HospitalInspections.org

Based on observation and interview the facility failed to assure the double doors leading into the OR suite were smoke tight. This deficient practice would allow smoke and fire to spread and would affect occupants in the area. The facility census was 6 patients.

Findings are:
Observations on 3-14-16 at 11:35 am revealed, the double doors leading into the OR suite had a gap greater than 1/8 inch.

During an interview on 3-14-16 at 11:35 am, Maintenance A confirmed the gap.

Based on observation and interview, the facility failed to maintain the doors to hazardous areas so they would to latch within their frame or were smoke tight. These deficient practices would allow fire and smoke to migrate out of the hazard areas into the exiting corridors which would delay egress. The facility census was 6 patients.

Findings are:
Observations on 3-14-16 at 11:12 am and 12:42 pm revealed:
1. The Janitorial Closet door in the Nursery work area, equipped with a self-closer the failed to latch.
2. The gap between the OR Equipment Storage room doors was greater than 1/8 inch.

During an interview on 3-14-16 at 11:12 am and 12:42 pm Maintenance A confirmed the findings.

NFPA Standard:
Hazardous areas shall be safeguarded by a fire barrier of one-hour fire resistance rating or provided with an automatic sprinkler system and doors shall have self-closing devices and positive latches. 2000 NFPA 101, 19.3.2.1 and 2000 NFPA 101, 8.4.1

Based on observation, record review and interview, this facility failed to prohibit the use of more than one locking device on a door within a means of egress, to allow for quick and reliable exiting to a public way (an area of safety). The facility failed to provide signage on the access control doors and allowed locking device on the access controlled door. This deficient practice would prohibit or delay egress during an emergency. The facility census was 6 patients.

Findings are:
Observation on 3-14-16 between 10:16 am and 11:58 am revealed:
1. The LND corridor door was equipped with a thumb lock and door hardware to exit the room.
2. The Emergency Department access controlled exit doors failed to provide signage for manual release of the door.
3. The Emergency Department access controlled exit door failed to provide 41.5 inches of clear opening when the door was opened in manual release.
4. The Sleep Study door was equipped with a doorknob and a thumb turn deadbolt lock to exit the room.
5. The Doctors Lounge door was equipped with a keyed deadbolt lock to exit the room and a thumb lock on the outside of the door, so that occupant could be locked inside the room.
6. The 10th Street access controlled exit door was equipped with a thumb lock.
7. The 10th Street access controlled exit door failed to provide signage for manual release of the door.

Record Review of the facility floor plans on 3-14-16 between 10:16 AM and 11:58 AM indicated these doors were located within a required means of egress for use in the event of an emergency that required evacuation

During an interview on 3-14-16 between 10:16 am and 11:58 am, Maintenance A confirmed the findings.

NFPA Standard:
A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 in. (86 cm), and not more than 48 in. (122 cm), above the finished floor. Doors shall be operable with not more than one releasing operation.
Exception No. 1*: Egress doors from individual living units and guest rooms of residential occupancies shall be permitted to be provided with devices that require not more than one additional releasing operation, provided that such device is operable from the inside without the use of a key or tool and is mounted at a height not exceeding 48 in. (122 cm) above the finished floor. Existing security devices shall be permitted to have two additional releasing operations. Existing security devices other than automatic latching devices shall not be located more than 60 in. (152 cm) above the finished floor. Automatic latching devices shall not be located more than 48 in. (122 cm) above the finished floor.
Exception No. 2: The minimum mounting height for the releasing mechanism shall not be applicable to existing installations. 2000 NFPA 101, 7.2.1.5.4*

A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 in. (86 cm), and not more than 48 in. (122 cm), above the finished floor. Doors shall be operable with not more than one releasing operation. 2000 NFPA 101, 7.2.1.5.4

Doors located in the means of egress that are permitted to be locked shall have adequate provisions for the rapid removal of occupants such as remote control, the keying of all locks to keys carried by staff at all times, or knowledge of the code. Only one such locking device shall be permitted on each door. 2000 NFPA 101, 18/19.2.2.2.5

NFPA Standard:
Where permitted in Chapters 11 through 42, doors in the means of egress shall be permitted to be equipped with an approved entrance and egress access control system, provided that the following criteria are met.
(a) A sensor shall be provided on the egress side and arranged to detect an occupant approaching the doors, and the doors shall be arranged to unlock in the direction of egress upon detection of an approaching occupant or loss of power to the sensor.
(b) Loss of power to the part of the access control system that locks the doors shall automatically unlock the doors in the direction of egress.
(c) The doors shall be arranged to unlock in the direction of egress from a manual release device located 40 in. to 48 in. (102 cm to 122 cm) vertically above the floor and within 5 ft (1.5 m) of the secured doors. The manual release device shall be readily accessible and clearly identified by a sign that reads as follows:
PUSH TO EXIT
When operated, the manual release device shall result in direct interruption of power to the lock - independent of the access control system electronics - and the doors shall remain unlocked for not less than 30 seconds.
(d) Activation of the building fire-protective signaling system, if provided, shall automatically unlock the doors in the direction of egress, and the doors shall remain unlocked until the fire-protective signaling system has been manually reset.
(e) Activation of the building automatic sprinkler or fire detection system, if provided, shall automatically unlock the doors in the direction of egress and the doors shall remain unlocked until the fire-protective signaling system has been manually reset.
2000 NFPA 101, 7.2.1.6.2

Based on observation and interview, the facility failed to provide emergency lighting in the Conference Room which has an occupant load of over 100. This deficient practice would cause confusion and delay egress during an emergency. The facility census was 6 patients.

Findings are:
Observations on 3-14-16 at 10:25 am revealed, the square footage of the Conference Room by counting ceiling tile determined the occupant load would be over 100 persons and no emergency lighting was provided.

During an interview on 3-14-16 at 10:25 am, Maintenance A confirmed the size of the room and the occupant load and stated no emergency lighting was provided.

NFPA Standard:
Emergency lighting shall be provided in accordance with Section 7.9. Private party tents not exceeding 1200 ft2 (111.5 m2) shall not be required to have emergency lighting. 2000 NFPA 101, 12.2.9

Based on observation and interview, the facility failed to mark the means of egress so that exits were readily apparent to occupants. This condition had the potential for occupants to not be able to find an exit in an emergency near the Cafeteria and the North Hall. This facility census was 6 patients.

Findings are:
Observations on 3-14-16 at 11:02 am and 12:41 pm revealed:
1. While looking west above the double doors leading to the Cafeteria no exit signage provided.
2. While looking south in the North corridor no exit signage provided.

During an interview on 3-14-16 at 11:02 am and 12:41 pm, Maintenance A confirmed the lack of exit signage.

NFPA Standard:
Means of egress shall have signs in accordance with Section 7.10. 2000 NFPA 101, 19.2.10.1

Access to exits shall be marked by approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent to the occupants. Sign placement shall be such that no point in an exit access corridor is in excess of 100 ft (30 m) from the nearest externally illuminated sign and is not in excess of the marked rating for internally illuminated signs. 2000 NFPA 101, 7.10.1.4

Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign readily visible from any direction of exit access. 2000 NFPA 101, 7.10.1.2

Based on documentation review and interview, the facility failed to hold fire drills at random times under varied conditions. When fire drills are held within the same time frame, they are not conducted under varied conditions. The deficient practice did not challenge facility staff under different times and conditions, which could impact staff response when faced with a real fire. The deficient practice had the potential to affect all occupants. The facility census was 6 patients.

