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Observation and discussion with the Maintenance Director between 9 am and 2:30 pm on 12/7/2011 revealed that certain requirements stipulated in NFPA 101 were not met.

Interior wall and ceiling finish complying with 10.2.3 shall be Class A or Class B in corridors, in exits, and in any space not separated from corridors and exits by partitions capable of retarding the passage of smoke; and Class A, Class B, or Class C in all other areas [Re: NFPA 101. Life Safety Code. 2000: ? 23.3.3.2.]

Findings: The staff did not have the required flame spread data for inspection at the time of the survey.

Observation and discussion with the Maintenance Director between 9 am and 2:30 pm on 12/7/2011 revealed that certain requirements stipulated in NFPA 101 were not met.

Interior wall and ceiling finish complying with 10.2.3 shall be Class A or Class B in corridors, in exits, and in any space not separated from corridors and exits by partitions capable of retarding the passage of smoke; and Class A, Class B, or Class C in all other areas [Re: NFPA 101. Life Safety Code. 2000: ? 23.3.3.2.]

Findings: The staff did not have the required flame spread data for inspection at the time of the survey.

Observation and discussion with the Maintenance Director between 9 am and 2:30 pm on 12/7/2011 revealed that certain requirements stipulated in NFPA 101 were not met.

Corridor walls shall form a barrier to limit the transfer of smoke [Re: NFPA 101, Life Safety Code, 2000: ? 19.3.6.2.2.]

Findings: The corridor wall [rated wall separation] observed [Corridor 200] had a number of sleeves that were not sealed properly. The facility shall affirm that all penetrations have been caulked properly.

Observation and discussion with the Maintenance Director between 9 am and 2:30 pm on 12/7/2011 revealed that certain requirements stipulated in NFPA 72 were not met.

The fire alarm system must be tested regularly to ensure continued availability and reliability: [Re: NFPA 72, National Fire Alarm Code, 1999: ? 7-3.2.] At least, the following are required: monthly system tests; semimonthly visual inspections, and routine testing pursuant to Table 7-3.2.

Findings: The staff was not able to confirm that these required tests were conducted. A log was not available for review.

Observation and discussion with the Maintenance Director between 9 am and 2:30 pm on 12/7/2011 revealed that certain requirements stipulated in NFPA 10 and the State Licensing Rules were not met.

a. Use of PVC

Soil stacks, drains, vents, waste lines, and leaders installed above ground within buildings shall be drain-waster-vent (DWV) weight or heavier and shall be: copper pipe, copper tube, cast iron pipe, or galvanized iron pipe [Re: 25 TAC, HLR, 2007: ? 133.162(d)(4)(A)(viii)(I).]

Findings: During the survey, PVC installations were observed in the Dietary Suite. These should be replaced with nonflammable materials.

b. Class K Extinguisher

The Class K Fire extinguisher [installed after 6/30/1998] shall have a placard placed nearby conspicuously to read " fire protection system shall be activated prior of using fire extinguisher " [Re: NFPA 10, Standard for Portable Fire Extinguishers, 2001: ?4.3.2.2.]

Findings: The placard was not in place near the fire extinguisher.

Observation and discussion with the Maintenance Director between 9 am and 2:30 pm on 12/7/2011 revealed that certain requirements stipulated in NFPA 101 were not met.

Draperies, curtains, including cubicle curtains, and other loosely hanging fabrics and films serving as furnishings or decorations in health care occupancies shall be in accordance with 10.3.1 [Re: NFPA 101, Life Safety Code. 2000: ? 19.7.5.1.]

Findings: This requirement was discussed and it was determined that the required documentation is not retained by the staff.

Observation and discussion with the Maintenance Director between 9 am and 2:30 pm on 12/7/2011 revealed that certain requirements stipulated in NFPA 99 and the State Licensing Rules were not met.

a. Line Isolation Monitor Tests

The Line Isolation Monitor [LIM] circuit shall be tested at intervals of not more than one month. The test switch shall activate both the visual and audible alarm indicator [Re: NFPA 99, Health Care Facilities, 1999: ? 3-3.3.4.2.]

Findings: During the survey, the staff did not affirm that these tests were conducted and a log confirming this was not available for review.

b. HVAC Filter Change Log

The facility is required to maintain a log indicating that the HVAC filters have been changed according to predetermined criteria [Re: 25 TAC, HLR, 2007: ? 133.162(d)(3)(D)(ii).]

