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FOUNDATION SURGICAL HOSPITAL OF SAN ANTONIO
No Description Available
Tag No.: K0052
Based on observations made during the survey of the facility between the hours of 12:30 pm and 5:00 pm, while accompanied by the Facility Manager and Chief of Nursing it was observed that the facility failed to provide a log indicating compliance with requirement for monthly testing by staff of the fire alarm system and its automatic signal response. Additionally, while it appeared that the facility had accomplished yearly inspections, their documentation was incomplete, and not logged in a systematic fashion.
No Description Available
Tag No.: K0130
Based on observations made during the survey of the facility between the hours of 12:30 pm and 5:00 pm, while accompanied by the Facility Manager and Chief of Nursing it was observed that the facility failed to provide the following:
1. The required smoke detectors for the supply and return air sides of the air handling units could not be located. Additionally for the AHU #4 the required smoke detector for the fresh air intake also could not be located. The fresh air intake detector is required because this air handling unit serves the O.R. which has a requirement for a smoke evacuation system.
(Re: NFPA 90A - INSTALLATION OF AIR-CONDITIONING AND VENTILATING SYSTEMS)
2. At cross-corridor doors in partitions dividing Smoke Compartments there were no smoke detectors located at the egress corridor ceiling within 5 feet of the doors. Because of the high corridor ceilings on both sides of the dividing partition it is required to have a smoke detector in both corridors.
(Re: NFPA 72, 2002: 5.14.6.5.1.3)
3. Provision for "no storage" within 18 inches of the fire sprinklers at the ceiling is not in compliance at the JANITOR CLOSET (across from Dining), and at the small CLOSET located in the MAIN OFFICE for Administration.
(Re: NFPA 13, 2002: 8.5.6.1. " A minimum clearance of 18 inches shall be maintained between the top of storage and sprinkler deflectors ... " )
4. While it appeared that filters were changed, there was no Air filter change log.
5. Electrical equipment inspections - Biomedical.
Critical Areas: Semi-annually.
General Areas: Annually
6. Electrical power and distribution and grounding systems - Effectiveness.
Critical Areas: Semi-annually.
General Areas: Annually
LIFE SAFETY CODE STANDARD
Tag No.: K0052
Based on observations made during the survey of the facility between the hours of 12:30 pm and 5:00 pm, while accompanied by the Facility Manager and Chief of Nursing it was observed that the facility failed to provide a log indicating compliance with requirement for monthly testing by staff of the fire alarm system and its automatic signal response. Additionally, while it appeared that the facility had accomplished yearly inspections, their documentation was incomplete, and not logged in a systematic fashion.
LIFE SAFETY CODE STANDARD
Tag No.: K0130
Based on observations made during the survey of the facility between the hours of 12:30 pm and 5:00 pm, while accompanied by the Facility Manager and Chief of Nursing it was observed that the facility failed to provide the following:
1. The required smoke detectors for the supply and return air sides of the air handling units could not be located. Additionally for the AHU #4 the required smoke detector for the fresh air intake also could not be located. The fresh air intake detector is required because this air handling unit serves the O.R. which has a requirement for a smoke evacuation system.
(Re: NFPA 90A - INSTALLATION OF AIR-CONDITIONING AND VENTILATING SYSTEMS)
2. At cross-corridor doors in partitions dividing Smoke Compartments there were no smoke detectors located at the egress corridor ceiling within 5 feet of the doors. Because of the high corridor ceilings on both sides of the dividing partition it is required to have a smoke detector in both corridors.
(Re: NFPA 72, 2002: 5.14.6.5.1.3)
3. Provision for "no storage" within 18 inches of the fire sprinklers at the ceiling is not in compliance at the JANITOR CLOSET (across from Dining), and at the small CLOSET located in the MAIN OFFICE for Administration.
(Re: NFPA 13, 2002: 8.5.6.1. " A minimum clearance of 18 inches shall be maintained between the top of storage and sprinkler deflectors ... " )
4. While it appeared that filters were changed, there was no Air filter change log.
5. Electrical equipment inspections - Biomedical.
Critical Areas: Semi-annually.
General Areas: Annually
6. Electrical power and distribution and grounding systems - Effectiveness.
Critical Areas: Semi-annually.
General Areas: Annually