Findings are:
Fire drill documentation review on 3-14-16 at 2:20 pm revealed:
1. The first shift drills were conducted at 2:33pm, 2:51pm, 1:27pm
2. The second shift drills were conducted at 4:04pm, 4:56pm, 5:34pm and 3:28pm
3. The third shift drill were conducted at 4:00am, 6:05am, 2:47am, and 5:58am
4. 14 of 14 fire drills were conducted at the end of the month or within a few day of the end of the month.

During an interview on 3-14-16 at 2:20 pm, Maintenance A confirmed all the findings.

NFPA Standard:
The proper protection of patients shall require the prompt and effective response of health care personnel. The basic response required of staff shall include the removal of all occupants directly involved with the fire emergency, transmission of an appropriate fire alarm signal to warn other building occupants and summon staff, confinement of the effects of the fire by closing doors to isolate the fire area, and the relocation of patients as detailed in the health care occupancy's fire safety plan. 2000 NFPA 101, 19.7.2.1

Requires drills be conducted at least quarterly on each shift under varied conditions to simulate the unusual conditions occurring in case of fire. The fire alarm shall be transmitted during drills although a coded announcement may be used between 9:00 p.m. and 6:00 a.m. The fire alarm shall be transmitted the day before or the day after the coded drill. 2000 NFPA 101, 19.7.1.2

Based on documentation review and interview, the facility failed to maintain the heat detectors. The facility did not provide and maintain complete documentation on the appropriate forms for the annual testing of the fire alarm system as required by NFPA 72. The deficient practice of not providing complete and verifiable documentation on the inspection, testing, and maintenance of the fire alarm system does not ensure proper operation and prompt repair affecting all occupants. The facility census was 6 patients.

Findings are:
Documentation review of the fire alarm tests on 3-14-16 at 2:51 pm revealed, the facility has six heat detectors and the fire alarm contractor has failed to test on reports provided and dated, 1-30-14, 7-17-14, 1-21-15, 8-18-15 and 2-5-15.


Record review on 3-14-16 at 2:50 pm, revealed the facility's report of annual testing dated 2-5-16 was incomplete, as it did not document all of the required testing and information on the fire alarm system. The documents provided did not list all devices, circuits, and the type, quantity, method of testing and the results of testing obtained. Information on all of the supervisory devices connected, tested and the results of testing were not documented.

During an interview on 3-14-16 at 2:50 pm, Maintenance A confirmed the findings.

NFPA Standard:
A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction. 2000 NFPA 101, 9.6.1.4

NFPA Standard:
A permanent record of all inspections, testing, and maintenance shall be provided that includes the following information regarding tests and all the applicable information requested in Figure 7-5.2.2, including: Date, Test frequency, Name of property, Address, Name of person performing inspection, maintenance, tests, or combination thereof, and affiliation, business address, and telephone number, Name, address, and representative of approving agency, Designation of the detector(s) tested, for example, " Tests performed in accordance with Section _. " , Functional test of detectors, Functional test of required sequence of operations, Check of all smoke detectors, Loop resistance for all fixed-temperature, line-type heat detectors, Other tests as required by equipment manufacturers, Other tests as required by the authority having jurisdiction, Signatures of tester and approved authority representative, Disposition of problems identified during test (for example, owner notified, problem corrected/successfully retested, device abandoned in place). 1999 NFPA 72, 7-5.2.2

NFPA Standard:
Fire alarm systems and other systems and equipment that are associated with fire alarm systems and accessory equipment shall be tested according to Table 7-2.2. 1999 NFPA 72, 7-2.2

NFPA Standard:
A permanent record of all inspections, testing, and maintenance shall be maintained that includes periodic tests and applicable information, per 1999 NFPA 72, 7-5.2.2 and figure 7-5.2.2; A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70. 2000 NFPA 101, 9.6.1.4

Based on documentation review and interview, the facility failed to have the sprinkler system inspected quarterly by personnel who have developed competence through training and experience. This deficient practice could affect the operation of the sprinkler system and would affect all occupants. The facility census was 6 patients.

Findings are:
Documentation review on 3-14-16 at 2:45 pm revealed, the facility had the sprinkler contractor do inspections on a yearly basis. The fire alarm company is doing inspection twice a year. The fourth quarter inspection of the sprinkler system is conducted by the facility.

During an interview on 3-14-16 at 2:45 pm, Maintenance A confirmed the findings.

NFPA Standard:
The responsibility for properly maintaining a water-based fire protection system shall be that of the owner(s) of the property. By means of periodic inspections, tests, and maintenance, the equipment shall be shown to be in good operating condition, or any defects or impairments shall be revealed.
Inspection, testing, and maintenance shall be implemented in accordance with procedures meeting or exceeding those established in this document and in accordance with the manufacturer ' s instructions. These tasks shall be performed by personnel who have developed competence through training and experience. 1998 NFPA 25, 1-4.2

Requires sprinkler systems to be continuously maintained in proper operating condition and an inspection every quarter of a calendar year. 1998 NFPA 25, 2-2 and 2000 NFPA 101, 4.6.12.1

Based on observation and interview, this facility did not provide unobstructed corridors that provide a clear path of egress. This deficient practice can limit and/or delay evacuation in the event of an emergency. This facility census was 6 patients.

Findings are:
Observation on 3-14-16 at 10:49 am and 11:52 am revealed:
1. Tables and chairs obstructed the Dining Room exit.
2. Two wheelchairs were stored in the ED corridor with no patients in the area.

During an interview 3-14-16 at 10:49 am and 11:52 am, Maintenance A confirmed the findings

NFPA Standard:
Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. 2000 NFPA 101, 7.1.10.1

Based on observation and interview, the facility failed to ensure empty and full oxygen tanks were adequately separated to prevent confusion when choosing tanks in an emergency. The facility census was 6 patients.

Findings are:
Observation on 3-14-16 at 11:03 am revealed, the Oxygen Storage room contained empty oxygen cylinders and full cylinders and the " K " sized oxygen cylinders were not physically separated.

During an interview on 3-14-16 at 11:03 am, Maintenance Staff A confirmed the lack of separation.

NFPA Standard:
If stored within the same enclosure, empty cylinders shall be segregated from full cylinders. Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed hurriedly. 1999 NFPA 99, 4.3.5.2.2

Based on documentation, observation and interview, the facility failed to have the Level 1 emergency generator installed in accordance with NFPA 110, 1999 edition failed to provide a manual stop station outside the area of the generator. This deficient practice had the potential to affect all occupants of the facility. The facility census was 6 patients.

Findings are:
Observation on 3-14-16 at 10:32 am revealed, the facility failed to provide a remote manual shutdown for the generator.

During an interview on 3-14-16 at 10:32 am, Maintenance A confirmed the facility failed to provide a manual shutdown and stated the generator was installed in 2003.

NFPA Standard:
All Level 1 and Level 2 installations shall have a remote manual stop station of a type similar to a break-glass station located outside the room housing the prime mover, where so installed, or located elsewhere on the premises where the prime mover is located outside the building.
For Level 1 and Level 2 systems located outdoors, the manual shutdown should be located external to the weatherproof enclosure and should be appropriately identified.1999 NFPA 110, 3-5.5.6*

Based on observation, interview and documentation review, the facility failed to maintain the Type I essential electrical system of the facility by having loads intermixed between the Life Safety Branch, the Critical Branch, and the Equipment System. This deficient practice had the potential to affect all occupants of the facility by affecting the egress lighting and emergency systems of the facility. The facility census is 6 patients.

Findings are:
Observations on 3-14-16 between 10:00 am and 1:30 pm revealed:
1. Electrical panel boxes throughout the facility have intermixed systems within the branches.