Findings: During the survey, the staff could not produce a log indicating that the HVAC filters were changed according to a system.

Observation and discussion with the Maintenance Director between 9 am and 2:30 pm on 12/7/2011 revealed that certain requirements stipulated in NFPA 99 and NFPA 110 were not met.


a. Weekly Battery Inspection

Storage batteries, including electrolyte levels, used in connection with Level 1 and Level 2 systems shall be inspected at intervals of not more than 7 days and shall be maintained in full compliance with manufacturer ' s specifications. Defective batteries shall be repaired or replaced immediately upon discovery of defects. [Re NFPA 110, Standard for Emergency and Standby Power Systems, 1999: ? 6-3.6.]

Findings: The staff indicated that these observations were not made and records were not available for review.


b. Maintenance Free Batteries

Starting batteries for Level I installations shall not be of the maintenance-free variety [Re NFPA 110, Standard for Emergency and Standby Power Systems, 1999: ? 3-5.4.5.]

Findings: The battery installed with the generator did not meet this requirement.

c. Circuit Breakers

Main and feeder circuit breakers shall be inspected annually and a program for periodically exercising the components shall be established according to manufacturer ' s recommendations [Re: NFPA 99, Health Care Facilities, 1999: ? 3-4.4.1.2.]

Findings: The staff indicated that these tests are not conducted and records were not available for review.

d. Load Tests

Monthly - Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods: (a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating; or (b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer. The date and time of day for required testing shall be decided by the owner, based on facility operations [Re: NFPA 110: Standard for Emergency and Standby Power Systems, 1999: ? 6-4.2.]

Annually

Diesel-powered EPS installations that do not meet the requirements of 6-4.2 shall be exercised monthly with the available EPSS load and exercised annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of 2 continuous hours [Re: NFPA 110: Standard for Emergency and Standby Power Systems, 1999: ? 6-4.2.2]

Findings: The staff indicated that these tests were not conducted and records were not available for review.

e. GenSet Light & Receptacle

No function other than those listed in (a) through (f) shall be connected to the life safety branch. The life safety branch of the emergency system shall supply power for the following lighting, receptacles, and equipment: ... ...(e) Generator Set Location. Task illumination battery charger for emergency battery-powered lighting unit(s) and selected receptacles at the generator set location [Re: NFPA 70, National Electrical Code, 1999: ?517-32(e).]

Findings: A light was installed in the generator set location; it could not be determined that it was powered by the emergency system. A receptacle was not provided at the generator set.

Observation and discussion with the Maintenance Director between 9 am and 2:30 pm on 12/7/2011 revealed that certain requirements stipulated in NFPA 70, NFPA 99 and the State Licensing Rules.

a. Type I Essential Electrical System

The hospital should have a Type I Essential Electrical System [EES] as described in NFPA 99, Health Care Facilities, 1999: ? 3-4.2.

Findings: It could not be determined if the hospital has a Type I EES. The facility shall produce a one-line diagram that portrays the interconnection of major electrical components and will be available for during future surveys and inspections.

b. Separation of Branches

The Type I EES shall be divided into the critical branch, life safety branch and the emergency system in accordance with NFPA 99 [Re: NFPA 99, Health Care Facilities, 1999: ?3.4.2.2.2.]

Findings: This requirement was discussed with the staff while observing the electrical installations; it could not be determined if this separation was provided.

c. Functional Allocation

The various functions powered by the Type I EES must be powered by the appropriate branch of the system [Re: NFPA 99, Health Care Facilities, 1999: ?3.4.2.2.2.]

Findings: This requirement was discussed with the staff while observing the electrical installations; this functional requirement was not satisfied.

d. Critical Powered Receptacles

The critical branch of the emergency system shall supply power for task illumination, fixed equipment, selected receptacles, and special power circuits serving the following areas and functions related to patient care: .... [Re: NFPA 70, National Electrical Code, 1999: ?517-33(a).]

Findings: The following functions shall be powered by the critical branch:

? Blood bank in the lab
? ED Exam Room receptacles
? Ice machines in the patient care areas
? Refrigerators for Meds

e. Marked Receptacles

The receptacles or the face plates for receptacles supplied by the critical branch shall have a distinctive color [traditionally red] or marking so as to be readily recognizable [Re: NFPA 70, National Electrical Code, 1999: ? 517-33[c].]

