HospitalInspections.org

K901 Fundamentals - Building System Categories
Findings:
The inspector observed, while accompanied by the COO, CNO and Operations Manager, during the hours of the inspection from 1:30 pm to 7:00 pm on 05/16/2023, that there were the following issues:
1) Based on review of the records, facility failed to perform risk assessment for the year 2022. As noted in the hazard vulnerability analysis (HVA), "the HVA tool is a living document. As they occur throughout the calendar year, incidents that align with the "Alert Type" on the HVA should be cataloged."

K907 Gas and Vacuum Piped Systems - Maintenance Program
Findings:
The inspector observed, while accompanied by the COO, CNO and Operations Manager, during the hours of the inspection from 1:30 pm to 7:00 pm on 05/16/2023, that there were the following issues:
1) Observed during tour in mechanical room, there was dissimilar metal contact with medical gas piping. [The Standard] Where the pipeline and the MGR assembly are of dissimilar metals, the connections shall be plated or otherwise protected from interaction between the metals. - - NFPA 99, 2012: 5.1.7.9*

K911 Electrical Systems - Others
Findings:
The inspector observed, while accompanied by the COO, CNO and Operations Manager, during the hours of the inspection from 1:30 pm to 7:00 pm on 05/16/2023, that there were the following issues:
1) Observed in during tour in electrical room, there was storage of combustible material near the electrical panels which present a fire hazard and reduced the clear working space. [The Standard] 110.26 Spaces About Electrical Equipment. Access and working space shall be provided and maintained about all electrical equipment to permit ready and safe operation and maintenance of such equipment. (NFPA 70, 2011).

K918 Electrical Systems - Essential Electric System Maintenance and Testing
Findings:
The inspector observed, while accompanied by the COO, CNO and Operations Manager, during the hours of the inspection from 1:30 pm to 7:00 pm on 05/16/2023, that there were the following issues:
1) Observed during tour at the generator location, the "individual unit equipment for emergency illumination" was not working. [The Standard] Battery-Powered Lighting Units. Individual unit equipment for backup illumination consisting of the following:
(1) Rechargeable battery;
(2) Battery-charging means;
(3) Provisions for one or more lamps mounted on the equipment, or with terminals for remote lamps, or both;
(4) Relaying device arranged to energize the lamps automatically upon failure of the supply to the unit equipment.