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Observation and discussion with the Administrator, the Director of Respiratory Therapy and the Director of Maintenance between 9 am and 2:45 pm, on 3/9/2010, revealed that certain requirements stipulated in NFPA 101 were not met.

Interior finish for corridors and exitways, including exposed interior surfaces of buildings such as fixed or movable walls, partitions, columns, and ceilings has a flame spread rating of Class A or Class B. [NFPA 101, Life Safety Code, 2003: ? 19.3.3.1, ? 19.3.3.2.]

Findings: This requirement was discussed and it was determined that the required documentation is not retained by the staff.

Observation and discussion with the Administrator, the Director of Respiratory Therapy and the Director of Maintenance between 9 am and 2:45 pm, on 3/9/2010, revealed that certain requirements stipulated in NFPA 101 were not met.

Interior finish for rooms and spaces not used for corridors or exitways, including exposed interior surfaces of buildings such as fixed or movable walls, partitions, columns, and ceilings has a flame spread rating of Class A or Class B. (In fully-sprinklered buildings, flame spread rating of Class A, Class B, or Class C may be continued in use within rooms separated in accordance with 19.3.6 from the access corridors.) [NFPA 101, Life Safety Code, 2003: ? 19.3.3.1, ? 19.3.3.2.]

Findings: This requirement was discussed and it was determined that the required documentation is not retained by the staff.

Observation and discussion with the Administrator, the Director of Respiratory Therapy and the Director of Maintenance between 9 am and 2:45 pm, on 3/9/2010, revealed that certain requirements stipulated in NFPA 101 were not met.

a. Smoke Passage Resisted

Corridor walls are constructed to resist smoke passage [Re: NFPA 101, Life Safety Code, 2003: ? 19.3.6.1.]

Findings: At the fire separation between the hospital and the clinic, extensive omission of caulking was apparent, thereby jeopardizing the integrity of the corridor. The facility shall affirm that all penetrations have been caulked.

b. Smoke Passage Resisted

Smoke compartments shall be designed to prevent the passage of smoke across the wall [Re: NFPA 101, Life Safety Code, 2003: ? 19.3.6.1.]

Findings: Above the double egress doors near the juncture between the hospital and the clinic, major holes were visible in the rated wall. The facility shall affirm that all these openings have been closed to preserve the integrity of the wall.

c. Roller Latches

Roller latches are prohibited by CMS regulations in all health care facilities [Re: NFPA 101, Life Safety Code, 2003: ? 19.3.6.3.]

Findings: Doors were observed throughout the facility that used roller latches. These are not allowed. The facility shall submit a plan for replacement of all roller latches.

Observation and discussion with the Administrator, the Director of Respiratory Therapy and the Director of Maintenance between 9 am and 2:45 pm, on 3/9/2010, revealed that certain requirements stipulated in NFPA 101 were not met.

Access to exits shall be marked by approved, readily visible signs, in all cases where the exit or way to reach exit is not readily apparent to the occupants [Re: NFPA 101, Life Safety Code, 2003: ? 7.10.1.4.]

Findings: While in the penthouse during the survey, it was noted that there was no exit sign posted. This deficiency should be mitigated.

Observation and discussion with the Administrator, the Director of Respiratory Therapy and the Director of Maintenance between 9 am and 2:45 pm, on 3/9/2010, revealed that certain requirements stipulated in NFPA 101 were not met.

Width of aisles and corridors [clear and unobstructed] serving as exit access shall be at least 4 feet .... [NFPA 101, Life Safety Code, 2003: ? 19.2.3.3.]

Findings: This requirement was discussed and it was noted during the survey that numerous items were stored in the egress corridors longer than 30 minutes, which is a violation of regulations.

Observation and discussion with the Administrator, the Director of Respiratory Therapy and the Director of Maintenance between 9 am and 2:45 pm, on 3/9/2010, revealed that certain requirements stipulated in NFPA 101 were not met.

The facility must maintain a log showing when fire drills are held; time of day in each instance; how initiated; names of staff members participating. [NFPA 101, Life Safety Code, 2003: ? 19.7.1.2.]

