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GREENE COUNTY HOSPITAL
Cooking Facilities
Tag No.: K0324
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Based on observation and interview, the facility failed to maintain the dietary hood per the requirements of:
2012 NFPA 101, 19.3.2.5.1, and 9.2.3
2011 NFPA 96, 6.2.3.3
Findings include:
On 6/26/2018, during a tour of the facility from 2:30 pm to 3:45 pm, the surveyor observed 3 gaps between the dietary hood grease filters equaling approximately 5" of total gaps.
A member of maintenance staff was present when the facility was identified.
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Fire Alarm System - Installation
Tag No.: K0341
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This deficiency is a rewrite from last survey.
Based on observation and interview, the facility failed to maintain an electrically locked exit door per the requirements of:
2012 NFPA 101, 19.3.4.1, and 9.6.1.3
2010 NFPA 72, 21.9
Findings include:
On 6/26/2018, during a tour of the facility from 2:30 pm to 3:45 pm, the surveyor observed an electrically locked exit door near room 134 failed to automatically unlock upon activation of the fire alarm system.
A member of the maintenance staff was present when this deficiency was identified.
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HVAC
Tag No.: K0521
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* Based on observation and interview, the facility failed to provide an HVAC system per the requirements of:
2012 NFPA 101, 19.5.2.1, and 9.2.1
2012 NFPA 90A, 4.3.12.1.1
Findings include:
On 06/26/2018, during a tour of the facility from 2:30 pm to 3:45 pm, the surveyor observed the corridor being used as a return air plenum for the HVAC.
A member of the maintenance staff was present when this deficiency was identified.
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Electrical Equipment - Testing and Maintenanc
Tag No.: K0921
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Based on observation and interview, the facility failed to maintain the patient care-related electrical equipment (PCREE) per the requirements of:
2012 NFPA 99, 10.3, 10.5.2.1, 10.5.2.1.2, 10.5.2.5, 10.5.3, 10.5.6, and 10.5.8
The deficiency could affect all residents.
On 6/27/2018, during a tour of the facility from 7:45 am to 9:15 am, the facility failed to provide all of the following documentation on the testing and maintenance of the PCREE:
1. File containing instruction manuals and maintenance manuals
2. Documentation of the required testing, repairs, or modification of equipment
3. Qualifications, training and continuous education of the personnel providing this service
A member of the maintenance staff was present when this deficiency was identified.