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Based on observation and interview during the survey of the facility on 07/27/17 with the Director of Quality Risk Management, the facility failed to provide the required fire resistance rating between the Specialty Hospital and adjacent spaces as required by NFPA 101, 8.2.3.2.2 and 21.3.7.1.

Observation on the morning of 07/27/17 revealed holes and unsealed penetrations in the rated demising wall between the Specialty Hospital and the adjacent facility.

In an interview on 07/27/17, the Director of Quality Risk Management stated that the holes will be properly sealed.

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Based on observation and interview during the survey of the facility on 07/27/17 with the Director of Quality Risk Management, the facility failed to provide at least a 1 hour fire resistance rating at required rooms per NFPA 101, 8.2.3.2.2 and 21.3.7.1.

Observation on 07/27/17 revealed holes and unsealed penetrations in the rated demising wall between the Specialty Hospital and the adjacent facility.

In an interview on 07/27/17, the Director of Quality Risk Management stated that the holes will be properly sealed.

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Based on observation the facility failed to provide a fully exhaust system throughout the facility, as required by:

Department of State Health Services, Facility Licensing Group, Title 25, Texas Administrative Code, Chapter 133, Hospital Licensing State Regulations
§133.162. New Construction Requirements.
(d)(3)(D) Heating, ventilating and air conditioning (HVAC) systems. All HVAC systems shall comply with and shall be installed in accordance with the requirements of National Fire Protection Association 90A, Standard for the Installation of Air Conditioning and Ventilating Systems, 2002 edition, (NFPA 90A), NFPA 99, Chapter 6, the requirements contained in this subparagraph, and the specific requirements for a particular unit in accordance with §133.163 of this title.

(i) General ventilation requirements. All rooms and areas in the hospital listed in Table 3 of §133.169(c) of this title shall have provision for positive ventilation. Fans serving exhaust systems shall be located at the discharge end and shall be conveniently accessible for service. Exhaust systems may be combined, unless otherwise noted, for efficient use of recovery devices required for energy conservation. The ventilation rates shown in Table 3 of §133.169(c) of this title shall be used only as minimum requirements since they do not preclude the use of higher rates that may be appropriate. Supply air to the building and exhaust air from the building shall be regulated to provide a positive pressure within the building with respect to the exterior.

(VII) Areas requiring fully ducted systems. Fully ducted supply, return and exhaust air for HVAC systems shall be provided for all critical care areas, sensitive care areas, all patient care areas, all areas requiring a sterile regimen, storage rooms, food preparation areas, and where required for fire safety purposes. Combination systems, utilizing both ducts and plenums for movement of air in these areas shall not be permitted.

(I) If the toilet is for patient use, an additional hand washing fixture shall be provided in each room at the entrance of the room. If the modular toilet/hand washing unit is for patient use, provision shall be made for patient privacy and odor control. The toilet room exhaust shall be in accordance with Table 3 of §133.169(c) of this title.

(C) The isolation room exhaust shall be a dedicated system which exhausts all air continuously to the exterior in accordance with Table 3 of §133.169(c) of this title. Multiple isolation rooms may be interconnected to the same exhaust system.

(viii) The isolation exhaust system shall be connected to the emergency essential electrical system.

The inspector observed, while accompanied by the Director of Quality Risk Management on 07/27/17 that the negative air at the exhaust grille would not hold a tissue in place when tested at several required locations.

The Director of Quality Risk Management stated on 07/27/17 that the facility would make required revisions.
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Based on observation, the facility failed to provide GFCI receptacles within three feet of a wash basin or sink, as required by:

NFPA 70, §517.20 and §517.21, shall be GFCI protected regardless of the branch of the electrical system serving the receptacle.

HLR 2007: §133.162(d)(5)(J) .....GFCI receptacles shall be provided for all general use receptacles located within three feet of a wash basin or sink. When GFCI receptacles are used, they shall be connected to not affect other devices connected to the circuit in the event of a trip. Receptacles connected to the critical branch that may be used for equipment that should not be interrupted do not have to be GFCI protected. Receptacles in wet locations, as defined by NFPA 70, §517.20 and §517.21, shall be GFCI protected regardless of the branch of the electrical system serving the receptacle.

The inspector observed, while accompanied by the Director of Quality Risk Management on 07/27/17 that the GFCI receptacles installed within three feet of a water source did not trip when tested.

The Director of Quality Risk Management stated on 07/27/17 that the facility would make required revisions.
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