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The inspector observed, while accompanied by the CEO, safety manager, director of the business operation, director of the facilities management &planning, facility manager and maintenance personnel, during the hours of the inspection from 01:40 PM to 06:30 PM on 11/08/2018 that there were the following issues. They were the following issues.

(A) There was door stops utilized at the dietary storage room which is a hazardous area. The door shall be maintained closed at all time at the hazardous rooms.

The inspector observed, while accompanied by the CEO, safety manager, director of the business operation, director of the facilities management &planning, facility manager and maintenance personnel, during the hours of the inspection from 01:40 PM to 06:30 PM on 11/08/2018 that there were the following issues. They were the following issues.

(A) There was a yellow tag attached to the sprinkler stand pipes system because of the reliable water motor bell was not operational. The system shall be maintained and operational at all time.

The inspector observed, while accompanied by the CEO, safety manager, director of the business operation, director of the facilities management &planning, facility manager and maintenance personnel, during the hours of the inspection from 01:40 PM to 06:30 PM on 11/08/2018 that there were the following issues. They were the following issues.

(A) The door inspection was not performed annually and the log was not available.

The inspector observed, while accompanied by the CEO, safety manager, director of the business operation, director of the facilities management &planning, facility manager and maintenance personnel, during the hours of the inspection from 01:40 PM to 06:30 PM on 11/08/2018 that there were the following issues. They were the following issues.

(A) The boiler certificate was expired.

The inspector observed, while accompanied by the CEO, safety manager, director of the business operation, director of the facilities management &planning, facility manager and maintenance personnel, during the hours of the inspection from 01:40 PM to 06:30 PM on 11/08/2018 that there were the following issues. They were the following issues.

(A) There was a missing receptacle powered from life safety branch at the generator set location and the automatic transfer switch location. This is not in accordance with NFPA 99, 1999: 3-4.2.2.2. (b)5. "The emergency generator location shall have task illumination, battery charger for emergency battery powered lighting unit(s), and selected receptacles at the generator set location and essential automatic transfer switch location"



(B) The electrical directory was not updated in accordance to the new or modified receptacles. This does not comply with NFPA 70, 2002: 408.4. - "Panel directories shall be labeled to legibly identify the purpose or use of each circuit."



(C) There is not a label outside the branch FACP indicating the panel and circuit number. Also, there is not a label and marked red for the all FACP breakers at the life safety branch electrical panel. This does not comply with NFPA 72, 2002: 4.4.1.4.2.2 -The electrical connection between the panel/breaker and the FACP must be cross referenced correctly. "The circuit breaker at the electrical panel board for the fire alarm shall have a red marking, shall be accessible only to authorized personnel, and shall be identified as "FIRE ALARM CIRCUIT CONTROL"" - NFPA 72, 2002: 4.4.1.4.2.2. "The location of the circuit disconnecting means shall be permanently identified at the fire alarm control unit." - NFPA 72, 2002: 4.4.1.4.2.3. Additionally, the circuit breaker that provides power to the Fire Alarm system shall be marked with a red color within the panel to meet the requirements of NFPA 72(2002)1-5.2.5.2.



(D) There were numerous flexible conduits utilized from emergency electrical panel at electrical rooms or closets. This wiring system shall be a nonflexible metal raceway. This does not comply with NFPA 70, §517.30(C)(3). - Mechanical protection of the emergency system. The wiring of the emergency system shall be mechanically protected by installation in nonflexible metal raceways.



(E) There was not a bonding wire provided between the normal and essential branch-circuits panelboards. This does not comply with NFPA 70, 2002: 517-14. - Panelboard bonding requires the equipment grounding terminal buses of the normal and essential branch-circuits panelboards serving the same individual patient vicinity be bonded together with an insulated continuous copper conductor not smaller than # 10 AWG.



(F) There was not a task illumination powered from the generator critical branch at the medication rooms This does not comply with NFPA 70, 517.33. -Only those items listed in NFPA 70, 517.33 are allowed to be placed on the critical branch of the essential electrical system that relate to patient care. NFPA 99, 2002, 4.4.2.2.2.3(3).- "The critical branch of the emergency system shall supply power for task illumination, fixed equipment, selected receptacles, and selected power circuits serving the following areas and functions related to patient care: (3) Task illumination and selected receptacles in the following: (a) patient care areas. (b) Medication preparation areas, (c) Pharmacy dispensing areas, (d) Nurses' stations (unless adequately lighted by corridor luminaires)." NFPA 70, 517.33 (A)(5).The nurse call system shall be on the critical branch of the emergency electrical system



(G) Receptacles were not tested or logged. Electrical Systems -Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. The facility shall establish a testing interval and maintain testing records.

The inspector observed, while accompanied by the CEO, safety manager, director of the business operation, director of the facilities management &planning, facility manager and maintenance personnel during the hours of the inspection from 01:40 PM to 06:30 PM on 11/08/2018 that there were the following issues. They were the following issues.


A) The 300 cu.ft. of medical gas storage was exceeded within 22500 sq. ft. areas or a single smoke compartment. Please provide a dedicated mechanical exhaust system that draw air from within 1 foot of the floor and operate continuously inside the medical storage rooms or natural ventilation provided at 72 sq. ft. within 12" of ceiling and at 72 sq. ft. within 12" of the floor. This does not comply with NFPA 99 as followed: Re. NFPA 99, 2002: 5.1.3.3.3.1(E). Where the total volume of medical gases connected and in storage is less than 3000 cu.ft. at STP, natural ventilation shall be permitted - NFPA 99, 2002: 5.1.3.3.1(D). Where natural ventilation is permitted, it shall consist of two louvered openings, each having a minimum free area of 72 in. sq., with one located within 1 ft. of the floor and one located within 1 ft. of the ceiling. Re. NFPA 99, 2002: 5.1.3.3.3.1(B). - Where the total volume of medical gases connected and in storage is greater than 3,000 cu.ft. at STP, indoor supply locations shall be provided with dedicated mechanical ventilation systems that draw air from within 1 foot of the floor and operate continuously Re. NFPA 99, 2002: 5.1.3.3.3.1(F).- Louvered natural ventilation opening shall not be located in an exit corridor. Re. NFPA 99, 2002: 5.1.3.3.3.1(G).- Mechanical natural ventilation shall be provided if the requirements of 5.1.3.3.3.1 cannot be met.