HospitalInspections.org

The inspector observed, while accompanied by the Plant Operations Director, during the hours of the inspection from 2:00PM to 6:00 PM on 06/10/2015 that there were the following issues:

A) There were unsealed penetrations on the smoke barrier wall located above the cross corridor doors near Medical Records room. The cables that passed through the penetrations appeared to resemble Ethernet data cables.

" Penetrations for cables, cable trays, conduits, pipes, tubes, combustion vents and exhaust vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a fire barrier shall be protected by a firestop system or device. " - NFPA 101, 2003, 8.3.5.1.

The inspector observed, while accompanied by the Plant Operations Director, during the hours of the inspection from 2:00PM to 6:00 PM on 06/10/2015 that there were the following issues:

A) The storage room located along a public corridor, identifiable by a plaque that reads " Equipment by Lake Motors " had no door closer.

" Doors to hazardous areas shall be self-closing or automatic-closing in accordance with 10.2.2.3. " -NFPA 101, 2003, 20.3.2.1.

The inspector observed, while accompanied by the Plant Operations Director, during the hours of the inspection from 2:00PM to 6:00 PM on 06/10/2015 that there were the following issues:

A) The FACP breaker was not marked red.

" The circuit breaker at the electrical panel board for the fire alarm shall have a red marking, shall be accessible only to authorized personnel, and shall be identified as "FIRE ALARM CIRCUIT CONTROL" " - NFPA 72, 2002: 4.4.1.4.2.2.

The inspector observed, while accompanied by the Plant Operations Director, during the hours of the inspection from 2:00PM to 6:00 PM on 06/10/2015 that there were the following issues:

A) Battery powered lighting fixture was not observed at the generator location.

" The emergency generator location shall have task illumination, battery charger for emergency battery powered lighting unit(s), and selected receptacles at the generator set location " - NFPA 99, 1999: 3-4.2.2.2.(b)5.

K0130 Receptacle Testing in Patient Care Areas

The inspector observed, while accompanied by the Plant Operations Director, during the hours of the inspection from 2:00PM to 6:00 PM on 06/10/2015 that there were the following issues:

A) Based on observation the facility failed to provide a history of records for receptacle testing per NFPA 99: 3-3.3.3. in critical care areas on a semi-annual basis.

" Testing Intervals. 1) The facility shall establish policies and protocols for the type of test and intervals of testing for each appliance. 2) All appliances used in patient care areas shall be tested in accordance with 8.4.1.3 or 8.4.2.2.1.1 before being put into service for the first time and after repair or modification. Patient-care-related electrical appliances retested at intervals determined by their normal location or area of normal use, but not exceeding the intervals listed below: (1) General care areas - 12 months; (2) Critical care areas - 6 months; (3) Wet locations - 6 months. " - NFPA 99 (2002), 8.5.1.2

K0130 Manual HVAC Shutdown.
The inspector observed, while accompanied by the Plant Operations Director, during the hours of the inspection from 2:00PM to 6:00 PM on 06/10/2015 that there were the following issues:

A) There was not a manual emergency shut down for the HVAC units observed at a location accessible to staff. This is typically a red mushroom button at a nurse station. It may be used to manually shut down a single air handler or multiple air handlers. This may be connected to the fire alarm system, but should not sound the general fire alarm system. These are typically covered with a transparent cover to prevent an accidental alarm. The use of this manual control must be integrated into fire alarm drills. There may be one switch for each air handler or one switch that shuts down multiple the air handlers.

" Each air distribution system shall be provided with at least one manually operable means for stopping the operation of the supply, return, and exhaust fan(s) in an emergency. The means of manual operation shall be located at an approved location. " NFPA 90A, 2002, 6.2.1 & 6.2.2

The inspector observed, while accompanied by the Plant Operations Director, during the hours of the inspection from 2:00PM to 6:00 PM on 06/10/2015 that there were the following issues:

A) There were unsealed penetrations on the smoke barrier wall located above the cross corridor doors near Medical Records room. The cables that passed through the penetrations appeared to resemble Ethernet data cables.

" Penetrations for cables, cable trays, conduits, pipes, tubes, combustion vents and exhaust vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a fire barrier shall be protected by a firestop system or device. " - NFPA 101, 2003, 8.3.5.1.

The inspector observed, while accompanied by the Plant Operations Director, during the hours of the inspection from 2:00PM to 6:00 PM on 06/10/2015 that there were the following issues:

A) The storage room located along a public corridor, identifiable by a plaque that reads " Equipment by Lake Motors " had no door closer.

" Doors to hazardous areas shall be self-closing or automatic-closing in accordance with 10.2.2.3. " -NFPA 101, 2003, 20.3.2.1.

The inspector observed, while accompanied by the Plant Operations Director, during the hours of the inspection from 2:00PM to 6:00 PM on 06/10/2015 that there were the following issues:

A) The FACP breaker was not marked red.

" The circuit breaker at the electrical panel board for the fire alarm shall have a red marking, shall be accessible only to authorized personnel, and shall be identified as "FIRE ALARM CIRCUIT CONTROL" " - NFPA 72, 2002: 4.4.1.4.2.2.

The inspector observed, while accompanied by the Plant Operations Director, during the hours of the inspection from 2:00PM to 6:00 PM on 06/10/2015 that there were the following issues:

A) Battery powered lighting fixture was not observed at the generator location.

" The emergency generator location shall have task illumination, battery charger for emergency battery powered lighting unit(s), and selected receptacles at the generator set location " - NFPA 99, 1999: 3-4.2.2.2.(b)5.

K0130 Receptacle Testing in Patient Care Areas

The inspector observed, while accompanied by the Plant Operations Director, during the hours of the inspection from 2:00PM to 6:00 PM on 06/10/2015 that there were the following issues:

A) Based on observation the facility failed to provide a history of records for receptacle testing per NFPA 99: 3-3.3.3. in critical care areas on a semi-annual basis.

" Testing Intervals. 1) The facility shall establish policies and protocols for the type of test and intervals of testing for each appliance. 2) All appliances used in patient care areas shall be tested in accordance with 8.4.1.3 or 8.4.2.2.1.1 before being put into service for the first time and after repair or modification. Patient-care-related electrical appliances retested at intervals determined by their normal location or area of normal use, but not exceeding the intervals listed below: (1) General care areas - 12 months; (2) Critical care areas - 6 months; (3) Wet locations - 6 months. " - NFPA 99 (2002), 8.5.1.2

K0130 Manual HVAC Shutdown.
The inspector observed, while accompanied by the Plant Operations Director, during the hours of the inspection from 2:00PM to 6:00 PM on 06/10/2015 that there were the following issues:

A) There was not a manual emergency shut down for the HVAC units observed at a location accessible to staff. This is typically a red mushroom button at a nurse station. It may be used to manually shut down a single air handler or multiple air handlers. This may be connected to the fire alarm system, but should not sound the general fire alarm system. These are typically covered with a transparent cover to prevent an accidental alarm. The use of this manual control must be integrated into fire alarm drills. There may be one switch for each air handler or one switch that shuts down multiple the air handlers.

" Each air distribution system shall be provided with at least one manually operable means for stopping the operation of the supply, return, and exhaust fan(s) in an emergency. The means of manual operation shall be located at an approved location. " NFPA 90A, 2002, 6.2.1 & 6.2.2