HospitalInspections.org

The inspector observed, while accompanied by the Supervisor of Plant Operations during the hours of the inspection from 9:00 am to 11:30 am on 08/31/2022 that there were the following issues. Documentation was not available showing that Records are maintained of 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 authority having jurisdiction per NFPA 80, 2010, Ch. 5.2. A written record of the inspections and testing shall be signed and kept for inspection by the authority having jurisdiction. NFPA101, 7.2.1.15

The inspector observed, while accompanied by the Supervisor of Plant Operations during the hours of the inspection from 9:00 am to 11:30 am on 08/31/2022 that there were the following issues. In the emergency room janitor's closet, the following requirement was not being met for clearance under sprinkler heads. "The clearance between the deflector and the top of storage shall be 18 inches or greater." - NFPA 13, 2010: 8.5.6.1.

sss

The inspector observed, while accompanied by the Supervisor of Plant Operations during the hours of the inspection from 9:00 am to 11:30 am on 08/31/2022 that there were the following issues: Documentation was not available to review for flame spread ratings for Draperies, Curtains, and Loosely Hanging Fabrics.

The inspector observed, while accompanied by the Supervisor of Plant Operations during the hours of the inspection from 9:00 am to 11:30 am on 08/31/2022 that there were the following issues: Documentation was not available to review for flame spread ratings for Upholstered Furniture and Mattresses.

The inspector observed, while accompanied by the Supervisor of Plant Operations during the hours of the inspection from 9:00 am to 11:30 am on 08/31/2022 that there were the following issues. Documentation was not available showing that Records are maintained of Risk Assessment: Building System Categories Building systems are designed to meet Category 1 through 4 requirements as detailed in NFPA 99. Categories are determined by a formal and documented risk assessment procedure performed by qualified personnel, see Chapter 4 (NFPA 99). The facility must define its risk assessment methodology, implement the methodology, and document the results in relation to the risk categories contained in the NFPA99 Health Care Facilities Code. No particular risk assessment procedure is required. The facility will determined the procedure that most meets their needs within the requirement of the NFPA code. For additional information see the appendix of NFPA 99, A4.1 and A4.2.

The inspector observed, while accompanied by the Supervisor of Plant Operations during the hours of the inspection from 9:00 am to 11:30 am on 08/31/2022 that there were the following issues. Medical gas piping in the exterior medical gas room were not properly isolated from metallic clamps. "Hangers and supports shall comply with and be installed in accordance with MSS SP-58, Pipe Hangers and Supports - Materials, Design, Manufacture, Selection, Application, and Installation." - NFPA 99, 2012, 5.1.10.11.4.2

The inspector observed, while accompanied by the Supervisor of Plant Operations during the hours of the inspection from 9:00 am to 11:30 am on 08/31/2022 that there were the following issues. Items were improperly being stored in the electrical rooms per the following requirement. "Dedicated Equipment Space: All switchboards, panelboards, distribution boards, and motor control centers shall be located in dedicated spaces and protected from damage." - NFPA 70, 2012, 110.26(E)

The inspector observed, while accompanied by the Supervisor of Plant Operations during the hours of the inspection from 9:00 am to 11:30 am on 08/31/2022 that there were the following issues: Documentation was not available to review for the 36-month load bank test for 4 continuous hours.

Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions includes a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel.

The inspector observed, while accompanied by the Supervisor of Plant Operations during the hours of the inspection from 9:00 am to 11:30 am on 08/31/2022 that there were the following issues. The following required documentation was not available for review. Procedures are established for operating room emergencies including alarm activation, evacuation, equipment shutdown, and control operations. Emergency procedures include the control of chemical spills, and extinguishment of drapery, clothing and equipment fires. Training is provided to new OR personnel (including surgeons), continuing education is provided, incidents are reviewed monthly, and procedures are reviewed annually. 15.13 (NFPA 99)