Findings: This requirement was discussed and it was determined that this log was not maintained in a current state.

Observation and discussion with the Administrator, the Director of Respiratory Therapy and the Director of Maintenance between 9 am and 2:45 pm, on 3/9/2010, revealed that certain requirements stipulated in NFPA 13 were not met.

A supply of spare sprinklers [never fewer than six] shall be maintained on the premises so that any sprinklers that have operated or been damaged in any way can be promptly replaced. These sprinklers shall correspond to the types and temperature ratings of the sprinklers in the property. The sprinklers shall be kept in a cabinet located where the temperature to which they are subjected will at no time exceed 100 degrees F [Re: NFPA 13, Installation of Sprinkler Systems, 1999: 3-2.9.1.]

Findings: This requirement was discussed and it was determined that no spare sprinklers are retained as required.

Observation and discussion with the Administrator, the Director of Respiratory Therapy and the Director of Maintenance between 9 am and 2:45 pm, on 3/9/2010, revealed that certain requirements stipulated in NFPA 10, NFPA 96, and the regulations enforced by the Department of State Health Services [DSHS] were not met.

a. Class K Extinguisher

Fire Extinguishers provided for the protection of cooking appliances that use combustible cooking media [vegetable or animal oils and fats] shall be listed and labeled for Class K fires. Class K fire extinguishers manufactured after 1 Jan 2002 shall not be equipped with " extended wand-type " discharge devices [Re: NFPA 10, Standard for Portable Fire Extinguishers, 2002; ? 4.3.2]

Findings: This requirement was discussed with the staff and the area was checked. A Class K fire extinguisher was installed, but it was not in view of the deep fry area and it was about 25 ' away. On the other hand, another fire extinguisher [not intended for these fires] was mounted very near the deep fry area. The facility shall replace the existing fire extinguisher with the Class K to provide the needed capability in the event of an emergency.

b. Placard

A placard shall be conspicuously placed near the extinguisher [Class K Fire Extinguishers for Cooking Oil Fires] that states that the fire protection system shall be activated prior to using the fire extinguisher [Re: NFPA 10, Standard for Portable Fire Extinguishers, 2002; ? 4.3.2.2]

Findings: This requirement was discussed with the staff and the area was checked. The required placard was mounted permanently near the Class K fire extinguisher. When the Class K extinguisher is moved pursuant to [a] above, the placard must also be moved. The facility shall ensure that this requirement is met.

c. Staff Toilet

A toilet room(s) with a hand washing fixture(s) with hands free operable controls shall be provided for the exclusive use of the dietary staff. Toilet room(s) shall not open directly into the food preparation areas, but must be in close proximity to them. For larger facilities, a locker room or space for lockers shall be provided for staff belongings [Re: 25 TAC, HLR, 2007: ? 133.163(e)(1)(B)(xiv).]

Findings: This requirement was discussed with the staff and the physical proximity was checked. The toilet rooms that are provided are in the corridor, near an exterior building door, and potentially used by a variety of people. The facility shall post signs at the entrance to these toilet rooms that say, " Dietary Staff Only. "

d. 16 " -18 " Separation

A minimum distance [16 " -18 " ] must be maintained between open flames and deep fry cooking facilities to minimize the potential of grease fires [Re: NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 1998.]

Findings: This requirement was discussed with the staff and the physical proximity was checked. The toilet rooms that are provided are in the corridor, near an exterior building door, and potentially used by a variety of people. The facility shall post signs at the entrance to these toilet rooms that say, " Dietary Staff Only. "

e. Illuminated switch

Exhaust hoods shall have an indicator light indicating that the exhaust fan is in operation [Re: 25 TAC, HLR, 2007: ? 133.163(e)(5)(A).]

Findings: This requirement was discussed with the staff and the existing fan switch was observed. The indicator that once was operational is now dysfunctional. The facility shall ensure that this requirement is met.

Observation and discussion with the Administrator, the Director of Respiratory Therapy and the Director of Maintenance between 9 am and 2:45 pm, on 3/9/2010, revealed that certain requirements stipulated in NFPA 101 were not met.

