HospitalInspections.org

K200 Inspection of Doors in Means of Egress
Findings:
The inspector observed, while accompanied by the Plant Operation Director, during the hours of the inspection from 12:00 PM to 3:00 PM on 06/19/19, that there were the following issues:
1) Based on staff interview, the facility has not yet implemented inspection of doors in means of egress as of this survey date (6/19/19). Please note the Centers for Medicare & Medicaid Services adopted the 2012 edition of NFPA 99 & 101 became effective as of July 5, 2016.

K364- Corridor - Openings
Findings:
The inspector observed, while accompanied by the Plant Operation Director, during the hours of the inspection from 12:00 PM to 3:00 PM on 06/19/19, that there were the following issues:
1) Based on observation, the were many doors in corridor that had air transfer grilles. Please note, "transfer grilles are not used in corridor walls or doors."

K500 Building Services - Other
Findings:
The inspector observed, while accompanied by the Plant Operation Director, during the hours of the inspection from 12:00 PM to 3:00 PM on 06/19/19, that there were the following issues:
1) Based on observation, the facility failed to implement Plan of Correction for K-tag No. 067 as cited on 07/21/2015, which now fall under K-tag No. 500 Building Services. The storage room that had been converted to janitor closet still was missing air exhaust option.

K712 Fire Drills
Findings:
The inspector observed, while accompanied by the Plant Operation Director, during the hours of the inspection from 12:00 PM to 3:00 PM on 06/19/19, that there were the following issues:
1) Based on record review, the facility failed to conduct fire drill in the second, third, and fourth quarter of 2018.

K901 Risk Assessment
Findings:
The inspector observed, while accompanied by the Plant Operation Director, during the hours of the inspection from 12:00 PM to 3:00 PM on 06/19/19, that there were the following issues:
1) Based on staff interview, the facility failed to have a formal and documented risk assessment procedure performed by qualified personnel. There is no record of a risk assessment ever being performed.

K911- Electrical Systems - Other
Findings:
The inspector observed, while accompanied by the Plant Operation Director, during the hours of the inspection from 12:00 PM to 3:00 PM on 06/19/19, that there were the following issues:
1) Based on observation, the facility failed to implement Plan of Correction for K-tag No. 147 as cited on 07/21/2015, which now fall under K-tag No. 911 Electrical Systems. The two electrical panels were still not locked to prevent unauthorized personnel from tampering.

K914 Maintenance and Testing
Findings:
The inspector observed, while accompanied by the Plant Operation Director, during the hours of the inspection from 12:00 PM to 3:00 PM on 06/19/19, that there were the following issues:
1) Based on record review, the facility failed to perform receptacle maintenance and testing for the current year (2019) and the prior two years (2018 & 2017). Receptacles at patient care areas, both red and white colors require testing performed at intervals defined by documented performance data and testing records maintained such that it is readily available for review by authority having jurisdiction. Please note NFPA 99-2012, section 6.3.3.2 lists the minimum requirements for receptacle testing regardless of hospital-grade or not.

K918 Electrical Systems - Essential Electric System Maintenance and Testing
Findings:
The inspector observed, while accompanied by the Plant Operation Director, during the hours of the inspection from 12:00 PM to 3:00 PM on 06/19/19, that there were the following issues:
1) Based on staff interview and record review, the facility failed to conduct weekly inspection of the generator and related components of the essential electrical system.