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EL PASO LTAC HOSPTIAL
No Description Available
Tag No.: K0056
Based on observations made during the survey of the facility while accompanied by the CEO, Chief Nursing Officer, and Safety Manager it was observed that the facility failed to provide a recorded history indicating consistent, systematic compliance with the requirement for yearly inspection by a sprinkler contractor on the sprinkler system.
No Description Available
Tag No.: K0130
Based on observations made during the survey of the facility while accompanied by the CEO, Chief Nursing Officer, and Safety Manager 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 issues and items:
1. Air filter change log.
2. Electrical equipment inspections - Biomedical.
Critical Areas: Semi-annually.
General Areas: Annually
3. Electrical power and distribution and grounding systems - Effectiveness.
Critical Areas: Semi-annually.
Additionally, the following Life Safety Deficiencies were identified:
4. Fire rated walls were observed which had multiple bundles of low voltage cabling penetrating the required protective membrane, and such penetrations were unsealed. This is not in compliance with the following:
NFPA 101, 2003: 3.3.23.1 " Fire Barrier - A continuous membrane ... designed and constructed with a specified fire resistance rating to limit the spread of fire ... "
NFPA 101, 2003: 8.3.5.6.1 " Membrane Penetrations. Membrane penetrations for cables, cable trays, conduits, pipes, tubes, combustion vents and exhaust vents, wires and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a membrane of a wall, floor, or floor / ceiling assembly constructed as a fire barrier shall be protected by a firestop system or device, and shall comply with 8.3.5.1 through 8.3.5.5 "
NFPA 101, 2003: 8.3.2.1 " The fire-resistive materials, assemblies, and systems used shall be limited to those permitted in this Code and this chapter. "
NFPA 101, 2003: 8.3.2.2 " The provisions of 8.3.5 shall govern the materials and methods of construction used to protect through-penetrations and membrane penetrations in fire walls, fire barrier walls, and fire resistance-rated horizontal assemblies ... "