HospitalInspections.org

Based on observation and interview with staff, the facility failed to provide a fire barrier having at least a two-hour fire resistance rating between the sprinklered hospital and the adjacent unsprinklered space housing the hospital based clinic, business office, medical records, and the space leased to a private medical clinic practice. Findings:

1) The wall above the north door into the adjacent nonconforming unsprinklered space is not constructed of approved materials having at least a two-hour fire resistance rating.

2) The door leading from waiting area of the licensed hospital space into the waiting room of the space leased to a private medical clinic practice does not have a closer.

3) There is no fire rated separation between the licensed hospital clinic space and the space leased to a private medical clinic practice.

Based on observation and interview with staff, the facility failed to provide separated corridors from use areas by partitions that resist the passage of smoke. Findings:

1) Throughout the facility, the suspended ceiling has damaged tiles that do not resist the passage of smoke.

Based on observation and interview with staff, the facility failed to provide hazardous areas protected in accordance with 19.3.2.1, which requires doors to be self-closing or automatic-closing. Findings:

1) The soiled linen room is considered a hazardous area per 19.3.2.1. The door into this room requires a closer, and requires the transom panel be re-installed above the door in the hollow metal frame.

Based on observation and interview with staff, the facility failed to provide generators exercised under load for 30 minutes per month. Findings:

1) The generator has a rating of 7.5 kva, having one transfer switch. There are no records of the generator being exercised under load for 30 minutes per month as required in NFPA 99, Section 3.4.4.1.

Based on observation and interview with staff, the facility failed to provide a fire barrier having at least a two-hour fire resistance rating between the sprinklered hospital and the adjacent unsprinklered space housing the hospital based clinic, business office, medical records, and the space leased to a private medical clinic practice. Findings:

1) The wall above the north door into the adjacent nonconforming unsprinklered space is not constructed of approved materials having at least a two-hour fire resistance rating.

2) The door leading from waiting area of the licensed hospital space into the waiting room of the space leased to a private medical clinic practice does not have a closer.

3) There is no fire rated separation between the licensed hospital clinic space and the space leased to a private medical clinic practice.

Based on observation and interview with staff, the facility failed to provide separated corridors from use areas by partitions that resist the passage of smoke. Findings:

1) Throughout the facility, the suspended ceiling has damaged tiles that do not resist the passage of smoke.

Based on observation and interview with staff, the facility failed to provide hazardous areas protected in accordance with 19.3.2.1, which requires doors to be self-closing or automatic-closing. Findings:

1) The soiled linen room is considered a hazardous area per 19.3.2.1. The door into this room requires a closer, and requires the transom panel be re-installed above the door in the hollow metal frame.

Based on observation and interview with staff, the facility failed to provide generators exercised under load for 30 minutes per month. Findings:

1) The generator has a rating of 7.5 kva, having one transfer switch. There are no records of the generator being exercised under load for 30 minutes per month as required in NFPA 99, Section 3.4.4.1.