HospitalInspections.org

Based on observation the facility failed to provide adequate smoke barriers.

The inspector observed, while accompanied by the Assistant Administrator during the hours of the inspection from 1:30 pm to 4:30 pm on 10/29/2013 that there were penetrations in the smoke barriers. They were in the following locations: 1) at the Administration/H.R. office, 2) at the Emergency Room, and 3) at the Pharmacy.

Based on observation the facility failed to provide adequate protection of hazardous areas.

The inspector observed, while accompanied by the Assistant Administrator during the hours of the inspection from 1:30 pm to 4:30 pm on 10/29/2013 that there were issues with hazardous areas. They were: 1) the Infection Control/Employee Health room and the Breakdown/Kitchen room were used for storage but did not have a closer, and 2) the EVS room was used for storage and had a closer but it did not close and latch on its own.

Based on observation the facility failed to provide adequate fire drills.

The inspector observed, while accompanied by the Assistant Administrator during the hours of the inspection from 1:30 pm to 4:30 pm on 10/29/2013 that there were no fire drills since 6/25/2013.

Based on observation the facility failed to provide adequate sprinkler head coverage.

The inspector observed, while accompanied by the Assistant Administrator during the hours of the inspection from 1:30 pm to 4:30 pm on 10/29/2013 that the Materials Management room had storage higher than the 18 " plane below the sprinkler heads.

Storage of Combustible Materials in the Emergency Generator Room.

The room or space in which the EPS equipment is located shall not be used for storage purposes. - NFPA 110, 2002: 7.11.1.

Based on observation the facility failed to provide an adequate enclosure for the emergency generator.

The inspector observed, while accompanied by the Assistant Administrator during the hours of the inspection from 1:30 pm to 4:30 pm on 10/29/2013 that there were oil soaked rags under the emergency generators from leaks.


Fire Alarm Testing

" Testing shall be performed in accordance with the schedules in Chapter 7 or more often if required by the authority having jurisdiction. If automatic testing is performed at least weekly by a remotely monitored fire alarm control unit specifically listed for the application, the manual testing frequency shall be permitted to be extended to annual. Table 7-3.2 shall apply. " - NFPA 72, 1999, 7-3.2.

Based on observation the facility failed to provide adequate records for the fire alarm tests.

The inspector observed, while accompanied by the Assistant Administrator during the hours of the inspection from 1:30 pm to 4:30 pm on 10/29/2013 that the last " annual " fire alarm inspection was done on 1/11/2012.


Annual Sprinkler System Inspection:

" A sprinkler system installed in accordance with this standard shall be properly inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, to provide at least the same level of performance and protection as designed. " - NFPA 13, 1999, 12-1.

" Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation. " - NFPA 25, 1999, 2-2.1.1.

Based on observation the facility failed to provide adequate fire sprinkler inspection records.

The inspector observed, while accompanied by the Assistant Administrator during the hours of the inspection from 1:30 pm to 4:30 pm on 10/29/2013 that the records for the first two quarters of 2011 and the 3rd and 4th quarter of 2010 were missing but will be sent from the inspection company.


Disaster Drills:

" Each organizational entity shall implement one or more specific responses of the emergency preparedness plan at least semi-annually. At least on semi-annual drill shall rehearse mass casualty response for health care facilities with emergency services, disaster receiving stations, or both. " - NFPA 99, 1999, 11-5.3.9.

Based on observation the facility failed to provide adequate disaster drills.

The inspector observed, while accompanied by the Assistant Administrator during the hours of the inspection from 1:30 pm to 4:30 pm on 10/29/2013 that there were the following issues. The facility was only doing one disaster drill per year and this was not a mass casualty drill.


Fuel and Water Preferred Customer Status

" Continuity of Essential Building Systems. When designated by the emergency preparedness management plan to provide continuous service in a disaster or emergency, health care facilities shall establish contingency plans for the continuity of essential building systems, as applicable: (a) Electricity, (b) Water, (c) Ventilation, (d) Fire protection systems, (e) Fuel sources, (f) Medical gas and vacuum systems (if applicable), (g) Communications systems. " - NFPA 99, 1999, 11-5.3.2

Based on observation the facility failed to provide letters from vendors for emergency fuel and water indicating that they have a preferred customer status in the event of an emergency.

The inspector observed, while accompanied by the Assistant Administrator during the hours of the inspection from 1:30 pm to 4:30 pm on 10/29/2013 that the letters were missing or out of date.


HVAC Filter Change Logs

Based on observation the facility failed to provide adequate HVAC filter change logs.

The inspector observed, while accompanied by the Assistant Administrator during the hours of the inspection from 1:30 pm to 4:30 pm on 10/29/2013 that there were no HVAC filter change logs since 2012.