Findings: The facility shall ensure this rule is met for each critical branch-powered receptacle in the ED Exam room and other critical areas.


f. Label Critical Receptacles

All critical care area receptacles powered by the emergency system shall be identified. The face plate for the receptacle(s) shall have a nonremovable label or be engraved indicating the panel and circuit number ....[Re: NFPA 70, National Electrical Code, 1999: ? 517-19.]

Findings: The receptacles were not labeled as required consistently in the ED Exam Room.


g Use of PVC

Soil stacks, drains, vents, waste lines, and leaders installed above ground within buildings shall be drain-waster-vent (DWV) weight or heavier and shall be: copper pipe, copper tube, cast iron pipe, or galvanized iron pipe [Re: 25 TAC, HLR, 2007: ? 133.162(d)(4)(A)(viii)(I).]

Findings: During the survey, PVC was used as a conduit for what appeared to be an emergency circuit. PVC is not allowed inside a hospital above grade and its use as a conduit is not allowed by 517-30[c](3), 1999 edition.


h. Fire Alarm Power

Alarm and alerting systems, including fire alarm systems, must be powered by the life safety branch [Re: NFPA 70, National Electrical Code, 1999: ?517.32[C](1)].

Findings: The facility shall identify the power sources for the fire alarm systems.


i. Circuit Directories

All circuits and circuit modifications shall be legibly identified as to purpose or use on a circuit directory located on the face or inside of the panel door in the case of a panelboard, and at each switch on a switchboard [Re: NFPA 70, National Electrical Code, 2002: ? 408.4.]

Findings: The circuit directories posted in certain panelboards were not meaningful and accurate. One panelboard labeled as Life Safety panelboard in a Janitor ' s Closet near the medical records area had no circuit directory. The facility shall update the directories.

j. Uncovered Junction Boxes

All pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction .... [Re: NFPA 70, National Electrical Code, 2002: ? 314.28[C].]

Findings: At least one junction box was observed without a cover as required. The facility shall ensure all junction boxes are provided with covers.

Observation and discussion with the Maintenance Director between 9 am and 2:30 pm on 12/7/2011 revealed that certain requirements stipulated in NFPA 101 were not met.

Interior wall and ceiling finish complying with 10.2.3 shall be Class A or Class B in corridors, in exits, and in any space not separated from corridors and exits by partitions capable of retarding the passage of smoke; and Class A, Class B, or Class C in all other areas [Re: NFPA 101. Life Safety Code. 2000: ? 23.3.3.2.]

Findings: The staff did not have the required flame spread data for inspection at the time of the survey.

Observation and discussion with the Maintenance Director between 9 am and 2:30 pm on 12/7/2011 revealed that certain requirements stipulated in NFPA 101 were not met.

Interior wall and ceiling finish complying with 10.2.3 shall be Class A or Class B in corridors, in exits, and in any space not separated from corridors and exits by partitions capable of retarding the passage of smoke; and Class A, Class B, or Class C in all other areas [Re: NFPA 101. Life Safety Code. 2000: ? 23.3.3.2.]

Findings: The staff did not have the required flame spread data for inspection at the time of the survey.

Observation and discussion with the Maintenance Director between 9 am and 2:30 pm on 12/7/2011 revealed that certain requirements stipulated in NFPA 101 were not met.

Corridor walls shall form a barrier to limit the transfer of smoke [Re: NFPA 101, Life Safety Code, 2000: ? 19.3.6.2.2.]

Findings: The corridor wall [rated wall separation] observed [Corridor 200] had a number of sleeves that were not sealed properly. The facility shall affirm that all penetrations have been caulked properly.

Observation and discussion with the Maintenance Director between 9 am and 2:30 pm on 12/7/2011 revealed that certain requirements stipulated in NFPA 72 were not met.

The fire alarm system must be tested regularly to ensure continued availability and reliability: [Re: NFPA 72, National Fire Alarm Code, 1999: ? 7-3.2.] At least, the following are required: monthly system tests; semimonthly visual inspections, and routine testing pursuant to Table 7-3.2.

Findings: The staff was not able to confirm that these required tests were conducted. A log was not available for review.

