HospitalInspections.org

K200 Means of Egress Requirements - Other
Findings:
The inspector observed, while accompanied by the Maintenance Director, during the hours of the inspection from 2:30 PM - 7 PM on 9/28/22, that there were the following issues:
1) Based on review of the records, facility failed to perform annual inspection of doors in means of egress.

K355 Portable Fire Extinguishers
Findings:
The inspector observed, while accompanied by the Maintenance Director, during the hours of the inspection from 2:30 PM - 7 PM on 9/28/22, that there were the following issues:
1) Based on review of the records, facility failed to do the following: fire extinguishers shall be inspected either manually or by means of an electronic monitoring device/system at a minimum of 30-day intervals.

K700 Emergency Preparedness Plan and Drills
Findings:
The inspector observed, while accompanied by the Maintenance Director, during the hours of the inspection from 2:30 PM - 7 PM on 9/28/22, that there were the following issues:
1) Based on review of the records, facility failed to perform annual disaster drill with written report. The authority having jurisdiction recommends staff review the Federal Register, 81 FR, 63859 to improve future disaster drills. Additionally, please consult NFPA 3000 Standard for an Active Shooter/Hostile Event Response (ASHER) Program for further insight into conducting active shooter drill.
2) Based on review of the records, facility failed to do the following: provide letters indicating preferred customers status in case of emergency situation for water.

K712 Fire Drills
Findings:
The inspector observed, while accompanied by the Maintenance Director, during the hours of the inspection from 2:30 PM - 7 PM on 9/28/22, that there were the following issues:
1) Based on review of the records, facility failed to perform fire drill at unexpected times.
2) Based on review of the records, facility failed to perform fire drill in 2021 for the night shift.

K914 Electrical Systems - Maintenance and Testing
Findings:
The inspector observed, while accompanied by the Maintenance Director, during the hours of the inspection from 2:30 PM - 7 PM on 9/28/22, that there were the following issues:
3) Based on review of the records, facility failed to do the following: Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered, are tested after initial installation, replacement or servicing at intervals not exceeding 12 months.
4) Based on review of the records, facility failed to do the following: Line isolation monitors (LIM), if installed, are tested at intervals of ? 1 month by actuating the LIM test switch per 6.3.2.6.3.6, which activates both visual and audible alarm. For, LIM circuits with automated self-testing, this manual test is performed at intervals ? 12 months. LIM circuits are tested per 6.3.3.3.2 after any repair or renovation to the electric distribution system.

K918 Electrical Systems - Essential Electric System Maintenance and Testing
Findings:
The inspector observed, while accompanied by the Maintenance Director, during the hours of the inspection from 2:30 PM - 7 PM on 9/28/22, that there were the following issues:
1) Based on review of the records and interview with Maintenance Director, facility failed to perform monthly load tests in accordance with NFPA 110 criteria for the generator.
2) Based on review of the records and interview with Maintenance Director, facility failed to perform load bank test for four continuous hours every 36 months.
3) Based on review of the records and interview with Maintenance Director, facility failed to perform annual inspection of the main and feeder circuit breakers. There was no program for periodically exercising the components according to manufacturer requirements.