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Observation and discussion with the Quality Manager and the Maintenance Lead between 1:30 pm and 5:30 pm on 8/29/2011 revealed that certain requirements stipulated in NFPA 101 were not met.

Interior wall and ceiling finish complying with 10.2.3 shall be Class A or Class B in corridors, in exits, and in any space not separated from corridors and exits by partitions capable of retarding the passage of smoke; and Class A, Class B, or Class C in all other areas [Re: NFPA 101. Life Safety Code. 2000: ? 23.3.3.2.]

Findings: The staff did not have the required flame spread data for inspection at the time of the survey.

Observation and discussion with the Quality Manager and the Maintenance Lead between 1:30 pm and 5:30 pm on 8/29/2011 revealed that certain requirements stipulated in NFPA 101 were not met.

Interior wall and ceiling finish complying with 10.2.3 shall be Class A or Class B in corridors, in exits, and in any space not separated from corridors and exits by partitions capable of retarding the passage of smoke; and Class A, Class B, or Class C in all other areas [Re: NFPA 101. Life Safety Code. 2000: ? 23.3.3.2.]

Findings: The staff did not have the required flame spread data for inspection at the time of the survey.

Observation and discussion with the Quality Manager and the Maintenance Lead between 1:30 pm and 5:30 pm on 8/29/2011 revealed that certain requirements stipulated in NFPA 101 were not met.

Smoke Passage Resisted

Corridor walls shall form a barrier to limit the transfer of smoke [Re: NFPA 101, Life Safety Code, 2000: ? 19.3.6.2.2.]

Findings: The corridor walls above the lay-in ceiling outside the HR office were not sealed properly. This deficiency will not adequately resist smoke passage. The facility shall affirm that all penetrations have been caulked properly.

Observation and discussion with the Quality Manager and the Maintenance Lead between 1:30 pm and 5:30 pm on 8/29/2011 revealed that certain requirements stipulated in NFPA 72 were not met.

Electrical Requirements

Connections to the light and power service shall be on a dedicated branch circuit(s). The circuit(s) and service shall be mechanically protected. Circuit disconnecting means shall have a red marking, shall be accessible only to authorized personnel, and shall be identified as FIRE ALARM CIRCUIT CONTROL. The location of the circuit disconnecting means shall be permanently identified at the fire alarm control unit [Re: NFPA 72, National Fire Alarm Code, 1999: ? 1-5.2.5.2.]

Findings: The main FACP was located in adjacent nursing home, but the booster panel observed in the mechanical room on the east hall, powered by circuit 6, panelboard ELS3, did not meet this requirement. The facility shall ensure that this requirement is met.

Observation and discussion with the Quality Manager and the Maintenance Lead between 1:30 pm and 5:30 pm on 8/29/2011 revealed that certain requirements stipulated in the State Licensing Rules were not met.

a. Ventilation Requirements

All rooms and areas in the hospital listed in Table 3 of ? 133.169[c] shall have provision for positive ventilation [Re: 25 TAC HLR 2007: ? 133.162(d)(3)(D)(i).]

Findings: During the survey, it was extremely difficult to determine which air handling unit served specific areas of the hospital, and what parameters were associated with the air flow. The facility shall develop a matrix that identifies each air handling unit, how many filters are in the unit, the level of filtration associated with each filter bank, and the CFM rating of the unit to facilitate maintenance and future inspections/surveys.

b. Draft Gauges

A manometer or draft gauge shall be installed across each filter bed having a required efficiency of 75% or more including hoods requiring high efficiency particulate air (HEPA) filters [Re: 25 TAC HLR 2007: ?133.162(d)(3)(D)(ii)(V).] T

Findings: During the survey, it was noted that the required draft gauges were not installed across each filter bed with efficiency greater than 75%. No gauge could be located for the pharmacy HEPA filter, and one gauge was not attached to the unit in the mechanical room and simply laying on the unit. The facility shall ensure that this requirement is satisfied.

c. Pharmacy Fresh Air Supply

Fresh air intakes must be 36 " off the deck for a roof top unit, and 25 ' from a building vent or exhaust to ensure that that air quality is optimal [Re: 25 TAC HLR 2007: ? 133.162(d)(3)(D)(i)(IV) and (III), respectively.]

Findings: During the survey, it was noted that the required distances were not observed for the Pharmacy 2 ton RTU. This ensures that the Pharmacy air is not as clean as it should be.

d. Pharmacy HEPA filter

When IV solutions are prepared, the required laminar-flow system shall include a nonhygroscopic filter rated at 99.97% (HEPA). A pressure gauge shall be installed for detection of leaks or defects [Re: 25 TAC HLR, 2007: ?133.163(x)(3)(A).]