Draperies, curtains, including cubicle curtains, and other loosely hanging fabrics and films serving as furnishings or decorations in health care occupancies shall be in accordance with 10.3.1. ..... [NFPA 101, Life Safety Code, 2003: ? 10.3.1.]

Findings: This requirement was discussed and it was determined that the required documentation is not retained by the staff.

Observation and discussion with the Administrator, the Director of Respiratory Therapy and the Director of Maintenance between 9 am and 2:45 pm, on 3/9/2010, revealed that certain requirements stipulated in NFPA 99, were not met.

Smoking, open flames, electric heating elements, and other sources of ignition shall be prohibited within storage locations and within 20 ft of outside storage locations [Re: NFPA 99, Health Care Facilities, 2002: ? 9.4.2(I).]

Findings: This requirement prohibits vehicle parking within 20 ft of outside liquid oxygen locations. It was apparent during the survey that this requirement was not observed.

Observation and discussion with the Administrator, the Director of Respiratory Therapy and the Director of Maintenance between 9 am and 2:45 pm, on 3/9/2010, revealed that certain requirements stipulated in NFPA 99, and the regulations enforced by the Department of State Health Services [DSHS] were not met.

a. Use of PVC

Soil Stacks, drains, vents, waste lines, and leaders installed above ground within buildings shall be drain-waste-vent (DWV) weight or heavier and shall be: copper pipe, copper tube, cast iron pipe, or galvanized iron pipe [Re: 25 TAC HLR, 2007: ? 133.162(d)(4)(viii)(A).]

Findings: This requirement does not allow the use of PVC, which is flammable, emits noxious odors and tends to melt and drip on patients. This requirement was discussed after observing several PVC installations in the Dietary Suite.

b. Nurse Call System

The nurse call shall be in accordance with ?133 162(d)(5)(L) and Table 7 of ?133.169(g) of this title [Re: 25 TAC HLR, 2007: 133.163(l)(5)(B).]

Findings: The DSHS regulations require nurse call stations to be installed in patient changing areas. Table 7 as referenced above requires:

(i) Emergency Calling System: Imaging Suite Patient Dressing Rooms; Rehab Therapy Suite; (ii) Staff Emergency Assistance Calling System [Code Blue]:
Imaging Procedure Room; Emergency Department Triage, Trauma, Exam and Treatment Rooms. [Note - the Nurse Call system must be UL1069 compliant and have two way voice capability for Code Blue.]

These were not installed. This requirement was discussed during the inspection. The facility shall ensure that these are installed as required.

c. Preferred Status Letter

When designated by the emergency preparedness management plan to provide continuous service in a disaster or emergency, health care facilities shall establish contingency plans for the continuity of essential building systems, as applicable: (a) * Electricity; (b) Water; (c) Ventilation; (d) Fire protection systems; (e) Fuel sources; (f) Medical gas and vacuum systems (if applicable); (g)* Communication systems. [Re: NFPA 99, Health Care Facilities, 1999: ? 11-5.3.2.] At a minimum, letters of preference for the delivery of water and fuel in the event of an emergency shall be available for review.

Findings: The letter for preferred status for fuel was not available for review.

Main and feeder circuit breakers shall be inspected annually and a program for periodically exercising the components shall be established according to manufacturer ' s recommendations [Re: NFPA 99, Health Care Facilities, 2002: ? 4.4.4.1.2.1.]

Findings: This requirement was discussed with the staff and it was determined that this requirement was not met. A log must be maintained letter for review.

Observation and discussion with the Administrator, the Director of Respiratory Therapy and the Director of Maintenance between 9 am and 2:45 pm, on 3/9/2010, revealed that certain requirements relevant to the required Type I Essential Electrical System in DSHS regulations and NFPA 70, National Electrical Code, 2002, and NFPA 99, Health Care Facilities, 2002, were not met.

a. Type I Essential Electrical System

A Type I essential electrical system shall be provided in each hospital in accordance with requirements of NFPA 99, Health Care Facilities, 2002 edition, NFPA 101, Life Safety Code, 2003 edition, and NFPA 110, Standard for Emergency and Standby Power Systems, 2002 edition [Re: 25 TAC, HLR, 2007: ?133.162(d)(5)(M).]

