HospitalInspections.org

Door Inspections:

Fire-rated door assemblies and certain other doors in the means of egress shall be tested annually or per an accepted performance-based evaluation schedule approved by the AHJ per NFPA 80, 2010, Ch. 5.2. A written record of the inspections and testing shall be signed and kept for inspection by the AHJ. NFPA;101, 7.2.1.15.

Based on observation the facility failed to maintain properly all the doors along the means of egress.

The inspector observed, while accompanied by the Chief Operating Officer (CEO) and Maintenance Officer during the hours of the inspection from 9:00 am to 12:00 pm on 4/03/2019 that the facility had not performed the required inspection of all the doors along the means of egress to ascertain their level of functionality as required by the code.

Manual Fire Pull Station or Box:

"A manual fire alarm box shall be provided as follows, unless modified by another section of the Code. (1) For new alarm system installations, the manual fire alarm box shall be located with 60 in. of the exit doorways. (2) For existing alarm system installations, the manual fire alarm box either shall be provided in the natural exit access path near each required exit or within 60 in. of exit doorways." - NFPA 101, 2012, 9.6.2.3

Based on observation the facility failed to provide adequate fire protection.

The inspector observed, while accompanied by the Chief Operating Officer (CEO) and Maintenance officer during the hours of the inspection from 9:00 am to 12:00 pm on 4/03/2019 that the manual fire pull box was more than 5 ft. from the door.

Tennant Separation Walls
"Health care facilities shall be separated from other tenants and occupancies and shall meet all of the following requirements:
(1) Walls shall have not less than a 1-hours fire resistance rating and shall extend from the floor slab below to the floor or roof
slab above.
(2) Doors shall be constructed of not less than 1 ¾ inch, solid-bonded wood core or the equivalent and shall be equipped with
positive latches.
(3) Doors shall be self-closing and shall be kept in the closed position, except when in use.
(4) Any windows in the barriers shall be of fixed fire window assemblies in accordance with Section 8.3." - NFPA 101, 2012,
21.3.7.1.
"Openings required to have a fire protection rating by Table 8.3.4.2 shall be protected by approved, listed, labeled fire door assemblies and fire window assemblies and their accompanying hardware, including all frames, closing devices, anchorage, and sills in accordance with the requirements of NFPA 80, Standard for Fire Doors and Other Opening Protectives, except as otherwise specified in this Code." - NFPA 101, 2012, 8.3.3.1.

Based on observation the facility failed to provide adequate fire separation.

The inspector observed, while accompanied by the Chief Operating Officer (CEO) and Maintenance officer during the hours of the inspection from 9:00 am to 12:00 pm on 4/03/2019 that the double egress door by the Nurse's station was not rated including view panel glass. It shall be at least 45 minutes rated.


SEPARATED OCCUPANCIES NFPA 101, 2012; 6.1.14.4:

6.1.14.4.1? Where separated occupancies are provided, each part of the building comprising a distinct occupancy, as described in this chapter, shall be completely separated from other occupancies by fire-resistive assemblies, as specified in 6.1.14.4.2, 6.1.14.4.3, Table 6.1.14.4.1(a), and Table 6.1.14.4.1(b), unless separation is provided by approved existing separations.

Based on observation the facility failed to provide adequate fire separation.

The inspector observed, while accompanied by the Chief Operating Officer (CEO) and Maintenance officer during the hours of the inspection from 9:00 am to 12:00 pm on 4/03/2019 that the separation between the hospital and the clinic, the double egress door was not rated. Including the view panel. It shall be at 90 minutes rated.

Signage (System Identification and Labeling):

Containers, cylinders and tanks are designed, fabricated, tested, and marked in accordance with 5.1.3.1.1 through 5.1.3.1.7. Locations containing only oxygen or medical air have doors labeled with "Medical Gases, NO Smoking or Open Flame". Locations containing other gases have doors labeled "Positive Pressure Gases, NO Smoking or Open Flame, Room May Have Insufficient Oxygen, Open Door and Allow Room to Ventilate Before Opening." 5.1.3.1, 5.2.3.1, 5.3.10 (NFPA 99)

Based on observation the facility failed to provide adequate signage at medical gas room.

The inspector observed, while accompanied by the Chief Operating Officer (CEO) and Maintenance officer during the hours of the inspection from 9:00 am to 12:00 pm on 4/03/2019 that the signage at entrance to medical gas room was inadequate as it had no warning about Open Flame and No Smoking signs.


Medical Gas Piping Labels:

"Pipe labels shall be located as follows: (1) at intervals of not more than 20 ft., (2) at least once in or above every room, (3) on both sides of walls or partitions penetrated by the piping, and (4) at least once in every story height traversed by risers." - NFPA 99, 2012, 5.1.11.1.2.

