been replaced with the pressure differential across the filter before and after replacement where differential pressure monitors are required.

Medical Gas storage

"Only gas cylinders, reusable shipping containers, and their accessories shall be permitted to be stored in rooms containing central supply systems or gas cylinders." - NFPA 99, 2012, 5.1.3.2.3

"No flammable materials, cylinders containing flammable gases, or containers containing flammable liquids shall be stored in rooms with gas cylinders." - NFPA 99, 2012, 5.1.3.2.4

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

The inspector observed, while accompanied by the Chief Nursing Officer (CNO) and Director of Plant Operations (DPO) during the hours of the inspection from 1:30 pm to 6:45 pm on 6-24-2020 that there were the medical gas bottles stored in a room with other flammable materials.

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 Chief Nursing Officer (CNO) and Director of Plant Operations (DPO) during the hours of the inspection from 1:30 pm to 6:45 pm on 6-24-2020 that the facility could not demonstrate to the inspector that the EPSS critical panel was bonded to the normal branch.

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 Essential Electrical System (EES).

The inspector observed, while accompanied by the Chief Nursing Officer (CNO) and Director of Plant Operations (DPO) during the hours of the inspection from 1:30 pm to 6:45 pm on 6-24-2020 that the panel directories were incorrect and difficult to read. Panel directories shall be legible.


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 had incorrect circuits connected in the essential electrical system.

The inspector observed, while accompanied by the Chief Nursing Officer (CNO) and Director of Plant Operations (DPO) during the hours of the inspection from 1:30 pm to 6:45 pm on 6-24-2020 that there were the following issues:

1. There were no select receptacles in the ATS locations - (inside the electrical room and at Generac ATS outside)
2. There were no select receptacles at the generator locations for generator 2 and 3.
3. The select receptacle at generator 1 location was not functional and not connected to the life safety branch.
4. Equipment panel EELB circuit #14 was for smoke damper, remove the circuit from equipment branch to life safety branch.
5. Elevator #1 and #2, the cabin lights and communication systems (phones) were not referenced or connected to life branch
panel.
6. Elevator #2 had no emergency communication system-phone.
7. FACP #11 was not referenced or connected to the ELLA panel in the electrical room- life safety branch.


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 Chief Nursing Officer (CNO) and Director of Plant Operations (DPO) during the hours of the inspection from 1:30 pm to 6:45 pm on 6-24-2020 that there were the following issues:

1. The critical panel ECLA in the electrical room had breaker numbers 22, 20, 18, 16, 14 and 12 for generator blocker heater.
These circuits shall be on life safety branch and not on critical branch.
2. The critical panel ECLA in the electrical room had breakers numbers 1, 7, 2, and 4 connected to items that were required to
be on equipment branch. Remove these items from critical panel and put them in the life safety branch.

Based on observation the facility failed to provide evidence adequate testing of line Isolation monitors.

The inspector observed, while accompanied by the Chief Nursing Officer (CNO) and Director of Plant Operations (DPO) during the hours of the inspection from 1:30 pm to 6:45 pm on 6-24-2020 that there were:
1. The patient care area receptacle tests were not being performed annually.
2. No records are kept for modification and repairs associated with line isolation monitor and receptacles.

Based on observation the facility failed to provide evidence performing risk assessment.

The inspector observed, while accompanied by the Chief Nursing Officer (CNO) and Director of Plant Operations (DPO) during the hours of the inspection from 1:30 pm to 6:45 pm on 6-24-2020 that the facility had not performed risk assessment of Essential Electrical System (EES).

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

The inspector observed, while accompanied by the Chief Nursing Officer (CNO) and Director of Plant Operations (DPO) during the hours of the inspection from 1:30 pm to 6:45 pm on 6-24-2020 that there were the following issues:

1. The 36-month load bank test was not being done correctly. The facility performs a 2-yearly load bank test. This is does not
meet code requirement.
2. The main and feeder circuit breakers were not being inspected annually and there was no program for periodically exercising
the components.
3. There were no records of maintenance and testing maintained.

Generator Remote Manual Stop:


"All installations shall have a remote manual stop station of a type to prevent inadvertent or unintentional operation located outside the room housing the prime mover, where so installed, or elsewhere on the premises where the prime mover is located outside the building" - NFPA 110, 2010, 5.6.5.6* Note: "For systems located outdoors, the manual shutdown should be located external to the weatherproof enclosure and should be appropriately identified." A.5.6.5.6.


Based on observation the facility failed to provide a remote emergency generator shut down switch.

The inspector observed, while accompanied by the Chief Nursing Officer (CNO) and Director of Plant Operations (DPO) during the hours of the inspection from 1:30 pm to 6:45 pm on 6-24-2020 that the generators 1,2 and 3 had the remote manual stop switch installed on the generators housing. These stop switches shall be installed outside the generators enclosure.

Based on observation the facility failed to provide adequate oversight on the competence of their equipment service personnel.

The inspector observed, while accompanied by the Chief Nursing Officer (CNO) and Director of Plant Operations (DPO) during the hours of the inspection from 1:30 pm to 6:45 pm on 6-24-2020 that the facility did not have in place a system of verifying the competence of the medical equipment service personnel.