Observation and discussion with the Maintenance Director between 9 am and 2:30 pm on 12/7/2011 revealed that certain requirements stipulated in NFPA 10 and the State Licensing Rules were not met.

a. Use of PVC

Soil stacks, drains, vents, waste lines, and leaders installed above ground within buildings shall be drain-waster-vent (DWV) weight or heavier and shall be: copper pipe, copper tube, cast iron pipe, or galvanized iron pipe [Re: 25 TAC, HLR, 2007: ? 133.162(d)(4)(A)(viii)(I).]

Findings: During the survey, PVC installations were observed in the Dietary Suite. These should be replaced with nonflammable materials.

b. Class K Extinguisher

The Class K Fire extinguisher [installed after 6/30/1998] shall have a placard placed nearby conspicuously to read " fire protection system shall be activated prior of using fire extinguisher " [Re: NFPA 10, Standard for Portable Fire Extinguishers, 2001: ?4.3.2.2.]

Findings: The placard was not in place near the fire extinguisher.

Observation and discussion with the Maintenance Director between 9 am and 2:30 pm on 12/7/2011 revealed that certain requirements stipulated in NFPA 101 were not met.

Draperies, curtains, including cubicle curtains, and other loosely hanging fabrics and films serving as furnishings or decorations in health care occupancies shall be in accordance with 10.3.1 [Re: NFPA 101, Life Safety Code. 2000: ? 19.7.5.1.]

Findings: This requirement was discussed and it was determined that the required documentation is not retained by the staff.

Observation and discussion with the Maintenance Director between 9 am and 2:30 pm on 12/7/2011 revealed that certain requirements stipulated in NFPA 99 and the State Licensing Rules were not met.

a. Line Isolation Monitor Tests

The Line Isolation Monitor [LIM] circuit shall be tested at intervals of not more than one month. The test switch shall activate both the visual and audible alarm indicator [Re: NFPA 99, Health Care Facilities, 1999: ? 3-3.3.4.2.]

Findings: During the survey, the staff did not affirm that these tests were conducted and a log confirming this was not available for review.

b. HVAC Filter Change Log

The facility is required to maintain a log indicating that the HVAC filters have been changed according to predetermined criteria [Re: 25 TAC, HLR, 2007: ? 133.162(d)(3)(D)(ii).]

Findings: During the survey, the staff could not produce a log indicating that the HVAC filters were changed according to a system.

Observation and discussion with the Maintenance Director between 9 am and 2:30 pm on 12/7/2011 revealed that certain requirements stipulated in NFPA 99 and NFPA 110 were not met.


a. Weekly Battery Inspection

Storage batteries, including electrolyte levels, used in connection with Level 1 and Level 2 systems shall be inspected at intervals of not more than 7 days and shall be maintained in full compliance with manufacturer ' s specifications. Defective batteries shall be repaired or replaced immediately upon discovery of defects. [Re NFPA 110, Standard for Emergency and Standby Power Systems, 1999: ? 6-3.6.]

Findings: The staff indicated that these observations were not made and records were not available for review.


b. Maintenance Free Batteries

Starting batteries for Level I installations shall not be of the maintenance-free variety [Re NFPA 110, Standard for Emergency and Standby Power Systems, 1999: ? 3-5.4.5.]

Findings: The battery installed with the generator did not meet this requirement.

c. Circuit Breakers

Main and feeder circuit breakers shall be inspected annually and a program for periodically exercising the components shall be established according to manufacturer ' s recommendations [Re: NFPA 99, Health Care Facilities, 1999: ? 3-4.4.1.2.]

Findings: The staff indicated that these tests are not conducted and records were not available for review.

d. Load Tests

Monthly - Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods: (a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating; or (b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer. The date and time of day for required testing shall be decided by the owner, based on facility operations [Re: NFPA 110: Standard for Emergency and Standby Power Systems, 1999: ? 6-4.2.]

Annually

Diesel-powered EPS installations that do not meet the requirements of 6-4.2 shall be exercised monthly with the available EPSS load and exercised annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of 2 continuous hours [Re: NFPA 110: Standard for Emergency and Standby Power Systems, 1999: ? 6-4.2.2]

Findings: The staff indicated that these tests were not conducted and records were not available for review.

e. GenSet Light & Receptacle

No function other than those listed in (a) through (f) shall be connected to the life safety branch. The life safety branch of the emergency system shall supply power for the following lighting, receptacles, and equipment: ... ...(e) Generator Set Location. Task illumination battery charger for emergency battery-powered lighting unit(s) and selected receptacles at the generator set location [Re: NFPA 70, National Electrical Code, 1999: ?517-32(e).]