Based on observation the facility failed to provide adequate labeling of medical gas piping.

The inspector observed, while accompanied by the Chief Operating Officer (CEO) and Maintenance officer during the hours of the inspection from 9:00 am to 12:00 pm on 4/03/2019 that the medical gas piping above in the mechanical room had no labels.


Securing of the Medical Gas Cylinders:

"Design and Construction. Locations for central supply systems and the storage of positive-pressure gases shall meet the following requirements: (7) They shall be provided with racks, chains, or other fastening to secure all cylinders from falling, whether connected, unconnected, full, or empty." - NFPA 99, 2012: 5.1.3.3.2

Based on observation the facility failed to provide adequate method for securing medical gas cylinders.

The inspector observed, while accompanied by the Chief Operating Officer (CEO) and Maintenance officer during the hours of the inspection from 9:00 am to 12:00 pm on 4/03/2019 that the medical gas cylinder (medium sized bottles) were on special stands but still were not secured with chains to prevent falling over. The big cylinders were also not chained.


Design and Construction:

NFPA, 99: 2012: 5.1.3.3.2*- Locations for central supply systems and the storage of positive-pressure gases shall meet the following requirements:

(1) They shall be constructed with access to move cylinders, equipment, and so forth, in and out of the location on hand trucks
complying with 11.4.3.1.1.
(2) They shall be secured with lockable doors or gates or otherwise secured.
(3) If outdoors, they shall be provided with an enclosure (wall or fencing) constructed of noncombustible materials with a minimum
of two entries/exits.

Based on observation the facility failed to provide adequate medical gas storage location.

The inspector observed, while accompanied by the Chief Operating Officer (CEO) and Maintenance officer during the hours of the inspection from 9:00 am to 12:00 pm on 4/03/2019 that there were the following issues. They were:

1. Medical gas house had no locks. It had no gates or doors nothing to be used to secure the area.
2. Medical gas house did not have two entries/exits.

Cross referencing and marking FACP:

"The location of the dedicated branch circuit disconnecting means shall be permanently identified at the control unit." - NFPA 72, 2010, 10.5.5.2.1.

"For fire alarm systems the circuit disconnecting means shall have a red marking." - NFPA 72, 2010, 10.5.5.2.3.

Based on observation the facility failed to provide adequate cross referencing of the FACP to the panel and breaker supplying power to the FACP.

The inspector observed, while accompanied by the Chief Operating Officer (CEO) and Maintenance officer during the hours of the inspection from 9:00 am to 12:00 pm on 4/03/2019 that the location of the dedicated branch circuit for disconnecting the FACP was not clearly identified at the control unit. In addition, the breaker supplying power to the FACP was not colored red.


Essential Electrical System Segregation (Life Safety):

"The essential electrical system shall be divided into the following three branches: (1) Life safety, (2) Critical, (3) Equipment." NFPA 99, 2012, 6.4.2.2.1.1.

6.4.2.2.3 Life Safety Branch.
6.4.2.2.3.1 The life safety branch shall be limited to circuits essential to life safety.

6.4.2.2.3.2 "The life safety branch shall supply power for lighting, receptacles, and equipment as follows:
(1) Illumination of means of egress in accordance with 101, Life Safety Code,
(2) Exit signs and exit directional signs in accordance with NFPA 101, Life Safety Code,
(3) Hospital communications systems, where used for issuing instruction during emergency conditions,
(4) Generator set locations 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,
(5) Elevator cab lighting, control, communications, and signal systems,
(6) Electrically powered doors used for building egress,
(7) Fire alarms and auxiliary functions of fire alarm combination systems complying with NFPA 72, National Fire Alarm and
Signaling Code."

6.4.2.2.3.3 "Alarm and alerting systems (other than fire alarm systems) shall be connected to the life safety branch or critical branch."

6.4.2.2.3.4 "Loads dedicated to a specific generator, including the fuel transfer pump(s), ventilation fans, electrically operated louvers, controls, cooling system, and other generator accessories essential for generator operation, shall be connected to the life safety branch or the output terminals of the generator with overcurrent protective devices."

6.4.2.2.3.5 "No functions other than those in 6.4.2.2.3.2, 6.4.2.2.3.3, and 6.4.2.2.3.4 shall be connected to the life safety branch, except as specifically permitted in 6.4.2.2.3."


Based on observation the facility failed to provide adequate essential electrical system.

The inspector observed, while accompanied by the Chief Operating Officer (CEO) and Maintenance officer during the hours of the inspection from 9:00 am to 12:00 pm on 4/03/2019 that there were the following issues. They were:

1. There was no select receptacle at the generator.
2 There was no select receptacle at the ATS location.
3. Life Safety Panel had breakers: #2 assigned to telephone equipment, #3,5 & 9 were assigned to AC units. Remove these from
life safety panel to equipment branch panel per the code.