Findings: During the survey, the filter was observed, but it could not be ascertained that it was a 99.97% efficiency filter. The facility shall affirm that the efficiency is 99.97%.

Observation and discussion with the Quality Manager and the Maintenance Lead between 1:30 pm and 5:30 pm on 8/29/2011 revealed that certain requirements stipulated in NFPA 101 were not met.

Draperies, curtains, including cubicle curtains, and other loosely hanging fabrics and films serving as furnishings or decorations in ambulatory health care occupancies shall be in accordance with 10.3.1 [Re: NFPA 101, Life Safety Code. 2000: ? 21.7.5.1.]

Findings: This requirement was discussed and it was determined that the required documentation is not retained by the staff.

Observation and discussion with the Quality Manager and the Maintenance Lead between 1:30 pm and 5:30 pm on 8/29/2011 revealed that certain requirements stipulated in the State Licensing Rules and NFPA 99 were not met.

a. Fire Marshal Inspection

Each time a licensed health facility applies for a license renewal, it is required to have a safety inspection by the Fire Marshal of the local authority having jurisdiction to ensure that the facility is worthy of receiving that license. The results are documented by a form provided by the department. The facility is always asked to provide this form during a Life Safety Code survey.

Findings: This requirement was discussed with the staff during the survey, and the required documentation was not available for inspection.

b. Disaster Drills

Each organizational entity shall implement one or more specific responses of the emergency preparedness plan at least semi-annually. At least one semi-annual drill shall rehearse mass casualty response for health care facilities with emergency service, disaster receiving stations, or both [Re: NFPA 99, Health Care Facilities, 1999: ? 11-5.3.9.]

The department requires the documentation of these drills be retained for a period of three years [Re: 25 TAC HLR 2007: ? 133.142[c][3].]

Findings: No documentation was available for review at the time of the survey.
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c. Letters of Preference

When designated by the emergency preparedness management plan to provide continuous service in a disaster or emergency, health care facilities shall establish plans for continuity of essential building systems, as applicable: ... (b) Water; .... (e) Fuel sources [Re: NFPA 99, Health Care Facilities, 1999: ? 11-5.3. 2.]

Findings: The department requires the hospital to have signed letters from vendors stating that the hospital is a preferred customer in the event of an emergency. These letters were not available for review at the time of the survey.

Observation and discussion with the Quality Manager and the Maintenance Lead between 1:30 pm and 5:30 pm on 8/29/2011 revealed that certain requirements stipulated in NFPA 99 were not met.

Emergency Procedures

Procedures for laboratory emergencies shall be developed. Such procedures shall include alarm actuation, evacuation, and equipment shutdown procedures, and provisions for control of emergencies that could occur in the laboratory, including specific detailed plans for control operations by an emergency control group within the organization or a public fire department [Re: NFPA 99, Health Care Facilities, 2002: ? 10.2.1.3.1, 18.3.2.2.]

Findings: This requirement was discussed with the staff and it was not known if such procedures were available.

Observation and discussion with the Quality Manager and the Maintenance Lead between 1:30 pm and 5:30 pm on 8/29/2011 revealed that certain requirements stipulated in NFPA 110 were not met.

Circuit Breakers

The emergency power supply system [EPSS] circuit breakers for Level 1 system usage, including main and feed breakers between the EPS and the transfer switch load terminals, shall be exercised annually with the emergency power supply [EPS] in the off position. Exception: Medium- and high-voltage circuit breakers for Level 1 system usage shall be exercised every 6 months and tested under simulated overload conditions every 2 years. [Re: NFPA 110, Standard for Emergency and Standby Power Systems, 1999: ? 6-4.6.]

Findings: Logs were not available that indicated these required tests were conducted.

Observation and discussion with the Quality Manager and the Maintenance Lead between 1:30 pm and 5:30 pm on 8/29/2011 revealed that certain requirements stipulated in NFPA 70 were not met.

a. GenSet Life Safety Features

A battery powered light where the battery is charged by the life safety branch and a receptacle powered by the life safety branch is required [Re: NFPA 70, National Electrical Code, 2002: ? 517.32[E].]

Findings: This topic was discussed during the survey and when the generator was observed, it was determined that this requirement was not met. The facility shall make the necessary changes to meet this requirement.

b. Flex Conduit

The wiring of the emergency system of a hospital shall be mechanically protected by installation in nonflexible metal raceways, or shall be wired with Type MI cable [Re: NFPA 70, National Electrical Code, 2002: ?517.30[C](3).]

Findings: This requirement is extended to the required grounding jumper in the electrical room in the mid hall. The jumper was done by a loosely hanging unprotected conductor, which is at risk. This shall be replaced with conduit to protect the integrity of the Type I Essential Electrical System.