HospitalInspections.org

K200 - Means of Egress Requirements - Other
Findings:
The surveyor observed, while accompanied by the Plant Ops Maintenance Technicians, during the hours of the survey from 8:30 am to 12:15 pm on 05/24/2024, that there were the following issues:

1) Based on review of the records, facility failed to show that it performed inspection of doors in means of egress for the year 2023. Per CMS Letter, "S&C 17-38-LSC," "full compliance with the annual fire door assembly inspection and testing in accordance with 2010 NFPA 80 is required by January 1, 2018." Per NFPA 80 (2010), "acceptance testing of fire door and window assemblies shall be performed by a qualified person with knowledge and understanding of the operating components of the type of assembly being subject to testing."

K372 - Subdivision of Building Spaces - Smoke Barrier Construction
Findings:
The surveyor observed, while accompanied by the Plant Ops Maintenance Technicians, during the hours of the survey from 8:30 am to 12:15 pm on 05/24/2024, that there were the following issues:

1) Based on observations, there were unsealed penetrations above the double doors in the path of smoke compartment due to data cable penetration on either side. This was observed throughout the facility where new cable data were pulled.

K500 - Building Services - Other
Findings:
The surveyor observed, while accompanied by the Plant Ops Maintenance Technicians, during the hours of the survey from 8:30 am to 12:15 pm on 05/24/2024, that there were the following issues:

1) Based on observations, the mechanical exhaust for patient toilet in the Emergency Department and for patient rooms 112 and 114 were not operational.
2) Observed in the small operating room, the low return vents failed to pull in air.

K901 Fundamentals - Building System Categories

Findings:
The surveyor observed, while accompanied by the Plant Ops Maintenance Technicians, during the hours of the survey from 8:30 am to 12:15 pm on 05/24/2024, that there were the following issues:

1) Based on review of the records, facility failed to take the hazard vulnerability assessment template and modify to fit its own hazard vulnerability model.

K907 Gas and Vacuum Piped Systems - Maintenance Program

Findings:
The surveyor observed, while accompanied by the Plant Ops Maintenance Technicians, during the hours of the survey from 8:30 am to 12:15 pm on 05/24/2024, that there were the following issues:

1) Based on review of the records and observations, multiple gauges for the vacuum system were no longer functional throughout the facility.

K914 - Electrical Systems - Maintenance and Testing

Findings:
The surveyor observed, while accompanied by the Plant Ops Maintenance Technicians, during the hours of the survey from 8:30 am to 12:15 pm on 05/24/2024, that there were the following issues:

1) Based on review of the records, facility did not perform any receptacle maintenance and testing at all in patient care areas. NFPA 99-2012, section 6.3.3.2 lists the minimum requirements for receptacle testing regardless of hospital-grade or not. Describe the facility justification of testing frequency (e.g. appropriate testing intervals) based on documented performance data. For example, experiential data shows that retention force of the grounding blade of each electrical receptacle decreases over time due to repeated usage. Thus, the failure rate has a direct correlation to time and usage.
2) Based on review of the records, facility failed to perform maintenance and testing of line isolation monitors at required intervals.

K918 Electrical Systems - Essential Electric System Maintenance and Testing
Findings:
The inspector observed, while accompanied by the Plant Ops Maintenance Technicians, during the hours of the survey from 8:30 am to 12:15 pm on 05/24/2024, that there were the following issues:
1) Based on observations, facility failed to label the automatic transfer switch (ATS 1 & 2) in accordance with the branch which it serves. The Standard: "Emergency panels shall be distinctively marked so that they are readily identifiable as a component of the essential electrical system." - NFPA 70, 2002: 110-22 and 700-9(a). They shall be labeled "LIFE SAFETY", "CRITICAL", or "EQUIPMENT" as applicable.
2) There was no EPO "kill switch" dedicated for the generator. The Standard: 5.6.5.6* 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, Standard for Emergency and Standby Power Systems. U.S.A.: NFPA; 2010