HospitalInspections.org

Based on observations made during the survey of the facility between the hours of 1:00 pm and 6:00 pm, while accompanied by the CFO, Director of Quality Management, Supervisor - Plant Ops it was observed that the facility failed to maintain the required fire/smoke rating for a portion of the SMOKE BARRIER WALL which was rated as a 2 hour fire/smoke barrier. There was a question as to whether the 2 hour rating was correct, or whether the rating should be only 1 hour fire/smoke. The facility shall assess and ensure that the correct rating for this wall is in place, and that the integrity of construction required to achieve such rating is in place.

Based on observations made during the survey of the facility between the hours of 1:00 pm and 6:00 pm, while accompanied by the CFO, Director of Quality Management, Supervisor - Plant Ops it was observed that the facility failed to provide a log indicating consistent, systematic compliance with requirement for quarterly fire drills on each shift. While it was documented that the facility had accomplished many fire drills for the past few years, their documentation was incomplete lacking signatures of participants.

Based on observations made during the survey of the facility between the hours of 1:00 pm and 6:00 pm, while accompanied by the CFO, Director of Quality Management, Supervisor - Plant Ops it was observed that the facility had a rusted sprinkler head in the MED GAS ROOM. This sprinkler head is not compliant.

Based on observations made during the survey of the facility between the hours of 1:00 pm and 6:00 pm, while accompanied by the CFO, Director of Quality Management, Supervisor - Plant Ops it was observed that while it appears the facility had accomplished some of the requirements, the facility failed to provide logs indicating consistent, systematic compliance on the following issues and items:

1. Electrical equipment inspections - Biomedical.
Critical Areas: Semi-annually.
General Areas: Annually
2. Electrical power and distribution and grounding systems - Effectiveness.
Critical Areas: Semi-annually.
General Areas: Annually

Additionally, the facility failed regarding the following:
4. The required lighting for the Emergency Generator Set (90 minute battery back-up task illumination) was missing.
NFPA 99, 2002: 4.4.2.2.2.2.(5). Task illumination, battery charger for emergency battery-powered lighting unit(s), and selected receptacles at the generator set location and essential electrical system transfer switch locations. "
5. The required red marking for the fire alarm circuit breaker was missing.
NFPA 72, 2002: 4.4.1.4.2.2. " 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". "

Based on observations made during the survey of the facility between the hours of 1:00 pm and 6:00 pm, while accompanied by the CFO, Director of Quality Management, Supervisor - Plant Ops it was observed that the facility failed to maintain the required fire/smoke rating for a portion of the SMOKE BARRIER WALL which was rated as a 2 hour fire/smoke barrier. There was a question as to whether the 2 hour rating was correct, or whether the rating should be only 1 hour fire/smoke. The facility shall assess and ensure that the correct rating for this wall is in place, and that the integrity of construction required to achieve such rating is in place.

Based on observations made during the survey of the facility between the hours of 1:00 pm and 6:00 pm, while accompanied by the CFO, Director of Quality Management, Supervisor - Plant Ops it was observed that the facility failed to provide a log indicating consistent, systematic compliance with requirement for quarterly fire drills on each shift. While it was documented that the facility had accomplished many fire drills for the past few years, their documentation was incomplete lacking signatures of participants.

Based on observations made during the survey of the facility between the hours of 1:00 pm and 6:00 pm, while accompanied by the CFO, Director of Quality Management, Supervisor - Plant Ops it was observed that the facility had a rusted sprinkler head in the MED GAS ROOM. This sprinkler head is not compliant.

Based on observations made during the survey of the facility between the hours of 1:00 pm and 6:00 pm, while accompanied by the CFO, Director of Quality Management, Supervisor - Plant Ops it was observed that while it appears the facility had accomplished some of the requirements, the facility failed to provide logs indicating consistent, systematic compliance on the following issues and items:

1. Electrical equipment inspections - Biomedical.
Critical Areas: Semi-annually.
General Areas: Annually
2. Electrical power and distribution and grounding systems - Effectiveness.
Critical Areas: Semi-annually.
General Areas: Annually

Additionally, the facility failed regarding the following:
4. The required lighting for the Emergency Generator Set (90 minute battery back-up task illumination) was missing.
NFPA 99, 2002: 4.4.2.2.2.2.(5). Task illumination, battery charger for emergency battery-powered lighting unit(s), and selected receptacles at the generator set location and essential electrical system transfer switch locations. "
5. The required red marking for the fire alarm circuit breaker was missing.
NFPA 72, 2002: 4.4.1.4.2.2. " 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". "