HospitalInspections.org

The facility did not ensure that the facility ' s air conditioning and ventilation equipment was in accordance with NFPA 90A: Standard for the Installation of Air Conditioning and Ventilation Systems as required by the referenced LSC.

On 12/14/10 at 09:45 AM, the surveyors were not provided with documentation from the Director of Physical Plant that indicated the smoke dampers were tested/inspected annually as required in NFPA 90A 3-4.7; i.e. not able to access some of the smoke dampers.

The facility did not ensure that piped in medical gas systems are in compliance with NFPA 99, 4.1, 4.1.1.

On 12/14/10 at 10:46 AM, the surveyors were not provided with documentation from the Director of Physical Plant to indicate that the facility has established and provided for a periodic testing, maintenance and operational program for Oxygen Medical Gas, Medical Air Compress and Vacuum System and equipment as required by NFPA 99; i.e. no reports for either of the med oxygen systems.

The facility did not ensure that Emergency and Standby Power Systems were being installed, inspected and maintained as required in NFPA 110 " Standard for Emergency and Standby Power Systems " .

1. On 12/14/10 at 09:45 AM, the surveyors were not provided with documentation from the Director of Physical Plant that indicated the facility ' s emergency generators were being maintained as required by NFPA 110 " Standard for Emergency and Standby Power Systems " Chapter 6 section 1.1 i.e. no records of Level 1 & 2 (major/minor) maintenance conducted on 350 KW since 12/08 or any at all for 80 KW.

2. On 12/13/10 at 10:30 AM, the surveyor while accompanied by the HVAC QCW, observed that the Emergency Power System (generator) was not provided with a remote, shut off switch; as required by NFPA 99 & NFPA 110; i.e. per staff interviews, staff knows of no location where switch is.

3. On 12/13/10 at 10:30 AM, the surveyor while accompanied by the HVAC QCW, observed that the Emergency Power System (generator) was not provided with a remote annunciator panel that was installed in a continuously attended position, as required by NFPA 99 & NFPA 110; i.e. panels installed in rooms that have no occupancy, never moved after identified at commissioning.

The facility did not ensure that Generators are inspected weekly and exercised under load for 30 minutes per month in accordance with NFPA 99 - 3.4.4.1.

On 12/14/10 at 10:10 AM, the surveyors were not provided with documentation from the Director of Physical Plant to indicate that the facility ' s two (2) emergency generators were being load tested monthly as required by NFPA 99 and 110; i.e. No monthly load test for 350 KW in June 2010 & no monthly load testing done at all for 80 KW that services fire pump house.