Findings: During the survey, many of the transfer switches, distribution panels and electrical panelboards were not labeled properly indicating the power source: the emergency system [critical branch and life safety branch] and the equipment branch. This hampered the survey and jeopardized the quality of the survey. The facility shall identify the power source for each transfer switch, distribution panel, panelboard and miscellaneous electrical devices. This is needed for effective facility operations and to support future surveys.

b. Functional Allocation

Specific requirements exist identifying the functions as they must be allocated to the critical branch [NFPA 70, National Electrical Code, 2002, ?517.33], life safety branch [NFPA 70, National Electrical Code, 2002, ?517.32], and the equipment system [NFPA 70, National Electrical Code, 2002, ?517.34].

Findings: During the survey, functions specifically designated for different systems and branches were intermingled on panelboards, etc. Once the power sources are identified as required above, the facility shall ensure that all functions are allocated appropriately to the correct power sources.

c. Equipment Labels

All boxes and enclosures (including transfer switches, transformers, distribution panels, and panelboards) for emergency circuits shall be permanently marked so they will be readily identified as a component of an emergency circuit or system [Re: NFPA 70, National Electrical Code, 2002: 700.9(A).] ' The above listed components shall be labeled with the words " LIFE SAFETY " , " CRITICAL " AND " EQUIPMENT " to be readily identifiable as part of the Essential Electrical System.

Findings: During the survey, it could not be determined which power source was connected to the various panelboards, etc. Once the 2 requirements above have been satisfied, each component must be labeled pursuant to this requirement.

d. Update Circuit Directories

All circuits and circuit modifications shall be legibly identified as to purpose or use on a circuit directory located on the face or inside of the panel door in the case of a panelboard, and at each switch on a switchboard [Re: NFPA 70, National Electrical Code, 2002: ? 408.4.]

Findings: All circuit directories must be updated to me meaningful following the fulfillment of the 1st 2 requirements above.

e. Panelboard Bonding

The equipment grounding terminal buses of the normal and essential branch-circuit panelboards serving the same individual patient vicinity shall be bonded together with an insulated continuous copper conductor not smaller than 10 AWG. Where more than two panels serve the same location, this conductor shall be continuous from panel to panel, but shall be permitted to be broken in order to terminate on the ground bus in each panel [Re: NFPA 70, National Electrical Code, 2002: ? 517.14.] General reminder.

Findings: This topic was discussed during the survey, and it was not possible to determine that this feature was implemented. The facility shall affirm that this safety feature is incorporated into the electrical system.

f. Junction Box Covers

All pull boxes, junction, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use. Where metal covers are used, they shall comply with the grounding requirements of 250.110. An extension from the cover of an exposed box shall comply with 314.22, Exception [Re: NFPA 70, National Electrical Code, 2002: ?314.28[C].]


Findings: While observing installations above the lay in ceiling, a number of junction boxes had no covers and electrical wiring was extending down into the space below the conduit. This is non-compliant and must be mitigated.


g. Patient Bed Receptacles

Each patient bed location shall be supplied by at least two branch circuits, one from the emergency system and one from the normal system. All ranch circuits from the normal system shall originate in the same panelboard [Re: NFPA 70, National Electrical Code, 2002: ? 517.18(A).]

Findings: While observing the patient bed locations, the receptacles at the head of a bed did not reflect the required configuration. All receptacles were not marked, indicating they may be powered by the normal branch. If any were powered by the emergency system, they were not marked as required. The facility shall determine the power source of the receptacles and ensure that they meet the marking requirements.


h. Emergency Powered Lighting in Patient Rooms

Each patient room must have a night light powered by the emergency system, switched at the door, and the toilet room must have some form of illumination powered by the emergency system [Re: 25 TAC, HLR, 2007: 133.163(t)(5)[c](iii).]

Findings: While observing the patient room amenities, it could not be determined if there was a night light, and if the toilet rooms had any lighting powered by the emergency system. The facility shall resolve these issues and ensure that the patient rooms are code compliant.

