HospitalInspections.org

42 CFR 483.70(a)
Based on observations, on January 23, 2013 at approximately 9:30am onward, the following building construction type was non-compliant, specific findings include; ceiling light fixtures were not boxed in.(west side only)

42 CFR 483.70(a)
Based on observations, on January 23, 2013 at approximately 9:30am onward, the following corridor doors were non-compliant, specific findings include;
A. Corridor doors without positive latching. (The back of the doctors area across from room 121.)
B. Holes in the door where the lock set had been changed out. (Throughout the facility)

42 CFR 483.70(a)
Based on observations, on January 23, 2013 at approximately 9:30am onward, the following smoke barrier was non-compliant, specific findings include; the one hour smoke barrier is incomplete. Barrier doesn't extend from outside wall to outside wall, and from floor to underside of floor slab above. (Back hall smoke wall)

42 CFR 483.70(a)
Based on observations, on January 23, 2013 at approximately 9:30am onward, the following hazardous areas were non-compliant, specific findings include;
A. Door not self closing with a UL listed closure. (The storage room/soiled linen room across from room 119.)
B. The kitchen storage was not one hour separated or sprinklered.
C. High hazardous areas require both one hour separation and sprinklers. The boiler area was not sprinklered nor was the door to the room labeled with a 3/4 hour, C-labeled, door.

42 CFR 483.70(a)
Based on observations, on January 23, 2013 at approximately 9:30am onward, the following exit access was non-compliant, specific findings include;
A. There were several doors that required more than one range of motion to exit the area. (Men and Women's restroom, room 119 and throughout)
B. There were several doors that the occupant could be locked inside the room.(Room 118, ASC directors office and throughout). This item was corrected.
C. The exit from the main corridor leading down the corridor of ER/radiology had magnetic devices on the access doors, that did not meet access control doors per 7.2.1.6.2 (This item was corrected)
D. There must be two means of egress available at all times. Exit from the ER/radiology corridor to the main corridor was not accessible during evening hours. (This item was corrected, the magnetic device was removed from the door)

42 CFR 483.70(a)
Based on observations, on January 23, 2013 at approximately 9:30am onward, the following Illumination of means of egress was non-compliant, specific findings include; a single bulb fixture at the NW corner exit near the helipad. Lighting must be arranged to provide light from the exit discharge leading to the public way (parking lot). The walking surfaces within the exit discharge shall be illuminated to values of at least 1 ft-candle measured at the floor. Failure of any single lighting unit does not result in an illumination level of less than 0.2 ft-candles in any designated area. NFPA 101 7.8.1.1, 7.8.1.3, and 7.8.1.4.

42 CFR 483.70(a)
Based on observations, on January 23, 2013 at approximately 9:30am onward, the following exit and directional signs was non-compliant, specific findings include; lack of exit signage leaving outpatient services and throughout. (facility currently identifying suites)

42 CFR 483.70(a)
Based on observations, on January 23, 2013 at approximately 9:30am onward, the following fire alarm system and it's components was non-compliant, specific findings include;
A. Horns and strobes should be provided per NFPA 72.
B. Smoke detectors should be provided per NFPA 72.
C. The visual/audible trouble signal at the Fire Alarm Control Panel (FACP) did not give a visual/audible trouble signal at a area where it was likely to be seen or heard with: loss of telephone line connection, loss of AC power, loss of battery back-up, sprinkler tamper per 9.6.3.1 and 9.7.2.1.

42 CFR 483.70(a)
Based on observations, on January 23, 2013 at approximately 9:30am onward, the following fire alarm system was non-compliant, specific findings include;
A. During testing of the facility fire alarm system the alarm was initiated and the audible alarms were silenced, the fire/smoke doors hold open devices were re-energized with the fire alarm control panel (FACP) in active alarm.
B. Facility documents were not available for smoke detector sensitivity inspections.

42 CFR 483.70(a)
Based on observations, on January 23, 2013 at approximately 9:30am onward, the following automatic sprinkler system was non-compliant, specific findings include;
A. Documentation for the five year obstruction test was not available.
B. The sprinkler system was tested in November 2012 and August 2012. Quarterly testing per NFPA 25 Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems (1999 edition) had not being completed.

42 CFR 483.70(a)
Based on observations, on January 23, 2013 at approximately 9:30am onward, the following Heating, Ventilating, and Air Conditioning system (HVAC) was non-compliant, specific findings include;
A. The HVAC system did not shut down with fire alarm activation.
B. There was not an emergency shut down switch located at a readily observed station. (All HVAC units)
C. The smoke evacuation system for the operating room area could not be tested or confirmed.
D. There was not documentation to indicate that the fire/smoke dampers had been inspected and tested within the past 6 years.

42 CFR 483.70(a)
Based on observations, on January 23, 2013 at approximately 9:30am onward, the following kitchen hood system was non-compliant, specific findings include; documentation from 9/25/12 indicated system due hydro test.