During an interview on 3-14-16 between 10:00 am and 1:30 pm, Maintenance A confirmed the findings.

NFPA Standard:
NFPA 70, 1999ed.
517.30 Essential Electrical Systems for Hospitals.
(A) Applicability. The requirements of Part III, 517.30 through 517.35, shall apply to hospitals where an essential electrical system is required.
(B) General.
(1) Separate Systems. Essential electrical systems for hospitals shall be comprised of two separate systems capable of supplying a limited amount of lighting and power service, which is considered essential for life safety and effective hospital operation during the time the normal electrical service is interrupted for any reason. These two systems shall be the emergency system and the equipment system.
(2) Emergency Systems. The emergency system shall be limited to circuits essential to life safety and critical patient care. These are designated the life safety branch and the critical branch.
(3) Equipment System. The equipment system shall supply major electrical equipment necessary for patient care and basic hospital operation.
(4) Transfer Switches. The number of transfer switches to be used shall be based on reliability, design, and load considerations. Each branch of the emergency system and each equipment system shall have one or more transfer switches. One transfer switch shall be permitted to serve one or more branches or systems in a facility with a maximum demand on the essential electrical system of 150 kVA.
(5) Other Loads. Loads served by the generating equipment not specifically named in Article 517 shall be served by their own transfer switches such that these loads:
(1) Shall not be transferred if the transfer will overload the generating equipment.
(2) Shall be automatically shed upon generating equipment overloading.
(6) Contiguous Facilities. Hospital power sources and alternate power sources shall be permitted to serve the essential electrical systems of contiguous or same site facilities. [NFPA 99, 3.4.2.2.1, 12.3.3.2]
(C) Wiring Requirements.
(1) Separation from Other Circuits. The life safety branch and critical branch of the emergency system shall be kept entirely independent of all other wiring and equipment and shall not enter the same raceways, boxes, or cabinets with each other or other wiring.
Wiring of the life safety branch and the critical branch shall be permitted to occupy the same raceways, boxes, or cabinets of other circuits not part of the branch where such wiring is as follows:
(1) In transfer equipment enclosures, or
(2) In exit or emergency luminaires (lighting fixtures) supplied from two sources, or
(3) In a common junction box attached to exit or emergency luminaires (lighting fixtures) supplied from two sources, or
(4) For two or more emergency circuits supplied from the same branch
The wiring of the equipment system shall be permitted to occupy the same raceways, boxes, or cabinets of other circuits that are not part of the emergency system.
(2) Isolated Power Systems. Where isolated power systems are installed in any of the areas in 517.33(A)(1) and (A)(2), each system shall be supplied by an individual circuit serving no other load.
(3) Mechanical Protection of the Emergency System. The wiring of the emergency system of a hospital shall be mechanically protected by installation in nonflexible metal raceways, or shall be wired with Type MI cable.
Exception No. 1: Flexible power cords of appliances, or other utilization equipment, connected to the emergency system shall not be required to be enclosed in raceways.
Exception No. 2: Secondary circuits of transformer-powered communications or signaling systems shall not be required to be enclosed in raceways unless otherwise specified by Chapters 7 or 8.
Exception No. 3: Schedule 80 rigid nonmetallic conduit shall be permitted if the branch circuits do not serve patient care areas and it is not prohibited elsewhere in this Code.
Exception No. 4: Where encased in not less than 50 mm (2 in.) of concrete, Schedule 40 rigid nonmetallic conduit or electrical nonmetallic tubing shall be permitted if the branch circuits do not serve patient care areas.
Exception No. 5: Flexible metal raceways and cable assemblies shall be permitted to be used in listed prefabricated medical headwalls, listed office furnishings, or where necessary for flexible connection to equipment.
(D) Capacity of Systems. The essential electrical system shall have adequate capacity to meet the demand for the operation of all functions and equipment to be served by each system and branch.
Feeders shall be sized in accordance with Articles 215 and 220. The generator set(s) shall have sufficient capacity and proper rating to meet the demand produced by the load of the essential electrical system(s) at any given time.
Demand calculations for sizing of the generator set(s) shall be based on the following:
(1) Prudent demand factors and historical data, or
(2) Connected load, or
(3) Feeder calculation procedures described in Article 220, or
(4) Any combination of the above
The sizing requirements in 700.5 and 701.6 shall not apply to hospital generator set(s).
(E) Receptacle Identification. The cover plates for the electrical receptacles or the electrical receptacles themselves supplied from the emergency system shall have a distinctive color or marking so as to be readily identifiable. [NFPA 99, 3.4.2.2.4(b)2]
517.31 Emergency System.
Those functions of patient care depending on lighting or appliances that are connected to the emergency system shall be divided into two mandatory branches: the life safety branch and the critical branch, described in 517.32 and 517.33. The branches of the emergency system shall be installed and connected to the alternate power source so that all functions specified herein for the emergency system shall be automatically restored to operation within 10 seconds after interruption of the normal source. [NFPA 99, 3.4.2.2.2(a), 3.5.2.2.2]
517.32 Life Safety Branch.
No function other than those listed in 517.32(A) through (G) shall be connected to the life safety branch. The life safety branch of the emergency system shall supply power for the following lighting, receptacles, and equipment.
(A) Illumination of Means of Egress. Illumination of means of egress, such as lighting required for corridors, passageways, stairways, and landings at exit doors, and all necessary ways of approach to exits. Switching arrangements to transfer patient corridor lighting in hospitals from general illumination circuits to night illumination circuits shall be permitted, provided only one of two circuits can be selected and both circuits cannot be extinguished at the same time.
(B) Exit Signs. Exit signs and exit directional signs.
(C) Alarm and Alerting Systems. Alarm and alerting systems including the following:
(1) Fire alarms
(2) Alarms required for systems used for the piping of nonflammable medical gases
(D) Communications Systems. Hospital communications systems, where used for issuing instructions during emergency conditions.
(E) Generator Set Location. Task illumination battery charger for emergency battery-powered lighting unit(s) and selected receptacles at the generator set location.
(F) Elevators. Elevator cab lighting, control, communications, and signal systems.
(G) Automatic Doors. Automatically operated doors used for building egress. [NFPA 99, 3.4.2.2.2(b)]
517.33 Critical Branch.
(A) Task Illumination and Selected Receptacles. The critical branch of the emergency system shall supply power for task illumination, fixed equipment, selected receptacles, and special power circuits serving the following areas and functions related to patient care:
(1) Critical care areas that utilize anesthetizing gases - task illumination, selected receptacles, and fixed equipment
(2) The isolated power systems in special environments
(3) Patient care areas - task illumination and selected receptacles in the following:
a. Infant nurseries
b. Medication preparation areas
c. Pharmacy dispensing areas
d. Selected acute nursing areas
e. Psychiatric bed areas (omit receptacles)
f. Ward treatment rooms
g. Nurses ' stations (unless adequately lighted by corridor luminaires)
(4) Additional specialized patient care task illumination and receptacles, where needed
(5) Nurse call systems
(6) Blood, bone, and tissue banks
(7) Telephone equipment rooms and closets
(8) Task illumination, selected receptacles, and selected power circuits for the following:
a. General care beds (at least one duplex receptacle per patient bedroom)
b. Angiographic labs
c. Cardiac catheterization labs
d. Coronary care units
e. Hemodialysis rooms or areas
f. Emergency room treatment areas (selected)
g. Human physiology labs
h. Intensive care units
i. Postoperative recovery rooms (selected)
(9) Additional task illumination, receptacles, and selected power circuits needed for effective hospital operation. Single-phase fractional horsepower motors shall be permitted to be connected to the critical branch. [NFPA 99, 3.4.2.2.2(c)]
(B) Subdivision of the Critical Branch. It shall be permitted to subdivide the critical branch into two or more branches.
517.34 Equipment System Connection to Alternate Power Source.
The equipment system shall be installed and connected to the alternate power source such that the equipment described in 517.34(A) is automatically restored to operation at appropriate time-lag intervals following the energizing of the emergency system. Its arrangement shall also provide for the subsequent connection of equipment described in 517.34(B). [NFPA 99, 3.4.2.2.3(b)]
Exception: For essential electrical systems under 150 kVA, deletion of the time-lag intervals feature for delayed automatic connection to the equipment system shall be permitted.
(A) Equipment for Delayed Automatic Connection. The following equipment shall be arranged for delayed automatic connection to the alternate power source.
(1) Central suction systems serving medical and surgical functions, including controls. Such suction systems shall be permitted on the critical branch.
(2) Sump pumps and other equipment required to operate for the safety of major apparatus, including associated control systems and alarms.
(3) Compressed air systems serving medical and surgical functions, including controls. Such air systems shall be permitted on the critical branch.
(4) Smoke control and stair pressurization systems, or both.
(5) Kitchen hood supply or exhaust systems, or both, if required to operate during a fire in or under the hood. [NFPA 99, 3.4.2.2.3(d)]
Exception: Sequential delayed automatic connection to the alternate power source to prevent overloading the generator shall be permitted where engineering studies indicate it is necessary.
(B) Equipment for Delayed Automatic or Manual Connection. The following equipment shall be arranged for either delayed automatic or manual connection to the alternate power source:
(1) Heating equipment to provide heating for operating, delivery, labor, recovery, intensive care, coronary care, nurseries, infection/isolation rooms, emergency treatment spaces, and general patient rooms and pressure maintenance (jockey or make-up) pump(s) for water-based fire protection systems.
Exception: Heating of general patient rooms and infection/isolation rooms during disruption of the normal source shall not be required under any of the following conditions:
(a) The outside design temperature is higher than -6.7°C (20°F).
(b) The outside design temperature is lower than -6.7°C (20°F), and where a selected room(s) is provided for the needs of all confined patients, only such room(s) need be heated.
(c) The facility is served by a dual source of normal power.
(2) An elevator(s) selected to provide service to patient, surgical, obstetrical, and ground floors during interruption of normal power. In instances where interruption of normal power would result in other elevators stopping between floors, throw-over facilities shall be provided to allow the temporary operation of any elevator for the release of patients or other persons who may be confined between floors.
(3) Supply, return, and exhaust ventilating systems for airborne infectious/isolation rooms, protective environment rooms, exhaust fans for laboratory fume hoods, nuclear medicine areas where radioactive material is used, ethylene oxide evacuation and anesthesia evacuation. Where delayed automatic connection is not appropriate, such ventilation systems shall be permitted to be placed on the critical branch. [NFPA 99, 3.4.2.2.3(e)(4)]
(4) Hyperbaric facilities.
(5) Hypobaric facilities.
(6) Automatically operated doors.
(7) Minimal electrically heated autoclaving equipment shall be permitted to be arranged for either automatic or manual connection to the alternate source.
(8) Controls for equipment listed in 517.34.
(9) Other selected equipment shall be permitted to be served by the equipment system. [NFPA 99, 3.4.2.2.3(e)]

