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1) Based on observation and interview with staff, the facility failed to provide at least a two-hour fire resistance rating to separate the nonconforming building (un-sprinkled/ un-protected portion of the building that houses the Urgent Care and Staff U office) with the sprinkled portion of the building. The last LSC Survey conducted stated that 1)The door leading from waiting area of the licensed hospital space into the waiting room of the space leased to a private medical clinic practice does not have a closer. 2) There is no fire rated separation between the licensed hospital clinic space and the space leased to a private medical clinic practice. These deficiencies were not fixed and still exist, they will be cited again. Findings include:

a) The door and wall to Staff U office does not meet a 2 hour fire rated assembly , the wall shall extend from outside of wall to outside of wall. The wired glass and door frame is not 2 hour rated.

b) The door in the corridor that separates the Urgent Care Clinic from the Licensed hospital does not have a two hour fire rating. This door and wall also separates the sprinkled portion (protected) of the building from the non sprinkled (un-protected), licensed space of the hospital.

1 Based on observation and interview with staff, the facility failed to provide doors, such as those constructed of 1¾ inch solid-bonded core wood, capable of resisting fire for at least 20 minutes. 19.3.6.3. Findings include:

a) Door to the IV store room adjacent to the Pharmacy was provided with a transfer grill.

b) Transfer Grill above the Pharmacy was installed.

c) IT Room across the corridor from the ER entrance was provided with a fan above the door blowing in air to cool the room.

Items a,b,c are not allowed because NFPA 101 18.3.6.4 states: " Transfer grilles, regardless of whether they are protected by fusible link-operated dampers, shall not be used in these walls or doors.

1) Based on observation and interview with staff, the facility failed to test, and maintain a fire alarm system required for life safety with applicable requirements of NFPA 70 and 72. Findings include:

a) Fire alarm last inspection was in 2011.

b) Staff members were asked to demonstrate a test of the system, however no one at the facility has been there long enough to be trained on how to manually test and silence the system.

c) Without documentation or training of staff, HVAC shut down upon activation of the fire alarm system or any of the other methods of force notification to shut down the units could not be identified.

1) Based on observation and interview with staff, the facility failed to continuously maintain the fire suppression system in a reliable method of inspecting and operating condition, system is to be inspected and tested periodically. 19.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.5. Findings include:

a) The sprinkler system last inspection could not be identified, documentation of inspection was believed to be in 2011, the riser room where the control valves and fire tree comes into the building was not accessible. No one had a key to the room.

1) Based on observation and interview with staff, the facility failed to maintain and provide Heating, ventilating, and air conditioning systems that comply with the provisions of section 9.2 and are installed in accordance with the manufacturer's specifications. 19.5.2.1, 9.2, NFPA 90A, and ANSI / ASHRI 15, 19.5.2.2. Findings include:

a) 4 exhaust fans on the roof were not working.

b) Facility failed to maintain safe air handling systems in patient care areas; pre-filters used on the return grill in front lobby area was too small and did not cover the entire surface of the return grill. 90% efficiency or greater filtration filters could not be found on any of the air handlers. Fresh air intakes for the air handlers were not 3 feet above the roof line and 25 feet from plumbing vents and other exhausts.

c) The new HVAC unit in the emergency generator room was not hooked up to serve the ER. Also drawings and specifications needed for installation were not available. Test and Balance for the unit was not available.

1) Based on observation and interview with staff, the facility failed to continuously maintain a Means of egress free of all obstructions or impediments to full instant use in the case of fire or other emergency. No furnishings, decorations, or other objects obstruct exits, access to, egress from, or visibility of exits. NFPA 101 7.1.10. Findings include:

a) Waiting area for the ER is in the corridor west of the egress door and adjacent to the ER entrance. ER waiting is not provided with negative air flow and seating arrangements do not keep the egress corridor free and clean of all impediments.

Based on observation and interview with staff, the facility failed to prevent the use of soiled linen or trash collection receptacles in a room or space does not exceed .5 gal/sq ft (20.4 L/sq m). A capacity of 32 gal (121 L) is not exceeded within any 64 sq ft (5.9-sq m) area. Mobile soiled linen or trash collection receptacles with capacities greater than 32 gal (121 L) are located in a room protected as a hazardous area when not attended. 19.7.5.5. Findings include:

a) The trash /soiled container in the room 103, that housed isolation patients on the day of the survey is greater than 32 gal. The size of the container was 50 gal.

