HospitalInspections.org

Based on observations made during the survey of the facility between the hours of 1:00 pm and 5:30 pm, while accompanied by the CEO, Director Of Plant Operations, Risk Manager, and Corporate Director Of Clinical Services it was observed that the facility failed to provide the names/signatures in the logs being kept on the quarterly fire drills. While it was documented that the facility had accomplished many fire drills for the past few years, their documentation was incomplete.

Based on observations made during the survey of the facility between the hours of 1:00 pm and 5:30 pm, while accompanied by the CEO, Director Of Plant Operations, Risk Manager, and Corporate Director Of Clinical Services it was observed that while it appears the facility had accomplished some of the requirements, the facility failed to provide logs indicating consistent, systematic compliance on the following Item #1:

1. Electrical power and distribution and grounding systems - Effectiveness.
General Areas: Annually


Additionally, as a GENERAL COMMENT for all of the buildings see Item #2:

2. Typically throughout the facility, it was observed that the required 1 hour fire/smoke partitions constructed as a separation between SMOKE COMPARTMENTS had multiple unsealed penetrations (both sides of rated partitions). Also the required fire-rated sealant continuous along the top of rated partitions was missing. This is not in compliance with NFPA.


Finally, it was observed that for the LEWIS BUILDING:

3. Air handler unit #1 has over 15,000 cfm, and was equipped with a duct detector on the RETURN side. NFPA 90A, 2002: 6.4.2.1(1) requires a duct detector for the supply side. This is not in compliance.