HVAC
Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer's specifications.
18.5.2.1, 19.5.2.1, 9.2
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Observations:
Name: BUILDING 01 (1928, 1970, 1983 WINGS) - Component: 01 - Tag: 0521
Based on observation and interview, it was determined the facility failed to properly install HVAC systems, affecting the entire facility.
Findings include:
Observation on September 5, 2024, at 8:30 a.m., revealed AHU 15, which has a capacity of 17,425 cfm, lacked smoke dampers. NFPA 90A, section 4.3.20.3, requires that all air-handling equipment with a capacity of greater than 15,000 cfm be installed with smoke dampers on both the building supply side and the return side.
Exit interview with the Facility Director and the COO on September 5, 2024, at 10:00 a.m., confirmed the lack of smoke dampers.
| | Plan of Correction - To be completed: 09/26/2024
Grand View Health values and promotes patient safety through compliance with fire protection regulations.
Based on further evaluation of air handler unit (AHU) 15 that serves the Medical/Surgical Unit including associated inspection documentation, it was determined there are three electric fire and smoke combination dampers installed on the air handler. The dampers are installed on the return and supply side. Additionally, there are supply and return duct detectors. The dampers last passed inspection in 2019 as required per NFPA regulations for periodic inspection and testing. The absence of these smoke dampers was not confirmed by the Facility Director and COO at survey exit as stated. The installed dampers were not reviewed by DSI during the onsite investigation.
Inspection and testing of all hospital fire safety and protection systems that include the HVAC system and dampers is performed as required by regulation. If any issues are identified during the inspections and testing of fire protection systems, the issues will be reviewed by the Life Safety Sub-Committee to determine further actions needed and reported at least annually to the Environment of Care Steering Committee that includes the President and CEO.
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