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Observation and discussion with the Maintenance Lead and the Maintenance Tech/Safety Officer between 9 am and 3 pm on 10/14/2010 revealed that certain requirements stipulated in NFPA 101 were not met.

Health care occupancies in buildings housing other occupancies shall be completely separated from them by construction having a fire resistance rating of not less than 2 hours as provided for additions in 19.1.1.4 [Re: NFPA 101, Life Safety Code, 2000: ? 19.1.2.2.]

Findings: The 2 hr rated wall constructed between the hospital and the adjacent nonhospital space appeared to have two problems: (1) the separation did not extend across the complete length of the separation; and (2) there were some holes in the wall that were not sealed. These factors reduce the effectiveness and quality of the separation. This facility shall ensure that the rated construction intended to protect the separation extends completely across the separation, and the openings [holes] must be sealed.

Observation and discussion with the Maintenance Lead and the Maintenance Tech/Safety Officer between 9 am and 3 pm on 10/14/2010 revealed that certain requirements stipulated in NFPA 101 were not met.

Interior finish for corridors and exitways, including exposed interior surfaces of buildings such as fixed or movable walls, partitions, columns, and ceilings has a flame spread rating of Class A or Class B. [NFPA 101, Life Safety Code, 2000: ? 19.3.3.2.]

Findings: This requirement was discussed and it was determined that the required documentation is not retained by the staff.

Observation and discussion with the Maintenance Lead and the Maintenance Tech/Safety Officer between 9 am and 3 pm on 10/14/2010 revealed that certain requirements stipulated in NFPA 101 were not met.

Smoke Passage Resisted

Corridor walls shall form a barrier to limit the transfer of smoke [Re: NFPA 101, Life Safety Code, 2000: ? 19.3.6.2.2.]

Findings: The corridor walls above the lay-in ceiling near the laboratory were not sealed properly. This deficiency will not adequately resist smoke passage. The facility shall affirm that all penetrations have been caulked properly.

Observation and discussion with the Maintenance Lead and the Maintenance Tech/Safety Officer between 9 am and 3 pm on 10/14/2010 revealed that certain requirements stipulated in NFPA 90A and the State Licensing Rules were not met.

a. Service Openings

Service openings shall be identified with letters having a minimum height of ? in. [1.27 cm] to indicate the location of the fire protection device[s] within [Re: NFPA 90A, Installation of Air Conditioning and Ventilating Systems, 1999: ? 2-3.4.2.]

Findings: During the inspection, at least one damper access panel was not labeled as required. The facility shall ensure that this requirement is satisfied.

b. Draft Gauges

A manometer or draft gauge shall be installed across each filter bed having a required efficiency of 75% or more including hoods requiring high efficiency particulate air (HEPA) filters [Re: 25 TAC HLR 2007: ?133.162(d)(3)(D)(ii)(V).] T

Findings: During the survey, it was noted that the required draft gauges were not installed across each filter bed with efficiency greater than 75%. The facility shall ensure that this requirement is satisfied.

Observation and discussion with the Maintenance Lead and the Maintenance Tech/Safety Officer between 9 am and 3 pm on 10/14/2010 revealed that certain requirements stipulated in NFPA 101 were not met.

Draperies, curtains, including cubicle curtains, and other loosely hanging fabrics and films serving as furnishings or decorations in ambulatory health care occupancies shall be in accordance with 10.3.1 [Re: NFPA 101, Life Safety Code. 2000: ? 21.7.5.1.]

Findings: This requirement was discussed and it was determined that the required documentation is not retained by the staff.

Observation and discussion with the Maintenance Lead and the Maintenance Tech/Safety Officer between 9 am and 3 pm on 10/14/2010 revealed that certain requirements stipulated in the state licensing regulations and NFPA 99 were not met.

a. Kitchen Hood Switch

Exhaust hoods shall have an indicator light indicating that the exhaust fan is in operation [Re: 25 TAC, HLR, 2007: ? 133.163(e)(5)(A).]