1) Based on observation and interview with staff, the facility failed to provide Piped in medical gas systems that comply with NFPA 99, Chapter 4. Findings include:

a) The Bulk Oxygen, Liquid fill supply replaced the Bottled supply system that was installed on the exterior of the building. The bulk system is not provided with all required equipment, alarms, duel line regulators, etc in accordance with NFPA 99 Figure 4-3.1.1.7.

b) Master alarm panel as required by NFPA 99 is not provided in accordance with 4-3.1.2.2 Gas Warning signals.

c) Area alarm for the Emergency Room is not provided as required by 4-3.1.2.2. ( c)

d) Oxygen Outlet located in the corridor, across from the entrance to the ER was not provided with a gas shut off valve and staff was not trained to know the location. No one could show this surveyor the location when asked.

e) Bottled reserve tanks are not protected and covered from sun rays, weather/ ice and snow. NFPA 99 4-3.5.2.2 (b) 3.

f) Storage tanks are not protected from rusting NFPA 99 4-3.5.2.2. (B) 3

1)Based on observation, interview with staff, review of Generator Test Logs,the facility failed inspected Generator weekly and exercised under load for 30 minutes per month in accordance with NFPA 99. 3.4.4.1. Findings include:

a) The Emergency Generator test log did not have transfer time, and all information required in accordance with NFPA 110 . The battery electrolyte levels shall be inspected every 7 days and was not documented, re-pairs and unsatisfactory condition and corrective action was not documented and maintained. The battery charger was not connected, inspection or reason was documented for battery charging system to be disconnected. A annunciator area alarm at a 24 hour manned station is not provided in the building to monitor status of the emergency generator.

b) The HVAC unit is not allowedto be installed in the emergency generator room, NFPA 99 3-4.1.1.6 + Work Space or Room requires Energy converters shall be located in a separate service room dedicated to the generating equipment, separated from the remainder of the building by fire separations having a minimum 2-hour fire rating, or located in an adequate enclosure outside the building capable of preventing the entrance of snow or rain and resisting maximum wind velocity required by the local building code. Rooms for such equipment shall not be shared with other equipment or electrical service equipment that is not a part of the essential electrical system. [110:5- 2.4]

c) The facility has a natural gas source of fuel without an onsite liquid reserve. Facility does not have a Reliability Letter stating that the fuel source is reliable. NFPA 99 Section 3-4.1.1.13 Fuel Supply -The fuel supply for the generator set shall comply with 3-1.1 and 3-4.2 of NFPA 110. CMS requires the facility to demonstrate the low probability of interruption of the off-site fuel by supplying a letter from the natural gas vendor. After May 29, 2009: CMS required the letter to state the fuel source was reasonably reliable. Natural Gas Generator Reliability Letter :
· 1. A statement of reasonable reliability of the natural gas delivery.
· 2. A brief description that supports the statement regarding the reliability.
· 3. A statement that there is a low probability of interruption of the natural gas.
· 4. A brief description that supports the statement regarding the low probability of interruption.
· 5. The signature of technical personnel from the natural gas vendor

1) Based on observation and interview with staff, the facility failed to maintain Electrical wiring and equipment that is in accordance with NFPA 70, National Electrical Code. 9.1.2. Findings include:

a) Line Isolation Monitor located in ER-1 was not on a monthly inspection program in accordance with NFPA 3-3.3.4.2 (b), the LIM certification commissioning report required after installation was not available in accordance with NFPA 99 1999 edition chapter 3-3.3.4.2 (a)

b) Circuit panel schedule used to identify circuits in the room was removed.

c) All of the Bio Medical Equipment stage and used in the Emergency Room was not tested annually. Stickers dated 4-2014 indicated that they were tested in April of 2014 and required re-testing in April of 2015, however Emergency Rooms are considered a Critical Care area and require testing of equipment on a semi annually basis NFPA 99 1999 edition chapter 7-6.2.1.1.

d) Patient care areas have not had an Impedance Ground Test program NFPA 99 3-3.3.2.1 or Receptacle Testing program in accordance with NFPA 99 3-3.3.3. Record Keeping for these areas are not in accordance with NFPA 99 3-3.4.3

e) Power strips used in ER 1 & ER 2 did not have a Bio Medical Sticker and were not a part of a testing program in accordance with NFPA 99 7-5.1.3.1. The CEO was asked at the entrance conference if any waivers were being used at this time. The governing body has not adopted Power strips use in patient care vicinity. The Centers for Medicare and Medicaid Services (CMS) released a categorical waiver allowing the use of power strips in new and existing healthcare facility patient care rooms, if the provider/supplier is in compliance with all applicable 2012 Life Safety Code (LSC) power strip requirements and with all other 2000 LSC electrical system and equipment provisions.
f) Emergency Receptacles are not marked in ER1 and in the Blood Bank. Receptacles shall be distinctly marked in accordance with NFPA 99 1999, chapter 3.4.2.2.4 (a) 2. The cover plates for electric outlets shall be distinctive in color or marked.

