HospitalInspections.org

Based on observations made during the survey of the facility between the hours of 1:00 pm and 5:00 pm, while accompanied by the Acting Administrator it was observed that the facility was not in compliance regarding the following:
A. MISSING FILTER UNITS: The required level of filtration for roof top air handling unit RTU-1 serving LEVEL 1. There were no filter units in the Final Filter Bed.
B. MISSING FILTER UNITS: The required level of filtration for roof top air handling unit RTU-3 serving LEVELS 2 & 3. Most of the required MERV 14 filter units in the Final Filter Bed were missing. Additionally, 4 to 5 filter units for the Pre-Filter Bed had been blown out of the filter bed.
C. CLEANING DUCTS: Because of these missing filters, it is required to CLEAN ALL DUCTWORK associated with RTU-1 and RTU-3 in accordance with the following Hospital Licensing Rules (HLR) requirements:

HLR, 2007: 133.162(d)(3)(D)(i)(VIII) "Ventilation start-up requirements. Air handling systems shall not be started or operated without the filters installed in place. This includes the 90% and 99.97% efficiency filters where required. Ducts shall be cleaned thoroughly and throughout by a certified air duct cleaning contractor when the air handling systems have been operating without the required filters in place. When ducts are determined to be dirty or dusty, the department will require a written report assuring cleanliness of duct and clean air quality."

D. PROVIDE REQUIRED LEVELS OF FILTERATION: After cleaning the ductwork, it is required to provide the proper level of filtration in accordance with the following:

HLR, 2007: 133.169 TABLE 4



ALSO:
Based on observations made during the survey of the facility between the hours of 1:00 pm and 5:00 pm, while accompanied by the Acting Administrator it was observed that the facility was not in compliance regarding the following:
READILY IDENTIFIABLE FIRE ALARM CIRCUIT - The Fire Alarm circuit must be labeled and made readily identifiable by use of special color (RED) in the electrical panel box for the LIFE SAFETY BRANCH. This is not in compliance with the following:

NFPA 72, 2002: 4.4.1.4.2.2. "The circuit breaker at the electrical panel board for the fire alarm shall have a red marking, shall be accessible only to authorized personnel, and shall be identified as "FIRE ALARM CIRCUIT CONTROL."


ADDITIONALLY:
Based on observations made during the survey of the facility between the hours of 1:00 pm and 5:00 pm, while accompanied by the Acting Administrator it was observed that the facility was not in compliance regarding the following:
MULTIPLE EMERGENCY ELECTRICAL PANELS WERE IMPROPERLY LABELED AS BOTH "LIFE SAFETY" and "CRITICAL" Branch. This is not in compliance. All EES panels are required to be permanently labeled, color coded to readily identify the emergency panel. Emergency panels shall be distinctively marked to make it readily identifiable as a component of the essential electrical system. They shall be labeled as one of the following: "LIFE SAFETY", "CRITICAL", or "EQUIPMENT" as applicable.

NFPA 70, 2011: 700.10(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."

Based on observations made during the survey of the facility between the hours of 1:00 pm and 5:00 pm, while accompanied by the Acting Administrator it was observed that the facility was not in compliance regarding the following:
MISSING DUCT DETECTORS - There were no duct detectors for the HVAC air handler units. This does not comply with the following:

NFPA 90A, 2012: 6.4.2.1 (1) Air duct supply from AHU -on systems greater than 2000 ft3/min

NFPA 90A, 2012: 6.4.2.1 (2) Air duct return to AHU- on systems greater than 15,000

(see also requirements in local code regarding INTERNATIONAL MECH. CODE req'mt. on RETURN side.)