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Observation and discussion with the Administrator and the Plant Engineer between 9:20 am and 2:40 pm on 6/22/2011 revealed that certain requirements stipulated in NFPA 72 were not met.

Markings

Connections to the light and power service shall be on a dedicated branch circuit(s). The circuits and connections shall be mechanically protected. Circuit disconnecting means shall have a red marking, shall be in accessible only to authorized personnel, and shall be identified as FIRE ALARM CIRUIT CONTROL. The location of the circuit disconnecting means shall be permanently identified at the fire alarm control unit [Re: NFPA 72, National Fire Alarm Code, 1999: ? 1-5.2.5.2.]

Findings: The marking was not present on panelboard LS1 for Circuit #12 as required.

Observation and discussion with the Administrator and the Plant Engineer between 9:20 am and 2:40 pm on 6/22/2011 revealed that certain requirements stipulated in the State Licensing Rules were not met.

a. Level of Filtration

All central air handling systems serving patient care areas, including nursing unit corridors, shall be equipped with filters having efficiencies equal to, or greater than, those specified in Table 4 of ?133.169(d) of this title. ..... [Re: 25 TAC HLR 2007: ? 133.162(d)(3)(D)(ii).]

Findings: During the survey, it was noted that laboratory had a single filter that was not identified as an 80% filter as required. It appeared to be a 30% filter. The facility shall ensure that the laboratory is supplied with 80% filtered air as required.

b. Draft Gauge

A manometer or draft gauge shall be installed across each filter bed having a required efficiency of 75% or more including hoods requiring high efficiency particulate air (HEPA) filters [Re: 25 TAC HLR 2007: ?133.162(d)(3)(D)(ii)(V).]

Findings: The level of air filtration in the lab [80%] requires a draft gauge. The facility shall ensure that this gauge is installed.

c. Ventilation Requirements

All rooms and areas in the hospital listed in Table 3 of ? 133.169[c] shall have provision for positive ventilation [Re: 25 TAC HLR 2007: ? 133.162(d)(3)(D)(i).]

Findings: The referenced table requires toilet rooms and janitors closets to be pressurized negatively, and this is accomplished by an exhaust fan operating continuously. During the survey, it was noted that Soiled Holding Room #201, and the Janitor ' s Closet in the Dietary Suite did not meet this requirement. The facility shall ensure that all pressure requirements are met.

d. Isolation Room

The isolation room must meet the air flow requirements as stipulated in Table 3, [see subsection c above] and must have a pressure monitor installed [Re: 25 TAC HLR 2007: ? 133.163(t)(1)(C)(v)] and a door closer on the door between the patient suite and the corridor [Re: 25 TAC HLR 2007: ? 133.163(t)(1)(C)(iv)]

Findings: These amenities were not provided; the facility shall ensure that the air flow meets the requirements and the pressure monitor and door closer are provided.

Observation and discussion with the Administrator and the Plant Engineer between 9:20 am and 2:40 pm on 6/22/2011 revealed that certain requirements stipulated in NFPA 99 and in the State Licensing Rules were not met.

a. Cylinder Restraint

Locations for central supply systems and the storage of medical gases shall meet the following requirements: .... (7) Be provided with racks, chains, or other fastenings to individually secure all cylinders, whether connected, unconnected, full, or empty from falling [Re: NFPA 99, Health Care Facilities, 2002: ?5.1.3.3.2(7).]

Findings: The reserve oxygen medical gas cylinders were restrained collectively as opposed to individually.

b. Medical Gas Outlets

Nonflammable medical gas and clinical vacuum system installations shall be designed, installed and certified in accordance with the requirements of NFPA 99, ?5.1 for Level I systems and the requirements of this clause [Re: 25 TAC HLR, 2007: ? 133.162(d)(4)(A)(iii).]

Nonflammable medical gas and vacuum outlets shall be provided in accordance with Table 6 of ?133.169(f) of this title [Re: 25 TAC HLR, 2007: ? 133.162(d)(4)(A)(iii)(I).]

