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Observation and discussion with the Director of Plant Operations between 9:00 am and 3:00 pm on 9/8/2011 revealed that certain requirements stipulated in NFPA 101 were not met.

Corridor walls shall form a barrier to limit the transfer of smoke [Re: NFPA 101, Life Safety Code, 2000: ? 19.3.6.2.2.]

Findings: The corridor wall [rated wall separation] outside the chapel above the dropped ceiling had conduit penetrations through the wall that were not sealed properly. Similarly, above the double doors outside rooms 112A and 112B the wall had penetrations that were not sealed properly. The facility shall affirm that all penetrations have been caulked properly.

Observation and discussion with the Director of Plant Operations between 9:00 am and 3:00 pm on 9/8/2011 revealed that certain requirements stipulated in NFPA 72 were not met.

a. Supervisory Signal Devices

Supervisory signal devices shall be exercised quarterly [Re: NFPA 72, National Fire Alarm Code, 2002: ? 7-3.2 and Table 7-3.2(15)(j).]

Findings: The staff was not able to confirm that these required tests were conducted. The facility shall ensure that this requirement is met.

b. Waterflow Device/Switches

Waterflow devices shall be exercised semi-annually [Re: NFPA 72, National Fire Alarm Code, 2002: ? 7-3.2 and Table 7-3.2(15)(k).] Valve tamper switches shall be exercised semi-annually [Re: NFPA 72, National Fire Alarm Code, 2002: ? 7-3.2 and Table 7-3.2(15)(l).]

Findings: The staff was not able to confirm that these required tests were conducted. The facility shall ensure that this requirement is met.

Observation and discussion with the Director of Plant Operations between 9:00 am and 3:00 pm on 9/8/2011 revealed that certain requirements stipulated in NFPA 90A were not met.

Air filters shall be rated either as Class 1 or Class 2 in accordance with UL 900, Standard for Safety Air Filter Units [Re: NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, 1999: ?2-2.2.2.]

Findings: Observation of the RTU serving the ED revealed that one of the secondary filters was not installed, thereby negating any filter action for the ED.

Observation and discussion with the Director of Plant Operations between 9:00 am and 3:00 pm on 9/8/2011 revealed that certain requirements stipulated in NFPA 90A were not met.

a. Hood Extinguisher System

The fire extinguishing system for the kitchen hood shall be inspected and serviced every 6 months by a properly trained and qualified person [Re: NFPA 96, Kitchen Equipment: 2002:?11.2.1.]

Findings: The facility performed this service annually which does not meet the requirement.

b. Class K Extinguisher

The Class K Fire extinguisher [installed after 6/30/1998] shall have a placard placed nearby conspicuously to read " fire protection system shall be activated prior of using fire extinguisher " [Re: NFPA 10, Standard for Portable Fire Extinguishers, 2001: ?4.3.2.2.]

Findings: The placard was not in place near the fire extinguisher.

Observation and discussion with the Director of Plant Operations between 9:00 am and 3:00 pm on 9/8/2011 revealed that certain requirements stipulated in the State Licensing Rules and NFPA 99 were not met.

a. Preferred Customer Status

The Department requires Letters of Preference for two critical resources to be retained by the Facility for two items: fuel and water [Re: NFPA 99, Health Care Facilities,1999: ?11-5.3.2.]

Findings: The letter for fuel was not available for review.

b. Use of PVC

Soil stacks, drains, vents, waste lines, and leaders installed above ground within buildings shall be drain-waster-vent (DWV) weight or heavier and shall be: copper pipe, copper tube, cast iron pipe, or galvanized iron pipe [Re: 25 TAC, HLR, 2007: ? 133.162(d)(4)(A)(viii)(I).]

Findings: During the survey, PVC installations were observed in the Dietary Suite. These should be replaced with nonflammable materials.

c. Reserved Toilet Facilities

The State rules require a toilet room to be provided inside the Dietary Suite for exclusive use of the staff for infection control purposes [Re: 25 TAC HLR, 2007: ?133.163(e)(1)(B)(xiv).] In the event that one is located in the corridor exterior to the Dietary Suite, a sign shall be posted indicating that its use is reserved for the dietary staff.

Findings: The nearest toilet room for the staff was in the corridor was being used by the general population which poses a risk.

d. Mirrors Disallowed in the Dietary Suite

Mirrors shall not be installed at hand washing fixtures in the food preparation areas [Re: 25 TAC HLR, 2007: ?133.163(e)(2)(A)(iv).]

Findings: A mirror was observed at the hand washing fixture between the dirty and clean areas of the Dietary Suite.

e. Ventilation Requirements

All rooms and areas in the hospital listed in Table 3 of ? 133.169[c] shall have provision for positive ventilation [Re: 25 TAC HLR 2007: ? 133.162(d)(3)(D)(i).]

