HospitalInspections.org

Door Inspections:

Fire-rated door assemblies and certain other doors in the means of egress shall be tested annually or per an accepted performance-based evaluation schedule approved by the AHJ per NFPA 80, 2010, Ch. 5.2. A written record of the inspections and testing shall be signed and kept for inspection by the AHJ. NFPA101, 7.2.1.15.

Based on observation the facility failed to maintain properly all the doors along the means of egress.

The inspector observed, while accompanied by the Chief Executive Officer (CEO) and Director of facility Management (DFM) during the hours of the inspection from 10:00 am to 4:00 pm on 10/12/2022 that fire rated doors along the means of egress were inspected annually however, there was no record of repairs performed on the doors identified as defective during inspections.

SMOKE BARRIER DOORS

Smoke barrier doors shall be a minimum of 1 3/4" thick, solid-bonded wood core or equivalent with self-closing or automatic-closing devices in accordance with 21.2.2.4. Latching hardware is not required. Doors are required to swing in the direction of egress travel. Rabbets, bevels, or astragals are at meeting edges, and stops are at the head and sides of door frames. Center mullions are prohibited in smoke barrier door openings 20.3.7.9, 20.3.7.10, 20.3.7.13, 20.3.7.14

Based on observation the facility failed to provide adequate smoke barrier doors.

The inspector observed, while accompanied by the Chief Executive Officer (CEO) and Director of facility Management (DFM) during the hours of the inspection from 10:00 am to 4:00 pm on 10/12/2022 that there were many double egress doors without astragal. Provide astragals on these doors for optimal smoke infiltration protection.

Final filters and Frames:

Final filters and filter frames should be visually inspected for pressure drop and for bypass monthly. Filters should be replaced based on pressure drop or maintenance schedule with filters that provide the efficiencies specified. (ASHRAE 170, Informative Appendix A, Operations and Maintenance Procedures.) A log of filter replacements should be maintained for each air handler.


Based on observation the facility failed to provide adequate monthly pressure drop records.

The inspector observed, while accompanied by the Chief Executive Officer (CEO) and Director of facility Management (DFM) during the hours of the inspection from 10:00 am to 4:00 pm on 10/12/2022 that there was no record or logs of each air handler showing dates when the final filters, pre-filters have been replaced with the pressure differential across the filter before and after replacement where differential pressure monitors are required.

Based on observation the facility failed to provide a risk assessment for the medical gas system.

The inspector observed, while accompanied by the Plant Services Officer, Market Facilities Compliance Officer, Plant Manager, Associate Vice President (AVP) Regulatory and Director of Quality & Patient Safety during the hours of the inspection from 12:00 pm to 5:00 pm on 9/19/2022 that the facility had not done a risk assessment to determine the procedures and schedule for testing the medical gas system.

Essential Electrical System Segregation (Critical Branch)

"General Care Areas. Patient Bed Location. Each patient bed location shall be supplied by at least two branch circuits, one from the emergency system and one from the normal system all Branch circuits from the normal system shall originate in the same panelboard." NFPA 70, 2011, 517.18(A)

Patient Bed Location Receptacles. Each patient bed location shall be provided with a minimum of four receptacles. They shall be permitted to be of the single, duplex, or quadruplex type, or any combination of the three. All receptacles, whether four or more, shall be listed "hospital grade" and so identified. The grounding terminal of each receptacle shall be connected to an insulated copper equipment grounding conductor sized in accordance with Table 250.122.

Exception No. 1: The requirements of 517.18(B) shall not apply to psychiatric, substance abuse, and rehabilitation hospitals meeting the requirement of 517.18(B)(2).

Exception No. 2: Psychiatric security rooms shall not be required to have receptacle outlets installed in the room.

Informational Note: It is not intended that there be a total, immediate replacement of existing non-hospital grade receptacles. It is intended, however, that non-hospital grade receptacles be replaced with hospital grade receptacles upon modification of use, renovation, or as existing receptacles need replacement." NPFA 70, 2011, 517.18(B)

Based on observation the facility failed to provide lights from critical branch lights to all the patient care areas and receptacles powered from critical branch.

The inspector observed, while accompanied by the Chief Executive Officer (CEO) and Director of facility Management (DFM) during the hours of the inspection from 10:00 am to 4:00 pm on 10/12/2022 that there were:
1. The imaging department had no lights, or any receptacle powered from the Critical branch. This is a patient care area as
such, it shall have all the lights and select receptacles powered from critical branch.
2. The Decontamination room/Sterilization room had no light on critical branch.
3. Pulmonary room, the restroom light was on normal power. The light shall be on critical branch.
4. Draw room/Drug Screen restroom light on normal power. The light shall be on critical branch.
5. Lab receiving room, the light was on normal power. The light shall be on critical power
6. Emergency Department Decontamination room light was on normal power. The light shall be on critical branch.
7. Emergency department, waiting area lights were on normal power. The lights shall be on critical power.
8. Assisted bathing room light was on normal power. The light shall be on critical branch.

Based on observation the facility failed to provide adequate maintenance and testing of Essential Electrical System.

The inspector observed, while accompanied by the Chief Executive Officer (CEO) and Director of facility Management (DFM) during the hours of the inspection from 10:00 am to 4:00 pm on 10/12/2022 that there were the following issues:
1. That additional testing was not being performed correctly in terms of referencing each receptacle to the different tests performed on
the particular receptacle in the patient care area at intervals defined by documented performance data on all the patient care
receptacles. The testing record shall be such that each area and receptacles tested must be identified.
2. Records of where, type of repairs performed and date of electrical maintenance and required tests performed in all the patient care
areas.

Based on observation the facility failed to provide adequate maintenance and testing of Essential Electrical System.

The inspector observed, while accompanied by the Chief Executive Officer (CEO) and Director of facility Management (DFM) during the hours of the inspection from 10:00 am to 4:00 pm on 10/12/2022 that there were the following issues:

1. The generator weekly inspection was not being done correctly.
2. The monthly generator load test was not being performed correctly.
3. The 36-month load bank test was not being performed correctly.
4. The main and feeder circuit breakers were not being inspected annually and there was no program for periodically exercising
the components.
5. There were no records of maintenance and testing maintained.

Based on observation the facility failed to provide adequate medical gas equipment testing.

The inspector observed, while accompanied by the Chief Executive Officer (CEO) and Director of facility Management (DFM) during the hours of the inspection from 10:00 am to 4:00 pm on 10/12/2022 that the facility had no scheduled maintenance program for medical gas equipment.