1) Based on observation and interview with staff, the facility failed to provide at least a two-hour fire resistance rating to separate the nonconforming building (un-sprinkled/ un-protected portion of the building that houses the Urgent Care and Staff U office) with the sprinkled portion of the building. The last LSC Survey conducted stated that 1)The door leading from waiting area of the licensed hospital space into the waiting room of the space leased to a private medical clinic practice does not have a closer. 2) There is no fire rated separation between the licensed hospital clinic space and the space leased to a private medical clinic practice. These deficiencies were not fixed and still exist, they will be cited again. Findings include:

a) The door and wall to Staff U office does not meet a 2 hour fire rated assembly , the wall shall extend from outside of wall to outside of wall. The wired glass and door frame is not 2 hour rated.

b) The door in the corridor that separates the Urgent Care Clinic from the Licensed hospital does not have a two hour fire rating. This door and wall also separates the sprinkled portion (protected) of the building from the non sprinkled (un-protected), licensed space of the hospital.

1 Based on observation and interview with staff, the facility failed to provide doors, such as those constructed of 1¾ inch solid-bonded core wood, capable of resisting fire for at least 20 minutes. 19.3.6.3. Findings include:

a) Door to the IV store room adjacent to the Pharmacy was provided with a transfer grill.

b) Transfer Grill above the Pharmacy was installed.

c) IT Room across the corridor from the ER entrance was provided with a fan above the door blowing in air to cool the room.

Items a,b,c are not allowed because NFPA 101 18.3.6.4 states: " Transfer grilles, regardless of whether they are protected by fusible link-operated dampers, shall not be used in these walls or doors.

1) Based on observation and interview with staff, the facility failed to test, and maintain a fire alarm system required for life safety with applicable requirements of NFPA 70 and 72. Findings include:

a) Fire alarm last inspection was in 2011.

b) Staff members were asked to demonstrate a test of the system, however no one at the facility has been there long enough to be trained on how to manually test and silence the system.

c) Without documentation or training of staff, HVAC shut down upon activation of the fire alarm system or any of the other methods of force notification to shut down the units could not be identified.

1) Based on observation and interview with staff, the facility failed to continuously maintain the fire suppression system in a reliable method of inspecting and operating condition, system is to be inspected and tested periodically. 19.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.5. Findings include:

a) The sprinkler system last inspection could not be identified, documentation of inspection was believed to be in 2011, the riser room where the control valves and fire tree comes into the building was not accessible. No one had a key to the room.

1) Based on observation and interview with staff, the facility failed to maintain and provide Heating, ventilating, and air conditioning systems that comply with the provisions of section 9.2 and are installed in accordance with the manufacturer's specifications. 19.5.2.1, 9.2, NFPA 90A, and ANSI / ASHRI 15, 19.5.2.2. Findings include:

a) 4 exhaust fans on the roof were not working.

b) Facility failed to maintain safe air handling systems in patient care areas; pre-filters used on the return grill in front lobby area was too small and did not cover the entire surface of the return grill. 90% efficiency or greater filtration filters could not be found on any of the air handlers. Fresh air intakes for the air handlers were not 3 feet above the roof line and 25 feet from plumbing vents and other exhausts.

c) The new HVAC unit in the emergency generator room was not hooked up to serve the ER. Also drawings and specifications needed for installation were not available. Test and Balance for the unit was not available.

1) Based on observation and interview with staff, the facility failed to continuously maintain a Means of egress free of all obstructions or impediments to full instant use in the case of fire or other emergency. No furnishings, decorations, or other objects obstruct exits, access to, egress from, or visibility of exits. NFPA 101 7.1.10. Findings include:

a) Waiting area for the ER is in the corridor west of the egress door and adjacent to the ER entrance. ER waiting is not provided with negative air flow and seating arrangements do not keep the egress corridor free and clean of all impediments.

Based on observation and interview with staff, the facility failed to prevent the use of soiled linen or trash collection receptacles in a room or space does not exceed .5 gal/sq ft (20.4 L/sq m). A capacity of 32 gal (121 L) is not exceeded within any 64 sq ft (5.9-sq m) area. Mobile soiled linen or trash collection receptacles with capacities greater than 32 gal (121 L) are located in a room protected as a hazardous area when not attended. 19.7.5.5. Findings include:

a) The trash /soiled container in the room 103, that housed isolation patients on the day of the survey is greater than 32 gal. The size of the container was 50 gal.