Observation and discussion with the Administrator, the Director of Respiratory Therapy and the Director of Maintenance between 9 am and 2:45 pm, on 3/9/2010, revealed that certain requirements stipulated in NFPA 101 were not met.

Interior finish for corridors and exitways, including exposed interior surfaces of buildings such as fixed or movable walls, partitions, columns, and ceilings has a flame spread rating of Class A or Class B. [NFPA 101, Life Safety Code, 2003: ? 19.3.3.1, ? 19.3.3.2.]

Findings: This requirement was discussed and it was determined that the required documentation is not retained by the staff.

Observation and discussion with the Administrator, the Director of Respiratory Therapy and the Director of Maintenance between 9 am and 2:45 pm, on 3/9/2010, revealed that certain requirements stipulated in NFPA 101 were not met.

Interior finish for rooms and spaces not used for corridors or exitways, including exposed interior surfaces of buildings such as fixed or movable walls, partitions, columns, and ceilings has a flame spread rating of Class A or Class B. (In fully-sprinklered buildings, flame spread rating of Class A, Class B, or Class C may be continued in use within rooms separated in accordance with 19.3.6 from the access corridors.) [NFPA 101, Life Safety Code, 2003: ? 19.3.3.1, ? 19.3.3.2.]

Findings: This requirement was discussed and it was determined that the required documentation is not retained by the staff.

Observation and discussion with the Administrator, the Director of Respiratory Therapy and the Director of Maintenance between 9 am and 2:45 pm, on 3/9/2010, revealed that certain requirements stipulated in NFPA 101 were not met.

a. Smoke Passage Resisted

Corridor walls are constructed to resist smoke passage [Re: NFPA 101, Life Safety Code, 2003: ? 19.3.6.1.]

Findings: At the fire separation between the hospital and the clinic, extensive omission of caulking was apparent, thereby jeopardizing the integrity of the corridor. The facility shall affirm that all penetrations have been caulked.

b. Smoke Passage Resisted

Smoke compartments shall be designed to prevent the passage of smoke across the wall [Re: NFPA 101, Life Safety Code, 2003: ? 19.3.6.1.]

Findings: Above the double egress doors near the juncture between the hospital and the clinic, major holes were visible in the rated wall. The facility shall affirm that all these openings have been closed to preserve the integrity of the wall.

c. Roller Latches

Roller latches are prohibited by CMS regulations in all health care facilities [Re: NFPA 101, Life Safety Code, 2003: ? 19.3.6.3.]

Findings: Doors were observed throughout the facility that used roller latches. These are not allowed. The facility shall submit a plan for replacement of all roller latches.

Observation and discussion with the Administrator, the Director of Respiratory Therapy and the Director of Maintenance between 9 am and 2:45 pm, on 3/9/2010, revealed that certain requirements stipulated in NFPA 101 were not met.

Access to exits shall be marked by approved, readily visible signs, in all cases where the exit or way to reach exit is not readily apparent to the occupants [Re: NFPA 101, Life Safety Code, 2003: ? 7.10.1.4.]

Findings: While in the penthouse during the survey, it was noted that there was no exit sign posted. This deficiency should be mitigated.

Observation and discussion with the Administrator, the Director of Respiratory Therapy and the Director of Maintenance between 9 am and 2:45 pm, on 3/9/2010, revealed that certain requirements stipulated in NFPA 101 were not met.

Width of aisles and corridors [clear and unobstructed] serving as exit access shall be at least 4 feet .... [NFPA 101, Life Safety Code, 2003: ? 19.2.3.3.]

Findings: This requirement was discussed and it was noted during the survey that numerous items were stored in the egress corridors longer than 30 minutes, which is a violation of regulations.

Observation and discussion with the Administrator, the Director of Respiratory Therapy and the Director of Maintenance between 9 am and 2:45 pm, on 3/9/2010, revealed that certain requirements stipulated in NFPA 101 were not met.

The facility must maintain a log showing when fire drills are held; time of day in each instance; how initiated; names of staff members participating. [NFPA 101, Life Safety Code, 2003: ? 19.7.1.2.]

