HospitalInspections.org

The inspector observed, while accompanied by the Plant Operations Manager during the hours of the inspection from 9:00 am to 11:30 am on 03/04/2015 that there were the following issues. They were: T smoke barrier double doors, located between the hospital and the clinic, did not latch properly when allowed to self-close.
The smoke barrier double doors, near the Medical Room, did not latch properly when allowed to self-close and they need an astragal.

Door openings in smoke barriers have at least a 20 minute fire protection rating or are at least 13/4 inch thick solid bonded core wood. Non-rated protective plates that do not exceed 48 inches from the bottom of the door are permitted. Horizontal sliding doors comply with 7.2.1.14. Swinging doors shall be arranged so that each door swings in an opposite direction. Doors shall be self-closing and rabbets, bevels or astragals are required at the meeting edges. Positive latching is not required. 18.3.7.5, 18.3.7.6, 18.3.7.8

The inspector observed, while accompanied by the Plant Operations Manager during the hours of the inspection from 9:00 am to 11:30 am on 03/04/2015 that there were the following issues. They were: The FACP breaker in the LS panel box was not marked in red.

" A dedicated electrical circuit to the life safety branch of the EES shall be provided. The circuit shall be identified with a red marking and identified as "FIRE ALARM CIRCUIT CONTROL". - NFPA 72, 1999: 1-5.2.5.2.

The inspector observed, while accompanied by the Plant Operations Manager during the hours of the inspection from 9:00 am to 11:30 am on 03/04/2015 that there were the following issues. They were: The nitrous gas storage tanks were in an area open, to inclement temperatures. Nocona Texas is far enough north such that these tanks must be protected from freezing.

The inspector observed, while accompanied by the Plant Operations Manager during the hours of the inspection from 9:00 am to 11:30 am on 03/04/2015 that there were the following issues. They were: Electrical power distribution and grounding system testing logs were not available for inspection at time of survey.

Receptacle Testing in Patient Care Areas - NFFA 99, 1999, 3-3.3.3

(a) The physical integrity of each receptacle shall be confirmed by visual inspection.
(b) The continuity of the grounding circuit in each electrical receptacle shall be verified.
(c) Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.
(d) The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz).

NFPA 99, 1999, 3-3.4.2.3(a) states that testing shall be performed after initial installation, replacement or servicing of a device, and that additional testing shall be performed at intervals defined by documented performance data in patient care areas. Since this data is not typically available and practical to use, testing once per year in all patient care areas is acceptable.

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HVAC Filter Change Logs.

The inspector observed, while accompanied by the Plant Operations Manager during the hours of the inspection from 9:00 am to 11:30 am on 03/04/2015 that there were the following issues. They were: Air filter change logs were not available for inspection at time of survey.

The inspector observed, while accompanied by the Plant Operations Manager during the hours of the inspection from 9:00 am to 11:30 am on 03/04/2015 that there were the following issues. They were: Generator full-load testing logs were not available for inspection at time of survey.

Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
The date and time of day for required testing shall be decided by the owner, based on facility operations.
6-4.2.1
Equivalent loads used for testing shall be automatically replaced with the emergency loads in case of failure of the primary source.
6-4.2.2
Diesel-powered EPS installations that do not meet the requirements of 6-4.2 shall be exercised monthly with the available EPSS load and exercised annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of 2 continuous hours. (Categorical Waiver for this see below)
6-4.3
Load tests of generator sets shall include complete cold starts.
6-4.4
Time delays shall be set as follows:
(a) Time delay on start: 1 second minimum
Exception: Gas turbine cycle: 0.5 second minimum.
(b) Time delay on transfer to emergency: no minimum required
(c) Time delay on restoration to normal: 5 minutes minimum (see A-4-2.4.7)
(d) Time delay on shutdown: 5 minutes minimum

The inspector observed, while accompanied by the Plant Operations Manager during the hours of the inspection from 9:00 am to 11:30 am on 03/04/2015 that there were the following issues. They were: T smoke barrier double doors, located between the hospital and the clinic, did not latch properly when allowed to self-close.
The smoke barrier double doors, near the Medical Room, did not latch properly when allowed to self-close and they need an astragal.

Door openings in smoke barriers have at least a 20 minute fire protection rating or are at least 13/4 inch thick solid bonded core wood. Non-rated protective plates that do not exceed 48 inches from the bottom of the door are permitted. Horizontal sliding doors comply with 7.2.1.14. Swinging doors shall be arranged so that each door swings in an opposite direction. Doors shall be self-closing and rabbets, bevels or astragals are required at the meeting edges. Positive latching is not required. 18.3.7.5, 18.3.7.6, 18.3.7.8

The inspector observed, while accompanied by the Plant Operations Manager during the hours of the inspection from 9:00 am to 11:30 am on 03/04/2015 that there were the following issues. They were: The FACP breaker in the LS panel box was not marked in red.

" A dedicated electrical circuit to the life safety branch of the EES shall be provided. The circuit shall be identified with a red marking and identified as "FIRE ALARM CIRCUIT CONTROL". - NFPA 72, 1999: 1-5.2.5.2.

The inspector observed, while accompanied by the Plant Operations Manager during the hours of the inspection from 9:00 am to 11:30 am on 03/04/2015 that there were the following issues. They were: The nitrous gas storage tanks were in an area open, to inclement temperatures. Nocona Texas is far enough north such that these tanks must be protected from freezing.

The inspector observed, while accompanied by the Plant Operations Manager during the hours of the inspection from 9:00 am to 11:30 am on 03/04/2015 that there were the following issues. They were: Electrical power distribution and grounding system testing logs were not available for inspection at time of survey.

Receptacle Testing in Patient Care Areas - NFFA 99, 1999, 3-3.3.3

(a) The physical integrity of each receptacle shall be confirmed by visual inspection.
(b) The continuity of the grounding circuit in each electrical receptacle shall be verified.
(c) Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.
(d) The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz).

NFPA 99, 1999, 3-3.4.2.3(a) states that testing shall be performed after initial installation, replacement or servicing of a device, and that additional testing shall be performed at intervals defined by documented performance data in patient care areas. Since this data is not typically available and practical to use, testing once per year in all patient care areas is acceptable.

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HVAC Filter Change Logs.

The inspector observed, while accompanied by the Plant Operations Manager during the hours of the inspection from 9:00 am to 11:30 am on 03/04/2015 that there were the following issues. They were: Air filter change logs were not available for inspection at time of survey.

The inspector observed, while accompanied by the Plant Operations Manager during the hours of the inspection from 9:00 am to 11:30 am on 03/04/2015 that there were the following issues. They were: Generator full-load testing logs were not available for inspection at time of survey.

Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
The date and time of day for required testing shall be decided by the owner, based on facility operations.
6-4.2.1
Equivalent loads used for testing shall be automatically replaced with the emergency loads in case of failure of the primary source.
6-4.2.2
Diesel-powered EPS installations that do not meet the requirements of 6-4.2 shall be exercised monthly with the available EPSS load and exercised annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of 2 continuous hours. (Categorical Waiver for this see below)
6-4.3
Load tests of generator sets shall include complete cold starts.
6-4.4
Time delays shall be set as follows:
(a) Time delay on start: 1 second minimum
Exception: Gas turbine cycle: 0.5 second minimum.
(b) Time delay on transfer to emergency: no minimum required
(c) Time delay on restoration to normal: 5 minutes minimum (see A-4-2.4.7)
(d) Time delay on shutdown: 5 minutes minimum