Findings: This requirement was discussed with the staff and the existing fan switch was observed. This switch must be replaced with one that illuminates when the fan is activated.

b. Letter of Preference

The facility is required to produce letters of preference for the provision of water and fuel in the event of a disaster or emergency [Re: NFPA 99, Health Care Facilities, 2002: ? 12.3.3.2.]

Findings: This staff could not provide letters of preference for fuel and water.

c. Use of PVC

Soil stacks, drains, vents, waste lines, and leaders installed above ground within buildings shall be drain-waster-vent (DWV) weight or heavier and shall be: copper pipe, copper tube, cast iron pipe, or galvanized iron pipe [Re: 25 TAC, HLR, 2007: ? 133.162(d)(4)(A)(viii)(I).]

Findings: PVC piping was installed beneath the disposal unit in the dietary suite; this is not permitted.

Observation and discussion with the Maintenance Lead and the Maintenance Tech/Safety Officer between 9 am and 3 pm on 10/14/2010 revealed that certain requirements stipulated in NFPA 110 were not met.

a. Under Full Load.

The generator must be tested under full load for 30 minutes 12 times per year with testing intervals not less that 20 days or exceeding 40 days [Re: NFPA 110, Standard for Emergency and Standby Power Systems, 2002: ? 8-4.1.1.]

Findings: This requirement was discussed and it was determined that a log was not maintained confirming that this test was conducted as required. The facility shall perform this test as required and maintain a log.

b. Load Tests.

The generator must be tested under full load for 4 hrs every 36 to 48 months [Re: NFPA 110, Standard for Emergency and Standby Power Systems, 2002: ? 8-4.8.]

Findings: This requirement was discussed and it was determined that this test has not been run, and it is not scheduled. The facility shall perform this test as required.

Observation and discussion with the Maintenance Lead and the Maintenance Tech/Safety Officer between 9 am and 3 pm on 10/14/2010 revealed that certain requirements stipulated in NFPA 70, NFPA 99, and the State Licensing Regulations were not met.

a. GenSet Life Safety Features

A battery powered light where the battery is charged by the life safety branch and a receptacle powered by the life safety branch is required [Re: NFPA 70, National Electrical Code, 2002: ? 517.32[E].]

Findings: This topic was discussed during the survey and when the generator was observed, it was obvious that this requirement was not met. The facility shall make the necessary changes to meet this requirement.

b. Junction Box Covers

All pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use. Where metal covers are used, they shall comply with the grounding requirements of Section 250.110. An extension from the cover of an exposed box shall comply with Section 370.22, Exception [Re: NFPA 70, National Electrical Code, 2002: ? 314.28(C).]

Findings: A number of junction boxes located above the lay-in ceiling and elsewhere did not have covers as required. One was located above the double doors near the pharmacy and one was at the generator set location. The facility shall affirm that all junction boxes have been installed with covers as required.

c. Flex Conduit

The wiring of the emergency system of a hospital shall be mechanically protected by installation in nonflexible metal raceways, or shall be wired with Type MI cable [Re: NFPA 70, National Electrical Code, 2002: ? 517.30[C](3).]

Findings: Flexible conduit was installed on panelboards LSA and CB, which is not permitted. These must be replaced with nonflexible metal installations.

d. Ice Dispensers

The critical branch shall be permitted to be subdivided into two or more branches. The critical branch of the emergency system shall supply power for task illumination, fixed equipment, selected receptacles, and selected power circuits serving the following areas and functions related to patient care: .... (3) Task illumination and selected receptacles in the following: .... (b) Medication prep areas, [c] Pharmacy dispensing areas, (d) Nurses stations [unless adequately lighted by {egress} corridor luminaries], .... (9) Additional task illumination, receptacles, and selected power circuits needed for effective facility operation. .... [Re: NFPA 99, Health Care Facilities, 2002: ? 4.4.2.2.2.3.] It is the policy of the Department, acting as the state level Authority Having Jurisdiction [AHJ], to require that at least one ice dispenser powered by the critical branch be within reasonable proximity to each patient.

Findings: The facility could not demonstrate that this requirement was met. This condition is required at any licensed general hospital. The facility shall ensure that this rule is followed.

