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Provider Name: HOLY CROSS HOSPITAL
Provider Type: Hospital
Inspection Data from January 1, 2008 to present
Export Results


Survey DateInspection TypeTrack IDDeficiencyRequirement DescriptionCorrection Date
02/02/2018Fire/Life/SafetyT6SMK0324COOKING FACILITIESCooking Facilities Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless: * residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2 * cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or * cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4. Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor. 18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2 05/02/2018
02/02/2018Fire/Life/SafetyT6SMK0353SPRINKLER SYSTEM - MAINTENANCE AND TESTINGSprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25 05/02/2018
02/02/2018Fire/Life/SafetyT6SMK0921ELECTRICAL EQUIPMENT - TESTING AND MAINTENANCElectrical Equipment - Testing and Maintenance Requirements The physical integrity, resistance, leakage current, and touch current tests for fixed and portable patient-care related electrical equipment (PCREE) is performed as required in 10.3. Testing intervals are established with policies and protocols. All PCREE used in patient care rooms is tested in accordance with 10.3.5.4 or 10.3.6 before being put into service and after any repair or modification. Any system consisting of several electrical appliances demonstrates compliance with NFPA 99 as a complete system. Service manuals, instructions, and procedures provided by the manufacturer include information as required by 10.5.3.1.1 and are considered in the development of a program for electrical equipment maintenance. Electrical equipment instructions and maintenance manuals are readily available, and safety labels and condensed operating instructions on the appliance are legible. A record of electrical equipment tests, repairs, and modifications is maintained for a period of time to demonstrate compliance in accordance with the facility's policy. Personnel responsible for the testing, maintenance and use of electrical appliances receive continuous training. 10.3, 10.5.2.1, 10.5.2.1.2, 10.5.2.5, 10.5.3, 10.5.6, 10.5.8 (NFPA 99) 05/02/2018
02/02/2018Fire/Life/SafetyT6SMK1008FIRESTOP SYSTEMS & DEVICESPenetrations for cables, cable trays, conduits, pipes, tubes, combustion vents and exhaust vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a fire barrier shall be protected by a firestop system or device. The firestop system or device shall be tested in accordance with ASTM E 814, Standard Test Method for Fire Tests of Through Penetration Fire Stops, or ANSI/UL 1479, Standard for Fire Tests of Through- Penetration Firestops, at a minimum positive pressure differential of 0.01 in. water column (2.5 N/m2) between the exposed and the unexposed surface of the test assembly. NFPA 101 (2012) 8.3.5.1. 05/02/2018
02/02/2018Fire/Life/SafetyT6SMK1051PLANS SUBMITTAL PRIOR TO WORKNo hospital construction work, including demolition, shall be started until prior written approval has been given by the Office of Plans and Construction. This includes all construction of new facilities and any and all additions, modifications, or renovations to existing facilities. When construction is required, either for new buildings or additions, alterations or renovations to existing buildings, the plans and specifications shall be prepared and submitted to the Office of Plans and Construction for approval by a Florida-registered architect and a Florida-registered professional engineer. Florida Administrative Code 59A-3.080 & Florida Building Code (2014) 5th Edition Section 449.1.1. 05/02/2018
07/26/2017ComplaintZW6SNoneNoneNoneNone
02/08/2017Complaint8ZTFNoneNoneNoneNone
02/08/2017ComplaintHONINoneNoneNoneNone
12/01/2016ComplaintMN87NoneNoneNoneNone
04/14/2016ComplaintDODVA0820IMPLEMENTATION OF A DISCHARGE PLAN(3) The hospital must arrange for the initial implementation of the patient's discharge plan. (5) As needed, the patient and family members or interested persons must be counseled to prepare them for post-hospital care. 
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