Essential Electrical System Segregation (Critical):

6.4.2.2.4.2 The critical branch shall supply power for task illumination, fixed equipment, select receptacles, and select power circuits serving the following areas and functions related to patient care:

(1) Critical care areas that utilize anesthetizing gases, task illumination, select receptacles, and fixed equipment
(2) Isolated power systems in special environments
(3) Task illumination and select receptacles in the following:
(a) Patient care rooms, including infant nurseries, selected acute nursing areas, psychiatric bed areas (omit receptacles), and
ward treatment rooms
(b) Medication preparation areas
(c) Pharmacy dispensing areas
(d) Nurses' stations (unless adequately lighted by corridor luminaires)
(4) Additional specialized patient care task illumination and receptacles, where needed
(5) Nurse call systems
(6) Blood, bone, and tissue banks
(7) Telephone equipment rooms and closets
(8) Task illumination, select receptacles, and select power circuits for the following areas:
(a) General care beds with at least one duplex receptacles per patient bedroom, and task illumination as required by the
governing body of the health care facility
(b) Angiographic labs
(c) Cardiac catheterization labs
(d) Coronary care units
(e) Hemodialysis rooms or areas
(f) Emergency room treatment areas (select)
(g) Human physiology labs
(h) Intensive care units
(i) Postoperative recovery rooms (select)
(9) Additional task illumination, receptacles, and select power circuits needed for effective facility operation, including single-
phase fractional horsepower motors, which are permitted to be connected to the critical branch


Based on observation the facility had incorrect circuit connected to the essential electrical system.

The inspector observed, while accompanied by the Chief Operating Officer (CEO) and Maintenance officer during the hours of the inspection from 9:00 am to 12:00 pm on 4/03/2019 that the critical panel had some many unrelated circuits connected to it. Re-wire the critical panel to include only the items listed above per the code.


Panel directory:

"Circuit Directory or Circuit Identification. Every circuit and circuit modification shall be legibly identified as to its clear, evident, and specific purpose or use. The identification shall include sufficient detail to allow each circuit to be distinguished from all others. Spare positions that contain unused overcurrent devices or switches shall be described accordingly. The identification shall be included in a circuit directory that is located on the face or inside of the panel door in the case of a panelboard, and located at each switch or circuit breaker in a switchboard. No circuit shall be described in a manner that depends on transient conditions of occupancy." - NFPA 70, 2011, 408.4 (A) Note: Labeling includes all disconnecting means, see 110.22.

Based on observation the facility failed to provide adequate panel board directories for the life safety and critical panels.

The inspector observed, while accompanied by the Chief Operating Officer (CEO) and Maintenance officer during the hours of the inspection from 9:00 am to 12:00 pm on 4/03/2019 that the life safety and critical panels were not correctly populated with the required items per the codes. Verify and update the directories.

Based on observation the facility failed to provide:

1. Evidence of adequate receptacles test in all the patient care areas.
2. Record of electrical maintenance and required tests performed.

The inspector observed, while accompanied by the Chief Operating Officer (CEO) and Maintenance Officer during the hours of the inspection from 9:00 am to 12:00 pm on 4/03/2019 that there were the following issues. They were:

1 There were no records of testing data and test interval of the patient care area receptacles as defined by Documented Performance
Data.
2. No records of where, type of repair performed and date of electrical maintenance and required tests performed in all the patient care
areas.

Based on observation the facility failed to provide all the required documentation for the essential electrical system maintenance.

The inspector observed, while accompanied by the Chief Operating Officer (CEO) and Maintenance Officer during the hours of the inspection from 9:00 am to 12:00 pm on 4/03/2019 that there were the following issues. They were:

1. There was no contract in place to ensure future routine 36 months' test of the generator set is performed.
2. There was no record of the main and feeder circuit breakers being inspected annually.

Generator Remote Manual Stop:

"All installations shall have a remote manual stop station of a type to prevent inadvertent or unintentional operation located outside the room housing the prime mover, where so installed, or elsewhere on the premises where the prime mover is located outside the building" - NFPA 110, 2010, 5.6.5.6* Note: "For systems located outdoors, the manual shutdown should be located external to the weatherproof enclosure and should be appropriately identified." A.5.6.5.6.

Based on observation the facility failed to provide remote emergency generator shut down button.

The inspector observed, while accompanied by the Chief Operating Officer (CEO) and Maintenance officer during the hours of the inspection from 9:00 am to 12:00 pm on 4/03/2019 that there was no remote shutdown switch for generator. Provide easily accessible remote shutdown switch for the generator.