Based on observation, interview and documentation review, the facility failed to provide a covers for open breakers in an electrical panel and failed to provide a directory for a panel box. The facility failed to conduct retention testing of newly installed electrical receptacles. The facility census was 6 patients.

Findings are:
Observations on 3-14-16 at 10:50 am and 12:18 pm revealed:
1. Numerous open breakers in the panel box ITB in the Server Room.
2. Electrical Panel Q in the VFD/Mechanical Room failed to provide a panel directory.

During an interview on 3-14-16 at 10:50 am and 12:18 pm, Maintenance A confirmed the findings.

Documentation review on 3-14-16 at 2:46 pm revealed, the facility failed to conduct retention testing every six months to newly installed outlets in critical care areas and wet areas.

During an interview on 3-14-16 at 2:46 pm, Maintenance A confirmed the lack of testing.

NFPA Standard:
Panelboards shall be mounted in cabinets, cutout boxes, or enclosures designed for the purpose and shall be dead front. 1999 NFPA 70, 384-18

All panelboards shall have a rating not less than the minimum feeder capacity required for the load computed in accordance with Article 220. Panelboards shall be durably marked by the manufacturer with the voltage and the current rating and the number of phases for which they are designed and with the manufacturer ' s name or trademark in such a manner so as to be visible after installation, without disturbing the interior parts or wiring. All panelboard circuits and circuit modifications shall be legibly identified as to purpose or use on a circuit directory located on the face or inside of the panel doors. 1999 NFPA 70, 384-13

Based on record review and interview, the facility failed to provide a policy regarding the procedures to be taken in the event that the sprinkler system is out of service for more than 4 hours in a 24-hour period. The lack of procedures would affect the actions taken by staff in the event of an emergency. This deficient practice affected all occupants in all smoke compartments. The facility census was 6 patients.

Findings are:
Documentation review on 3-14-16 at 2:47 pm revealed:
1. The facility's policy failed to include notification of the local fire department immediately.
2. The facility's policy failed to include that the individual conducting the fire watch shall have no other assigned duties.
3. The facility's policy failed to include that the individual conducting the fire watch shall have access to all portions of the building.
4. The facility's policy failed to include that the individual conducting the fire watch shall be trained to recognize fire hazards and know the procedures for occupant and fire department notification and occupant evacuation.

During an interview on 3-14-16 at 2:47 pm, Maintenance A confirmed the lack of information on the policy.

NFPA Standard:
When a required sprinkler system is out of service for more than 4 hours in a 24-hour period, the AHJ shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties until the fire alarm system has been returned to service. A fire watch should consist of trained personnel who continuously patrol the effected area, with ready access to fire extinguishers and the ability to promptly notify the fire department. During the patrol of the area, the person should look for fire, and that other fire protection features of the building such as egress routes and alarm systems are available and functioning properly. 2000 NFPA 101, 9.6.1.8

Based on record review and interview, the facility failed to provide a policy regarding the procedures to be taken in the event that the fire alarm system is out of service for more than 4 hours in a 24-hour period. The lack of procedures would affect the actions taken by staff in the event of an emergency. This deficient practice affects all occupants in all smoke compartments. The facility census was 6 patients.

Findings are:
Documentation review on 3-14-16 at 2:47 pm revealed:
1. The facility's policy failed to include notification of the local fire department immediately.
2. The facility's policy failed to include that the individual conducting the fire watch shall have no other assigned duties.
3. The facility's policy failed to include that the individual conducting the fire watch shall have access to all portions of the building.
4. The facility's policy failed to include that the individual conducting the fire watch shall be trained to recognize fire hazards and know the procedures for occupant and fire department notification and occupant evacuation.

During an interview on 3-14-16 at 2:47 pm, Maintenance A confirmed the lack of information on the policy.

NFPA Standard:
When a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the AHJ shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties until the fire alarm system has been returned to service. A fire watch should consist of trained personnel who continuously patrol the effected area, with ready access to fire extinguishers and the ability to promptly notify the fire department. During the patrol of the area, the person should look for fire, and that other fire protection features of the building such as egress routes and alarm systems are available and functioning properly. 2000 NFPA 101, 9.6.1.8

Based on observation and interview the facility failed to assure the double doors leading into the OR suite were smoke tight. This deficient practice would allow smoke and fire to spread and would affect occupants in the area. The facility census was 6 patients.

