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Tag No.: K0052
Based on obersvations made during review of the logs, policies and procedures of the facility between the hours of 9:00 am and 1:00 pm while accompanied by the Director of Facility Management, Electronics Construction Manager, Structures Manager, and the Safety / Emergency Management Director the facility failed to provide logs documenting that the fire alarm system was tested monthly by staff as required.
Tag No.: K0130
Based on obersvations made during review of the logs, policies and procedures of the facility between the hours of 9:00 am and 1:00 pm while accompanied by the Director of Facility Management, Electronics Construction Manager, Structures Manager, and the Safety / Emergency Management Director the facility failed to provide stand-alone logs documenting the following requirements:
1. The annual inspections on the biomedical electrical equipment.
2. The annual testing on the effectiveness of the electrical power distribution and grounding systems.
Additionally, Based on obersvations made during the walk-through inspection of the facility between the hours of 9:00 am and 1:00 pm while accompanied by the Director of Facility Management, Electronics Construction Manager, Structures Manager, and the Safety / Emergency Management Director the facility failed to meet the minimum requirements on the following issues:
3. In LINEN 5122 and NURSE WORK 5114 areas storage near the ceiling violated the minimum clearance of 18 inches below the ceiling mounted sprinkler heads.
4. In MAIN CORRIDOR the 2 hour fire-rated partition assembly located at the double doors leading to CENTER SECTION was missing the required fire-rated sealant where the top of the wall meets the bottom of the structural deck above.