HospitalInspections.org

Observation and discussion with the Director of Plant Operations and the Lead Maintenance representative between 8:20 am and 12:30 pm, on 6/30/2010, revealed that certain requirements stipulated in the state licensing regulations were not met.


Minimum Laboratory Facilities.

When laboratory services are provided off site by contract, the following minimum facilities shall be provided within the hospital.

Laboratory work room. The laboratory work room shall include a counter and a sink with hands-free operable controls.

General storage. Cabinets or closets shall be provided for supplies and equipment used in obtaining samples for testing. A refrigerator or other similar equipment shall be provided for specimen storage waiting for transfer to offsite testing.

Blood storage facilities. Refrigerated blood storage facilities for transfusions shall be provided. The blood storage refrigerator shall be equipped with temperature monitoring and alarm signals.

Specimen collection facilities. A blood collection area shall be provided with a counter, space for seating, and hand washing fixture with hands-free operable controls. A toilet and lavatory with hands free operable controls shall be provided for specimen collection. This facility may be outside the laboratory suite if conveniently located.

Findings: It was determined that the hospital has no laboratory capabilities as required. A plan shall be submitted, complete with a calendar that describes how the facility will meet the requirements.

Observation and discussion with the Director of Plant Operations and the Lead Maintenance representative between 8:20 am and 12:30 pm on 6/30/2010, revealed that certain requirements stipulated in NFPA 90A and the state licensing regulations were not met.

a. Proximity of Exhaust.

Outside air intakes shall be located at least 25 ' from exhaust outlets of ventilating systems, combustion equipment stacks, medical-surgical vacuum system outlets, plumbing vents, or areas which may collect vehicular exhaust or other noxious fumes. [Prevailing winds and proximity to other structures may require other arrangements.] Plumbing and vacuum vents that terminate 5 ' above the level of the top of the air intake may be located as close as 10 ' . [Re: 25 TAC HLR, 2007: ? 133.162(d)(3)(D)(i)(III).]

Findings: During the survey, three issues were identified on the roof of the facility:

RTU #11 is 15 ' from EF 33.
RTU #10 is 5 ' from a building vent [Pharmacy HVAC unit.]
RTU #13 is 20 ' from a building vent [Patient corridor HVAC unit.]

These distances are not acceptable because of the dirty air that is being recirculated back into the hospital.

b. Labels.

Service openings shall be identified with letters having a minimum height of 0.5 inches to indicate the location of the fire protection device(s) within [Re: NFPA 90A, Installation of Air-Conditioning and Ventilating Systems, 1999: ? 2-3.4.2.]

Findings: This rule was not met in the middle corridor when the fire/smoke dampers were observed. The facility shall affirm that these labels have been applied.

c. Manual Control.

Each air distribution system shall be provided with at least one manually operable means for stopping the operation of the supply, return, and exhaust fan[s] in an emergency. The means of manual operation shall be located at an approved location [Re: NFPA 90A, Installation of Air-Conditioning and Ventilating Systems, 1999: ? 4-2.] Acting as the state-level authority having jurisdiction [AHJ], the Department requests that the facility determine which one of the following 5 techniques will be employed for each unit: 1) a thermostat available to, and in proximity of, the staff assigned to the location served by the unit; 2) a circuit breaker, available to, and in proximity to the staff assigned to the location served by the unit; 3) a manual fire alarm pull station, if the results include shutting down the unit; 4) notification report to a constantly staffed building automation system; and 5) an emergency power off switch.

Findings: This was discussed during the exit conference. The facility shall include the required approach for manual control of each unit in their internal procedures.

Observation and discussion with the Director of Plant Operations and the Lead Maintenance representative between 8:20 am and 12:30 pm on 6/30/2010, revealed that certain requirements stipulated in NFPA 70 were not met.

No functions other than those listed in 517.32(A) through (G) shall be connected to the life safety branch ... ..... [Re: NFPA 70, National Electrical Code, 2002: ? 517.32.]

Findings: When observing the life safety panelboard LLA, it was noted that the generator fuel pump was being powered from the life safety branch. This function is not one of the allowable functions. The facility should recircuit this load to the critical or equipment panelboard.