HospitalInspections.org

Based on observation and interview with the Clinical Supervisor, the facility failed to provide documentation for protective systems. Records for protective systems shall be made available to the authority having jurisdiction upon request.

Findings included:

During the facility record review with the Clinical Supervisor on 06/18/2020 between 11:00 a.m. and 2:00 p.m. at the John Hopkins All Children's Outpatient Rehabilitation located in Brandon, FL., the facility failed to provide documentation for protective systems. An interview with the Clinical Supervisor said that all preventive maintenance inspections were electronic and that she did not have access or knowledge on how to access those records.

per NFPA 101 (2012 Edition) 4.6.12, 4.6.12.5
per NFPA 72 (2010 Edition) 14.6, 14.6.2
per NFPA 25 (2011 Edition) 4.3

Based on observation, record review, and interview with the Director of Facilities, the facility failed to maintain emergency battery back-up exit lighting. Battery back-up exit lighting is required to ensure the safety of building occupants in the event of a public utility failure.

Findings included:

During the facility record review of the Johns Hopkins All Children's Rehabilitation Center in St. Petersburg, FL with the Director of Facilities on 06/19/2020 between 9:15 a.m. and 10:45 a.m., the facility failed to perform and document testing of the exit lights equipped with battery back-up on an annual basis as required per NFPA 101. During the tour of the Rehabilitation Center between 12:45 p.m. and 1:30 p.m., it was found that 2/4 battery back-up exit lights failed to test in the gym, located on the first floor. An interview was conducted with the Director of Facilities concurrent with the observations and confirmed the findings.

per NFPA 101 (2012 Edition) 4.6.12, 7.9.3.1.1(3), 7.10.4

Based on observation, record review, and interview, the facility failed to maintain the Fire Alarm System. Maintaining the Fire Alarm System ensures proper operation and lessens the chance of a delayed alarm activation under hazardous conditions.

Findings included:

1) During the facility record review with the Clinical Supervisor and maintenance personnel on 06/18/2020 between 11:00 a.m. and 2:00 p.m. at the Johns Hopkins All Children's Outpatient Rehabilitation located in Brandon, FL., the facility failed to:
a) Provide evidence of the annual duct detector differential testing, the factory range listed for the duct detectors were for the smoke sensitivity and not the pressure range.
b) Provide evidence of the biennial smoke detector sensitivity testing. Documentation revealed the actual readings of the test were not recorded.
An interview was conducted with the Clinical Supervisor and maintenance personnel concurrent with the observations and confirmed the findings.

per NFPA 101 (2012 Edition) 4.6.12
per NFPA 99 (2012 Edition) 15.7.1.2
per NFPA 72 (2010 Edition) 14.4.2.2, 14.4.2.2(14)(g)(6), 14.4.5.3

2) During record review with the Clinical Supervisor and maintenance personnel on 06/19/2020 between 8:00 a.m. and 10:30 a.m. at the Johns Hopkins All Children's Outpatient Rehabilitation located in Lakeland, FL., the facility failed to:
a) Provide evidence of the biennial smoke detector sensitivity testing. Documentation revealed the actual readings of the test were not recorded.
b) The facility failed to test 1 of 3 smoke detectors for sensitivity located in the soiled holding room.
An interview was conducted with the clinical supervisor and maintenance personnel concurrent with the observations and confirmed the findings.

per NFPA 101 (2012 Edition) 4.6.12
per NFPA 99 (2012 Edition) 15.7.1.2
per NFPA 72 (2010 Edition) 14.4.2.2, 14.4.5.3

3) During record review with the Director of Facilities on 06/19/2020 between 9:15 a.m. and 10:45 a.m., the facility failed to provide evidence of the annual duct detector differential testing for the Johns Hopkins All Children's Rehabilitation Center in St. Petersburg, and the Outpatient Care Center in St. Petersburg. An interview was conducted with the Director of Facilities concurrent with the observations and confirmed the findings.

per NFPA 101 (2012 Edition) 4.6.12
per NFPA 99 (2012 Edition) 15.7.1.2
per NFPA 72 (2010 Edition) 14.4.2.2, 14.4.2.2(14)(g)(6)

Based on observation, record review, and interview, the facility failed to maintain inspections of the automatic fire sprinkler system (AFSS). Failure to maintain or inspect the system could lead to an AFSS failure.

Findings included:

1) During the facility tour with the Safety Director on 06/19/2020 between 10:30 a.m. and 2:30 p.m., it was found that the sprinklers throughout all of the mechanical rooms on the fourth floor of the main hospital campus were loaded. An interview was conducted with the Safety Director concurrent with the observations and confirmed the findings.

per NFPA 101 (2012 Edition) 19.3.5.3, 9.7
per NFPA 25 (2011 Edition) 5.2.1.1.1, 5.2.1.1.2

2) During the facility record review with the Director of Facilities on 06/19/2020 between 9:15 a.m. and 10:45 a.m., the facility failed to provide evidence that the St. Petersburg Rehabilitation Center's diesel fire pump's batteries' electrolyte levels were within an acceptable range. An interview was conducted with the Director of Facilities concurrent with the observations and confirmed the findings.

per NFPA 101 (2012 Edition) 4.6.12
per NFPA 99 (2012 Edition) 15.12.1
per NFPA 25 (2011 Edition) 8.2.2(4)(k)

3) During the facility tour with the Clinical Supervisor and maintenance personnel on 06/18/2020 between 11:00 a.m. and 2:00 p.m. at the Johns Hopkins All Children's Outpatient Rehabilitation located in Brandon, FL., the facility failed to provide a list of each type of sprinkler installed in the property per NFPA 13 and NFPA 25. An interview was conducted with the Clinical Supervisor and maintenance personnel concurrent with the observations and confirmed the findings.

per NFPA 101 (2012 Edition) 4.6.12
per NFPA 99 (2012 Edition) 15.8.1.1
per NFPA 13 (2010 Edition) 6.2.9.7, 6.2.9.7.1 (1-4)

4) During the facility tour with the Clinical Supervisor and maintenance personnel on 06/19/2020 between 8:00 a.m. and 10:30 a.m. at the Johns Hopkins All Children's Outpatient Rehabilitation located in Lakeland, FL., the facility failed to provide a list of each type of sprinkler installed in the property per NFPA 13 and NFPA 25. An interview was conducted with the Clinical Supervisor and maintenance personnel concurrent with the observations and confirmed the findings.

per NFPA 101 (2012 Edition) 4.6.12
per NFPA 99 (2012 Edition) 15.8.1.1
per NFPA 13 (2010 Edition) 6.2.9.7, 6.2.9.7.1 (1-4)