HospitalInspections.org

Findings:
The surveyor observed, while accompanied by the VP of Risk & Quality, Supervisor Facility Management, and Maintenance Tech 3, during the hours of the survey from 3:30 PM to 7:30 PM on 05/29/18 that there were the following issues:

1) Based on observation, there was construction activity in the sleep suites. However, there is no application number on file with Texas Health and Human Services Commission. Please note the following requirement from the Hospital Licensing Rules:

(C) Minor remodeling or alterations. All remodeling or alterations which do not involve alterations to load bearing members or partitions, change functional operation, affect fire safety (e.g. modifications to the fire, smoke, and corridor walls), add or subtract beds or services for which the hospital is licensed, and do not involve changes listed in subparagraph (B) of this paragraph, shall be submitted for approval without submitting contract documents. Such approval shall be requested in writing with a brief description of the proposed changes in accordance with §133.167(f)(3) of this title." - HLR 2007, 133.161 (a)(2)(C).

Findings:
The surveyor observed, while accompanied by the VP of Risk & Quality, Supervisor Facility Management, and Maintenance Tech 3, during the hours of the survey from 3:30 PM to 7:30 PM on 05/29/18 that there were the following issues:

1) Based on observation in the Mechanical Room near Building E, there was direct contact between copper pipe and stainless steel hanger without the use of insulator which promotes bimetallic electrolyte action. This item was observed as corrected by the Life Safety Code Surveyor.

Findings:
The surveyor observed, while accompanied by the VP of Risk & Quality, Supervisor Facility Management, and Maintenance Tech 3, during the hours of the survey from 3:30 PM to 7:30 PM on 05/29/18 that there were the following issues:

1) Based on observation, there was a large piece of equipment being temporarily stored in the emergency electrical room that prevented access to the ATS panels. It is important for maintenance staff to make a conscious effort to be vigilant and proactive in regards to physical environment safety. This item was observed as corrected by the Life Safety Code Surveyor.

Findings:
The surveyor observed, while accompanied by the VP of Risk & Quality, Supervisor Facility Management, and Maintenance Tech 3, during the hours of the survey from 3:30 PM to 7:30 PM on 05/29/18 that there were the following issues:

1) Based on review of the records, there was gap in the maintenance and testing of hospital-grade receptacles at patient bed locations and in patient care areas. No records were available to review for the year 2016 and 2017.