HospitalInspections.org

Spare Sprinkler Heads:

"A supply of at least six spare sprinklers (never fewer than six) shall be maintained on the premises so that any sprinklers that have operated or been damaged in any way can be promptly replaced." - NFPA 13, 2010, 6.2.9.1* ("A minimum of two sprinklers of each type and temperature rating should be provided." A.6.2.9.1)
"One sprinkler wrench as specified by the sprinkler manufacturer shall be provided in the cabinet for each type of sprinkler installed to be used for the removal and installation of sprinklers in the system." - NFPA 13, 2010, 6.2.9.6

Based on observation the facility failed to provide adequate fire protection.

The inspector observed, while accompanied by the Chief Executive Officer (CEO), Assistant Chief Nursing Officer (ACNO), EVS Manager, Quality Manager, Electrician and Maintenance Technicians during the hours of the inspection from 1:30 pm am to 7:30 pm on 8/06/2019 that there were:

1. There were three types of sprinkler heads in use in the facility but there were less than six spares heads of each of the three
types in the red box in the riser room. Ensure that each head type has six spares.
2. There was only one sprinkler wrench in the red box. There shall be three sprinkler wrenches.

Tennant Separation Walls:

"Health care facilities shall be separated from other tenants and occupancies and shall meet all of the following requirements:

(1) Walls shall have not less than a 1-hours fire resistance rating and shall extend from the floor slab below to the floor or roof
slab above.
(2) Doors shall be constructed of not less than 1 ¾ inch, solid-bonded wood core or the equivalent and shall be equipped with
positive latches.
(3) Doors shall be self-closing and shall be kept in the closed position, except when in use.
(4) Any windows in the barriers shall be of fixed fire window assemblies in accordance with Section 8.3." - NFPA 101, 2012,
21.3.7.1.
"Openings required to have a fire protection rating by Table 8.3.4.2 shall be protected by approved, listed, labeled fire door assemblies and fire window assemblies and their accompanying hardware, including all frames, closing devices, anchorage, and sills in accordance with the requirements of NFPA 80, Standard for Fire Doors and Other Opening Protectives, except as otherwise specified in this Code." - NFPA 101, 2012, 8.3.3.1.


Based on observation the facility failed to provide adequate fire protection.

The inspector observed, while accompanied by the Chief Executive Officer (CEO), Assistant Chief Nursing Officer (ACNO), EVS Manager, Quality Manager, Electrician and Maintenance Technicians during the hours of the inspection from 1:30 pm am to 7:30 pm on 8/06/2019 that in the Medical gas room there were:

1. The fire stop caulking material used could not be validated as 1-hr fire rated.
2. There were openings around the pipes passage that were not caulked.

Emergency Shutoff:

"Each air distribution system shall be provided with at least one manually operable means for stopping the operation of the supply, return, and exhaust fan(s) in an emergency. The means of manual operation shall be located at an approved location." NFPA 90A, 2012, 6.2.1 & 6.2.2. The emergency stop or kill switch is typically a red "mushroom" button at a nurse station. There may be one switch for each air handler or one switch that shuts down multiple the air handlers.

Based on observation the facility failed to provide adequate emergency system.

The inspector observed, while accompanied by the Chief Executive Officer (CEO), Assistant Chief Nursing Officer (ACNO), EVS Manager, Quality Manager, Electrician and Maintenance Technicians during the hours of the inspection from 1:30 pm am to 7:30 pm on 8/06/2019 that there were eight Roof Top Units (RTUs) serving the facility but only three kill Switches. Ensure that each kill switch is labelled to match the unit or units it controls and ensure that the kill switches are located around the nurse stations.

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), Assistant Chief Nursing Officer (ACNO), EVS Manager, Quality Manager, Electrician and Maintenance Technicians during the hours of the inspection from 1:30 pm am to 7:30 pm on 8/06/2019 that there was no record of the monthly pressure drops across the filters in the air handling units and the maintenance schedule for the filter change was not documenting the type of filters being changed.

Mechanical Ventilation

9.3.7.5.3.1? Mechanical exhaust to maintain a negative pressure in the space shall be provided continuously, unless an alternative design is approved by the authority having jurisdiction.
9.3.7.5.3.2? Mechanical exhaust shall be at a rate of 1 L/sec of airflow for each 300 L (1 cfm per 5 ft3 of fluid) designed to be stored in the space and not less than 24 L/sec (50 cfm) nor more than 235 L/sec (500 cfm).
9.3.7.5.3.3? Mechanical exhaust inlets shall be unobstructed and shall draw air from within 300 mm (1 ft) of the floor and adjacent to the cylinder or containers.
9.3.7.5.3.4? Mechanical exhaust air fans shall be supplied with electrical power from the essential electrical system.
9.3.7.5.3.5? Dedicated exhaust systems shall not be required, provided that the system does not connect to spaces that contain combustible or flammable materials.


Based on observation the facility failed to provide adequate mechanical ventilation.in the medical gas storage room.

