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A. Due to the number, variety, and severity of the life safety deficiencies observed
during the survey walk-through, the provider shall institute the appropriate Interim Life
Safety Measures until all cited deficiencies are corrected. The provider shall include,
as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed
narrative and proposed schedule for all such measures. The narrative shall describe
all measures to be implemented, as well as the frequency with which they are to be
conducted, and shall indicate the manner in which the measures are to be
documented. The narrative shall also include comments related to changes in the
Interim Life Safety Measures to remain in place as work toward the completion of its
PoC progresses.

Based on random observation during the survey walk through while accompanied by the facility electrician, the surveyor found that the electrical system installation did not meet all of the requirements of NFPA-70. This could affect all occupants of the hospital if the emergency power system does not operate correctly.

Findings include:

A. At 1:25 on 11/5/2013 it was observed that the transfer switch in the electrical room on the second floor at the north end of the building next to the elevator is serving all three branches of emergency power. This does not meet the requirements of NFPA-70, Section 517-30 through 517-35, for a system that serves over 150 KVA in loads.

B. At 1:30 PM on 11/5/2013 it was observed that panel 2EC in the second floor north electrical room is serving a mix of life safety, critical and equipment loads which does not meet the requirements of NFPA-70, Section 517-32 through 517-34.

C. At 2:05 PM on 11/5/2013 it was observed that the transfer switches and panels serving the emergency power in the mechanical room north of the laundry are not properly separated into branches to meet the requirements of NFPA70, Sections 517-30 through 517-35.

D. At 2:20 PM on 11/5/2013 it was observed that the transfer switch serving the kitchen and boiler room is serving mostly equipment but has some loads that are required to be served from the life safety panel, including some exit and emergency lighting served from panel HE, and the elevator cab lighting served from panel LEA, which does not meet the requirements of NFPA-70, Section 517-32.

Based on random observation during the survey walk through while accompanied by the facility electrician, the surveyor found that the electrical system installation did not meet all of the requirements of NFPA-70.

Findings include:

A. At 1:45 PM on 11/5/2013 it was observed that the cab lighting for the traction elevator is not served from the life safety panel as required by NFPA-70, Section 517-32, and there is not a disconnect switch for cab lighting and controls within the elevator equipment room as required by NFPA-70, Section 620-22. This could affect any occupant of the building using the elevator during a power outage.