Findings: A light was installed in the generator set location; it could not be determined that it was powered by the emergency system. A receptacle was not provided at the generator set.

Observation and discussion with the Maintenance Director between 9 am and 2:30 pm on 12/7/2011 revealed that certain requirements stipulated in NFPA 70, NFPA 99 and the State Licensing Rules.

a. Type I Essential Electrical System

The hospital should have a Type I Essential Electrical System [EES] as described in NFPA 99, Health Care Facilities, 1999: ? 3-4.2.

Findings: It could not be determined if the hospital has a Type I EES. The facility shall produce a one-line diagram that portrays the interconnection of major electrical components and will be available for during future surveys and inspections.

b. Separation of Branches

The Type I EES shall be divided into the critical branch, life safety branch and the emergency system in accordance with NFPA 99 [Re: NFPA 99, Health Care Facilities, 1999: ?3.4.2.2.2.]

Findings: This requirement was discussed with the staff while observing the electrical installations; it could not be determined if this separation was provided.

c. Functional Allocation

The various functions powered by the Type I EES must be powered by the appropriate branch of the system [Re: NFPA 99, Health Care Facilities, 1999: ?3.4.2.2.2.]

Findings: This requirement was discussed with the staff while observing the electrical installations; this functional requirement was not satisfied.

d. Critical Powered Receptacles

The critical branch of the emergency system shall supply power for task illumination, fixed equipment, selected receptacles, and special power circuits serving the following areas and functions related to patient care: .... [Re: NFPA 70, National Electrical Code, 1999: ?517-33(a).]

Findings: The following functions shall be powered by the critical branch:

? Blood bank in the lab
? ED Exam Room receptacles
? Ice machines in the patient care areas
? Refrigerators for Meds

e. Marked Receptacles

The receptacles or the face plates for receptacles supplied by the critical branch shall have a distinctive color [traditionally red] or marking so as to be readily recognizable [Re: NFPA 70, National Electrical Code, 1999: ? 517-33[c].]

Findings: The facility shall ensure this rule is met for each critical branch-powered receptacle in the ED Exam room and other critical areas.


f. Label Critical Receptacles

All critical care area receptacles powered by the emergency system shall be identified. The face plate for the receptacle(s) shall have a nonremovable label or be engraved indicating the panel and circuit number ....[Re: NFPA 70, National Electrical Code, 1999: ? 517-19.]

Findings: The receptacles were not labeled as required consistently in the ED Exam Room.


g Use of PVC

Soil stacks, drains, vents, waste lines, and leaders installed above ground within buildings shall be drain-waster-vent (DWV) weight or heavier and shall be: copper pipe, copper tube, cast iron pipe, or galvanized iron pipe [Re: 25 TAC, HLR, 2007: ? 133.162(d)(4)(A)(viii)(I).]

Findings: During the survey, PVC was used as a conduit for what appeared to be an emergency circuit. PVC is not allowed inside a hospital above grade and its use as a conduit is not allowed by 517-30[c](3), 1999 edition.


h. Fire Alarm Power

Alarm and alerting systems, including fire alarm systems, must be powered by the life safety branch [Re: NFPA 70, National Electrical Code, 1999: ?517.32[C](1)].

Findings: The facility shall identify the power sources for the fire alarm systems.


i. Circuit Directories

All circuits and circuit modifications shall be legibly identified as to purpose or use on a circuit directory located on the face or inside of the panel door in the case of a panelboard, and at each switch on a switchboard [Re: NFPA 70, National Electrical Code, 2002: ? 408.4.]

Findings: The circuit directories posted in certain panelboards were not meaningful and accurate. One panelboard labeled as Life Safety panelboard in a Janitor ' s Closet near the medical records area had no circuit directory. The facility shall update the directories.

j. Uncovered Junction Boxes

All pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction .... [Re: NFPA 70, National Electrical Code, 2002: ? 314.28[C].]

Findings: At least one junction box was observed without a cover as required. The facility shall ensure all junction boxes are provided with covers.