1) Based on observation and interview with staff, the facility failed to provide Piped in medical gas systems that comply with NFPA 99, Chapter 4. Findings include:

a) The Bulk Oxygen, Liquid fill supply replaced the Bottled supply system that was installed on the exterior of the building. The bulk system is not provided with all required equipment, alarms, duel line regulators, etc in accordance with NFPA 99 Figure 4-3.1.1.7.

b) Master alarm panel as required by NFPA 99 is not provided in accordance with 4-3.1.2.2 Gas Warning signals.

c) Area alarm for the Emergency Room is not provided as required by 4-3.1.2.2. ( c)

d) Oxygen Outlet located in the corridor, across from the entrance to the ER was not provided with a gas shut off valve and staff was not trained to know the location. No one could show this surveyor the location when asked.

e) Bottled reserve tanks are not protected and covered from sun rays, weather/ ice and snow. NFPA 99 4-3.5.2.2 (b) 3.

f) Storage tanks are not protected from rusting NFPA 99 4-3.5.2.2. (B) 3

1)Based on observation, interview with staff, review of Generator Test Logs,the facility failed inspected Generator weekly and exercised under load for 30 minutes per month in accordance with NFPA 99. 3.4.4.1. Findings include:

a) The Emergency Generator test log did not have transfer time, and all information required in accordance with NFPA 110 . The battery electrolyte levels shall be inspected every 7 days and was not documented, re-pairs and unsatisfactory condition and corrective action was not documented and maintained. The battery charger was not connected, inspection or reason was documented for battery charging system to be disconnected. A annunciator area alarm at a 24 hour manned station is not provided in the building to monitor status of the emergency generator.

b) The HVAC unit is not allowedto be installed in the emergency generator room, NFPA 99 3-4.1.1.6 + Work Space or Room requires Energy converters shall be located in a separate service room dedicated to the generating equipment, separated from the remainder of the building by fire separations having a minimum 2-hour fire rating, or located in an adequate enclosure outside the building capable of preventing the entrance of snow or rain and resisting maximum wind velocity required by the local building code. Rooms for such equipment shall not be shared with other equipment or electrical service equipment that is not a part of the essential electrical system. [110:5- 2.4]

c) The facility has a natural gas source of fuel without an onsite liquid reserve. Facility does not have a Reliability Letter stating that the fuel source is reliable. NFPA 99 Section 3-4.1.1.13 Fuel Supply -The fuel supply for the generator set shall comply with 3-1.1 and 3-4.2 of NFPA 110. CMS requires the facility to demonstrate the low probability of interruption of the off-site fuel by supplying a letter from the natural gas vendor. After May 29, 2009: CMS required the letter to state the fuel source was reasonably reliable. Natural Gas Generator Reliability Letter :
· 1. A statement of reasonable reliability of the natural gas delivery.
· 2. A brief description that supports the statement regarding the reliability.
· 3. A statement that there is a low probability of interruption of the natural gas.
· 4. A brief description that supports the statement regarding the low probability of interruption.
· 5. The signature of technical personnel from the natural gas vendor

1) Based on observation and interview with staff, the facility failed to maintain Electrical wiring and equipment that is in accordance with NFPA 70, National Electrical Code. 9.1.2. Findings include:

a) Line Isolation Monitor located in ER-1 was not on a monthly inspection program in accordance with NFPA 3-3.3.4.2 (b), the LIM certification commissioning report required after installation was not available in accordance with NFPA 99 1999 edition chapter 3-3.3.4.2 (a)

b) Circuit panel schedule used to identify circuits in the room was removed.

c) All of the Bio Medical Equipment stage and used in the Emergency Room was not tested annually. Stickers dated 4-2014 indicated that they were tested in April of 2014 and required re-testing in April of 2015, however Emergency Rooms are considered a Critical Care area and require testing of equipment on a semi annually basis NFPA 99 1999 edition chapter 7-6.2.1.1.

d) Patient care areas have not had an Impedance Ground Test program NFPA 99 3-3.3.2.1 or Receptacle Testing program in accordance with NFPA 99 3-3.3.3. Record Keeping for these areas are not in accordance with NFPA 99 3-3.4.3

e) Power strips used in ER 1 & ER 2 did not have a Bio Medical Sticker and were not a part of a testing program in accordance with NFPA 99 7-5.1.3.1. The CEO was asked at the entrance conference if any waivers were being used at this time. The governing body has not adopted Power strips use in patient care vicinity. The Centers for Medicare and Medicaid Services (CMS) released a categorical waiver allowing the use of power strips in new and existing healthcare facility patient care rooms, if the provider/supplier is in compliance with all applicable 2012 Life Safety Code (LSC) power strip requirements and with all other 2000 LSC electrical system and equipment provisions.
f) Emergency Receptacles are not marked in ER1 and in the Blood Bank. Receptacles shall be distinctly marked in accordance with NFPA 99 1999, chapter 3.4.2.2.4 (a) 2. The cover plates for electric outlets shall be distinctive in color or marked.