HospitalInspections.org

Based on observations, the facility failed to provide a one half hour rating in accordance with NFPA 101 sections 8.3, 19.3.7.3, and 19.3.7.6. The deficient practice affected two (2) of two (2) smoke compartments in the facility on the day of the survey.
Findings Include:
On 2-1-18 at 11:25 AM, observation revealed openings and unsealed penetrations throughout the single smoke barrier wall constructed in the hospital.
The finding was acknowledged by the Administrator and Maintenance Director verified this observation during the exit interview on 2-1-18.

Based on the review of documentation, the facility failed to properly inspect and do preventive maintenance of the generator as directed by NFPA 99 sections 6.4.4.1.1.3 and 6.4.4.2. These deficient practices have the potential of affecting the entire facility on the day of survey.
Findings include:
On 2-1-18 at 10:45 AM, the facility could not produce documentation showing current annual testing of the generator over the last 12 months. The last annual test of the generator dated was 01-26-17. The facility also could provide the weekly inspection and monthly load test for the generator over the last 12 months.
The findings were acknowledged by the Administrator and the Maintenance Director verified this observation during the exit interview on 2-1-18.