HospitalInspections.org

Based on observations during the survey walk at the Edinburg, Texas campus on the afternoon of 7/26/2011while being accompanied by with the COO, Plan Ops tech and Director of Plant Operations, the facility failed to maintain the fire resistance rating of the smoke barriers. Smoke compartment wall above the cross-corridor doors, adjacent to the staff lounge, had electrical conduit sleeve penetrations that were not sealed which would prevent the passage of smoke and the products of combustion.

Based on observations during the survey walk at the McAllen, Texas campus on the afternoon of 7/26/2011, with the CCO, Director of Quality and Management, Maintenance Assistant and Director of Plant Operations, the facility failed to provide a generator ' s emergency system electrical receptacle. This receptacle is required to be red with the circuit and panelboard numbers on the receptacle ' s plate. Per NFPA 99 ..... The cover plates for the electrical receptacles or the electrical receptacles themselves supplied from the emergency system shall have a distinctive color or marking so as to be readily identifiable. This receptacle must be powered from the electrical Type 1 EES panelboard.

Based on observations during the survey walk at the Edinburg, Texas campus on the afternoon of 7/26/2011while being accompanied by with the COO, Plan Ops tech and Director of Plant Operations, the facility failed to assure that the essential electrical system was in full compliance. Fire/smoke damper and a time clock were supplied with power from the life safety branch of the essential electrical system and need to be moved to the either the critical or equipment branch panel.
Additionally it could not be confirmed if the battery backup generator light was powered from the life safety branch; it should be. Please verify.
The life safety branch of the emergency system shall supply power for the following lighting, receptacles and equipment: 1. Illumination of means of egress as required in NFPA 101, Life Safety Code; 2. Exit signs and exit direction signs required in NFPA 101, Life safety Code; 3. Alarm and alerting systems including the following: a. Fire Alarms, b. Alarms required for systems used for the piping of nonflammable medical gases as specified in Chapter 4, "Gas and Vacuum Systems;" 4. (Hospital or ASC) communication systems, where used for issuing instruction during emergency conditions; 5. Task illumination, battery charger for emergency battery-powered lighting unit(s), and selected receptacles at the generator set location; 6. Elevator ... 7. Automatically opened doors used for building egress. No functions other than those listed above in items 1 through 7 shall be connected to the life safety branch.


Based on observations during the survey walk at the McAllen, Texas campus on the afternoon of 7/26/2011, with the CCO, Director of Quality and Management, Maintenance Assistant and Director of Plant Operations, the facility failed to assure that the essential electrical system was in full compliance. Five receptacles and a time clock and a blood lab receptacle were supplied with power from the life safety branch of the essential electrical system and need to be moved to the either the critical or equipment branch panel. The life safety branch of the emergency system shall supply power for the following lighting, receptacles and equipment: 1. Illumination of means of egress as required in NFPA 101, Life Safety Code; 2. Exit signs and exit direction signs required in NFPA 101, Life safety Code; 3. Alarm and alerting systems including the following: a. Fire Alarms, b. Alarms required for systems used for the piping of nonflammable medical gases as specified in Chapter 4, "Gas and Vacuum Systems;" 4. (Hospital or ASC) communication systems, where used for issuing instruction during emergency conditions;
5. Task illumination, battery charger for emergency battery-powered lighting unit(s), and selected receptacles at the generator set location; 6. Elevator ... 7. Automatically opened doors used for building egress. No functions other than those listed above in items 1 through 7 shall be connected to the life safety branch.