Volume 2025 | No. 2
SURVEYOR
PHYSICAL ENVIRONMENT AND LIFE SAFETY
Examples of ACHC Surveyor findings:
13.05.04 Generator inspection Frequency of the citation: 26%
■ Floor 5 south corridor is missing four ceiling tiles. ■ The following areas had gaps in the ceiling greater than 1/8-inch:
Overview of the requirement: Emergency power generators must meet NFPA requirements for location and inspection of all related components. Comment on deficiencies: Compliance is assessed through observation and document review. Surveyors noted issues with: ■ Fuel quality testing.
ٝ Outside the pharmacy on floor 7 (one conduit penetration). ٝ Main kitchen dishwasher area (three conduit penetrations). ٝ Floor 7 ICU main central station is penetrated by one square pole. ٝ Surgery department sterile processing decontamination room had three unsealed pipe penetrations. ٝ Dialysis equipment room, seven ceiling holes.
■ Main building third floor soiled utility room had two broken ceiling tiles in need of replacement. ■ In the OR ortho substerile room, facilities personnel were observed working in the ceiling with the tiles removed without proper containment and no infection control risk assessment available. Compliance tips for:
■ Generator room separation. ■ Remote manual stop stations. ■ Battery maintenance and testing.
Examples of ACHC Surveyor findings: ■ The annual fuel quality report was not available at the time of the survey.
Look up! Ceilings with smoke detectors, in corridors, and in hazardous rooms are required to limit the passage of smoke. Penetrations for piping/cables/ conduit must be sealed to eliminate gaps larger than 1/8-inch. Suspended grid and acoustical tile ceilings can limit the passage of smoke, but tiles are often removed or damaged, rendering them less effective. ■ Monitor ceilings as part of environmental rounding, examining them from the perspective of preventing the passage of smoke. Drop-in acoustical ceilings are not fire barriers, and do not require fire caulking. ■ Replace and reseat tiles that are damaged or temporarily removed. ■ Seal around penetrations to reduce or eliminate gaps greater than 1/8 of an- inch. Latex caulk or mineral wool are acceptable materials for this use. ■ Educate staff to include “back of the house” spaces when examining ceilings. Deficiencies are less likely to be immediately noticed and corrected in these locations.
Nerd Newbies (understand the requirement)
■ The two 600KW generators located in the boiler house were not installed in a separate room with a minimum of two-hour fire-rated barriers as required and were combined with three boilers in the same room. ■ The 750KW generator that is located outside the building did not have a remote manual stop station located on the premises as required. ■ The organization did not provide documentation of the generator battery conductance testing being performed weekly.
Nerd Apprentices (audit for excellence)
Nerd Trailblazers (prepare the path for others)
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