Observation and discussion with the Maintenance Lead and the Maintenance Tech/Safety Officer between 9 am and 3 pm on 10/14/2010 revealed that certain requirements stipulated in NFPA 101 were not met.

Health care occupancies in buildings housing other occupancies shall be completely separated from them by construction having a fire resistance rating of not less than 2 hours as provided for additions in 19.1.1.4 [Re: NFPA 101, Life Safety Code, 2000: ? 19.1.2.2.]

Findings: The 2 hr rated wall constructed between the hospital and the adjacent nonhospital space appeared to have two problems: (1) the separation did not extend across the complete length of the separation; and (2) there were some holes in the wall that were not sealed. These factors reduce the effectiveness and quality of the separation. This facility shall ensure that the rated construction intended to protect the separation extends completely across the separation, and the openings [holes] must be sealed.

Observation and discussion with the Maintenance Lead and the Maintenance Tech/Safety Officer between 9 am and 3 pm on 10/14/2010 revealed that certain requirements stipulated in NFPA 101 were not met.

Interior finish for corridors and exitways, including exposed interior surfaces of buildings such as fixed or movable walls, partitions, columns, and ceilings has a flame spread rating of Class A or Class B. [NFPA 101, Life Safety Code, 2000: ? 19.3.3.2.]

Findings: This requirement was discussed and it was determined that the required documentation is not retained by the staff.

Observation and discussion with the Maintenance Lead and the Maintenance Tech/Safety Officer between 9 am and 3 pm on 10/14/2010 revealed that certain requirements stipulated in NFPA 101 were not met.

Smoke Passage Resisted

Corridor walls shall form a barrier to limit the transfer of smoke [Re: NFPA 101, Life Safety Code, 2000: ? 19.3.6.2.2.]

Findings: The corridor walls above the lay-in ceiling near the laboratory were not sealed properly. This deficiency will not adequately resist smoke passage. The facility shall affirm that all penetrations have been caulked properly.

Observation and discussion with the Maintenance Lead and the Maintenance Tech/Safety Officer between 9 am and 3 pm on 10/14/2010 revealed that certain requirements stipulated in NFPA 90A and the State Licensing Rules were not met.

a. Service Openings

Service openings shall be identified with letters having a minimum height of ? in. [1.27 cm] to indicate the location of the fire protection device[s] within [Re: NFPA 90A, Installation of Air Conditioning and Ventilating Systems, 1999: ? 2-3.4.2.]

Findings: During the inspection, at least one damper access panel was not labeled as required. The facility shall ensure that this requirement is satisfied.

b. Draft Gauges

A manometer or draft gauge shall be installed across each filter bed having a required efficiency of 75% or more including hoods requiring high efficiency particulate air (HEPA) filters [Re: 25 TAC HLR 2007: ?133.162(d)(3)(D)(ii)(V).] T

Findings: During the survey, it was noted that the required draft gauges were not installed across each filter bed with efficiency greater than 75%. The facility shall ensure that this requirement is satisfied.

Observation and discussion with the Maintenance Lead and the Maintenance Tech/Safety Officer between 9 am and 3 pm on 10/14/2010 revealed that certain requirements stipulated in NFPA 101 were not met.

Draperies, curtains, including cubicle curtains, and other loosely hanging fabrics and films serving as furnishings or decorations in ambulatory health care occupancies shall be in accordance with 10.3.1 [Re: NFPA 101, Life Safety Code. 2000: ? 21.7.5.1.]

Findings: This requirement was discussed and it was determined that the required documentation is not retained by the staff.

Observation and discussion with the Maintenance Lead and the Maintenance Tech/Safety Officer between 9 am and 3 pm on 10/14/2010 revealed that certain requirements stipulated in the state licensing regulations and NFPA 99 were not met.

a. Kitchen Hood Switch

Exhaust hoods shall have an indicator light indicating that the exhaust fan is in operation [Re: 25 TAC, HLR, 2007: ? 133.163(e)(5)(A).]

