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Based on review of facilities records, the "Preferred Provider/Supplier" for emergency generator fuel and water did not indicate a date of contract and contract termination.
NFPA-101 4.8? Emergency Plan.
4.8.1? Where Required. Emergency plans shall be provided as follows:
(1)?Where required by the provisions of Chapters 11 through 42
(2)?Where required by action of the authority having jurisdiction.
4.8.2? Plan Requirements.
4.8.2.1* Emergency plans shall include the following:
(1)?Procedures for reporting of emergencies
(2)?Occupant and staff response to emergencies
(3)*Evacuation procedures appropriate to the building, its occupancy, emergencies, and hazards (see Section 4.3)
(4)?Appropriateness of the use of elevators
(5)?Design and conduct of fire drills
(6)?Type and coverage of building fire protection systems
(7)?Other items required by the authority having jurisdiction
4.8.2.2? Required emergency plans shall be submitted to the authority having jurisdiction for review.
4.8.2.3? Emergency plans shall be reviewed and updated as required by the authority having jurisdiction.



Based on observation at the time of the survey, the facility failed to properly identify Fire and Smoke Rated Walls with a sign or stenciling.
All fire walls, fire barriers, fire partitions, smoke barriers, and smoke partitions shall be effectively and permanently identified with signs or stenciling per IBC 2012 section 703.7.

NFPA 5000 8.1.2.3* Wall Marking and Identification. For other than existing assemblies, where there is an accessible concealed floor, floor/ceiling, or attic space, fire walls, fire barriers, smoke barriers, and smoke partitions shall be permanently identified with signs or stenciling in the concealed space and shall comply with all the following:

(1) Be located in accessible concealed floor, floor/ceiling, or attic spaces

(2) Be located within 15 ft (4572 mm) of the end of each wall and at intervals not exceeding 30 ft (9144 mm) measured horizontally along the wall or partition

(3) Include lettering not less than 3 in. (76 mm) in height with a minimum 3 ?8 in. (9.5 mm) stroke in a contrasting color

(4) Identify the wall type and its fire resistive rating as applicable

Based on observation at the time of the survey, components of the Hospital Occupancy (MRI Fire Sprinkler Riser Room, and Electrical Equipment) are located in the Business Occupancy adjacent to the hospital (on the Business Occupancy side of a two-hour Fire Wall) and not contiguous with the Hospital Occupancy.

NFPA-101 18.1.3.4? Contiguous Non-Health Care Occupancies.
18.1.3.4.1* Ambulatory care facilities, medical clinics, and similar facilities that are contiguous to health care occupancies, but are primarily intended to provide outpatient services, shall be permitted to be classified as business occupancies or ambulatory health care facilities, provided that the facilities are separated from the health care occupancy by construction having a minimum 2-hour fire resistance rating, and the facility is not intended to provide services simultaneously for four or more inpatients who are incapable of self preservation.

TAC Title 25 Chapter §133.165(c) Hospitals in buildings with non-health care occupancies.

(1) General.
Before a hospital is licensed in a building also containing occupancies other than health care occupancies, all requirements of this chapter and the following requirements shall be met.

(A) Construction of the building shall conform to the requirements of NFPA 101, Chapter 18, and the building shall be fully sprinklered.

(B) The hospital shall be in one identifiable contiguous location and shall be separated (vertically and horizontally) with two-hour fire rated noncombustible construction from the other occupancies.

Based on observation at the time of the survey, the facility failed to properly provide UL or ASTM Approved Assemblies at Fire and Smoke Wall Penetrations. (Scabbed on sheet rock with fire caulk).

NFPA-101 8.3.5.1* Firestop Systems and Devices Required. Penetrations for cables, cable trays, conduits, pipes, tubes, combustion vents and exhaust vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a fire barrier shall be protected by a firestop system or device. The firestop system or device shall be tested in accordance with ASTM E 814, Standard Test Method for Fire Tests of Through Penetration Fire Stops, or ANSI/UL 1479, Standard for Fire Tests of Through-Penetration Firestops, at a minimum positive pressure differential of 0.01 in. water column (2.5 N/m2) between the exposed and the unexposed surface of the test assembly.

Based on the documents presented by the facility, the hospital has failed to maintain rated doors within the facility. (90% Failure Rate)

NFPA-101 8.3.3.4? Floor fire door assemblies shall be tested in accordance with NFPA 288, Standard Methods of Fire Tests of Floor Fire Door Assemblies Installed Horizontally in Fire Resistance-Rated Floor Systems, and shall achieve a fire resistance rating not less than the assembly being penetrated. Floor fire door assemblies shall be listed and labeled.