Findings: This requirement was discussed and it was determined that this log was not maintained in a current state.

Observation and discussion with the Administrator, the Director of Respiratory Therapy and the Director of Maintenance between 9 am and 2:45 pm, on 3/9/2010, revealed that certain requirements stipulated in NFPA 13 were not met.

A supply of spare sprinklers [never fewer than six] shall be maintained on the premises so that any sprinklers that have operated or been damaged in any way can be promptly replaced. These sprinklers shall correspond to the types and temperature ratings of the sprinklers in the property. The sprinklers shall be kept in a cabinet located where the temperature to which they are subjected will at no time exceed 100 degrees F [Re: NFPA 13, Installation of Sprinkler Systems, 1999: 3-2.9.1.]

Findings: This requirement was discussed and it was determined that no spare sprinklers are retained as required.

Observation and discussion with the Administrator, the Director of Respiratory Therapy and the Director of Maintenance between 9 am and 2:45 pm, on 3/9/2010, revealed that certain requirements stipulated in NFPA 10, NFPA 96, and the regulations enforced by the Department of State Health Services [DSHS] were not met.

a. Class K Extinguisher

Fire Extinguishers provided for the protection of cooking appliances that use combustible cooking media [vegetable or animal oils and fats] shall be listed and labeled for Class K fires. Class K fire extinguishers manufactured after 1 Jan 2002 shall not be equipped with " extended wand-type " discharge devices [Re: NFPA 10, Standard for Portable Fire Extinguishers, 2002; ? 4.3.2]

Findings: This requirement was discussed with the staff and the area was checked. A Class K fire extinguisher was installed, but it was not in view of the deep fry area and it was about 25 ' away. On the other hand, another fire extinguisher [not intended for these fires] was mounted very near the deep fry area. The facility shall replace the existing fire extinguisher with the Class K to provide the needed capability in the event of an emergency.

b. Placard

A placard shall be conspicuously placed near the extinguisher [Class K Fire Extinguishers for Cooking Oil Fires] that states that the fire protection system shall be activated prior to using the fire extinguisher [Re: NFPA 10, Standard for Portable Fire Extinguishers, 2002; ? 4.3.2.2]

Findings: This requirement was discussed with the staff and the area was checked. The required placard was mounted permanently near the Class K fire extinguisher. When the Class K extinguisher is moved pursuant to [a] above, the placard must also be moved. The facility shall ensure that this requirement is met.

c. Staff Toilet

A toilet room(s) with a hand washing fixture(s) with hands free operable controls shall be provided for the exclusive use of the dietary staff. Toilet room(s) shall not open directly into the food preparation areas, but must be in close proximity to them. For larger facilities, a locker room or space for lockers shall be provided for staff belongings [Re: 25 TAC, HLR, 2007: ? 133.163(e)(1)(B)(xiv).]

Findings: This requirement was discussed with the staff and the physical proximity was checked. The toilet rooms that are provided are in the corridor, near an exterior building door, and potentially used by a variety of people. The facility shall post signs at the entrance to these toilet rooms that say, " Dietary Staff Only. "

d. 16 " -18 " Separation

A minimum distance [16 " -18 " ] must be maintained between open flames and deep fry cooking facilities to minimize the potential of grease fires [Re: NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 1998.]

Findings: This requirement was discussed with the staff and the physical proximity was checked. The toilet rooms that are provided are in the corridor, near an exterior building door, and potentially used by a variety of people. The facility shall post signs at the entrance to these toilet rooms that say, " Dietary Staff Only. "

e. Illuminated switch

Exhaust hoods shall have an indicator light indicating that the exhaust fan is in operation [Re: 25 TAC, HLR, 2007: ? 133.163(e)(5)(A).]

Findings: This requirement was discussed with the staff and the existing fan switch was observed. The indicator that once was operational is now dysfunctional. The facility shall ensure that this requirement is met.

Observation and discussion with the Administrator, the Director of Respiratory Therapy and the Director of Maintenance between 9 am and 2:45 pm, on 3/9/2010, revealed that certain requirements stipulated in NFPA 101 were not met.