The exam and trauma rooms of the Emergency Department are required to have Med Gas outlets.
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Findings: The hospital ' s medical air system has been decommissioned and the ED does not have outlets installed for med air. Discussion during the survey included the possibility of using cylinders. This approach is not acceptable because of the requirement for a Type I system.

Observation and discussion with the Administrator and the Plant Engineer between 9:20 am and 2:40 pm on 6/22/2011 revealed that certain requirements stipulated in 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: PVC piping was installed as condensate drain lines for the HVAC unit in the laboratory and for the Liebert cooling unit in the CT Scan Procedure Room, and for drain lines in the Dietary Suite beneath the triple sink and the soiled ware cleaning room. This is not permitted.

b. Dietary Suite Mirror

Mirrors shall not be installed at hand washing fixtures in the food prep areas [Re: 25 TAC HLR, 1997: ? 133.163(e)(2)(A)(iv).]

Findings: A mirror was observed above the hand washing fixture in the food prep area. This is not permitted.

c. Dedicated Dietary Suite Toilet Room

A toilet room(s) with a hand washing fixture[s] with hands-free operable controls shall be provided for the exclusive use of the dietary staff. Toilet room[s] shall not open directly into the food prep areas, but must be in close proximity to them. For large facilities, a locker room or space for lockers shall be provided for staff belongings [Re: 25 TAC HLR, 1997: ? 133.163(e)(1)(B)(xiv).]

Findings: A dedicated toilet room was not provided. The facility has the option of designating a toilet room in close proximity with a sign restricting use of the toilet room to the dietary staff.

d. Nurse Call Installations

... The hospital shall comply with the requirements of this subparagraph in addition to any specific requirements for nurses calling systems for the particular unit of the hospital in accordance with ?133.163 and Table 7 of ?133.169(g) of this title .....[Re: 25 TAC HLR, 2007: ?133.162(d)(5)(L).]

Findings: The patient dressing areas [Imaging Suite] did not have nurse call stations installed in the dressing rooms and the nurse call stations in the procedure rooms did not have dome lights installed in the corridor as required.

Observation and discussion with the Administrator and the Plant Engineer between 9:20 am and 2:40 pm on 6/22/2011 revealed that certain requirements stipulated in NFPA 70, NFPA 99, and the State Licensing Rules were not met.

a. GenSet Life Safety Features

A battery powered light where the battery is charged by the life safety branch and a receptacle powered by the life safety branch is required [Re: NFPA 70, National Electrical Code, 2002: ? 517.32[E].]

Findings: This topic was discussed during the survey and when the generator was observed, it was obvious that this requirement was not met. The facility shall make the necessary changes to meet this requirement.

b. Functional Allocation

Specific requirements exist identifying the functions as they must be allocated to the critical branch [NFPA 70, National Electrical Code, 2002, ?517.33], life safety branch [NFPA 70, National Electrical Code, 2002, ?517.32], and the equipment system [NFPA 70, National Electrical Code, 2002, ?517.34].

Findings: During the survey, a number of functions were determined to be improperly circuited. On life safety panelboard LS1, a sump pump and a GFI receptacle allocated for elevator use were noted . These are not allowable functions. Life safety panelboard LSB located in the " electrical room " also had several disallowed functions powered by the life safety branch.

c. Circuit Directory

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: All circuit directories must be updated to be legible and meaningful.

d. Receptacle Installations

Each Procedure Room in the Imaging Suite must have 4 receptacles installed [Re: 25 TAC HLR, 2007: ?133.163(l)(5)(A)(i)] and a normal powered receptacle must be installed at each patient treatment location or position [Re: 25 TAC HLR, 2007: ?133.162(d)(5)(H)(ii)].

Findings: Exam Room #2 in the Imaging Suite needs another receptacle installed and the Ultrasound Procedure Room must have a normal-powered receptacle installed.