NFPA-101 8.4.3.1? Doors in smoke partitions shall comply with 8.4.3.2 through 8.4.3.5.

NFPA-101 8.7.1.3? Doors in barriers required to have a fire resistance rating shall have a minimum ¾-hour fire protection rating and shall be in accordance with 7.2.1.8.



Based on observation at the time of the survey, the kitchen walk-in cooler and freezer did not have door hardware which would allow a person to always exit and not be subject to an inoperable door due to a hasp lock.

OSHA 1910.36(d)(1) "Employees must be able to open and exit route door from the inside at all times without keys, tools, or special knowledge".

Based on observation at the time of the survey and review of documents provided by the facility, many rated doors requiring Self-Closing Devices required maintenance to meet performance requirements for the rating and function of the door.

NFPA-101 7.2.1.8? Self-Closing Devices.
7.2.1.8.1* A door leaf normally required to be kept closed shall not be secured in the open position at any time and shall be self-closing or automatic-closing in accordance with 7.2.1.8.2, unless otherwise permitted by 7.2.1.8.3.

Based on observation at the time of the survey the ICU Suite had only one marked Exit. Non-Sleeping Suites of moor than 1000 ft2 require two identifiable exits.

NFPA-101 18.2.5.5.1? Sleeping rooms of more than 1000 ft2 (93 m2) shall have not less than two exit access doors remotely located from each other.

NFPA-101 7.10.1.2.1* Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign that is readily visible from any direction of exit access.

Based on observations at the time of the survey, the mechanical penthouse was being used for storage of boxes and supplies creating a storage area of over 100sf with combustible material.

NFPA-101 18.3.2.1* Hazardous Areas. Any hazardous areas shall be protected in accordance with Section 8.7, and the areas described in Table 18.3.2.1 shall be protected as indicated.
Table 18.3.2.1? Hazardous Area Protection
Hazardous Area Description Protection/
Separation +
Boiler and fuel-fired heater rooms 1 hour
Central/bulk laundries larger than
100 ft2 (9.3 m2) 1 hour
Laboratories employing flammable or
combustible materials in quantities
less than those that would be considered a severe hazard See 18.3.6.3.11.
Closer
Laboratories that use hazardous
materials that would be classified as a
severe hazard in accordance with
NFPA 99, Standard for Health Care Facilities 1 hour
Paint shops employing hazardous
substances and materials in quantities
less than those that would be classified as a severe hazard 1 hour
Physical plant maintenance shops 1 hour
Rooms with soiled linen in volume
exceeding 64 gal (242 L) 1 hour
Storage rooms larger than 50 ft2
(4.6 m2) but not exceeding
100 ft2 (9.3 m2) and storing
combustible material See 18.3.6.3.11.
Closer
Storage rooms larger than 100 ft2
(9.3 m2) and storing combustible
material 1 hour
Rooms with collected trash in volume
exceeding 64 gal (242 L) 1 hour
+Minimum fire resistance rating.

Based on observation at the time of the survey, the kitchen fryer was located at the edge of the vent hood.

NFPA-96 12.1.2.4 All deep-fat fryers shall be installed with at least a
406 mm (16. in.) space between the fryer and surface flames
from adjacent cooking equipment.

Based on review of facility records, and observations made at the time of the survey, the Type K Kitchen Fire Extinguisher was "Red-Tagged" (past its usable date).

NFPA-10 4.4.2? Any fire extinguisher that can no longer be serviced in accordance with the manufacturer's maintenance manual is considered obsolete and shall be removed from service.

Based on observations at the time of the survey, the Ware Washing Room did not have a functional door with a closer, nor was the room in negative pressure as required by TAC Title 25 Chapter §133.

TAC Title 25 Chapter §133.163(e)(1)(B) (viii) Ware washing room.
A ware washing room equipped with commercial type dishwasher equipment shall be located separate from the food preparation and serving areas. Space shall be provided for receiving, scraping, sorting, and stacking soiled tableware and for transferring clean tableware to the using areas. Hand washing facilities with hands-free operable controls shall be located within the soiled dish wash area. A physical separation to prevent cross-traffic between "dirty side" and "clean side" of the dish wash areas shall be provided.