Findings: During the survey, it was extremely difficult to determine which air handling unit served specific areas of the hospital, and what parameters were associated with the air flow. The facility shall develop a matrix that identifies each air handling unit, how many filters are in the unit, the level of filtration associated with each filter bank, and the CFM rating of the unit to facilitate maintenance and future inspections/surveys.

f. Negatively Pressurized Rooms

Specific rooms in a hospital must be negatively pressurized for infection control purposes and for the comfort of the patients [Re: 25 TAC HLR 2007: ? 133.162(d)(3)(D)(i).] In order to achieve this, the Department requires all exhaust fans in a toilet room or a soiled utility room, or in similar locations, to operate continuously and not to be affected by switches that activate room lighting.

Findings: During the survey, it was noted that a number of these locations did not satisfy this requirement. The facility shall ensure that this requirement is satisfied.

Observation and discussion with the Director of Plant Operations between 9:00 am and 3:00 pm on 9/8/2011 revealed that certain requirements stipulated in NFPA 70, 99 and 110 were not met.

a. Circuit Breakers

The circuit breakers that are impacted by transfer switch operation shall be exercised annually pursuant to manufacturer ' s recommendations [Re: NFPA 99, Health Care Facilities, 2002: ? 3-4.4.1.2.]

Findings: The staff indicated that these tests were not conducted and records were not available for review.

b. Load Tests

The generator must be operated under full load for 4 hours or more every 3 to 4 years [Re: NFPA 110: Standard for Emergency and Standby Power Systems, 1999: ? 8-4.8.]

Findings: The staff indicated that these tests were not conducted and records were not available for review.

c. GenSet Light & Receptacle

No function other than those listed in (a) through (f) shall be connected to the life safety branch. The life safety branch of the emergency system shall supply power for the following lighting, receptacles, and equipment: ... ...(e) Generator Set Location. Task illumination battery charger for emergency battery-powered lighting unit(s) and selected receptacles at the generator set location [Re: NFPA 70, National Electrical Code, 1999: ?517-32(e).]

Findings: These amenities were not installed as required.

Observation and discussion with the Director of Plant Operations between 9:00 am and 3:00 pm on 9/8/2011 revealed that certain requirements stipulated in NFPA 70 were not met.

Critical Powered Receptacles

The critical branch of the emergency system shall supply power for task illumination, fixed equipment, selected receptacles, and special power circuits serving the following areas and functions related to patient care: .... 3. Patient care areas - task illumination and selected receptacles in the following: ...
b. Medication preparation areas; c. Pharmacy dispensing areas .....[Re: NFPA 70, National Electrical Code, 1999: ?517-33(a).]

Findings: The med refrigerator located across from the nurses ' station [near LDR] was powered by the normal branch which does meet the requirement.

Observation and discussion with the Director of Plant Operations between 9:00 am and 3:00 pm on 9/8/2011 revealed that certain requirements stipulated in NFPA 101 were not met.

Corridor walls shall form a barrier to limit the transfer of smoke [Re: NFPA 101, Life Safety Code, 2000: ? 19.3.6.2.2.]

Findings: The corridor wall [rated wall separation] outside the chapel above the dropped ceiling had conduit penetrations through the wall that were not sealed properly. Similarly, above the double doors outside rooms 112A and 112B the wall had penetrations that were not sealed properly. The facility shall affirm that all penetrations have been caulked properly.

Observation and discussion with the Director of Plant Operations between 9:00 am and 3:00 pm on 9/8/2011 revealed that certain requirements stipulated in NFPA 72 were not met.

a. Supervisory Signal Devices

Supervisory signal devices shall be exercised quarterly [Re: NFPA 72, National Fire Alarm Code, 2002: ? 7-3.2 and Table 7-3.2(15)(j).]

Findings: The staff was not able to confirm that these required tests were conducted. The facility shall ensure that this requirement is met.

b. Waterflow Device/Switches

Waterflow devices shall be exercised semi-annually [Re: NFPA 72, National Fire Alarm Code, 2002: ? 7-3.2 and Table 7-3.2(15)(k).] Valve tamper switches shall be exercised semi-annually [Re: NFPA 72, National Fire Alarm Code, 2002: ? 7-3.2 and Table 7-3.2(15)(l).]

Findings: The staff was not able to confirm that these required tests were conducted. The facility shall ensure that this requirement is met.

Observation and discussion with the Director of Plant Operations between 9:00 am and 3:00 pm on 9/8/2011 revealed that certain requirements stipulated in NFPA 90A were not met.

Air filters shall be rated either as Class 1 or Class 2 in accordance with UL 900, Standard for Safety Air Filter Units [Re: NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, 1999: ?2-2.2.2.]

Findings: Observation of the RTU serving the ED revealed that one of the secondary filters was not installed, thereby negating any filter action for the ED.

Observation and discussion with the Director of Plant Operations between 9:00 am and 3:00 pm on 9/8/2011 revealed that certain requirements stipulated in NFPA 90A were not met.

a. Hood Extinguisher System

The fire extinguishing system for the kitchen hood shall be inspected and serviced every 6 months by a properly trained and qualified person [Re: NFPA 96, Kitchen Equipment: 2002:?11.2.1.]