Draperies, curtains, including cubicle curtains, and other loosely hanging fabrics and films serving as furnishings or decorations in health care occupancies shall be in accordance with 10.3.1. ..... [NFPA 101, Life Safety Code, 2003: ? 10.3.1.]

Findings: This requirement was discussed and it was determined that the required documentation is not retained by the staff.

Observation and discussion with the Administrator, the Director of Respiratory Therapy and the Director of Maintenance between 9 am and 2:45 pm, on 3/9/2010, revealed that certain requirements stipulated in NFPA 99, were not met.

Smoking, open flames, electric heating elements, and other sources of ignition shall be prohibited within storage locations and within 20 ft of outside storage locations [Re: NFPA 99, Health Care Facilities, 2002: ? 9.4.2(I).]

Findings: This requirement prohibits vehicle parking within 20 ft of outside liquid oxygen locations. It was apparent during the survey that this requirement was not observed.

Observation and discussion with the Administrator, the Director of Respiratory Therapy and the Director of Maintenance between 9 am and 2:45 pm, on 3/9/2010, revealed that certain requirements stipulated in NFPA 99, and the regulations enforced by the Department of State Health Services [DSHS] were not met.

a. Use of PVC

Soil Stacks, drains, vents, waste lines, and leaders installed above ground within buildings shall be drain-waste-vent (DWV) weight or heavier and shall be: copper pipe, copper tube, cast iron pipe, or galvanized iron pipe [Re: 25 TAC HLR, 2007: ? 133.162(d)(4)(viii)(A).]

Findings: This requirement does not allow the use of PVC, which is flammable, emits noxious odors and tends to melt and drip on patients. This requirement was discussed after observing several PVC installations in the Dietary Suite.

b. Nurse Call System

The nurse call shall be in accordance with ?133 162(d)(5)(L) and Table 7 of ?133.169(g) of this title [Re: 25 TAC HLR, 2007: 133.163(l)(5)(B).]

Findings: The DSHS regulations require nurse call stations to be installed in patient changing areas. Table 7 as referenced above requires:

(i) Emergency Calling System: Imaging Suite Patient Dressing Rooms; Rehab Therapy Suite; (ii) Staff Emergency Assistance Calling System [Code Blue]:
Imaging Procedure Room; Emergency Department Triage, Trauma, Exam and Treatment Rooms. [Note - the Nurse Call system must be UL1069 compliant and have two way voice capability for Code Blue.]

These were not installed. This requirement was discussed during the inspection. The facility shall ensure that these are installed as required.

c. Preferred Status Letter

When designated by the emergency preparedness management plan to provide continuous service in a disaster or emergency, health care facilities shall establish contingency plans for the continuity of essential building systems, as applicable: (a) * Electricity; (b) Water; (c) Ventilation; (d) Fire protection systems; (e) Fuel sources; (f) Medical gas and vacuum systems (if applicable); (g)* Communication systems. [Re: NFPA 99, Health Care Facilities, 1999: ? 11-5.3.2.] At a minimum, letters of preference for the delivery of water and fuel in the event of an emergency shall be available for review.

Findings: The letter for preferred status for fuel was not available for review.

Main and feeder circuit breakers shall be inspected annually and a program for periodically exercising the components shall be established according to manufacturer ' s recommendations [Re: NFPA 99, Health Care Facilities, 2002: ? 4.4.4.1.2.1.]

Findings: This requirement was discussed with the staff and it was determined that this requirement was not met. A log must be maintained letter for review.

Observation and discussion with the Administrator, the Director of Respiratory Therapy and the Director of Maintenance between 9 am and 2:45 pm, on 3/9/2010, revealed that certain requirements relevant to the required Type I Essential Electrical System in DSHS regulations and NFPA 70, National Electrical Code, 2002, and NFPA 99, Health Care Facilities, 2002, were not met.

a. Type I Essential Electrical System

A Type I essential electrical system shall be provided in each hospital in accordance with requirements of NFPA 99, Health Care Facilities, 2002 edition, NFPA 101, Life Safety Code, 2003 edition, and NFPA 110, Standard for Emergency and Standby Power Systems, 2002 edition [Re: 25 TAC, HLR, 2007: ?133.162(d)(5)(M).]