Findings are:
Observations on 3-14-16 at 11:35 am revealed, the double doors leading into the OR suite had a gap greater than 1/8 inch.

During an interview on 3-14-16 at 11:35 am, Maintenance A confirmed the gap.

Based on observation and interview, the facility failed to maintain the doors to hazardous areas so they would to latch within their frame or were smoke tight. These deficient practices would allow fire and smoke to migrate out of the hazard areas into the exiting corridors which would delay egress. The facility census was 6 patients.

Findings are:
Observations on 3-14-16 at 11:12 am and 12:42 pm revealed:
1. The Janitorial Closet door in the Nursery work area, equipped with a self-closer the failed to latch.
2. The gap between the OR Equipment Storage room doors was greater than 1/8 inch.

During an interview on 3-14-16 at 11:12 am and 12:42 pm Maintenance A confirmed the findings.

NFPA Standard:
Hazardous areas shall be safeguarded by a fire barrier of one-hour fire resistance rating or provided with an automatic sprinkler system and doors shall have self-closing devices and positive latches. 2000 NFPA 101, 19.3.2.1 and 2000 NFPA 101, 8.4.1

Based on observation, record review and interview, this facility failed to prohibit the use of more than one locking device on a door within a means of egress, to allow for quick and reliable exiting to a public way (an area of safety). The facility failed to provide signage on the access control doors and allowed locking device on the access controlled door. This deficient practice would prohibit or delay egress during an emergency. The facility census was 6 patients.

Findings are:
Observation on 3-14-16 between 10:16 am and 11:58 am revealed:
1. The LND corridor door was equipped with a thumb lock and door hardware to exit the room.
2. The Emergency Department access controlled exit doors failed to provide signage for manual release of the door.
3. The Emergency Department access controlled exit door failed to provide 41.5 inches of clear opening when the door was opened in manual release.
4. The Sleep Study door was equipped with a doorknob and a thumb turn deadbolt lock to exit the room.
5. The Doctors Lounge door was equipped with a keyed deadbolt lock to exit the room and a thumb lock on the outside of the door, so that occupant could be locked inside the room.
6. The 10th Street access controlled exit door was equipped with a thumb lock.
7. The 10th Street access controlled exit door failed to provide signage for manual release of the door.

Record Review of the facility floor plans on 3-14-16 between 10:16 AM and 11:58 AM indicated these doors were located within a required means of egress for use in the event of an emergency that required evacuation

During an interview on 3-14-16 between 10:16 am and 11:58 am, Maintenance A confirmed the findings.

NFPA Standard:
A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 in. (86 cm), and not more than 48 in. (122 cm), above the finished floor. Doors shall be operable with not more than one releasing operation.
Exception No. 1*: Egress doors from individual living units and guest rooms of residential occupancies shall be permitted to be provided with devices that require not more than one additional releasing operation, provided that such device is operable from the inside without the use of a key or tool and is mounted at a height not exceeding 48 in. (122 cm) above the finished floor. Existing security devices shall be permitted to have two additional releasing operations. Existing security devices other than automatic latching devices shall not be located more than 60 in. (152 cm) above the finished floor. Automatic latching devices shall not be located more than 48 in. (122 cm) above the finished floor.
Exception No. 2: The minimum mounting height for the releasing mechanism shall not be applicable to existing installations. 2000 NFPA 101, 7.2.1.5.4*

A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 in. (86 cm), and not more than 48 in. (122 cm), above the finished floor. Doors shall be operable with not more than one releasing operation. 2000 NFPA 101, 7.2.1.5.4

Doors located in the means of egress that are permitted to be locked shall have adequate provisions for the rapid removal of occupants such as remote control, the keying of all locks to keys carried by staff at all times, or knowledge of the code. Only one such locking device shall be permitted on each door. 2000 NFPA 101, 18/19.2.2.2.5

NFPA Standard:
Where permitted in Chapters 11 through 42, doors in the means of egress shall be permitted to be equipped with an approved entrance and egress access control system, provided that the following criteria are met.
(a) A sensor shall be provided on the egress side and arranged to detect an occupant approaching the doors, and the doors shall be arranged to unlock in the direction of egress upon detection of an approaching occupant or loss of power to the sensor.
(b) Loss of power to the part of the access control system that locks the doors shall automatically unlock the doors in the direction of egress.
(c) The doors shall be arranged to unlock in the direction of egress from a manual release device located 40 in. to 48 in. (102 cm to 122 cm) vertically above the floor and within 5 ft (1.5 m) of the secured doors. The manual release device shall be readily accessible and clearly identified by a sign that reads as follows:
PUSH TO EXIT
When operated, the manual release device shall result in direct interruption of power to the lock - independent of the access control system electronics - and the doors shall remain unlocked for not less than 30 seconds.
(d) Activation of the building fire-protective signaling system, if provided, shall automatically unlock the doors in the direction of egress, and the doors shall remain unlocked until the fire-protective signaling system has been manually reset.
(e) Activation of the building automatic sprinkler or fire detection system, if provided, shall automatically unlock the doors in the direction of egress and the doors shall remain unlocked until the fire-protective signaling system has been manually reset.
2000 NFPA 101, 7.2.1.6.2

Based on observation and interview, the facility failed to provide emergency lighting in the Conference Room which has an occupant load of over 100. This deficient practice would cause confusion and delay egress during an emergency. The facility census was 6 patients.

Findings are:
Observations on 3-14-16 at 10:25 am revealed, the square footage of the Conference Room by counting ceiling tile determined the occupant load would be over 100 persons and no emergency lighting was provided.

During an interview on 3-14-16 at 10:25 am, Maintenance A confirmed the size of the room and the occupant load and stated no emergency lighting was provided.

NFPA Standard:
Emergency lighting shall be provided in accordance with Section 7.9. Private party tents not exceeding 1200 ft2 (111.5 m2) shall not be required to have emergency lighting. 2000 NFPA 101, 12.2.9

Based on observation and interview, the facility failed to mark the means of egress so that exits were readily apparent to occupants. This condition had the potential for occupants to not be able to find an exit in an emergency near the Cafeteria and the North Hall. This facility census was 6 patients.

Findings are:
Observations on 3-14-16 at 11:02 am and 12:41 pm revealed:
1. While looking west above the double doors leading to the Cafeteria no exit signage provided.
2. While looking south in the North corridor no exit signage provided.

During an interview on 3-14-16 at 11:02 am and 12:41 pm, Maintenance A confirmed the lack of exit signage.

NFPA Standard:
Means of egress shall have signs in accordance with Section 7.10. 2000 NFPA 101, 19.2.10.1

Access to exits shall be marked by approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent to the occupants. Sign placement shall be such that no point in an exit access corridor is in excess of 100 ft (30 m) from the nearest externally illuminated sign and is not in excess of the marked rating for internally illuminated signs. 2000 NFPA 101, 7.10.1.4

Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign readily visible from any direction of exit access. 2000 NFPA 101, 7.10.1.2

Based on documentation review and interview, the facility failed to hold fire drills at random times under varied conditions. When fire drills are held within the same time frame, they are not conducted under varied conditions. The deficient practice did not challenge facility staff under different times and conditions, which could impact staff response when faced with a real fire. The deficient practice had the potential to affect all occupants. The facility census was 6 patients.

