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Based on observation, the facility failed to meet the requirement of NFPA-5000 as indicated below.
Smoke and Fire Walls should be labeled per NFPA-5000,

Based on observation, the facility failed to meet the reqquirement of ASHRE 170 as indicated below.
The Isolation Room requires a 10' Exhaust per ASHRE 170 2008.

Based on observation, the facility failed to provide adequate documentation to denote facility Life Safety Plans denoting rated walls, Smoke Barrier Walls and Egress Routes per NFPA-101

Based on observations at the time of the inspection, the facility's Smoke Barriers and Rated Wall Assemblies had applied ("Scabbed-On") sheetrock not installed per ASTM/UL rated assembly in multiple locations. NFPA-101 19.3.7.3.? Smoke Barrier Walls had opening which were not sealed.

NFPA-101 19.3.7.3? Any required smoke barrier shall be constructed in accordance with Section 8.5 and shall have a minimum ½-hour fire resistance rating, unless otherwise permitted by one of the following:
(1)?This requirement shall not apply where an atrium is used, and both of the following criteria also shall apply:
(a)?Smoke barriers shall be permitted to terminate at an atrium wall constructed in accordance with 8.6.7(1)(c).
(b)?Not less than two separate smoke compartments shall be provided on each floor,
(2)*Smoke dampers shall not be required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air-conditioning systems where an approved, supervised automatic sprinkler system in accordance with 19.3.5.8 has been provided for smoke compartments adjacent to the smoke barrier.

At the time of inspection, the inspector was unable verify Final Filters at the Emergency Room Air Handling Unit. (See Reference Below)

NFPA-90A 2-2.2 Air Cleaners and Air Filters.
2-2.2.1
Electrostatic air cleaners shall be listed in accordance with UL 867, Standard for Safety Electrostatic Air Cleaners, and shall be installed in conformance with the conditions of the manufacturer's listing.
TAC 133,169(d)
Figure: 25 TAC §133.169(d) Page 1 of 1

TABLE 4
FILTER EFFICIENCIES FOR CENTRAL VENTILATION
AND AIR CONDITIONING SYSTEMS



General procedure operating rooms,
delivery rooms, nurseries, critical care units, patient care areas and treatment, diagnostic and related areas
Number of Filter Beds - 2 Filter Bed #1 (Percent) 25, (Merv) 7 Filter Bed #2 (Percent) 90, (Merv) 14

During observations at the time of the inspection, the Inspector was unable to identify Flame Spread and Smoke Development rating on Cubical Curtains and Furnishings. Hospital does not have a purchasing policy regarding FF&E.

NFPA- 101 10.3.1* Where required by the applicable provisions of this Code, draperies, curtains, and other similar loosely hanging furnishings and decorations shall meet the flame propagation performance criteria contained in NFPA 701, Standard Methods of Fire Tests for Flame Propagation of Textiles and Films.

NFPA-101 19.7.5.1* Draperies, curtains, and other loosely hanging fabrics and films serving as furnishings or decorations in health care occupancies shall be in accordance with the provisions of 10.3.1 (see 19.3.5.11), and the following also shall apply:
(1)?Such curtains shall include cubicle curtains.

At the time of the inspection, and based on document and material review, the Inspector was unable to identify Flame Spread and Smoke Development rating on Furnishings. Hospital does not have a purchasing policy regarding FF&E.

NFPA-101 19.7.5.2? Newly introduced upholstered furniture within health care occupancies shall comply with one of the following provisions, unless otherwise provided in 19.7.5.3: