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Based upon observations made in the presence of the plant manager on 08-27-2019, it was determined that the facility did not maintain the fire alarm system in accordance with NFPA 101 19.3.4.4, 9.6.5. And NFPA 72 Table 14.4.2.2.

This deficiency affected all smoke compartments.

Findings include:
1-During the record review the facility failed to provide the testing documentation that the (Emergency control functions) smoke damper operations had been tested annually with the initiating device that activates the damper. All inspections and testing shall be documented, indicating the location of the fire, fire smoke dampers, date(s) of inspection, name of inspector, and deficiencies discovered. The documentation shall have a space to indicate when and how the deficiencies were corrected in accordance with NFPA 80 19.3.4., NFPA 72 Table 14.4.2.2 and not in accordance with NFPA 19.5.2.1, 9.2 and NFPA 72 Table 14.4.2.2

K-345 Based upon record review made in the presence of the plant manager on 08-27-2019, it was determined that the facility did not maintain the fire alarm system in accordance with NFPA 101 9.6.1.3, 9.6.1.5.; and NFPA 72.

. This deficiency affected one of several of the required fire alarm system tests

Findings include:
During the record review the facility failed to provide documentation that the fire alarm control panel batteries had been tested under load two times in the last year. Batteries need to be tested semiannually in accordance with NFPA 101 19.3.4.1. & 9.6.1.1.; and NFPA 72 Table 14.4.5

K-0511 Based upon observations made in the presence of the plant manager on 08-27-2019, it was determined that the facility did not maintain electrical equipment in accordance with NFPA 101 19.5.1 and 9.1.2.

This deficiency affected 5 of several GFIC outlets.

Findings include
1-During the facility tour it was observed that the outlet at the outpatient clinic hand wash sink was not GFIC protected and were observed to be within 6ft of the sink. GFCI outlets are required where the receptacles are installed to serve the countertop surfaces and are located within 6 ft. (1.83 m) of the outside edge of the sink. NFPA 101 Section 19.5.1, 9.1.2; 1999 NFPA 70 Article 210-8(7)
2-During the facility tour it was observed that the outlet at the Pharmacy hand wash sink was not GFIC protected and were observed to be within 6ft of the sink. GFCI outlets are required where the receptacles are installed to serve the countertop surfaces and are located within 6 ft. (1.83 m) of the outside edge of the sink. NFPA 101 Section 19.5.1, 9.1.2; 1999 NFPA 70 Article 210-8(7)
3-During the facility tour in the Lab it was observed that there was 2 outlets that were not GFIC protected and were observed to be within 6ft of the sink. GFCI outlets are required where the receptacles are installed to serve the countertop surfaces and are located within 6 ft. (1.83 m) of the outside edge of the sink. NFPA 101 Section 19.5.1, 9.1.2; 1999 NFPA 70 Article 210-8(7)
4- During the facility tour it was observed that the outlet at the Radiology X ray room hand wash sink was not GFIC protected and were observed to be within 6ft of the sink. GFCI outlets are required where the receptacles are installed to serve the countertop surfaces and are located within 6 ft. (1.83 m) of the outside edge of the sink. NFPA 101 Section 19.5.1, 9.1.2; 1999 NFPA 70 Article 210-8(7)

Based upon made in the presence of the plant manager on 08-27-2019, it was determined that the facility did not install or maintain the buildings heating, ventilating and air conditioning systems in accordance with NFPA 101 19.5.2.1 and 9.2., NFPA 72 Table 14.4.2.2

This deficiency affected all fire/smoke dampers.

Findings include:
1-During the record review the facility failed to provide an itemized list fire/smoke damper locations and the tests that were performed with the specific damper. All inspections and testing shall be documented, indicating the location of the fire, fire/ smoke dampers, date(s) of inspection, name of inspector, and deficiencies discovered. The documentation shall have a space to indicate when and how the deficiencies were corrected in accordance with NFPA 80 19.3.4., NFPA 72 Table 14.4.2.2

Based upon observations made in the presence of the plant manager on 08-27-2019, it was determined that the facility did not test the Line Isolation Monitors in accordance with NFPA 99 6.3.4.1.4, 6.3.3.3.2

The deficiency affected the line isolation monitor.

Findings include:
1-During the document review it discovered that there was no tests being performed on the Line Isolation Monitor circuits. .Line Isolation Monitors shall be tested at intervals of not more than 1 month by actuating the LIM test switch (see 6.3.2.6.3.6).
For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months. Actuation of the test switch shall activate both visual and audible alarm indicators. And not in accordance with NFPA 99 6.3.4.1.4

K-918 Based upon record review made in the presence of the plant manager on 08-27-2019, it was determined that the facility did not maintain, inspect and exercise the facilities emergency generator set in accordance with NFPA 99 6.4.4 and NFPA 110 8.4.2.3.

This deficiency affected one of the required tests.

Findings include:
1-During the record review the facility failed to provide documentation that the Maintenance of the generator batteries had been conducted. Maintenance of Lead-acid batteries shall include the monthly testing and recording of electrolyte specific gravity. Battery conductance testing shall be permitted in lieu of the testing of specific gravity when applicable or warranted in accordance with NFPA 110 8.3, 8.3.7