Findings: During the survey, many of the transfer switches, distribution panels and electrical panelboards were not labeled properly indicating the power source: the emergency system [critical branch and life safety branch] and the equipment branch. This hampered the survey and jeopardized the quality of the survey. The facility shall identify the power source for each transfer switch, distribution panel, panelboard and miscellaneous electrical devices. This is needed for effective facility operations and to support future surveys.

b. Functional Allocation

Specific requirements exist identifying the functions as they must be allocated to the critical branch [NFPA 70, National Electrical Code, 2002, ?517.33], life safety branch [NFPA 70, National Electrical Code, 2002, ?517.32], and the equipment system [NFPA 70, National Electrical Code, 2002, ?517.34].

Findings: During the survey, functions specifically designated for different systems and branches were intermingled on panelboards, etc. Once the power sources are identified as required above, the facility shall ensure that all functions are allocated appropriately to the correct power sources.

c. Equipment Labels

All boxes and enclosures (including transfer switches, transformers, distribution panels, and panelboards) for emergency circuits shall be permanently marked so they will be readily identified as a component of an emergency circuit or system [Re: NFPA 70, National Electrical Code, 2002: 700.9(A).] ' The above listed components shall be labeled with the words " LIFE SAFETY " , " CRITICAL " AND " EQUIPMENT " to be readily identifiable as part of the Essential Electrical System.

Findings: During the survey, it could not be determined which power source was connected to the various panelboards, etc. Once the 2 requirements above have been satisfied, each component must be labeled pursuant to this requirement.

d. Update Circuit Directories

All circuits and circuit modifications shall be legibly identified as to purpose or use on a circuit directory located on the face or inside of the panel door in the case of a panelboard, and at each switch on a switchboard [Re: NFPA 70, National Electrical Code, 2002: ? 408.4.]

Findings: All circuit directories must be updated to me meaningful following the fulfillment of the 1st 2 requirements above.

e. Panelboard Bonding

The equipment grounding terminal buses of the normal and essential branch-circuit panelboards serving the same individual patient vicinity shall be bonded together with an insulated continuous copper conductor not smaller than 10 AWG. Where more than two panels serve the same location, this conductor shall be continuous from panel to panel, but shall be permitted to be broken in order to terminate on the ground bus in each panel [Re: NFPA 70, National Electrical Code, 2002: ? 517.14.] General reminder.

Findings: This topic was discussed during the survey, and it was not possible to determine that this feature was implemented. The facility shall affirm that this safety feature is incorporated into the electrical system.

f. Junction Box Covers

All pull boxes, junction, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use. Where metal covers are used, they shall comply with the grounding requirements of 250.110. An extension from the cover of an exposed box shall comply with 314.22, Exception [Re: NFPA 70, National Electrical Code, 2002: ?314.28[C].]


Findings: While observing installations above the lay in ceiling, a number of junction boxes had no covers and electrical wiring was extending down into the space below the conduit. This is non-compliant and must be mitigated.


g. Patient Bed Receptacles

Each patient bed location shall be supplied by at least two branch circuits, one from the emergency system and one from the normal system. All ranch circuits from the normal system shall originate in the same panelboard [Re: NFPA 70, National Electrical Code, 2002: ? 517.18(A).]

Findings: While observing the patient bed locations, the receptacles at the head of a bed did not reflect the required configuration. All receptacles were not marked, indicating they may be powered by the normal branch. If any were powered by the emergency system, they were not marked as required. The facility shall determine the power source of the receptacles and ensure that they meet the marking requirements.


h. Emergency Powered Lighting in Patient Rooms

Each patient room must have a night light powered by the emergency system, switched at the door, and the toilet room must have some form of illumination powered by the emergency system [Re: 25 TAC, HLR, 2007: 133.163(t)(5)[c](iii).]

Findings: While observing the patient room amenities, it could not be determined if there was a night light, and if the toilet rooms had any lighting powered by the emergency system. The facility shall resolve these issues and ensure that the patient rooms are code compliant.