HospitalInspections.org

Based on observations made during the survey of the facility between the hours of 2:30 pm and 6:00 pm, while accompanied by the Guest Hospital's CEO, Dir. of Business Development, Dir. of Clinical Quality, as well as the Host Hospital ' s Plant Ops Mgr., Admin. Asst., and HVAC Mechanic it was observed that the 1 hour fire-rated partition construction typical at all of the ELECTRICAL ROOMS (2 on each floor level) were not in compliance with the requirements for rated wall construction. The following deficiencies were identified:
1. LEVEL 3 - SMALL ELECTRICAL RM. contained a Pneumatic Tube Transfer Station from which one of the tubes was positioned such that a portion of the vertical tubing was half-in and half-out of the rated wall. This is a non-compliant penetration of the required continuous membrane, compromising the integrity of the rated wall assembly.

Additionally, construction of the rated wall was incomplete where the gypsum board was missing at the top of the same wall.

Based on observations made during the survey of the facility between the hours of 2:30 pm and 6:00 pm, while accompanied by the Guest Hospital's CEO, Dir. of Business Development, Dir. of Clinical Quality, as well as the Host Hospital ' s Plant Ops Mgr., Admin. Asst., and HVAC Mechanic it was observed that while it appears the facility had accomplished some of the requirements, the facility failed to provide logs indicating consistent, systematic compliance on the following issues and items:

1. Air filter change log.
2. Electrical equipment inspections - Biomedical.
Critical Areas: Semi-annually.
General Areas: Annually
3. Electrical power and distribution and grounding systems - Effectiveness.
Critical Areas: Semi-annually.
General Areas: Annually

Additionally, the facility failed regarding the following:
4. The required manual " KILL " switch on the AHU-6 (providing OUTSIDE AIR) for the GUEST HOSPITAL (Levels 3 & 4) was not provided. Switch(es) shall be located at a continually staffed location. Ensure that each device is clearly and permanently labeled regarding which system it controls.
NOTE: When the HVAC air handling units are electronically monitored by a " building automation system " capable of automatically shutting off the air handling units during emergency conditions then a placard satisfying the location requirement(s), as well as the labeling requirements noted above may be provided in-lieu-of the manual switch device.
Additionally, there shall be coordination with the facility for correct wording on the following information for the placard:
· PROCEDURE - Hospital staff must briefly be advised on how to proceed in the event that smoke is seen coming from the HVAC system.
· CONTACT INFORMATION - Hospital staff must briefly be advised on who to contact, and how to immediately contact them.

For emergency shutdown of the air handling unit a manual " KILL " switch, or " building automation system " must be in compliance with the following:
NFPA 90A, 2002: 6.2 - " Each air distribution system shall be provided with at least one manually operable means for stopping the operation of the supply, return, and exhaust fan(s) in an emergency. "