HospitalInspections.org

Based on the findings of the life Safety Code survey it was determined that the hospital was not in compliance with the Condition of
Physical Environment as a result of the following deficiencies found as part of that survey:

Main Hospital
1. K0341 Failure to ensure that the fire alarm system functioned as required ;
2. K0342 and K0343 - Failure to ensure that the Fire Alarm system was maintained as required;
3. K0352 - Failure to ensure that the fire alarm tests located all devices tested;
4. K0353 - Failure to ensure that the sprinkler heads were maintained as required;
5. K0907 - Failure to ensure that the bulk storage areas for the medical gases were maintained as required;
6. K908 - Failure to ensure that the outdoor bulk storage areas for medical gases were maintained as required, and
7. K0932 - Failure to ensure that the foam extinguishing system on the roof of the north Wing functioned as required.

Clatonoff Pavilion
1. K0321- Failure to ensure that all wall and ceiling penetrations were properly sealed;
2. K0363- Failure to ensure that corridor doors did not contain any open transfer grill systems.
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Based on observation while conducting a tour of the facility food service operation, it was determined that facility staff failed to ensure that sanitizer levels for manual dishwashing were adequate.

The findings include:

On December 13, 2016, at 9:46 AM, in the main kitchen in the south tower, on surveyor request, the sanitizer in the three compartment sink was measured by staff and found to be at zero ppm (parts per million). At 10:46 AM on December 13, 2016, in the Clatanoff Kitchen, on surveyor request, the sanitizer in the three compartment sink was also found to be at zero ppm. On December 14, 2016, on follow up for the main kitchen in the south tower, the food service director notified the surveyor that the dispenser for the sanitizer was malfunctioning and the service vendor had been contacted to complete repairs. For manual dishwashing, staff must ensure that quaternary ammonia levels are between 15 and 400 ppm to ensure that dishes are adequately sanitized.