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Observation and discussion with the Administrator between 2:00 pm and 4:45 pm on 6/28/2011 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: ? 23.3.3.2.]

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

Observation and discussion with the Administrator between 2:00 pm and 4:40 pm on 6/28/2011 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: ? 23.3.3.2.]

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

Observation and discussion with the Administrator between 2:00 pm and 4:45 pm on 6/28/2011 revealed that certain requirements stipulated in NFPA 72 were not met.

a. Visual Inspections

Visual inspection(s) shall be performed in accordance with the schedule(s) in Section 7.3 or more often if required by the authority having jurisdiction. The visual inspection(s) shall be made to ensure that there are no changes that effect equipment performance [Re: NFPA 72, National Fire Alarm Code, 1999: ? 7-3.1.] Note: the frequencies of the visual inspections are specified in Table 7-3.1.]

Findings: A log was not available indicating that these required visual inspections are performed.

b. Component Testing

Testing shall be performed in accordance with the schedules in Chapter 7 or more often if required by the authority having jurisdiction. If automatic testing is performed at least weekly by a remotely monitored fire alarm control unit specifically listed for the application, the manual testing frequency shall be permitted to be extended to annual. Table 7-3.2 shall apply. [Re: NFPA 72, National Fire Alarm Code, 1999: ? 7-3.2.] Note: the frequencies of the testing are specified in Table 7-3.2.]

Findings: A log was not available indicating that these required tests were performed.

c. 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 main FACP was located in the corridor near the nurses ' station, but was locked and it could not be determined if this requirement was met. The facility shall ensure that this requirement is met.

Observation and discussion with the Administrator between 2:00 pm and 4:45 pm on 6/28/2011 revealed that certain requirements stipulated in NFPA 101 and NFPA 72 were not met.

Inspections & Tests

The provisions of Section 9.6 cover the basic functions of a complete fire alarm system, including fire detection, alarm and communications. These systems are primarily intended to provide the indication and warning of abnormal conditions, the summoning of appropriate aid, and the control of occupancy facilities to enhance protection of life [Re: NFPA 101, Life Safety Code, 2000: ? 9.6.1.3.] All required smoke detectors, including those activating door hold-open devices, are approved, maintained, inspected and tested in accordance with the manufacturer ' s specifications. The inspection and testing frequency of the detectors are specified in Tables 7-3.1 and 7-3.2 [Re: NFPA 72, National Fire Alarm Code, 1999: ? 7-3.1 and 2.]

Findings: A log was not available indicating that these required inspections and tests were performed.

Observation and discussion with the Administrator between 2:00 pm and 4:45 pm on 6/28/2011 revealed that certain requirements stipulated in NFPA 25 were not met.

a. Inspections

Records shall indicate the procedure performed (eg, inspection, test, or maintenance), the organization that performed the work, the results and the date [Re: NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998: ?1-8.1.]

b. Records

Records shall be maintained by the owner. Original records shall be retained for the life of the system. Subsequent records shall be retained for a period of one year after the next inspection, test, or maintenance required by the standard [Re: NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998: ?1-8.2.]

c. Frequency

Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation [Re: NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998: ?2-2.1.1.]

Findings: No log or any paper work was available indicating that these required inspections were performed.

Observation and discussion with the Administrator between 2:00 pm and 4:45 pm on 6/28/2011 revealed that certain requirements stipulated in the State Licensing Rules were not met.

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 Janitor ' s Closet in the Surgical Suite did not meet this requirement. The facility shall ensure that all pressure requirements are met.

Observation and discussion with the Administrator between 2:00 pm and 4:45 pm on 6/28/2011 revealed that certain requirements stipulated in NFPA 96 were not met.

a. Inspections Required

An inspection and servicing of the fire-extinguishing system and listed exhaust hoods containing a constant or fire-actuated water system shall be made at least every 6 months by properly trained and qualified persons [Re: NFPA 96,
Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 1998: ? 8-2.]

b. Hood Fusible Link

Fusible links (including fusible links on fire-actuated damper assemblies) and automatic sprinkler heads shall be replaced at least annually, or more frequently if necessary, to ensure proper operation of the system. Other detection devices shall be serviced or replaced in accordance with the manufacturer ' s recommendations. Exception: Where automatic bulb-type sprinklers or spray nozzles are used and annual examination shows no buildup of grease or other material on the sprinkler or spray nozzles [Re: NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 1998: ? 8-2.2.]