Findings are:
Fire drill documentation review on 3-14-16 at 2:20 pm revealed:
1. The first shift drills were conducted at 2:33pm, 2:51pm, 1:27pm
2. The second shift drills were conducted at 4:04pm, 4:56pm, 5:34pm and 3:28pm
3. The third shift drill were conducted at 4:00am, 6:05am, 2:47am, and 5:58am
4. 14 of 14 fire drills were conducted at the end of the month or within a few day of the end of the month.

During an interview on 3-14-16 at 2:20 pm, Maintenance A confirmed all the findings.

NFPA Standard:
The proper protection of patients shall require the prompt and effective response of health care personnel. The basic response required of staff shall include the removal of all occupants directly involved with the fire emergency, transmission of an appropriate fire alarm signal to warn other building occupants and summon staff, confinement of the effects of the fire by closing doors to isolate the fire area, and the relocation of patients as detailed in the health care occupancy's fire safety plan. 2000 NFPA 101, 19.7.2.1

Requires drills be conducted at least quarterly on each shift under varied conditions to simulate the unusual conditions occurring in case of fire. The fire alarm shall be transmitted during drills although a coded announcement may be used between 9:00 p.m. and 6:00 a.m. The fire alarm shall be transmitted the day before or the day after the coded drill. 2000 NFPA 101, 19.7.1.2

Based on documentation review and interview, the facility failed to maintain the heat detectors. The facility did not provide and maintain complete documentation on the appropriate forms for the annual testing of the fire alarm system as required by NFPA 72. The deficient practice of not providing complete and verifiable documentation on the inspection, testing, and maintenance of the fire alarm system does not ensure proper operation and prompt repair affecting all occupants. The facility census was 6 patients.

Findings are:
Documentation review of the fire alarm tests on 3-14-16 at 2:51 pm revealed, the facility has six heat detectors and the fire alarm contractor has failed to test on reports provided and dated, 1-30-14, 7-17-14, 1-21-15, 8-18-15 and 2-5-15.


Record review on 3-14-16 at 2:50 pm, revealed the facility's report of annual testing dated 2-5-16 was incomplete, as it did not document all of the required testing and information on the fire alarm system. The documents provided did not list all devices, circuits, and the type, quantity, method of testing and the results of testing obtained. Information on all of the supervisory devices connected, tested and the results of testing were not documented.

During an interview on 3-14-16 at 2:50 pm, Maintenance A confirmed the findings.

NFPA Standard:
A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction. 2000 NFPA 101, 9.6.1.4

NFPA Standard:
A permanent record of all inspections, testing, and maintenance shall be provided that includes the following information regarding tests and all the applicable information requested in Figure 7-5.2.2, including: Date, Test frequency, Name of property, Address, Name of person performing inspection, maintenance, tests, or combination thereof, and affiliation, business address, and telephone number, Name, address, and representative of approving agency, Designation of the detector(s) tested, for example, " Tests performed in accordance with Section _. " , Functional test of detectors, Functional test of required sequence of operations, Check of all smoke detectors, Loop resistance for all fixed-temperature, line-type heat detectors, Other tests as required by equipment manufacturers, Other tests as required by the authority having jurisdiction, Signatures of tester and approved authority representative, Disposition of problems identified during test (for example, owner notified, problem corrected/successfully retested, device abandoned in place). 1999 NFPA 72, 7-5.2.2

NFPA Standard:
Fire alarm systems and other systems and equipment that are associated with fire alarm systems and accessory equipment shall be tested according to Table 7-2.2. 1999 NFPA 72, 7-2.2

NFPA Standard:
A permanent record of all inspections, testing, and maintenance shall be maintained that includes periodic tests and applicable information, per 1999 NFPA 72, 7-5.2.2 and figure 7-5.2.2; A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70. 2000 NFPA 101, 9.6.1.4

Based on documentation review and interview, the facility failed to have the sprinkler system inspected quarterly by personnel who have developed competence through training and experience. This deficient practice could affect the operation of the sprinkler system and would affect all occupants. The facility census was 6 patients.

Findings are:
Documentation review on 3-14-16 at 2:45 pm revealed, the facility had the sprinkler contractor do inspections on a yearly basis. The fire alarm company is doing inspection twice a year. The fourth quarter inspection of the sprinkler system is conducted by the facility.

During an interview on 3-14-16 at 2:45 pm, Maintenance A confirmed the findings.

NFPA Standard:
The responsibility for properly maintaining a water-based fire protection system shall be that of the owner(s) of the property. By means of periodic inspections, tests, and maintenance, the equipment shall be shown to be in good operating condition, or any defects or impairments shall be revealed.
Inspection, testing, and maintenance shall be implemented in accordance with procedures meeting or exceeding those established in this document and in accordance with the manufacturer ' s instructions. These tasks shall be performed by personnel who have developed competence through training and experience. 1998 NFPA 25, 1-4.2

Requires sprinkler systems to be continuously maintained in proper operating condition and an inspection every quarter of a calendar year. 1998 NFPA 25, 2-2 and 2000 NFPA 101, 4.6.12.1

Based on observation and interview, this facility did not provide unobstructed corridors that provide a clear path of egress. This deficient practice can limit and/or delay evacuation in the event of an emergency. This facility census was 6 patients.

Findings are:
Observation on 3-14-16 at 10:49 am and 11:52 am revealed:
1. Tables and chairs obstructed the Dining Room exit.
2. Two wheelchairs were stored in the ED corridor with no patients in the area.

During an interview 3-14-16 at 10:49 am and 11:52 am, Maintenance A confirmed the findings

NFPA Standard:
Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. 2000 NFPA 101, 7.1.10.1

Based on observation and interview, the facility failed to ensure empty and full oxygen tanks were adequately separated to prevent confusion when choosing tanks in an emergency. The facility census was 6 patients.

Findings are:
Observation on 3-14-16 at 11:03 am revealed, the Oxygen Storage room contained empty oxygen cylinders and full cylinders and the " K " sized oxygen cylinders were not physically separated.

During an interview on 3-14-16 at 11:03 am, Maintenance Staff A confirmed the lack of separation.

NFPA Standard:
If stored within the same enclosure, empty cylinders shall be segregated from full cylinders. Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed hurriedly. 1999 NFPA 99, 4.3.5.2.2

Based on documentation, observation and interview, the facility failed to have the Level 1 emergency generator installed in accordance with NFPA 110, 1999 edition failed to provide a manual stop station outside the area of the generator. This deficient practice had the potential to affect all occupants of the facility. The facility census was 6 patients.

Findings are:
Observation on 3-14-16 at 10:32 am revealed, the facility failed to provide a remote manual shutdown for the generator.

During an interview on 3-14-16 at 10:32 am, Maintenance A confirmed the facility failed to provide a manual shutdown and stated the generator was installed in 2003.

NFPA Standard:
All Level 1 and Level 2 installations shall have a remote manual stop station of a type similar to a break-glass station located outside the room housing the prime mover, where so installed, or located elsewhere on the premises where the prime mover is located outside the building.
For Level 1 and Level 2 systems located outdoors, the manual shutdown should be located external to the weatherproof enclosure and should be appropriately identified.1999 NFPA 110, 3-5.5.6*

Based on observation, interview and documentation review, the facility failed to maintain the Type I essential electrical system of the facility by having loads intermixed between the Life Safety Branch, the Critical Branch, and the Equipment System. This deficient practice had the potential to affect all occupants of the facility by affecting the egress lighting and emergency systems of the facility. The facility census is 6 patients.

Findings are:
Observations on 3-14-16 between 10:00 am and 1:30 pm revealed:
1. Electrical panel boxes throughout the facility have intermixed systems within the branches.

