HospitalInspections.org

K200 MEANS OF EGRESS REQUIREMENTS - OTHER

DOOR AND FRAME INSPECTIONS:
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 AHJ per NFPA 80, 2010, Ch. 5.2. A written record of the inspections and testing shall be signed and kept for inspection by the AHJ. NFPA101, 2012, 7.2.1.15

Based on observation the facility failed to provide evidence of inspection of doors in means of egress.

The inspector observed, while accompanied by the Hospital Administrator and the Maintenance Director during the hours of the inspection from 1:30 pm to 6:00 pm on 4/01/2019 that there were no records of inspection and maintenance of all the doors in means of egress as required.

Based on observation the facility failed to provide adequate illumination at an egress exit.

The inspector observed, while accompanied by the Hospital Administrator and the Maintenance Director during the hours of the inspection from 1:30 pm to 6:00 pm on 4/01/2019 that the Outpatient Egress Exit had no lights for illumination. These lights shall be on life safety panel.

Level of Protection.

"A building, where protected by an automatic sprinkler system installation, shall be provided with sprinklers in all areas except where specific sections of this standard permit the omission of sprinklers". -NFPA, 13, 2010:4.1.

Based on observation the facility failed to provide an adequate automatic sprinkler system.

The inspector observed, while accompanied by the Hospital Administrator and the Maintenance Director during the hours of the inspection from 1:30 pm to 6:00 pm on 4/01/2019 that there were no sprinkler heads in the electrical room 1.


"Sprinklers shall be installed under fixed obstructions over 4 feet wide such as ducts, decks, open grate flooring, cutting tables and overhead doors" - NFPA 13, 8.5.5.3.1

Based on observation the facility failed to provide an adequate automatic sprinkler system.


The inspector observed, while accompanied by the Hospital Administrator and the Maintenance Director during the hours of the inspection from 1:30 pm to 6:00 pm on 4/01/2019 that Sprinkler head(s) were missing under a duct wider than four feet in the Mechanical room.

Final filters and Frames:

Final filters and filter frames should be visually inspected for pressure drop and for bypass monthly. Filters should be replaced based on pressure drop or maintenance schedule with filters that provide the efficiencies specified. (ASHRAE 170, Informative Appendix A, Operations and Maintenance Procedures.) A log of filter replacements should be maintained for each air handler.

Based on observation the facility failed to provide adequate monthly pressure drop records.

The inspector observed, while accompanied by the Hospital Administrator and the Maintenance Director during the hours of the inspection from 1:30 pm to 6:00 pm on 4/01/2019 that there was no record of the monthly pressure drops across the filters in the air handling units.

Based on observation the facility failed to provide a risk assessment per NFPA 99,2012.

The inspector observed, while accompanied by the Hospital Administrator and the Maintenance Director during the hours of the inspection from 1:30 pm to 6:00 pm on 4/01/2019 that risk analyses for the essential electrical system and the medical gas system that complies with NFPA 99, 2012 had not been performed.

Screens on Pressure Relief Outlets:

"Relief Valves. All pressure relief valves shall meet the following requirements: ...They shall have the discharge terminal turned down and screened to prevent the entry of rain, snow, or vermin." - NFPA 99, 2012, 5.1.3.5.6.1(8).

Based on observation the facility failed to provide adequate screen on the pressure relief outlet.

The inspector observed, while accompanied by the Hospital Administrator and the Maintenance Director during the hours of the inspection from 1:30 pm to 6:00 pm on 4/01/2019 that there was no screen on one of the pressure relief outlets.

Marking FACP:

"For fire alarm systems the circuit disconnecting means shall have a red marking." - NFPA 72, 2010, 10.5.5.2.3.

Based on observation the facility failed to provide adequate marking on the breaker supplying power to the FACP.

The inspector observed, while accompanied by the Hospital Administrator and the Maintenance Director during the hours of the inspection from 1:30 pm to 6:00 pm on 4/01/2019 that the breaker supplying power to the FACP was not colored red.

Based on observation the facility failed to provide:

1. Evidence of adequate receptacles test in all the patient care areas.
2. Record of electrical maintenance and required tests performed.

The inspector observed, while accompanied by the Hospital Administrator and the Maintenance Director during the hours of the inspection from 1:30 pm to 6:00 pm on 4/01/2019 that there were the following issues. They were:

1. That only retention force test was performed on the receptacles in the OR rooms., polarity, grounding and physical integrity tests
were not performed. On the other patient care areas, none of the above listed tests were performed on the receptacles.
2 No records of where, type of repair performed and date of electrical maintenance and required tests performed in all the patient care
areas.

Based on observation the facility failed to provide all the required documentation for the essential electrical system maintenance.

The inspector observed, while accompanied by the Hospital Administrator and the Maintenance Director during the hours of the inspection from 1:30 pm to 6:00 pm on 4/01/2019 that there were the following issues. They were:

1. The 36-month load bank test was not being done and there was no contract in place to ensure that future routine 36 months' load
bank test of the generator set is performed.
2. The monthly load tests were not being performed
3. The weekly inspections were not being properly performed as the record did not document all the required elements of the weekly
inspections being inspected and documented.
4. There was no record of the main and feeder circuit breakers being inspected annually.

Generator Remote Manual Stop:

"All installations shall have a remote manual stop station of a type to prevent inadvertent or unintentional operation located outside the room housing the prime mover, where so installed, or elsewhere on the premises where the prime mover is located outside the building" - NFPA 110, 2010, 5.6.5.6* Note: "For systems located outdoors, the manual shutdown should be located external to the weatherproof enclosure and should be appropriately identified." A.5.6.5.6.

Based on observation the facility failed to provide remote emergency generator shut down button.

The inspector observed, while accompanied by the Hospital Administrator and the Maintenance Director during the hours of the inspection from 1:30 pm to 6:00 pm on 4/01/2019 that there was no remote shutdown switch for generator #2. Generator #1 had a remote shutdown switch that was located in a locked location. Provide easily accessible remote shutdown switches for both generators.

Based on observation the facility failed to provide adequate biomedical electrical maintenance and inspection reports.

The inspector observed, while accompanied by the hospital administrator and the maintenance director during the hours of the inspection from 1:30 pm to 6:00 pm on 4/01/2019 that there were the following issues:

1. The facility was not keeping records of electrical equipment tests, repairs and modifications to demonstrate compliance in
accordance with the facility policy.
2. There were no records of personnel training or continuing education on the equipment in the facility.