HospitalInspections.org

The inspector observed, while accompanied by The Assistant Administrator, Administrator director and Maintenance supervisor during the hours of the inspection from 11:00 AM to 3:30 PM on 03/22/2017 that there were the following issues. They were the following issues.

A) The front lobby entrance vestibule did not have a sprinkler head provided at the area renovated on 2002. Please provide a sprinkler system at the front lobby vestibule.

The inspector observed, while accompanied by The Assistant Administrator, Administrator director and Maintenance supervisor during the hours of the inspection from 11:00 AM to 3:30 PM on 03/22/2017 that there were the following issues. They were the following issues:

A) There were numerous doors were not released from the magnetic lock device upon activate the fire alarm system which prevent from free egress out of building.

The inspector observed, while accompanied by The Assistant Administrator, Administrator director and Maintenance supervisor during the hours of the inspection from 11:00 AM to 3:30 PM on 03/22/2017 that there were the following issues. They were the following issues:

A) There were missing astragals for the smoke barrier cross corridors doors for the areas inspected. NFPA 101, 2003: 18.3.7.10 - Rabbets, bevels, or astragals shall be required at the meeting edges, and stops shall be required at the head and sides of door frames in smoke barriers. Positive latching hardware shall not be required. Center mullion shall be prohibited.

The inspector observed, while accompanied by The Assistant Administrator, Administrator director and Maintenance supervisor during the hours of the inspection from 11:00 AM to 3:30 PM on 03/22/2017 that there were the following issues. They were the following issues.

A.) There were missing battery powered operated light fixture at the generator set locations and the generator automatic Transfer switch locations.


B.) The transfer switch was not tested each month.



C.) There labels provided for the electrical panels and the essential transfer switches were not readily identifiable to identify life safety, critical and equipment branch. NFPA 70, 2002: 110-22 and 700-9(a). - "Emergency panels shall be distinctively marked so that they are readily identifiable as a component of the essential electrical system." - They shall be labeled "LIFE SAFETY", "CRITICAL", or "EQUIPMENT" as applicable.

The inspector observed, while accompanied by The Assistant Administrator, Administrator director and Maintenance supervisor during the hours of the inspection from 11:00 AM to 3:30 PM on 03/22/2017 that there were the following issues. They were the following issues.

A) There were flex conduit being used from the top of the emergency generator electrical panels. The flex conduit are not permissible.
NFPA 70, §517.30(C)(3). - Mechanical protection of the emergency system. The wiring of the emergency system shall be mechanically protected by installation in nonflexible metal raceways.

The inspector observed, while accompanied by The Assistant Administrator, Administrator director and Maintenance supervisor during the hours of the inspection from 11:00 AM to 3:30 PM on 03/22/2017 that there were the following issues. They were the following issues:

A) Please update the signage at the medical gas storage room.
NFPA 99, 2002: 5.1.3.1.5. The door shall have the following label:

CAUTION
Medical Gases
NO Smoking or Open Flame



B) There were not an insulation between the metal hanger supports and the copper medical gas pipes at the Mechanical room. NFPA 99, 2002: 5.1.10.6.4 - "Copper piping shall be separated or insulated from dissimilar metal piping and supports to prevent bimetallic electrolyte action."



C) The distance between the parked vehicle and the bulk storage tank was less than 10'-0". NFPA 50, 2001, 2.2.12 - "The minimum distance from any bulk oxygen system to any public sidewalk or parked vehicle shall be 10 ft." .