During an interview on 3-14-16 between 10:00 am and 1:30 pm, Maintenance A confirmed the findings.

NFPA Standard:
NFPA 70, 1999ed.
517.30 Essential Electrical Systems for Hospitals.
(A) Applicability. The requirements of Part III, 517.30 through 517.35, shall apply to hospitals where an essential electrical system is required.
(B) General.
(1) Separate Systems. Essential electrical systems for hospitals shall be comprised of two separate systems capable of supplying a limited amount of lighting and power service, which is considered essential for life safety and effective hospital operation during the time the normal electrical service is interrupted for any reason. These two systems shall be the emergency system and the equipment system.
(2) Emergency Systems. The emergency system shall be limited to circuits essential to life safety and critical patient care. These are designated the life safety branch and the critical branch.
(3) Equipment System. The equipment system shall supply major electrical equipment necessary for patient care and basic hospital operation.
(4) Transfer Switches. The number of transfer switches to be used shall be based on reliability, design, and load considerations. Each branch of the emergency system and each equipment system shall have one or more transfer switches. One transfer switch shall be permitted to serve one or more branches or systems in a facility with a maximum demand on the essential electrical system of 150 kVA.
(5) Other Loads. Loads served by the generating equipment not specifically named in Article 517 shall be served by their own transfer switches such that these loads:
(1) Shall not be transferred if the transfer will overload the generating equipment.
(2) Shall be automatically shed upon generating equipment overloading.
(6) Contiguous Facilities. Hospital power sources and alternate power sources shall be permitted to serve the essential electrical systems of contiguous or same site facilities. [NFPA 99, 3.4.2.2.1, 12.3.3.2]
(C) Wiring Requirements.
(1) Separation from Other Circuits. The life safety branch and critical branch of the emergency system shall be kept entirely independent of all other wiring and equipment and shall not enter the same raceways, boxes, or cabinets with each other or other wiring.
Wiring of the life safety branch and the critical branch shall be permitted to occupy the same raceways, boxes, or cabinets of other circuits not part of the branch where such wiring is as follows:
(1) In transfer equipment enclosures, or
(2) In exit or emergency luminaires (lighting fixtures) supplied from two sources, or
(3) In a common junction box attached to exit or emergency luminaires (lighting fixtures) supplied from two sources, or
(4) For two or more emergency circuits supplied from the same branch
The wiring of the equipment system shall be permitted to occupy the same raceways, boxes, or cabinets of other circuits that are not part of the emergency system.
(2) Isolated Power Systems. Where isolated power systems are installed in any of the areas in 517.33(A)(1) and (A)(2), each system shall be supplied by an individual circuit serving no other load.
(3) Mechanical Protection of the Emergency System. The wiring of the emergency system of a hospital shall be mechanically protected by installation in nonflexible metal raceways, or shall be wired with Type MI cable.
Exception No. 1: Flexible power cords of appliances, or other utilization equipment, connected to the emergency system shall not be required to be enclosed in raceways.
Exception No. 2: Secondary circuits of transformer-powered communications or signaling systems shall not be required to be enclosed in raceways unless otherwise specified by Chapters 7 or 8.
Exception No. 3: Schedule 80 rigid nonmetallic conduit shall be permitted if the branch circuits do not serve patient care areas and it is not prohibited elsewhere in this Code.
Exception No. 4: Where encased in not less than 50 mm (2 in.) of concrete, Schedule 40 rigid nonmetallic conduit or electrical nonmetallic tubing shall be permitted if the branch circuits do not serve patient care areas.
Exception No. 5: Flexible metal raceways and cable assemblies shall be permitted to be used in listed prefabricated medical headwalls, listed office furnishings, or where necessary for flexible connection to equipment.
(D) Capacity of Systems. The essential electrical system shall have adequate capacity to meet the demand for the operation of all functions and equipment to be served by each system and branch.
Feeders shall be sized in accordance with Articles 215 and 220. The generator set(s) shall have sufficient capacity and proper rating to meet the demand produced by the load of the essential electrical system(s) at any given time.
Demand calculations for sizing of the generator set(s) shall be based on the following:
(1) Prudent demand factors and historical data, or
(2) Connected load, or
(3) Feeder calculation procedures described in Article 220, or
(4) Any combination of the above
The sizing requirements in 700.5 and 701.6 shall not apply to hospital generator set(s).
(E) Receptacle Identification. The cover plates for the electrical receptacles or the electrical receptacles themselves supplied from the emergency system shall have a distinctive color or marking so as to be readily identifiable. [NFPA 99, 3.4.2.2.4(b)2]
517.31 Emergency System.
Those functions of patient care depending on lighting or appliances that are connected to the emergency system shall be divided into two mandatory branches: the life safety branch and the critical branch, described in 517.32 and 517.33. The branches of the emergency system shall be installed and connected to the alternate power source so that all functions specified herein for the emergency system shall be automatically restored to operation within 10 seconds after interruption of the normal source. [NFPA 99, 3.4.2.2.2(a), 3.5.2.2.2]
517.32 Life Safety Branch.
No function other than those listed in 517.32(A) through (G) shall be connected to the life safety branch. The life safety branch of the emergency system shall supply power for the following lighting, receptacles, and equipment.
(A) Illumination of Means of Egress. Illumination of means of egress, such as lighting required for corridors, passageways, stairways, and landings at exit doors, and all necessary ways of approach to exits. Switching arrangements to transfer patient corridor lighting in hospitals from general illumination circuits to night illumination circuits shall be permitted, provided only one of two circuits can be selected and both circuits cannot be extinguished at the same time.
(B) Exit Signs. Exit signs and exit directional signs.
(C) Alarm and Alerting Systems. Alarm and alerting systems including the following:
(1) Fire alarms
(2) Alarms required for systems used for the piping of nonflammable medical gases
(D) Communications Systems. Hospital communications systems, where used for issuing instructions during emergency conditions.
(E) Generator Set Location. Task illumination battery charger for emergency battery-powered lighting unit(s) and selected receptacles at the generator set location.
(F) Elevators. Elevator cab lighting, control, communications, and signal systems.
(G) Automatic Doors. Automatically operated doors used for building egress. [NFPA 99, 3.4.2.2.2(b)]
517.33 Critical Branch.
(A) Task Illumination and Selected Receptacles. The critical branch of the emergency system shall supply power for task illumination, fixed equipment, selected receptacles, and special power circuits serving the following areas and functions related to patient care:
(1) Critical care areas that utilize anesthetizing gases - task illumination, selected receptacles, and fixed equipment
(2) The isolated power systems in special environments
(3) Patient care areas - task illumination and selected receptacles in the following:
a. Infant nurseries
b. Medication preparation areas
c. Pharmacy dispensing areas
d. Selected acute nursing areas
e. Psychiatric bed areas (omit receptacles)
f. Ward treatment rooms
g. Nurses ' stations (unless adequately lighted by corridor luminaires)
(4) Additional specialized patient care task illumination and receptacles, where needed
(5) Nurse call systems
(6) Blood, bone, and tissue banks
(7) Telephone equipment rooms and closets
(8) Task illumination, selected receptacles, and selected power circuits for the following:
a. General care beds (at least one duplex receptacle per patient bedroom)
b. Angiographic labs
c. Cardiac catheterization labs
d. Coronary care units
e. Hemodialysis rooms or areas
f. Emergency room treatment areas (selected)
g. Human physiology labs
h. Intensive care units
i. Postoperative recovery rooms (selected)
(9) Additional task illumination, receptacles, and selected power circuits needed for effective hospital operation. Single-phase fractional horsepower motors shall be permitted to be connected to the critical branch. [NFPA 99, 3.4.2.2.2(c)]
(B) Subdivision of the Critical Branch. It shall be permitted to subdivide the critical branch into two or more branches.
517.34 Equipment System Connection to Alternate Power Source.
The equipment system shall be installed and connected to the alternate power source such that the equipment described in 517.34(A) is automatically restored to operation at appropriate time-lag intervals following the energizing of the emergency system. Its arrangement shall also provide for the subsequent connection of equipment described in 517.34(B). [NFPA 99, 3.4.2.2.3(b)]
Exception: For essential electrical systems under 150 kVA, deletion of the time-lag intervals feature for delayed automatic connection to the equipment system shall be permitted.
(A) Equipment for Delayed Automatic Connection. The following equipment shall be arranged for delayed automatic connection to the alternate power source.
(1) Central suction systems serving medical and surgical functions, including controls. Such suction systems shall be permitted on the critical branch.
(2) Sump pumps and other equipment required to operate for the safety of major apparatus, including associated control systems and alarms.
(3) Compressed air systems serving medical and surgical functions, including controls. Such air systems shall be permitted on the critical branch.
(4) Smoke control and stair pressurization systems, or both.
(5) Kitchen hood supply or exhaust systems, or both, if required to operate during a fire in or under the hood. [NFPA 99, 3.4.2.2.3(d)]
Exception: Sequential delayed automatic connection to the alternate power source to prevent overloading the generator shall be permitted where engineering studies indicate it is necessary.
(B) Equipment for Delayed Automatic or Manual Connection. The following equipment shall be arranged for either delayed automatic or manual connection to the alternate power source:
(1) Heating equipment to provide heating for operating, delivery, labor, recovery, intensive care, coronary care, nurseries, infection/isolation rooms, emergency treatment spaces, and general patient rooms and pressure maintenance (jockey or make-up) pump(s) for water-based fire protection systems.
Exception: Heating of general patient rooms and infection/isolation rooms during disruption of the normal source shall not be required under any of the following conditions:
(a) The outside design temperature is higher than -6.7°C (20°F).
(b) The outside design temperature is lower than -6.7°C (20°F), and where a selected room(s) is provided for the needs of all confined patients, only such room(s) need be heated.
(c) The facility is served by a dual source of normal power.
(2) An elevator(s) selected to provide service to patient, surgical, obstetrical, and ground floors during interruption of normal power. In instances where interruption of normal power would result in other elevators stopping between floors, throw-over facilities shall be provided to allow the temporary operation of any elevator for the release of patients or other persons who may be confined between floors.
(3) Supply, return, and exhaust ventilating systems for airborne infectious/isolation rooms, protective environment rooms, exhaust fans for laboratory fume hoods, nuclear medicine areas where radioactive material is used, ethylene oxide evacuation and anesthesia evacuation. Where delayed automatic connection is not appropriate, such ventilation systems shall be permitted to be placed on the critical branch. [NFPA 99, 3.4.2.2.3(e)(4)]
(4) Hyperbaric facilities.
(5) Hypobaric facilities.
(6) Automatically operated doors.
(7) Minimal electrically heated autoclaving equipment shall be permitted to be arranged for either automatic or manual connection to the alternate source.
(8) Controls for equipment listed in 517.34.
(9) Other selected equipment shall be permitted to be served by the equipment system. [NFPA 99, 3.4.2.2.3(e)]

