HospitalInspections.org

K521 - HVAC
Findings:
The surveyor observed, while accompanied by the Facility Manager, Director of Plant Ops, and Maintenance Tech Lead, during the hours of the survey from 3:30 pm - 9:15 pm on 09/09/2025 and 8:45 am - 10:45 am on 09/10/2025 that there were the following issues:

1) Observed in Main Building Level 1 Mechanical Room - the mechanical unit drain pan was filled with stagnant water due to poor drainage.
2) Observed on Fifth floor CV Tower - there was peeling of HVAC duct insulation.
3) Observed on Third floor Doctors Tower Mechanical Room - there was peeling of HVAC duct insulation.

K906 - Gas and vacuum piped systems - central supply systems operations
Findings:
The surveyor observed, while accompanied by the Facility Manager, Director of Plant Ops, and Maintenance Tech Lead, during the hours of the survey from 3:30 pm - 9:15 pm on 09/09/2025 and 8:45 am - 10:45 am on 09/10/2025 that there were the following issues:

1) Based on observations in Medical Gas Room - the mechanical exhaust air grille was clogged with debris thus restricting its airflow.

K907 Gas and Vacuum Piped Systems - Maintenance Program

Findings:
The surveyor observed, while accompanied by the Facility Manager, Director of Plant Ops, and Maintenance Tech Lead, during the hours of the survey from 3:30 pm - 9:15 pm on 09/09/2025 and 8:45 am - 10:45 am on 09/10/2025 that there were the following issues:

1) Based on observations in Fifth floor CV Tower Mechanical Room - the medical air pipe was rusting.

K914 - Electrical Systems - Maintenance and Testing

Findings:
The surveyor observed, while accompanied by the Facility Manager, Director of Plant Ops, and Maintenance Tech Lead, during the hours of the survey from 3:30 pm - 9:15 pm on 09/09/2025 and 8:45 am - 10:45 am on 09/10/2025 that there were the following issues:

1) Based on further review of the codes and records, facility failed to perform any receptacle maintenance and testing at all in patient care areas at least once per year. NFPA 99-2012, section 6.3.3.2 lists the minimum requirements for receptacle testing regardless of hospital-grade or not. Describe the facility justification of testing frequency (e.g. appropriate testing intervals) based on documented performance data. For example, experiential data shows that retention force of the grounding blade of each electrical receptacle decreases over time due to repeated usage. Thus, the failure rate has a direct correlation to time and usage.