William H. McCully, CHFM, SASHE – Life Safety Code Specialist

 

Surveyor Program(s): Hospital

Surveyor Tenure: x 2007

Lives: Arkansas

TJC Bio:

Other Background:

Comments & Recommendations

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** Sample Survey Citations (Premier Level)**

[private Membership premier]

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Sample Citations:

2013

• EC.02.02.01/EP5/On several units, there was an eye wash unit installed on a standard faucet with hot and cold water on and no way to control the water temperature without adjusting both faucets. This faucet does not meet ANSI standards for eye wash. The hospital staff stated that the hot water had been shut off all these sinks and the valve handle was removed during the survey. In the Dental Office, the eye wash station did not meet ANSI standards. There was no temperature control function. When it was tested during the visit, the water flow was insufficient to flush the eyes. The Dental Office performs chemical disinfecting of instruments and chemical x-ray file development.
• EC.02.03.01/EP1/ Above the ceiling at the entry to unit “A” there was an electrical box that did not have a cover and the wires were hanging out.  In the back room of the unsprinkled Medical Records Department there was not a smoke detector in the room. There were detectors in the other rooms of the department. The department was made of several rooms filled with records including the back room.
• EC.02.03.05/EP4/Neither the audible or visual fire alarm devices throughout the facility had not been inventoried and tested so it was not possible to determine that each device was tested.
• EC.02.03.05/EP19/ There was a minimum of 2 air handling units in each of the buildings on campus. The automatic smoke detection shutdown devices were not being documented as tested on each of these units.
• EC.02.05.01/EP1/ A new generator (Feb. 2013) does not have a battery powered emergency light installed in the room where the unit is housed.
• EC.02.06.01/EP20/In the men’s shower room on Unit X, there were tiles missing/chipped tiles in the shower stall, rusted light fixtures and visible dirt in the air vents, all of which created an unsanitary environment.
• LS.02.01.10/EP5/ The fire/smoke corridor entry doors to several units did not latch properly when tested. The hospital staff stated that the doors had been repaired during the survey.
• LS.02.01.10/EP9/In the penthouse area above several units, there were penetrations through the floor at the area around the support beams that need to be filled with fire stop.  In unit “X” entry to the medical records department there was a large hole in the fire barrier above the ceiling that was not filled with fire stop.
• LS.02.01.20/EP1/The hospital has 10-15 bed units that each have three exit doors. One main door is used for access to and from the unit by all staff and visitors and ALL staff have keys to this door. The other two doors have limited keys available and is not accessible by all staff. All three doors have electronically controlled magnetic locks that hold the door closed at all times and can be released by a key OR a switch located at each nursing station. These doors are not tied to the fire alarm system so they do not release when the fire alarm is activated. The staff indicated the nursing station was manned 24/7 however this surveyor observed that on at least one occasion during the building tour the nurse station was empty of staff.
• LS.02.01.10/EP28/In the Auditorium and Gym, there were exit lights that were completely out and not illuminated at all. The staff stated that the light had been repaired during the survey.

2010

• EM.01.01.01/EP2/ Observed in document review, a Hazard Vulnerability Analysis had not been developed in recent years to identify potential emergencies/Indirect
• EM.03.01.01/EP1/ An annual evaluation of the Hazard Vulnerability Analysis had not been completed/Indirect observed in Individual Tracer
• EC.02.03.05/EP 2/ Observed in document review, the testing documents for the Value Tamper Switches and the Water Flow Valves were not clear that these devices were tested semi annually/Direct
• EC.02.03.05/EP 3/ Every 12 months, the hospital tests duct detectors, electromechanical releasing devices, heat detectors, manual fire alarm boxes, and smoke detectors. The completion date of the tests is documented. The documentation for the annual testing of the electro-mechanical devices and the electronic door locks was not documented for 2008 or 2007./ Indirect  EP10. For automatic sprinkler systems: Every quarter, the hospital inspects all fire department water supply connections. The completion dates of the inspections are documented. There was no documentation that the fire department connections are being inspected quarterly/ Indirect
• EC.02.03.05/EP 3/ Observed in document review, there was no inventory of the electro mechanical releasing devices nor documentation that they were tested during the annual testing in 20##/Direct/
• EC.02.03.05/EP 4/ Observed in document review, the documentation of the testing of the audible and visual devices was not clear as to whether all devices were tested during the annual testing of the devices in 20## or 20##. There was not an inventory of all devices, where they are located, and whether they passed or failed/Direct
• EC.02.04.03/EP 2/ The hospital inspects, tests, and maintains all life support equipment. These activities are documented. The AED was checked for annual maintenance, but there was no documentation of daily checks for several dates./ Direct
  
• EC.02.06.01/EP 1/Interior spaces meet the needs of the patient population and are safe and suitable to the care, treatement, and services provided.  In two storage rooms there were light fixtures with exposed fluorescent tubes that need to have protective tubes installed./Indirect/ 
• LS.01.01.01/EP 14/ Observed in document review, 3 sets of smoke doors listed on the PFI, 2 smoke barrier walls that are incomplete listed on the PFI and PFI’s listed as GG-2-10005 and GA-2-10012 have not been evaluated from an ILSM perspective to determine the risk and how to mitigate it.
  