Findings: This requirement was discussed with the staff and the existing fan switch was observed. This switch must be replaced with one that illuminates when the fan is activated.

b. Letter of Preference

The facility is required to produce letters of preference for the provision of water and fuel in the event of a disaster or emergency [Re: NFPA 99, Health Care Facilities, 2002: ? 12.3.3.2.]

Findings: This staff could not provide letters of preference for fuel and water.

c. Use of PVC

Soil stacks, drains, vents, waste lines, and leaders installed above ground within buildings shall be drain-waster-vent (DWV) weight or heavier and shall be: copper pipe, copper tube, cast iron pipe, or galvanized iron pipe [Re: 25 TAC, HLR, 2007: ? 133.162(d)(4)(A)(viii)(I).]

Findings: PVC piping was installed beneath the disposal unit in the dietary suite; this is not permitted.

Observation and discussion with the Maintenance Lead and the Maintenance Tech/Safety Officer between 9 am and 3 pm on 10/14/2010 revealed that certain requirements stipulated in NFPA 110 were not met.

a. Under Full Load.

The generator must be tested under full load for 30 minutes 12 times per year with testing intervals not less that 20 days or exceeding 40 days [Re: NFPA 110, Standard for Emergency and Standby Power Systems, 2002: ? 8-4.1.1.]

Findings: This requirement was discussed and it was determined that a log was not maintained confirming that this test was conducted as required. The facility shall perform this test as required and maintain a log.

b. Load Tests.

The generator must be tested under full load for 4 hrs every 36 to 48 months [Re: NFPA 110, Standard for Emergency and Standby Power Systems, 2002: ? 8-4.8.]

Findings: This requirement was discussed and it was determined that this test has not been run, and it is not scheduled. The facility shall perform this test as required.

Observation and discussion with the Maintenance Lead and the Maintenance Tech/Safety Officer between 9 am and 3 pm on 10/14/2010 revealed that certain requirements stipulated in NFPA 70, NFPA 99, and the State Licensing Regulations were not met.

a. GenSet Life Safety Features

A battery powered light where the battery is charged by the life safety branch and a receptacle powered by the life safety branch is required [Re: NFPA 70, National Electrical Code, 2002: ? 517.32[E].]

Findings: This topic was discussed during the survey and when the generator was observed, it was obvious that this requirement was not met. The facility shall make the necessary changes to meet this requirement.

b. Junction Box Covers

All pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use. Where metal covers are used, they shall comply with the grounding requirements of Section 250.110. An extension from the cover of an exposed box shall comply with Section 370.22, Exception [Re: NFPA 70, National Electrical Code, 2002: ? 314.28(C).]

Findings: A number of junction boxes located above the lay-in ceiling and elsewhere did not have covers as required. One was located above the double doors near the pharmacy and one was at the generator set location. The facility shall affirm that all junction boxes have been installed with covers as required.

c. Flex Conduit

The wiring of the emergency system of a hospital shall be mechanically protected by installation in nonflexible metal raceways, or shall be wired with Type MI cable [Re: NFPA 70, National Electrical Code, 2002: ? 517.30[C](3).]

Findings: Flexible conduit was installed on panelboards LSA and CB, which is not permitted. These must be replaced with nonflexible metal installations.

d. Ice Dispensers

The critical branch shall be permitted to be subdivided into two or more branches. The critical branch of the emergency system shall supply power for task illumination, fixed equipment, selected receptacles, and selected power circuits serving the following areas and functions related to patient care: .... (3) Task illumination and selected receptacles in the following: .... (b) Medication prep areas, [c] Pharmacy dispensing areas, (d) Nurses stations [unless adequately lighted by {egress} corridor luminaries], .... (9) Additional task illumination, receptacles, and selected power circuits needed for effective facility operation. .... [Re: NFPA 99, Health Care Facilities, 2002: ? 4.4.2.2.2.3.] It is the policy of the Department, acting as the state level Authority Having Jurisdiction [AHJ], to require that at least one ice dispenser powered by the critical branch be within reasonable proximity to each patient.

Findings: The facility could not demonstrate that this requirement was met. This condition is required at any licensed general hospital. The facility shall ensure that this rule is followed.