HospitalInspections.org

Based on observations made during review of the logs, policies and procedures of the faciity between the hours of 2:30 pm and 5:30 pm, while accompanied by the Administrator and the Building Maintenance Director, the facility failed to provide acceptable documentation of a Class I Flame Spread rating for the new finish floor material used as required in NFPA 101, 2000: 19.3.3.3.
(The finish floor material was identified as: KONECTO - Sierra Plank.)

Based on observations made during review of the logs, policies and procedures of the faciity between the hours of 2:30 pm and 5:30 pm, while accompanied by the Administrator and the Building Maintenance Director, the facility failed to posts floor plans in prominant locations showing evacuation routes as part of compliance with the Evacuation and Relocation Plan in NFPA 101, 2000: 19.7.1.1.

Based on observations made during review of the logs, policies and procedures of the faciity between the hours of 2:30 pm and 5:30 pm, while accompanied by the Administrator and the Building Maintenance Director, the facility failed to provide acceptable documentation logging the required inspections for smoke detector sensitivity as required in NFPA 72: 7-3.2.1.

Based on observations made during review of the logs, policies and procedures of the faciity between the hours of 2:30 pm and 5:30 pm, while accompanied by the Administrator and the Building Maintenance Director, the facility failed to provide acceptable documentation or labels showing that mattresses are in compliance with the requirement on "char length" as required by NFPA 101, 2000: 10.3.2(3).

Based on observations made during review of the logs, policies and procedures of the faciity between the hours of 2:30 pm and 5:30 pm, while accompanied by the Administrator and the Building Maintenance Director, the facility failed to provide task illumination lighting and a power receptacle at the emergency generator set as required in:
NFPA 99, 1999: 3-4.2.2.2.(b)5.

Based on observations made during review of the logs, policies and procedures of the faciity between the hours of 2:30 pm and 5:30 pm, while accompanied by the Administrator and the Building Maintenance Director, the facility failed to provide a means for emegency shut down of the HVAC system as required in NFPA 90A, 1999: 4.2.

Based on observations made during review of the logs, policies and procedures of the faciity between the hours of 2:30 pm and 5:30 pm, while accompanied by the Administrator and the Building Maintenance Director, the facility failed to provide documentation logging the last 3 years of semi-annual response exercises relating to the emergency preparedness plan as required in NFPA 99, 11-5.3.9 and hospital regulations.

Based on observations made during review of the logs, policies and procedures of the faciity between the hours of 2:30 pm and 5:30 pm, while accompanied by the Administrator and the Building Maintenance Director, the facility failed to provide acceptable documentation of a Class I Flame Spread rating for the new finish floor material used as required in NFPA 101, 2000: 19.3.3.3.
(The finish floor material was identified as: KONECTO - Sierra Plank.)

Based on observations made during review of the logs, policies and procedures of the faciity between the hours of 2:30 pm and 5:30 pm, while accompanied by the Administrator and the Building Maintenance Director, the facility failed to posts floor plans in prominant locations showing evacuation routes as part of compliance with the Evacuation and Relocation Plan in NFPA 101, 2000: 19.7.1.1.

Based on observations made during review of the logs, policies and procedures of the faciity between the hours of 2:30 pm and 5:30 pm, while accompanied by the Administrator and the Building Maintenance Director, the facility failed to provide acceptable documentation logging the required inspections for smoke detector sensitivity as required in NFPA 72: 7-3.2.1.

Based on observations made during review of the logs, policies and procedures of the faciity between the hours of 2:30 pm and 5:30 pm, while accompanied by the Administrator and the Building Maintenance Director, the facility failed to provide acceptable documentation or labels showing that mattresses are in compliance with the requirement on "char length" as required by NFPA 101, 2000: 10.3.2(3).

Based on observations made during review of the logs, policies and procedures of the faciity between the hours of 2:30 pm and 5:30 pm, while accompanied by the Administrator and the Building Maintenance Director, the facility failed to provide task illumination lighting and a power receptacle at the emergency generator set as required in:
NFPA 99, 1999: 3-4.2.2.2.(b)5.

Based on observations made during review of the logs, policies and procedures of the faciity between the hours of 2:30 pm and 5:30 pm, while accompanied by the Administrator and the Building Maintenance Director, the facility failed to provide a means for emegency shut down of the HVAC system as required in NFPA 90A, 1999: 4.2.

Based on observations made during review of the logs, policies and procedures of the faciity between the hours of 2:30 pm and 5:30 pm, while accompanied by the Administrator and the Building Maintenance Director, the facility failed to provide documentation logging the last 3 years of semi-annual response exercises relating to the emergency preparedness plan as required in NFPA 99, 11-5.3.9 and hospital regulations.