The inspector observed, while accompanied by the Chief Executive Officer (CEO), Assistant Chief Nursing Officer (ACNO), EVS Manager, Quality Manager, Electrician and Maintenance Technicians during the hours of the inspection from 1:30 pm am to 7:30 pm on 8/06/2019 that in the Medical gas room, the mechanical ventilating systems was not working.

Essential Electrical System Segregation (Life Safety):

"The essential electrical system shall be divided into the following three branches: (1) Life safety, (2) Critical, (3) Equipment." NFPA 99, 2012, 6.4.2.2.1.1.

6.4.2.2.3 Life Safety Branch.
6.4.2.2.3.1 The life safety branch shall be limited to circuits essential to life safety.

6.4.2.2.3.2 "The life safety branch shall supply power for lighting, receptacles, and equipment as follows:
(1) Illumination of means of egress in accordance with 101, Life Safety Code,
(2) Exit signs and exit directional signs in accordance with NFPA 101, Life Safety Code,
(3) Hospital communications systems, where used for issuing instruction during emergency conditions,
(4) Generator set locations as follows:
(a) Task illumination,
(b) Battery charger for emergency battery-powered lighting unit(s),
(c) Select receptacles at the generator set location and essential electrical system transfer switch locations,
(5) Elevator cab lighting, control, communications, and signal systems,
(6) Electrically powered doors used for building egress,
(7) Fire alarms and auxiliary functions of fire alarm combination systems complying with NFPA 72, National Fire Alarm and Signaling Code."

6.4.2.2.3.3 "Alarm and alerting systems (other than fire alarm systems) shall be connected to the life safety branch or critical branch."

6.4.2.2.3.4 "Loads dedicated to a specific generator, including the fuel transfer pump(s), ventilation fans, electrically operated louvers, controls, cooling system, and other generator accessories essential for generator operation, shall be connected to the life safety branch or the output terminals of the generator with overcurrent protective devices."

6.4.2.2.3.5 "No functions other than those in 6.4.2.2.3.2, 6.4.2.2.3.3, and 6.4.2.2.3.4 shall be connected to the life safety branch, except as specifically permitted in 6.4.2.2.3."


Based on observation the facility failed to provide adequate essential electrical system.


The inspector observed, while accompanied by the Chief Executive Officer (CEO), Assistant Chief Nursing Officer (ACNO), EVS Manager, Quality Manager, Electrician and Maintenance Technicians during the hours of the inspection from 1:30 pm am to 7:30 pm on 8/06/2019 that the Life Safety Panel had circuit breakers that were not required to be on Life Safety panel.

Essential Electrical System Segregation (Critical):

6.4.2.2.4.2 The critical branch shall supply power for task illumination, fixed equipment, select receptacles, and select power circuits serving the following areas and functions related to patient care:

(1) Critical care areas that utilize anesthetizing gases, task illumination, select receptacles, and fixed equipment
(2) Isolated power systems in special environments
(3) Task illumination and select receptacles in the following:
(a) Patient care rooms, including infant nurseries, selected acute nursing areas, psychiatric bed areas (omit receptacles), and ward treatment rooms
(b) Medication preparation areas
(c) Pharmacy dispensing areas
(d) Nurses' stations (unless adequately lighted by corridor luminaires)
(4) Additional specialized patient care task illumination and receptacles, where needed
(5) Nurse call systems
(6) Blood, bone, and tissue banks
(7) Telephone equipment rooms and closets
(8) Task illumination, select receptacles, and select power circuits for the following areas:
(a) General care beds with at least one duplex receptacles per patient bedroom, and task illumination as required by the governing body of the health care facility
(b) Angiographic labs
(c) Cardiac catheterization labs
(d) Coronary care units
(e) Hemodialysis rooms or areas
(f) Emergency room treatment areas (select)
(g) Human physiology labs
(h) Intensive care units
(i) Postoperative recovery rooms (select)
(9) Additional task illumination, receptacles, and select power circuits needed for effective facility operation, including single-phase fractional horsepower motors, which are permitted to be connected to the critical branch


Based on observation the facility failed to provide proper circuits on the essential electrical system.


The inspector observed, while accompanied by the Chief Executive Officer (CEO), Assistant Chief Nursing Officer (ACNO), EVS Manager, Quality Manager, Electrician and Maintenance Technicians during the hours of the inspection from 1:30 pm am to 7:30 pm on 8/06/2019 that there were:
1. There were some circuit breakers in the critical panel that ought to be on the Equipment panel. Ensure that these circuits are moved to the correct branch.
2. Some care area receptacles were shown or connected to critical panel. Verify and make the corrections.

Panel directory:
"Circuit Directory or Circuit Identification. Every circuit and circuit modification shall be legibly identified as to its clear, evident, and specific purpose or use. The identification shall include sufficient detail to allow each circuit to be distinguished from all others. Spare positions that contain unused overcurrent devices or switches shall be described accordingly. The identification shall be included in a circuit directory that is located on the face or inside of the panel door in the case of a panelboard, and located at each switch or circuit breaker in a switchboard. No circuit shall be described in a manner that depends on transient conditions of occupancy." - NFPA 70, 2011, 408.4 (A) Note: Labeling includes all disconnecting means, see 110.22.

Based on observation the facility failed to provide adequate panel board directories.

