HospitalInspections.org

Based upon observations made in the presence of the plant manager on 06/08/2021, it was determined that the facility did not maintain hazardous areas to be fire and smoke separated from other sections of the facility in accordance with NFPA 101 19.3.2.1, 19.3.2.1.1 through 19.3.2.1.5

This deficiency affected 1 of 6 smoke compartments

Findings include:

During the facility tour a 1'x1' hole was observed in the ceiling of the electrical room. Hazardous areas shall be fire and smoke separated from other sections of the facility in accordance with NFPA 101 19.3.2.1.

Based upon observations made in the presence of the plant manager on 06/08/2021, it was determined that the facility did not maintain the door openings in smoke barriers to have at least a 20 minute fire protective rating. The doors shall be self-closing or automatic closing in accordance with NFPA 101 19.3.7.8.

This deficiency affected 2 of 6 smoke compartments.

Findings include:

During the facility tour the O.B. corridor fire rated doors failed to latch when closed, in accordance with NFPA 80 5.2.4.2 (8) Fire doors are to latch in the closed position. NFPA 19.3.7.3, 8.5, 8.3.3.1, NFPA 80 5.2.4.2

Based upon record review made in the presence of the plant manager on 06/08/2021, it was determined that the facility did not maintain, inspect and exercise the facilities emergency generator set in accordance with NFPA 19.5.1, NFPA 99 6.4.4.1.3 and NFPA 110 8.3.7.1.

This deficiency affected 1 of the several generator maintenance tests required.

Findings include:

During the record review the facility failed to provide documentation of the required monthly testing and recording of electrolyte specific gravity or conductance results (CCA) of the lead acid batteries in connection with the emergency power supply system. Maintenance of lead-acid batteries shall include the monthly testing and recording of electrolyte specific gravity. Battery conductance testing shall be permitted in lieu of the testing of specific gravity when applicable or warranted in accordance with NFPA 110 8.3.7.1

During the facility tour it was observed that the generator did not have a remote manual stop located outside of the enclosure. 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 in accordance with NFPA 99 6.5.4 and NFPA 110 5.6.5.6.