Based on observation, interview and documentation review, the facility failed to provide a covers for open breakers in an electrical panel and failed to provide a directory for a panel box. The facility failed to conduct retention testing of newly installed electrical receptacles. The facility census was 6 patients.

Findings are:
Observations on 3-14-16 at 10:50 am and 12:18 pm revealed:
1. Numerous open breakers in the panel box ITB in the Server Room.
2. Electrical Panel Q in the VFD/Mechanical Room failed to provide a panel directory.

During an interview on 3-14-16 at 10:50 am and 12:18 pm, Maintenance A confirmed the findings.

Documentation review on 3-14-16 at 2:46 pm revealed, the facility failed to conduct retention testing every six months to newly installed outlets in critical care areas and wet areas.

During an interview on 3-14-16 at 2:46 pm, Maintenance A confirmed the lack of testing.

NFPA Standard:
Panelboards shall be mounted in cabinets, cutout boxes, or enclosures designed for the purpose and shall be dead front. 1999 NFPA 70, 384-18

All panelboards shall have a rating not less than the minimum feeder capacity required for the load computed in accordance with Article 220. Panelboards shall be durably marked by the manufacturer with the voltage and the current rating and the number of phases for which they are designed and with the manufacturer ' s name or trademark in such a manner so as to be visible after installation, without disturbing the interior parts or wiring. All panelboard circuits and circuit modifications shall be legibly identified as to purpose or use on a circuit directory located on the face or inside of the panel doors. 1999 NFPA 70, 384-13

Based on record review and interview, the facility failed to provide a policy regarding the procedures to be taken in the event that the sprinkler system is out of service for more than 4 hours in a 24-hour period. The lack of procedures would affect the actions taken by staff in the event of an emergency. This deficient practice affected all occupants in all smoke compartments. The facility census was 6 patients.

Findings are:
Documentation review on 3-14-16 at 2:47 pm revealed:
1. The facility's policy failed to include notification of the local fire department immediately.
2. The facility's policy failed to include that the individual conducting the fire watch shall have no other assigned duties.
3. The facility's policy failed to include that the individual conducting the fire watch shall have access to all portions of the building.
4. The facility's policy failed to include that the individual conducting the fire watch shall be trained to recognize fire hazards and know the procedures for occupant and fire department notification and occupant evacuation.

During an interview on 3-14-16 at 2:47 pm, Maintenance A confirmed the lack of information on the policy.

NFPA Standard:
When a required sprinkler system is out of service for more than 4 hours in a 24-hour period, the AHJ shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties until the fire alarm system has been returned to service. A fire watch should consist of trained personnel who continuously patrol the effected area, with ready access to fire extinguishers and the ability to promptly notify the fire department. During the patrol of the area, the person should look for fire, and that other fire protection features of the building such as egress routes and alarm systems are available and functioning properly. 2000 NFPA 101, 9.6.1.8

Based on record review and interview, the facility failed to provide a policy regarding the procedures to be taken in the event that the fire alarm system is out of service for more than 4 hours in a 24-hour period. The lack of procedures would affect the actions taken by staff in the event of an emergency. This deficient practice affects all occupants in all smoke compartments. The facility census was 6 patients.

Findings are:
Documentation review on 3-14-16 at 2:47 pm revealed:
1. The facility's policy failed to include notification of the local fire department immediately.
2. The facility's policy failed to include that the individual conducting the fire watch shall have no other assigned duties.
3. The facility's policy failed to include that the individual conducting the fire watch shall have access to all portions of the building.
4. The facility's policy failed to include that the individual conducting the fire watch shall be trained to recognize fire hazards and know the procedures for occupant and fire department notification and occupant evacuation.

During an interview on 3-14-16 at 2:47 pm, Maintenance A confirmed the lack of information on the policy.

NFPA Standard:
When a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the AHJ shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties until the fire alarm system has been returned to service. A fire watch should consist of trained personnel who continuously patrol the effected area, with ready access to fire extinguishers and the ability to promptly notify the fire department. During the patrol of the area, the person should look for fire, and that other fire protection features of the building such as egress routes and alarm systems are available and functioning properly. 2000 NFPA 101, 9.6.1.8