The inspector observed, while accompanied by the Chief Executive Officer (CEO), Assistant Chief Nursing Officer (ACNO), EVS Manager, Quality Manager, Electrician and Maintenance Technicians during the hours of the inspection from 1:30 pm am to 7:30 pm on 8/06/2019 that the critical and life safety panel were not populated correctly.

Panelboard Bonding:

"Panelboard Bonding. The equipment grounding terminal buses of the normal and essential branch-circuits panelboards serving the same individual patient vicinity shall be connected together with an insulated continuous copper conductor not smaller than # 10 AWG." - NFPA 70, 2011: 517-14.

Based on observation the facility failed to provide adequate safety for Essential Electrical System.

The inspector observed, while accompanied by the Chief Executive Officer (CEO), Assistant Chief Nursing Officer (ACNO), EVS Manager, Quality Manager, Electrician and Maintenance Technicians during the hours of the inspection from 1:30 pm am to 7:30 pm on 8/06/2019 that the facility could not demonstrate to the satisfaction of the inspector that the EPSS critical panel was bonded to the normal branch. Provide evidence that the EPSS critical panel is bonded to the Normal branch.

Based on observation the facility failed to provide adequate risk assessment for all the operating rooms.

The inspector observed, while accompanied by the Chief Executive Officer (CEO), Assistant Chief Nursing Officer (ACNO), EVS Manager, Quality Manager, Electrician and Maintenance Technicians during the hours of the inspection from 1:30 pm am to 7:30 pm on 8/06/2019 that risk assessment was not performed by the governing body to determine if the Operating rooms were wet or dry locations. If determined to be wet, they shall be protected by line isolation monitors or GFCIs.

Based on observation the facility failed to provide adequate inspection of the electrical system.

The inspector observed, while accompanied by the Chief Executive Officer (CEO), Assistant Chief Nursing Officer (ACNO), EVS Manager, Quality Manager, Electrician and Maintenance Technicians during the hours of the inspection from 1:30 pm am to 7:30 pm on 8/06/2019 that there were the following issues:

1. There were no records of testing data and test interval of the patient care area receptacles as defined by Documented Performance
Data.
2. The Line Isolation Monitor was not being tested monthly or annually per the code.
3. There were no records of where, type of repair performed and date of electrical maintenance and required tests performed in all the
patient care areas.

Based on observation the facility failed to provide all the required documentation for the essential electrical system maintenance.

The inspector observed, while accompanied by the Chief Executive Officer (CEO), Assistant Chief Nursing Officer (ACNO), EVS Manager, Quality Manager, Electrician and Maintenance Technicians during the hours of the inspection from 1:30 pm am to 7:30 pm on 8/06/2019 that there were the following issues. They were:

1. The weekly inspections were not being properly performed as the record did not document all the required elements of the
weekly inspections as required by the code.
2. There was no record of the main and feeder circuit breakers being inspected annually.
3. There were no written records of maintenance and testing kept.

Generator Remote Manual Stop:

"All installations shall have a remote manual stop station of a type to prevent inadvertent or unintentional operation located outside the room housing the prime mover, where so installed, or elsewhere on the premises where the prime mover is located outside the building" - NFPA 110, 2010, 5.6.5.6* Note: "For systems located outdoors, the manual shutdown should be located external to the weatherproof enclosure and should be appropriately identified." A.5.6.5.6.


Based on observation the facility failed to provide remote emergency generator shut down button.

The inspector observed, while accompanied by the Chief Executive Officer (CEO), Assistant Chief Nursing Officer (ACNO), EVS Manager, Quality Manager, Electrician and Maintenance Technicians during the hours of the inspection from 1:30 pm am to 7:30 pm on 8/06/2019 that there was no remote shutdown switch for the generator. Provide easily accessible remote shutdown switch for the generator.

Based on observation the facility failed to provide adequate biomedical electrical maintenance and inspection reports.

The inspector observed, while accompanied by the Chief Executive Officer (CEO), Assistant Chief Nursing Officer (ACNO), EVS Manager, Quality Manager, Electrician and Maintenance Technicians during the hours of the inspection from 1:30 pm am to 7:30 pm on 8/06/2019 that there were the following issues:

1. The facility was not keeping records of electrical equipment tests, repairs and modifications to demonstrate compliance in
accordance with the facility policy.
2. There were no records of personnel training or continuing education on the personnel responsible for equipment test and
maintenance in the facility.

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

The inspector observed, while accompanied by the Chief Executive Officer (CEO), Assistant Chief Nursing Officer (ACNO), EVS Manager, Quality Manager, Electrician and Maintenance Technicians during the hours of the inspection from 1:30 pm am to 7:30 pm on 8/06/2019 that the facility had no scheduled maintenance program for medical gas equipment

Based on observation the facility failed to provide adequate fire loss prevention.

The inspector observed, while accompanied by the Chief Executive Officer (CEO), Assistant Chief Nursing Officer (ACNO), EVS Manager, Quality Manager, Electrician and Maintenance Technicians during the hours of the inspection from 1:30 pm am to 7:30 pm on 8/06/2019 that there was no established procedure for operating room emergencies.