HospitalInspections.org

Based on observations during the survey walk of the facility on the afternoon of 05/26/2016, while being accompanied by the Chief Executive Officer, the facility failed to maintain the fire resistance rating of the rated barrier, which separated the facility from the medical office building. The administration door, which is a rated fire door with no magnetic hold open, was held open by a door wedge. This door remained opened at all times and should be closed at all times, unless held open with magnetic hold open tied to the fire alarm. If this situation does occur, then notify the state of this change to the fire alarm.

Based on review of records during the survey of the facility on the afternoon of 05/26/2016, with the Chief Executive Officer, the facility failed to perform proper fire drills. Upon conducting fire drills, the facility shall include the transmission of a fire alarm signal to offsite location.

Based on review of records during the survey of the facility on the afternoon of 05/26/2016, with the Chief Executive Officer, the facility failed to provide documentation that the grounding system at inpatient care areas is being tested as follows: receptacle testing in patient care areas should be at least annually. Facility must initiate a log to retain these records although via conversation this was being conducted, just not logged.
Receptacle testing in patient care areas shall be tested as follows:
Physical integrity of each receptacle.(visual)
Continuity of the grounding of each receptacle.(test)
Correct polarity of hot and neutral connections in each receptacle.(test)
The retention force of the grounding blade shall be not less than 4 oz. (test)

Based on review of records during the survey of the facility on the afternoon of 05/26/2016, with the Chief Executive Officer, the facility to ensure that disaster drills were conducted in accordance with the 1999 edition of the Standard for Health Care Facilities, NFPA 99 (National Fire Protection Association). At least one semi-annual drill shall rehearse mass casualty response for emergency services, disaster receiving stations, or both and be logged in. Facility only had one report of a previous disaster drill on site when reviewing the records.




Based on review of records during the survey of the facility on the afternoon of 05/26/2016, with the Chief Executive Officer, the facility failed to provide documentation of air filter change logs. Although the medical office building maintenance team was conducting these filer change logs, the logs were not on site and could not be presented at time of inspection. The facility must retain these records at their facility.



Based on observations during the survey walk of the facility on the afternoon of 05/26/2016, while being accompanied by the Chief Executive Officer, the facility failed to ensure that all staff has keys at all times during their work hours for the fire extinguisher cabinets. Social service personnel did not have a key and a staff member did have a key but did not know which one opens the extinguisher cabinet.

Based on observations during the survey walk of the facility on the afternoon of 05/26/2016, while being accompanied by the Chief Executive Officer, the facility failed to assure that the essential electrical system was in full compliance. Generator GFI receptacle was supplied with power from the critical branch but should be powered by the life safety branch of the essential electrical system. Also verify that a battery back up light for th generator set is on the life safety branch panel.
The life safety branch of the emergency system shall supply power for the following lighting, receptacles and equipment: 1. Illumination of means of egress as required in NFPA 101, Life Safety Code; 2. Exit signs and exit direction signs required in NFPA 101, Life safety Code; 3. Alarm and alerting systems including the following: a. Fire Alarms, b. Alarms required for systems used for the piping of nonflammable medical gases as specified in Chapter 4, "Gas and Vacuum Systems;" 4. (Hospital or ASC) communication systems, where used for issuing instruction during emergency conditions;
5. Task illumination, battery charger for emergency battery-powered lighting unit(s), and selected receptacles at the generator set location; 6. Elevator ... 7. Automatically opened doors used for building egress. No functions other than those listed above in items 1 through 7 shall be connected to the life safety branch

Based on observations during the survey walk of the facility on the afternoon of 05/26/2016, while being accompanied by the Chief Executive Officer, the facility failed to maintain the fire resistance rating of the rated barrier, which separated the facility from the medical office building. The administration door, which is a rated fire door with no magnetic hold open, was held open by a door wedge. This door remained opened at all times and should be closed at all times, unless held open with magnetic hold open tied to the fire alarm. If this situation does occur, then notify the state of this change to the fire alarm.

Based on review of records during the survey of the facility on the afternoon of 05/26/2016, with the Chief Executive Officer, the facility failed to perform proper fire drills. Upon conducting fire drills, the facility shall include the transmission of a fire alarm signal to offsite location.

Based on review of records during the survey of the facility on the afternoon of 05/26/2016, with the Chief Executive Officer, the facility failed to provide documentation that the grounding system at inpatient care areas is being tested as follows: receptacle testing in patient care areas should be at least annually. Facility must initiate a log to retain these records although via conversation this was being conducted, just not logged.
Receptacle testing in patient care areas shall be tested as follows:
Physical integrity of each receptacle.(visual)
Continuity of the grounding of each receptacle.(test)
Correct polarity of hot and neutral connections in each receptacle.(test)
The retention force of the grounding blade shall be not less than 4 oz. (test)

Based on review of records during the survey of the facility on the afternoon of 05/26/2016, with the Chief Executive Officer, the facility to ensure that disaster drills were conducted in accordance with the 1999 edition of the Standard for Health Care Facilities, NFPA 99 (National Fire Protection Association). At least one semi-annual drill shall rehearse mass casualty response for emergency services, disaster receiving stations, or both and be logged in. Facility only had one report of a previous disaster drill on site when reviewing the records.




Based on review of records during the survey of the facility on the afternoon of 05/26/2016, with the Chief Executive Officer, the facility failed to provide documentation of air filter change logs. Although the medical office building maintenance team was conducting these filer change logs, the logs were not on site and could not be presented at time of inspection. The facility must retain these records at their facility.



Based on observations during the survey walk of the facility on the afternoon of 05/26/2016, while being accompanied by the Chief Executive Officer, the facility failed to ensure that all staff has keys at all times during their work hours for the fire extinguisher cabinets. Social service personnel did not have a key and a staff member did have a key but did not know which one opens the extinguisher cabinet.

Based on observations during the survey walk of the facility on the afternoon of 05/26/2016, while being accompanied by the Chief Executive Officer, the facility failed to assure that the essential electrical system was in full compliance. Generator GFI receptacle was supplied with power from the critical branch but should be powered by the life safety branch of the essential electrical system. Also verify that a battery back up light for th generator set is on the life safety branch panel.
The life safety branch of the emergency system shall supply power for the following lighting, receptacles and equipment: 1. Illumination of means of egress as required in NFPA 101, Life Safety Code; 2. Exit signs and exit direction signs required in NFPA 101, Life safety Code; 3. Alarm and alerting systems including the following: a. Fire Alarms, b. Alarms required for systems used for the piping of nonflammable medical gases as specified in Chapter 4, "Gas and Vacuum Systems;" 4. (Hospital or ASC) communication systems, where used for issuing instruction during emergency conditions;
5. Task illumination, battery charger for emergency battery-powered lighting unit(s), and selected receptacles at the generator set location; 6. Elevator ... 7. Automatically opened doors used for building egress. No functions other than those listed above in items 1 through 7 shall be connected to the life safety branch