• LS.02.01.30/EP 11/ Corridor doors are fitted with positive latching hardware, are arranged to restrict the movement of smoke, and are hinged so that they swing. The gap between meeting edges of door pairs is no wider than 1/8 inch, and undercuts are no larger than 1 inch. Roller latches are not acceptable. In two areas the corridor smoke door did not close properly and was not smoke tight. The shell area being used for storage had the double doors leading into that area blocked open with a chain holding one door and an installed doorstop on the other. / Indirect
• LS.02.01.30/EP 18/ Smoke barriers extend from the floor slab to the floor or roof slab above, through any concealed spaces (such as those above suspended ceilings and interstitial spaces), and extend continuously from exterior wall to exterior wall. All penetrations are properly sealed. The smoke wall above the ceiling was penetrated with several pipes that were not sealed properly. – There were several pipes that were sealed with insulation that is not approved for fire/smoke stop material. The smoke barrier above the smoke doors by one room did not have sheetrock to the roof deck./ Indirect/

2009

• EC.02.01.01/EP1/ Observed in building tour, the smoke/fire dampers were tested with 11 issues of some type of failure noted. Documentation 1 was fixed, but no other documentation for the 10 others was found.
• EC.02.01.01/EP3/ Observed in admission area, this area had not been added to the hospital safety of environment surveillance. Observed in the records review, a VA style environment of care risk surveillance was implemented. On 3 units, electric beds are found. Protocols for when these beds may be used in a safe manner have not been developed/Direct
  
• EC.02.03.05 EP3. Every 12 months, the hospital tests duct detectors, electromechanical releasing devices, heat detectors, manual fire alarm boxes, and smoke detectors. The completion date of the tests is documented. The documentation for the annual testing of the electro-mechanical devices and the electronic door locks was not documented for 2008 or 2007./ Indirect
  EP10. For automatic sprinkler systems: Every quarter, the hospital inspects all fire department water supply connections. The
  completion dates of the inspections are documented. There was no documentation that the fire department connections are being
  inspected quarterly/ Indirect /
• EC.02.04.03 EP2. The hospital inspects, tests, and maintains all life support equipment. These activities are documented. The AED was checked for annual maintenance, but there was no documentation of daily checks for several dates./ Direct
• EC.02.05.07 EP 6. Twelve times a year, at intervals of not less than 20 days and not more than 40 days, the hospital tests all
  automatic transfer switches. The completion date of the tests is documented. During the document review it was observed that the Automatic Transfer switches were not being documented as being tested every month. There was no documented evidence that every switch was exercised each month./ Direct /
• EC.02.05.07/EP 6/ Observed in document review, 3 automatic transfer switches were not tested every month during 20##/Direct/ Twelve times a year, at intervals of not less than 20 days and not more than 40 days, the hospital tests all automatic transfer switches. The completion date of the tests is documented. During the document review it was observed that the Automatic Transfer switches were not being documented as being tested every month. There was no documented evidence that every switch was exercised each month./ Direct
• EC 02.05.07/ EP 6/ – We were doing and documenting the tests on the emergency generator including
  documenting the equipment on it came on, but did not document that the transfer switches had worked/ Direct/
  Surveyor #3
  
• EM.02.02.13/EP5/The medical staff Bylaws have a disaster credentialing process that does not require a
  governmental photo identification. It only requires one source of verification of medical credentials as outlined in
  this standard/Direct
• LS 01.01.01/ EP1 – No document assigning responsibility for SOC and eBBI/ Indirect/ Surveyor #3
• LS 02.01.10/ EP 3 – Barrier walls not sealed to deck above – corrugated deck causing small gaps/ indirect/
• LS 02.01.30/ EP 18/ holes in firewall. Primarily an issue of the building being constructed with 2 hour firewalls
  when only 1 hour were needed. We were maintaining as 1 hour walls but because they were constructed as 2
  hour we were cited for this
  
  

 

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