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Observation and discussion with the Central Supply Supervisor and the Director of Medical Staff Services between 9:15 am and 2 pm on 8/17/2011 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: ? 19.3.3.2.]

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

Observation and discussion with the Central Supply Supervisor and the Director of Medical Staff Services between 9:15 am and 2 pm on 8/17/2011 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: ? 19.3.3.2.]

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

Observation and discussion with the Central Supply Supervisor and the Director of Medical Staff Services between 9:15 am and 2 pm on 8/17/2011 revealed that certain requirements stipulated in NFPA 72 were not met.

Electrical Requirements

Connections to the light and power service shall be on a dedicated branch circuit(s). The circuit(s) and service shall be mechanically protected. Circuit disconnecting means shall have a red marking, shall be accessible only to authorized personnel, and shall be identified as FIRE ALARM CIRCUIT 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 FACP and booster panels [nurses break room], and circuit #11, Life Safety panelboard, did not meet this requirement. The facility shall ensure that this requirement is met.

Observation and discussion with the Central Supply Supervisor and the Director of Medical Staff Services between 9:15 am and 2 pm on 8/17/2011 revealed that certain requirements stipulated in the State Licensing rules were not met.

a. 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: During the survey, it was extremely difficult to determine which air handling unit served specific areas of the hospital, and what parameters were associated with the air flow. The facility shall develop a matrix that identifies each air handling unit, how many filters are in the unit, the level of filtration associated with each filter bank, and the CFM rating of the unit to facilitate maintenance and future inspections/surveys.

b. Draft Gauges

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: During the survey, it was noted that the required draft gauges were not installed across each filter bed with efficiency greater than 75%. No gauge could be located for the RTU that serves the surgical unit. The facility shall ensure that this requirement is satisfied.

c. Negatively Pressurized Rooms

Specific rooms in a hospital must be negatively pressurized for infection control purposes and for the comfort of the patients [Re: 25 TAC HLR 2007: ? 133.162(d)(3)(D)(i).] In order to achieve this, the Department requires all exhaust fans in a toilet room or a soiled utility room, or in similar locations, to operate continuously and not to be affected by switches that activate room lighting.

Findings: During the survey, it was noted that a number of these locations did not satisfy this requirement [specifically, near the Dietary Suite and in the ED.] The facility shall ensure that this requirement is satisfied.

d. Isolation Room Air Flow

Each licensed hospital must have at least one isolation room with an ante room that meets the air flow requirements specified in State regulations [Re: 25 TAC HLR 2007: ? 133.162(d)(3)(D)(i).] The air flow must move from the corridor to the ante room [if applicable] and then to the patient room prior to being evacuated from the building by an exhaust fan. In order to achieve this, the Department requires all exhaust fans to operate continuously and not subject to switching off.

Findings: During the survey, it was noted that an isolation room had the exhaust fan turned off with a switch, thereby defeating the purpose of the exhaust fan, and introducing the possibility of airborne germs not being eliminated from the building. The facility shall ensure that this requirement is satisfied.

e. Fresh Air Intakes

The bottom of outside air intakes serving central systems shall be located as high as practical but at least six feet above ground level, or if installed above the roof, three feet above the roof level [Re: 25 TAC HLR, 2007: ?133. 162(d)(3)(D)(i)(IV).]

Findings: During the survey, it was noted that the air intake for the central unit on the roof was situated too close to the deck, thereby allowing the intake of dirty air. The facility shall ensure that this requirement is met.

Observation and discussion with the Central Supply Supervisor and the Director of Medical Staff Services between 9:15 am and 2 pm on 8/17/2011 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 Central Supply Supervisor and the Director of Medical Staff Services between 9:15 am and 2 pm on 8/17/2011 revealed that certain requirements stipulated in State Licensing Rules were not met.

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 two places in the Dietary Suite. These should be replaced with nonflammable materials.

Observation and discussion with the Central Supply Supervisor and the Director of Medical Staff Services between 9:15 am and 2 pm on 8/17/2011 revealed that certain requirements stipulated in State Licensing Rules and NFPA 70 were not met.

a. Emergency Receptacles in Critical Areas

All critical area receptacles 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: 25 TAC HLR 2007: ? 133.162(d)(5)(H)(vi).]

Findings: During the survey, it was noted that emergency powered receptacles in the Emergency Department (ED) were not labeled as required. The facility shall ensure that all emergency powered receptacles in critical areas [ie, surgery, recovery and ED] are labeled as required.

b. Use of Power Strips

Extension cords and cables shall not be used for permanent wiring [Re: 25 TAC HLR 2007: ? 133.162(d)(5)(A)(ii).]

Findings: During the survey, the use of a power strip was noted in the Dietary Suite. This would be classified as an extension cord by the Department and the installation appeared to be permanent. The facility shall replace this power strip with a permanent, safe, allowable installation.

c. Critical Branch Loads

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: ..... (3)[b] Medication prep areas, and (3)[c] Pharmacy dispensing areas, ..... [Re: NFPA 70, National Electrical Code, 2002: ? 517.33(A)(3).]

Findings: During the survey, it was noted that the med refrigerator at the nurses ' station was powered by the normal system which is not permitted. The facility shall ensure that all med refrigerators are powered by the critical branch.

d. Ice Dispensers

Acting as the State-level Authority Having Jurisdiction [AHJ], the Department requires at least one ice dispenser located within reasonable proximity to each patient, to be powered by the critical branch of the Emergency System to ensure ice availability during anomalous conditions.

Findings: During the survey, ice dispensers powered by the emergency system could not be identified as required. The facility shall ensure that this requirement is met.