Findings: No log or any paper work was available indicating that these required inspections were performed.

Observation and discussion with the Administrator between 2:00 pm and 4:45 pm on 6/28/2011 revealed that certain requirements stipulated in the State Licensing Rules and NFPA 99 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 for drain lines in the Dietary Suite. This is not permitted.

b. Disaster Drills

Each organizational entity shall implement one or more specific responses of the emergency preparedness plan at least semi-annually. At least one semi-annual drill shall rehearse mass casualty response for health care facilities with emergency service, disaster receiving stations, or both [Re: NFPA 99, Health Care Facilities, 1999: ? 11-5.3.9.]

The department requires the documentation of these drills be retained for a period of three years [Re: 25 TAC HLR 2007: ? 133.142[c][3].]

Findings: No documentation was available for review at the time of the survey.

c. Electrical Equipment

All appliances used in patient care areas shall be tested in accordance with 7-5.1.3 or 7-5.2.2.1 before being put into service for the first time and after repair or modification. Patient-care-related electrical appliances shall be retested at intervals determined by their normal location or area of normal use, but not exceeding the following intervals: general care areas - 12 months; critical care areas - 6 months; and wet locations - 6 months [Re: NFPA 99, Health Care Facilities, 1999: ? 7-6.2.1.2. ]

Findings: Documentation was not available for review at the time of the survey indicating that these intervals were observed. Of particular interest is the equipment for critical areas [ie, the emergency department and the surgical suite.

d. Letters of Preference

When designated by the emergency preparedness management plan to provide continuous service in a disaster or emergency, health care facilities shall establish plans for continuity of essential building systems, as applicable: ... (b) Water; .... (e) Fuel sources [Re: NFPA 99, Health Care Facilities, 1999: ? 11-5.3. 2.]

Findings: The department requires the hospital to have signed letters from vendors stating that the hospital is a preferred customer in the event of an emergency. These letters were not available for review at the time of the survey.

Observation and discussion with the Administrator between 2:00 pm and 4:45 pm on 6/28/2011 revealed that certain requirements stipulated in NFPA 110 were not met.

a. Transfer Switches

Level 1 and Level 2 transfer switches shall be operated monthly. The monthly test of a transfer switch shall consist of electrically operating the transfer switch from the standard position to the alternate position and then a return to the standard position [Re: NFPA 110, Standard for Emergency and Standby Power Systems, 1999: ? 6-4.5.]

b. Circuit Breakers

The emergency power supply system [EPSS] circuit breakers for Level 1 system usage, including main and feed breakers between the EPS and the transfer switch load terminals, shall be exercised annually with the emergency power supply [EPS] in the off position. Exception: Medium- and high-voltage circuit breakers for Level 1 system usage shall be exercised every 6 months and tested under simulated overload conditions every 2 years. [Re: NFPA 110, Standard for Emergency and Standby Power Systems, 1999: ? 6-4.6.]

Findings: Logs were not available that indicated these required tests were conducted.

Observation and discussion with the Administrator between 2:00 pm and 4:45 pm on 6/28/2011 revealed that certain requirements stipulated in NFPA 70 were not met.

a. 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]. It is departmental policy to permit an electrical system to be configured with a normal branch and an emergency branch provided the hospital was built before 1981 and deliveries and surgeries are not performed, and life support systems are not employed. This facility meets these conditions.

Findings: During the survey, a number of functions were determined to be improperly circuited. The facility shall ensure that only the proper loads are circuited from the appropriate panelboards.

b. 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.

c. Component Labels

All boxes and enclosures (including transfer switches, transformers, distribution panels, and panelboards) for emergency circuits shall be permanently marked so they will be readily identified as a component of an emergency circuit or system [Re: NFPA 70, NEC, 2002: 700.9(A).]

Findings: The above listed components shall be labeled with the words " EMERGENCY " to be readily identifiable as part of the Essential Electrical System.

d. 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.

e. Flex Conduit

The wiring of the emergency system of a hospital shall be mechanically protected by installation in nonflexible metal raceways, or shall be wired with Type MI cable [Re: NFPA 70, National Electrical Code, 2002: ?517.30[C](3).]

Findings: This requirement was discussed with the staff while observing the electrical installations; flexible conduit was installed on all types of power circuits, and this is not allowed on emergency circuits.