HospitalInspections.org

Based on observations made during the survey of the facility between the hours of 9:00 am and 1:00 pm, while accompanied by the Hospital's CEO it was observed that the facility failed to provide the following requirements:

The "As-Built" RECORD DOCUMENTS - specifically the LIFE SAFETY FLOOR PLAN DRAWING(s) are not maintained to accurately represent current on-site (as-built) conditions. The LIFE SAFETY FLOOR PLAN DRAWING(s) are required to be accurate, current, and up-to-date for the Licensed Hospital Facility's use whether constructing or maintaining COMPLIANCE throughout the Facility for the life of the Facility. This requirement applies whether a facility is being newly constructed, or is undergoing "alterations, additions, conversions, modernizations, or renovations to existing buildings."

HLR, 2007: 133.167 (f)
"(f) Final construction documents. Final construction documents and specifications shall be submitted to the department for review and approval prior to start of construction. All final documents and specifications shall be appropriately sealed and signed by the project registered architect and professional engineer(s) licensed by the state of Texas.

(1) Submission of final construction documents. The hospital owner/operator shall submit to the department for review and approval the items in subsection (b)(1)(A) - (C) of this section (if not previously submitted with preliminary documents) and one set of final construction documents and specifications covering the construction of new buildings or alterations, additions, conversions, modernizations, or renovations to existing buildings.
(2) Preparation of final construction documents. Construction documents shall be well-prepared so that clear and distinct prints may be obtained, shall be accurately and adequately dimensioned, and shall include all necessary explanatory notes, schedules, and legends and shall be adequate for contract purposes. Compliance with model building codes and this chapter shall be indicated. The type of construction, as classified by National Fire Protection Association 220, Standard on Types of Building Construction, 1999 edition, shall be provided for existing and new facilities. Final plans shall be drawn to a sufficiently large-scale to clearly illustrate the proposed design but not less than one-eighth inch equals one foot. All spaces shall be identified by usage (using the names of spaces used in this chapter) on all plans (architectural, fire safety, mechanical, electrical, etc.) submitted. Separate drawings shall be prepared for each of the following branches of work.
(B) Fire safety plans. These drawings shall be provided for all newly constructed buildings, conversions of existing buildings for facilities, additions to existing licensed facilities, and remodeled portions of existing buildings containing licensed facilities. Fire safety plans shall be of a sufficiently large-scale to clearly illustrate the proposed design but not less than one-sixteenth inch equals one foot and shall include the following information:
(i) separate fire safety plans (preferably one floor plan per sheet) shall indicate location of fire protection rated walls and partitions, location and fire resistance rating of each fire damper, and the required means of egress (corridors, stairs, exits, exit passageways);
(I) when a new building is to contain a proposed facility, when an existing building is converted to a facility, or when an addition is made to an existing facility building, plans of each floor and roof shall be provided;
(II) when a portion of a building is remodeled or when a new service is added, only the plan of the floor where the remodeling will take place or new service will be introduced and the plan of the floor of discharge shall be provided;
(ii) designated smoke compartments with floor areas of each compartment, location and fire resistance rating (one or two hour) of each smoke partition, location, type and fire resistance rating of each smoke damper;
(iii) location of all required fire alarm devices, including all fire alarm control panels, manual pull stations, audible and visual fire alarm signaling devices, smoke detectors (ceiling and duct-mounted), fire alarm annunciators, fire alarm transmission devices, fire sprinkler flow switches and control valve supervisory switches on each of the floor plans; and
(iv) areas protected with fire sprinkler systems (pendant, sidewall or upright, normal or quick response, and temperature rating shall be indicated), stand pipe system risers and sizes with valves and inside and outside fire department connections, fire sprinkler risers and sizes, location and type of portable fire extinguishers.

Based on observations made during the survey of the facility between the hours of 9:00 am and 1:00 pm, while accompanied by the Hospital's CEO it was observed that the facility failed to provide the following requirements:

NON-COMPLIANT EMERGENCY GENERATOR "GEN-SET" WHICH INCLUDES BOTH 90-MINUTE BATTERY-BACKUP LIGHTING AND A RECEPTACLE THAT ARE BOTH ELECTRICALLY POWERED BY THE LIFE SAFETY BRANCH. - The Emergency Generator was missing the required Battery Charger for emergency battery-powered lighting units. Also, the existing Receptacle was not RED in color as required to make it distinguishable from "NORMAL" powered receptacles.

NFPA 99, 2012: 6.4.2.2.3.2. The life safety branch shall supply power for the lighting, receptacles, and equipment as follows:
(1) Illumination of means of egress as required in accordance with NFPA 101, Life Safety Code
(2) Exit signs and exit direction signs in accordance with NFPA 101, Life Safety Code
(3) Hospital communication systems where used for issuing instruction during emergency conditions
(4) Generator Set Location as follows:
(a) Task illumination
(b) Battery charger for emergency battery-powered lighting unit(s)
(c) Select receptacles at the generator set location and essential electrical system transfer switch locations

NFPA 99, 2012: 6.5.2.2.4.2 "The electrical receptacles or the cover plates for the electrical receptacles supplied from the life safety and equipment branches shall have a distinctive color or marking so as to readily identifiable."

NFPA 99, 2002: 4.4.2.2.4.2(B) "The electrical receptacles or the cover plates for the electrical receptacles supplied from the emergency system shall have a distinctive color or marking so as to readily identifiable."

Based on observations made during the survey of the facility between the hours of 9:00 am and 1:00 pm, while accompanied by the Hospital's CEO it was observed that the facility failed to provide the following requirements:

MISSING THE AUTOMATIC SHUTOFF (SHUNT) FOR FUEL/POWER SUPPLYING COOKING EQUIPMENT - Kitchen COOKING EQUIPMENT (where hood suppression protection is required) shall be provided with the required automatic shut off for sources of fuel and electrical power.

NFPA 96, 2011, 10.4.1 "Fuel and Electric Power Shutoff. Upon activation of any fire-extinguishing system for a cooking operation, all sources of fuel and electrical power that produce heat to all equipment requiring protection by that system shall automatically shut off."