Based on observation the facility failed to provide adequate smoke barriers.

The inspector observed, while accompanied by the Assistant Administrator during the hours of the inspection from 1:30 pm to 4:30 pm on 10/29/2013 that there were penetrations in the smoke barriers. They were in the following locations: 1) at the Administration/H.R. office, 2) at the Emergency Room, and 3) at the Pharmacy.

Based on observation the facility failed to provide adequate protection of hazardous areas.

The inspector observed, while accompanied by the Assistant Administrator during the hours of the inspection from 1:30 pm to 4:30 pm on 10/29/2013 that there were issues with hazardous areas. They were: 1) the Infection Control/Employee Health room and the Breakdown/Kitchen room were used for storage but did not have a closer, and 2) the EVS room was used for storage and had a closer but it did not close and latch on its own.

Based on observation the facility failed to provide adequate fire drills.

The inspector observed, while accompanied by the Assistant Administrator during the hours of the inspection from 1:30 pm to 4:30 pm on 10/29/2013 that there were no fire drills since 6/25/2013.

Based on observation the facility failed to provide adequate sprinkler head coverage.

The inspector observed, while accompanied by the Assistant Administrator during the hours of the inspection from 1:30 pm to 4:30 pm on 10/29/2013 that the Materials Management room had storage higher than the 18 " plane below the sprinkler heads.

Storage of Combustible Materials in the Emergency Generator Room.

The room or space in which the EPS equipment is located shall not be used for storage purposes. - NFPA 110, 2002: 7.11.1.

Based on observation the facility failed to provide an adequate enclosure for the emergency generator.

The inspector observed, while accompanied by the Assistant Administrator during the hours of the inspection from 1:30 pm to 4:30 pm on 10/29/2013 that there were oil soaked rags under the emergency generators from leaks.


Fire Alarm Testing

" Testing shall be performed in accordance with the schedules in Chapter 7 or more often if required by the authority having jurisdiction. If automatic testing is performed at least weekly by a remotely monitored fire alarm control unit specifically listed for the application, the manual testing frequency shall be permitted to be extended to annual. Table 7-3.2 shall apply. " - NFPA 72, 1999, 7-3.2.

Based on observation the facility failed to provide adequate records for the fire alarm tests.

The inspector observed, while accompanied by the Assistant Administrator during the hours of the inspection from 1:30 pm to 4:30 pm on 10/29/2013 that the last " annual " fire alarm inspection was done on 1/11/2012.


Annual Sprinkler System Inspection:

" A sprinkler system installed in accordance with this standard shall be properly inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, to provide at least the same level of performance and protection as designed. " - NFPA 13, 1999, 12-1.

" Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation. " - NFPA 25, 1999, 2-2.1.1.

Based on observation the facility failed to provide adequate fire sprinkler inspection records.

The inspector observed, while accompanied by the Assistant Administrator during the hours of the inspection from 1:30 pm to 4:30 pm on 10/29/2013 that the records for the first two quarters of 2011 and the 3rd and 4th quarter of 2010 were missing but will be sent from the inspection company.


Disaster Drills:

" Each organizational entity shall implement one or more specific responses of the emergency preparedness plan at least semi-annually. At least on semi-annual drill shall rehearse mass casualty response for health care facilities with emergency services, disaster receiving stations, or both. " - NFPA 99, 1999, 11-5.3.9.

Based on observation the facility failed to provide adequate disaster drills.

The inspector observed, while accompanied by the Assistant Administrator during the hours of the inspection from 1:30 pm to 4:30 pm on 10/29/2013 that there were the following issues. The facility was only doing one disaster drill per year and this was not a mass casualty drill.


Fuel and Water Preferred Customer Status

" Continuity of Essential Building Systems. When designated by the emergency preparedness management plan to provide continuous service in a disaster or emergency, health care facilities shall establish contingency plans for the continuity of essential building systems, as applicable: (a) Electricity, (b) Water, (c) Ventilation, (d) Fire protection systems, (e) Fuel sources, (f) Medical gas and vacuum systems (if applicable), (g) Communications systems. " - NFPA 99, 1999, 11-5.3.2

Based on observation the facility failed to provide letters from vendors for emergency fuel and water indicating that they have a preferred customer status in the event of an emergency.

The inspector observed, while accompanied by the Assistant Administrator during the hours of the inspection from 1:30 pm to 4:30 pm on 10/29/2013 that the letters were missing or out of date.


HVAC Filter Change Logs

Based on observation the facility failed to provide adequate HVAC filter change logs.

The inspector observed, while accompanied by the Assistant Administrator during the hours of the inspection from 1:30 pm to 4:30 pm on 10/29/2013 that there were no HVAC filter change logs since 2012.