42 CFR 483.70(a)
Based on observations, on January 23, 2013 at approximately 9:30am onward, the following means of egress was non-compliant, specific findings include; corridor door to electrical equipment room across from room 147 swings into the corridor without a listed closure and the door does not swing 180 degrees but leaves a projection of approximately 18" into the corridor. NFPA 7.2.1.4.4 states during its swing, any door in a means of egress shall leave not less than one-half of the required width of an aisle, corridor, or landing unobstructed and shall not project more than 7 in. (17.8 cm) into the required width of an aisle, corridor, passageway, or landing, when fully open.

42 CFR 483.70(a)
Based on observations, on January 23, 2013 at approximately 9:30am onward, the following medical gas storage was non-compliant, specific findings include;
A. The outside oxygen cylinders were stored directly on the ground and will need to be protected from inclement weather. (outside tank farm)
B. Nitrous Oxide cylinders were gang chained together. Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation. [NFPA 99 4-3.1.1.2 a(3)] There was not any signage on the oxygen tank storage indicating full or empty. Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed hurriedly. [NFPA 99 4-3.5.2.2b(2)] (oxygen storage near the morgue)

42 CFR 483.70(a)
Based on observations, on January 23, 2013 at approximately 9:30am onward, the following relative humidity was non-compliant, specific findings include; percent relative humidity was not controled per NFPA 99.

42 CFR 483.70(a)
Based on observations, on January 23, 2013 at approximately 9:30am onward, the following master alarm was non-compliant, specific findings include; master O2 alarm was last tested on 4/20/2012 and could not be tested during the survey.

42 CFR 483.70(a)
Based on observations, on January 23, 2013 at approximately 9:30am onward, the following exit access was non-compliant, specific findings include;
A. Documentation for monthly load test was conducted without recording percent rated load or temperature rise. A load bank test had not been completed within the past year.
B. Documentation for weekly generator inspections was not available.

NFPA 99 3-4.4.2 Record keeping. A written record of inspection, performance, exercising period, and repairs shall be regularly maintained and available for inspection by the authority having jurisdiction.
NFPA 110 6-4.2 (1999 edition) generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer.
NFPA 110 6-4.2.2 (1999 edition) Diesel-powered EPS installations that do not meet the requirements of 6-4.2 shall be exercised monthly with the available EPPS load and exercised annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of 2 continuous hours. (load bank testing)

42 CFR 483.70(a)
Based on observations, on January 23, 2013 at approximately 9:30am onward, the following electrical item was non-compliant, specific findings include; the electrical outlets in the operating room did not have a redundant ground per NFPA 70.

42 CFR 483.70(a)
Based on observations, on January 23, 2013 at approximately 9:30am onward, the following building construction type was non-compliant, specific findings include; ceiling light fixtures were not boxed in.(west side only)

42 CFR 483.70(a)
Based on observations, on January 23, 2013 at approximately 9:30am onward, the following corridor doors were non-compliant, specific findings include;
A. Corridor doors without positive latching. (The back of the doctors area across from room 121.)
B. Holes in the door where the lock set had been changed out. (Throughout the facility)

42 CFR 483.70(a)
Based on observations, on January 23, 2013 at approximately 9:30am onward, the following smoke barrier was non-compliant, specific findings include; the one hour smoke barrier is incomplete. Barrier doesn't extend from outside wall to outside wall, and from floor to underside of floor slab above. (Back hall smoke wall)

42 CFR 483.70(a)
Based on observations, on January 23, 2013 at approximately 9:30am onward, the following hazardous areas were non-compliant, specific findings include;
A. Door not self closing with a UL listed closure. (The storage room/soiled linen room across from room 119.)
B. The kitchen storage was not one hour separated or sprinklered.
C. High hazardous areas require both one hour separation and sprinklers. The boiler area was not sprinklered nor was the door to the room labeled with a 3/4 hour, C-labeled, door.

42 CFR 483.70(a)
Based on observations, on January 23, 2013 at approximately 9:30am onward, the following exit access was non-compliant, specific findings include;
A. There were several doors that required more than one range of motion to exit the area. (Men and Women's restroom, room 119 and throughout)
B. There were several doors that the occupant could be locked inside the room.(Room 118, ASC directors office and throughout). This item was corrected.
C. The exit from the main corridor leading down the corridor of ER/radiology had magnetic devices on the access doors, that did not meet access control doors per 7.2.1.6.2 (This item was corrected)
D. There must be two means of egress available at all times. Exit from the ER/radiology corridor to the main corridor was not accessible during evening hours. (This item was corrected, the magnetic device was removed from the door)

42 CFR 483.70(a)
Based on observations, on January 23, 2013 at approximately 9:30am onward, the following Illumination of means of egress was non-compliant, specific findings include; a single bulb fixture at the NW corner exit near the helipad. Lighting must be arranged to provide light from the exit discharge leading to the public way (parking lot). The walking surfaces within the exit discharge shall be illuminated to values of at least 1 ft-candle measured at the floor. Failure of any single lighting unit does not result in an illumination level of less than 0.2 ft-candles in any designated area. NFPA 101 7.8.1.1, 7.8.1.3, and 7.8.1.4.