Findings: The facility performed this service annually which does not meet the requirement.

b. Class K Extinguisher

The Class K Fire extinguisher [installed after 6/30/1998] shall have a placard placed nearby conspicuously to read " fire protection system shall be activated prior of using fire extinguisher " [Re: NFPA 10, Standard for Portable Fire Extinguishers, 2001: ?4.3.2.2.]

Findings: The placard was not in place near the fire extinguisher.

Observation and discussion with the Director of Plant Operations between 9:00 am and 3:00 pm on 9/8/2011 revealed that certain requirements stipulated in the State Licensing Rules and NFPA 99 were not met.

a. Preferred Customer Status

The Department requires Letters of Preference for two critical resources to be retained by the Facility for two items: fuel and water [Re: NFPA 99, Health Care Facilities,1999: ?11-5.3.2.]

Findings: The letter for fuel was not available for review.

b. Use of PVC

Soil stacks, drains, vents, waste lines, and leaders installed above ground within buildings shall be drain-waster-vent (DWV) weight or heavier and shall be: copper pipe, copper tube, cast iron pipe, or galvanized iron pipe [Re: 25 TAC, HLR, 2007: ? 133.162(d)(4)(A)(viii)(I).]

Findings: During the survey, PVC installations were observed in the Dietary Suite. These should be replaced with nonflammable materials.

c. Reserved Toilet Facilities

The State rules require a toilet room to be provided inside the Dietary Suite for exclusive use of the staff for infection control purposes [Re: 25 TAC HLR, 2007: ?133.163(e)(1)(B)(xiv).] In the event that one is located in the corridor exterior to the Dietary Suite, a sign shall be posted indicating that its use is reserved for the dietary staff.

Findings: The nearest toilet room for the staff was in the corridor was being used by the general population which poses a risk.

d. Mirrors Disallowed in the Dietary Suite

Mirrors shall not be installed at hand washing fixtures in the food preparation areas [Re: 25 TAC HLR, 2007: ?133.163(e)(2)(A)(iv).]

Findings: A mirror was observed at the hand washing fixture between the dirty and clean areas of the Dietary Suite.

e. Ventilation Requirements

All rooms and areas in the hospital listed in Table 3 of ? 133.169[c] shall have provision for positive ventilation [Re: 25 TAC HLR 2007: ? 133.162(d)(3)(D)(i).]

Findings: During the survey, it was extremely difficult to determine which air handling unit served specific areas of the hospital, and what parameters were associated with the air flow. The facility shall develop a matrix that identifies each air handling unit, how many filters are in the unit, the level of filtration associated with each filter bank, and the CFM rating of the unit to facilitate maintenance and future inspections/surveys.

f. Negatively Pressurized Rooms

Specific rooms in a hospital must be negatively pressurized for infection control purposes and for the comfort of the patients [Re: 25 TAC HLR 2007: ? 133.162(d)(3)(D)(i).] In order to achieve this, the Department requires all exhaust fans in a toilet room or a soiled utility room, or in similar locations, to operate continuously and not to be affected by switches that activate room lighting.

Findings: During the survey, it was noted that a number of these locations did not satisfy this requirement. The facility shall ensure that this requirement is satisfied.

Observation and discussion with the Director of Plant Operations between 9:00 am and 3:00 pm on 9/8/2011 revealed that certain requirements stipulated in NFPA 70, 99 and 110 were not met.

a. Circuit Breakers

The circuit breakers that are impacted by transfer switch operation shall be exercised annually pursuant to manufacturer ' s recommendations [Re: NFPA 99, Health Care Facilities, 2002: ? 3-4.4.1.2.]

Findings: The staff indicated that these tests were not conducted and records were not available for review.

b. Load Tests

The generator must be operated under full load for 4 hours or more every 3 to 4 years [Re: NFPA 110: Standard for Emergency and Standby Power Systems, 1999: ? 8-4.8.]

Findings: The staff indicated that these tests were not conducted and records were not available for review.

c. GenSet Light & Receptacle

No function other than those listed in (a) through (f) shall be connected to the life safety branch. The life safety branch of the emergency system shall supply power for the following lighting, receptacles, and equipment: ... ...(e) Generator Set Location. Task illumination battery charger for emergency battery-powered lighting unit(s) and selected receptacles at the generator set location [Re: NFPA 70, National Electrical Code, 1999: ?517-32(e).]

Findings: These amenities were not installed as required.

Observation and discussion with the Director of Plant Operations between 9:00 am and 3:00 pm on 9/8/2011 revealed that certain requirements stipulated in NFPA 70 were not met.

Critical Powered Receptacles

The critical branch of the emergency system shall supply power for task illumination, fixed equipment, selected receptacles, and special power circuits serving the following areas and functions related to patient care: .... 3. Patient care areas - task illumination and selected receptacles in the following: ...
b. Medication preparation areas; c. Pharmacy dispensing areas .....[Re: NFPA 70, National Electrical Code, 1999: ?517-33(a).]

Findings: The med refrigerator located across from the nurses ' station [near LDR] was powered by the normal branch which does meet the requirement.