Figure: 25 TAC §133.169(c)

TABLE 3
VENTILATION REQUIREMENTS FOR HOSPITALS AND OUTPATIENT FACILITIES ¹

Based on review of facility records, fire drills were conducted quarterly (one per quarter per shift) however no notes as to the initiation of a fire alarm signal or simulation thereof.

NFPA-101 18.7.1.4* Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions.

Based on review of the facility's Smoking Policy, no designated smoking area was listed in the policy, nor did the policy specifically state the campus was a 100% "Non-Smoking" campus. The smoking policy shall specifically outline the facility's posture regarding smoking.

NFPA-101 18.7.4* Smoking. Smoking regulations shall be adopted and shall include not less than the following provisions:
(1)?Smoking shall be prohibited in any room, ward, or individual enclosed space where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such areas shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking.
(2)?In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required.
(3)?Smoking by patients classified as not responsible shall be prohibited.
(4)?The requirement of 18.7.4(3) shall not apply where the patient is under direct supervision.
(5)?Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted.
(6)?Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted.

Based on observation at the time of the survey, multiple rooms had been converted to support spaces with out removal of the medical gas and the nurse call. Patient Care Rooms shall be designed by the governing body of the facility and meet the requirements by room type in NFPA-99, 101, and TAC Title 25 Chapter 133. Change of Room Function requires submission to Texas HHS, Regulatory Division ARU.

NFPA-101 1.3.4? Patient Care Rooms.
1.3.4.1? The governing body of the facility or its designee shall establish the following areas in accordance with the type of patient care anticipated and with the following definitions of the classification (see definition of patient care room in Chapter 3):
(1)?Critical care rooms
(2)?General care rooms
(3)?Basic care rooms
(4)?Support rooms
TAC Title 25 Chapter §133.161 (a) Compliance.
All buildings in which existing hospitals licensed by the Department of State Health Services (department) are located shall comply with this subsection.

(2) Remodeling of existing facilities. All requirements listed in this chapter relating to new construction are applicable to renovations, additions and alterations unless stated otherwise.

(A) Alteration or installation of new equipment. Any alteration or any installation of new equipment shall be accomplished as nearly as practicable with the requirements for new construction, except that when existing conditions make changes impractical to accomplish, minor deviations from functional requirements may be permitted if the intent of the requirements is met and if the care and safety of patients will not be jeopardized.

(B) Installation, alteration, or extension approval. No new system of mechanical, electrical, plumbing, fire protection, or piped medical gas system may be installed or any such existing system may be replaced, materially altered or extended in an existing building licensed as a hospital, until complete plans and specifications for the replacement, installation, alteration, or extension have been submitted to the department, reviewed and approved in accordance with §133.167 of this title (relating to Preparation, Submittal, Review and Approval of Plans, and Retention of Records).

(C) Minor remodeling or alterations. All remodeling or alterations which do not involve alterations to load bearing members or partitions, change functional operation, affect fire safety (e.g. modifications to the fire, smoke, and corridor walls), add or subtract beds or services for which the hospital is licensed, and do not involve changes listed in subparagraph (B) of this paragraph, shall be submitted for approval without submitting contract documents. Such approval shall be requested in writing with a brief description of the proposed changes in accordance with §133.167(f)(3) of this title.

TAC Title 25 Chapter §133.167(a)(3) The names of spaces used in the functional program narrative, preliminary documents, final construction documents and specifications shall be consistent with the names of the spaces used in this chapter.

Based on observation at the time of the survey, multiple locations where noted where low-voltage wiring was being supported by the suspended ceiling grid, and locations of open J-boxes without covers.

NFPA-70 800.24 Mechanical Execution of Work.
Communications circuits and equipment shall be installed in a neat and workmanlike manner. Cables installed exposed on the surface of ceilings and sidewalls shall be supported by the building structure in such a manner that the cable will not be damaged by normal building use. Such cables shall be secured by hardware, including straps, staples, cable ties, hangers, or similar fittings designed and installed so as not to damage the cable

NFPA-70 314.28 (C) Covers. All pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use. Where used, metal covers shall comply with the grounding requirements of 250.110.

Based on observation at the time of the survey, the operating rooms did not contain a Line Isolation Monitor, nor did they include GFCI electrical receptacles as required by NFPA-99 6.3.2.2.8.7.