42 CFR 483.70(a)
Based on observations, on January 23, 2013 at approximately 9:30am onward, the following exit and directional signs was non-compliant, specific findings include; lack of exit signage leaving outpatient services and throughout. (facility currently identifying suites)

42 CFR 483.70(a)
Based on observations, on January 23, 2013 at approximately 9:30am onward, the following fire alarm system and it's components was non-compliant, specific findings include;
A. Horns and strobes should be provided per NFPA 72.
B. Smoke detectors should be provided per NFPA 72.
C. The visual/audible trouble signal at the Fire Alarm Control Panel (FACP) did not give a visual/audible trouble signal at a area where it was likely to be seen or heard with: loss of telephone line connection, loss of AC power, loss of battery back-up, sprinkler tamper per 9.6.3.1 and 9.7.2.1.

42 CFR 483.70(a)
Based on observations, on January 23, 2013 at approximately 9:30am onward, the following fire alarm system was non-compliant, specific findings include;
A. During testing of the facility fire alarm system the alarm was initiated and the audible alarms were silenced, the fire/smoke doors hold open devices were re-energized with the fire alarm control panel (FACP) in active alarm.
B. Facility documents were not available for smoke detector sensitivity inspections.

42 CFR 483.70(a)
Based on observations, on January 23, 2013 at approximately 9:30am onward, the following automatic sprinkler system was non-compliant, specific findings include;
A. Documentation for the five year obstruction test was not available.
B. The sprinkler system was tested in November 2012 and August 2012. Quarterly testing per NFPA 25 Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems (1999 edition) had not being completed.

42 CFR 483.70(a)
Based on observations, on January 23, 2013 at approximately 9:30am onward, the following Heating, Ventilating, and Air Conditioning system (HVAC) was non-compliant, specific findings include;
A. The HVAC system did not shut down with fire alarm activation.
B. There was not an emergency shut down switch located at a readily observed station. (All HVAC units)
C. The smoke evacuation system for the operating room area could not be tested or confirmed.
D. There was not documentation to indicate that the fire/smoke dampers had been inspected and tested within the past 6 years.

42 CFR 483.70(a)
Based on observations, on January 23, 2013 at approximately 9:30am onward, the following kitchen hood system was non-compliant, specific findings include; documentation from 9/25/12 indicated system due hydro test.

42 CFR 483.70(a)
Based on observations, on January 23, 2013 at approximately 9:30am onward, the following means of egress was non-compliant, specific findings include; corridor door to electrical equipment room across from room 147 swings into the corridor without a listed closure and the door does not swing 180 degrees but leaves a projection of approximately 18" into the corridor. NFPA 7.2.1.4.4 states during its swing, any door in a means of egress shall leave not less than one-half of the required width of an aisle, corridor, or landing unobstructed and shall not project more than 7 in. (17.8 cm) into the required width of an aisle, corridor, passageway, or landing, when fully open.

42 CFR 483.70(a)
Based on observations, on January 23, 2013 at approximately 9:30am onward, the following medical gas storage was non-compliant, specific findings include;
A. The outside oxygen cylinders were stored directly on the ground and will need to be protected from inclement weather. (outside tank farm)
B. Nitrous Oxide cylinders were gang chained together. Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation. [NFPA 99 4-3.1.1.2 a(3)] There was not any signage on the oxygen tank storage indicating full or empty. Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed hurriedly. [NFPA 99 4-3.5.2.2b(2)] (oxygen storage near the morgue)

42 CFR 483.70(a)
Based on observations, on January 23, 2013 at approximately 9:30am onward, the following relative humidity was non-compliant, specific findings include; percent relative humidity was not controled per NFPA 99.

42 CFR 483.70(a)
Based on observations, on January 23, 2013 at approximately 9:30am onward, the following master alarm was non-compliant, specific findings include; master O2 alarm was last tested on 4/20/2012 and could not be tested during the survey.

42 CFR 483.70(a)
Based on observations, on January 23, 2013 at approximately 9:30am onward, the following exit access was non-compliant, specific findings include;
A. Documentation for monthly load test was conducted without recording percent rated load or temperature rise. A load bank test had not been completed within the past year.
B. Documentation for weekly generator inspections was not available.

NFPA 99 3-4.4.2 Record keeping. A written record of inspection, performance, exercising period, and repairs shall be regularly maintained and available for inspection by the authority having jurisdiction.
NFPA 110 6-4.2 (1999 edition) generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer.
NFPA 110 6-4.2.2 (1999 edition) Diesel-powered EPS installations that do not meet the requirements of 6-4.2 shall be exercised monthly with the available EPPS load and exercised annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of 2 continuous hours. (load bank testing)

42 CFR 483.70(a)
Based on observations, on January 23, 2013 at approximately 9:30am onward, the following electrical item was non-compliant, specific findings include; the electrical outlets in the operating room did not have a redundant ground per NFPA 70.