NFPA-99 6.3.2.2.8? Wet Procedure Locations.
6.3.2.2.8.1* Wet procedure locations shall be provided with special protection against electric shock.
6.3.2.2.8.2? This special protection shall be provided as follows:
(1)?Power distribution system that inherently limits the possible ground-fault current due to a first fault to a low value, without interrupting the power supply
(2)*Power distribution system in which the power supply is interrupted if the ground-fault current does, in fact, exceed the trip value of a Class A GFCI
6.3.2.2.8.3? Patient beds, toilets, bidets, and wash basins shall not be required to be considered wet procedure locations.

6.3.2.2.8.4* Operating rooms shall be considered to be a wet procedure location, unless a risk assessment conducted by the health care governing body determines otherwise

6.3.2.2.8.7* Operating rooms defined as wet procedure locations shall be protected by either isolated power or ground-fault circuit interrupters.

Based on review of the facility's records, no indication was provided regarding the testing of electrical receptacles at patient bed locations, and where deep sedation or general anesthesia is administered.
NFPA-99 6.3.4.1? Maintenance and Testing of Electrical System.
6.3.4.1.1? Where hospital-grade receptacles are required at patient bed locations and in locations where deep sedation or general anesthesia is administered, testing shall be performed after initial installation, replacement, or servicing of the device.
6.3.4.1.2? Additional testing of receptacles in patient care rooms shall be performed at intervals defined by documented performance data.

Based on observation at the time of the survey, electrical disconnects (specific to equipment) which are associated with the EES did not have proper labels to indicate disconnecting means (panel and circuit from which the device was fed).

NFPA-70 110.22 Identification of Disconnecting Means.
(A) General. Each disconnecting means shall be legibly marked to indicate its purpose unless located and arranged so the purpose is evident. The marking shall be of sufficient durability to withstand the environment involved.

NFPA-70 700.10 Wiring, Emergency System.
(A) Identification. All boxes and enclosures (including transfer switches, generators, and power panels) for emergency circuits shall be permanently marked so they will be readily identified as a component of an emergency circuit or system.

Upon review of the facility records, one of the two Medical Gas Master Alarm Panels had malfunction regarding the Bulk Oxygen System.

NFPA-99 5.1.12.1.1? Inspection and testing shall be performed on all new piped gas systems, additions, renovations, temporary installations, or repaired systems to ensure, by a documented procedure, that all applicable provisions of this document have been adhered to and system integrity has been achieved or maintained.
5.1.12.1.2? Inspection and testing shall include all components of the system, or portions thereof, including, but not limited to, gas bulk source(s); manifolds; compressed air source systems (e.g., compressors, dryers, filters, regulators); source alarms and monitoring safeguards; master alarms; pipelines; isolation valves; area alarms; zone valves; and station inlets (vacuum) and outlets (pressure gases).
5.1.12.1.3? All systems that are breached and components that are subject to additions, renovations, or replacement (e.g., new gas sources: bulk, manifolds, compressors, dryers, alarms) shall be inspected and tested.

Based on review of the facility's maintenance records, it was noted that one of the anesthesia machines was not in the record as being tested and maintained.

NFPA-99 11.4? Performance Criteria and Testing.
11.4.1? Portable Patient Care Gas Equipment.
11.4.1.1* Anesthetic apparatus shall be subject to approval by the authority having jurisdiction.
11.4.1.2* Each yoke on anesthetic apparatus constructed to allow attachment of a small cylinder equipped with a flush-type valve shall have two pins installed as specified in CGA V-1, Standard for Compressed Gas Cylinder Valve Outlet and Inlet Connections (ANSI B57.1).
11.4.1.3? Testing.
11.4.1.3.1? Interventions requiring testing shall include, but not be limited to, the following:
(1) Alteration of pipeline hose or pipeline fittings
(2) Alteration of internal piping
(3) Adjustment of selector switches or flush valves
(4) Replacement or repair of flowmeters or bobbins
11.4.1.3.2? After any adjustment or repair involving use of tools, or any modification of the gas piping supply connections or the pneumatic power supply connections for the anesthesia ventilator, or other pneumatically powered device, if one is present, and before use on patients, the gas anesthesia apparatus shall be tested at the final common path to the patient to determine that oxygen, and only oxygen, is delivered from the oxygen flowmeters and the oxygen flush valve, if any.
11.4.1.3.3? Before the gas anesthesia apparatus is returned to service, each fitting and connection shall be checked to verify its proper indexing to the respective gas service involved.
11.4.1.3.4? Before the gas anesthesia apparatus is returned to service, an oxygen analyzer, or a similar device, shall be used to verify the oxygen concentration.