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Based on observations and interview, this facility is not providing a firewall with a two-hour fire rating for the common wall between the facility and a non-conforming assisted living facility in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition, 8.2.1.3 and 19.1.3.5, by ensuring holes and gaps around penetrations are sealed with fire rated materials. This deficient practice affects all occupants in buildings on both sides of the firewall. This facility had a capacity of 25 and a census of 10 patients at the time of the survey.

Findings include:

Observations and interview on 03/08/2019 at 11:45 a.m., revealed the two-hour firewall located between the Hancock County Memorial Hospital and the Britt Clinic had penetrations above the lay-in ceiling tile south of the Clinic connector door. This wall contained an approximately four-inch by 1/2-inch gap along the exterior of a fire-rated firestop cable pathway. This wall also contained an approximately 3/4-inch hole for a fire alarm wire penetrating the wall. According to the facility layout, this was a required firewall to separate the occupancies.

The Director of Facilities confirmed these observations at the time of the survey.

Based on record review and testing, the facility failed to maintain the emergency egress lighting system and document periodic testing of emergency lighting equipment in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition, 19.2.9.1, 7.9.2.1, and 7.9.3, by not ensuring emergency illumination be provided for a minimum of 1 1/2 hours in the event of failure of normal lighting. This deficient practice affects light fixtures in the Wesley, Kanawha, and Garner Clinics.

Findings include:

1. Record review on 03/07/2019 at the times listed below, revealed three of the Clinic facilities were unable to provide documentation of annual functional testing (90-minute duration) for any battery backup emergency light fixture throughout the building. They included: the Wesley Clinic at 12:40 p.m., the Kanawha Clinic at 1:27 p.m., and the Garner Clinic at 2:33 p.m.

2. Testing and observations on 03/07/2019 at the times listed below, revealed the battery backup emergency lights located in the following locations in two of the Clinics failed to illuminate when tested:

(a) At 12:46 p.m., the emergency light in Exam Room 2 at the Wesley Clinic;

(b) At 12:50 p.m., the emergency light in the Employee Restroom at the Wesley Clinic;

(c) At 2:42 p.m., the emergency light in the corridor outside of Exam Room 121 at the Garner Clinic; and

(d) At 2:45 p.m., the emergency light in the corridor outside of the Resource Nurse Room at the Garner Clinic.

The Clinical Director and Maintenance Staff A verified these observations at the times of discovery.

Based on observation and interview, the facility failed to provide separation of hazardous areas from other compartments in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition, 19.3.2.1.3. This deficient practice could affect staff within the Kitchen. The facility had a capacity of 25 and a census of 10 patients at the time of the survey.

Findings include:

Observation on 03/08/2019 at 12:15 p.m., revealed the Storage Pantry in the Kitchen exceeded 50 square feet in size and did not contain a self-closure device on the door. This room contained storage of canned as well as dry goods. Interview of the Director of Facilities revealed the door previously had a closure on it but it had likely been removed to allow easier movement between the room and the rest of the Kitchen.

The Director of Facilities confirmed this observation at the time of the survey process.

Based on observation and interview, the facility failed to ensure the fire alarm system is installed and maintained in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition, 9.6.1.3 and NFPA Standard 72, National Fire Alarm and Signaling Code, 2010 edition, 10.5.5.3 by ensuring the fire alarm dedicated branch circuit(s) be mechanically protected. This deficient practice affects all occupants of the building. This facility had a capacity of 25 and a census of 10 patients at the time of the survey.

Findings include:

Observation and interview on 03/08/2019 at 11:36 a.m., revealed the fire alarm breaker, located in electrical panel N1D circuit #23 in the Maintenance Office, was not secured with any type of mechanical protection.

The Director of Facilities verified this observation at the time of discovery.

Based on record review and interview, the facility failed to inspect, test, and maintain the fire alarm system within the facility or provide records of such that include all required information in accordance with the National Fire Protection Association (NFPA) Standard 72, National Fire Alarm and Signaling Code, 2010 edition, 14.6.2.4, 14.4.6, and Chapter 14 respectively. These deficient practices could affect all occupants within the facilities. The facility had a capacity of 25 and a census of 10 patients at the time of the survey.

Findings include:

1. Record review on 03/07/2019 at 11:39 a.m. of the facility's fire alarm inspection records, revealed the semi-annual inspection reports provided to the facility by Johnson Controls on 08/01/2018 and 02/04/2019 failed to provide device test results sheets that individually listed all alarm notification appliances (to wit: audible/visual devices), devices connected to the fire alarm system (to wit: door holders), and interface relays (to wit: HVAC relays and elevator recall) and did not include the device type, address, location, or test results for those devices. Interview of the Director of Facilities revealed the facility was not aware all of those components needed to be listed individually on the fire alarm reports.

2. Record review on 03/07/2019 at 1:37 p.m., revealed the facility could not provide documentation of monthly testing of single- and/or multiple-station smoke alarms installed in the Kanawha Clinic. Interview of Maintenance Staff A revealed it was typically part of the monthly maintenance procedure, but a documented testing log could not be located.

3. Record review on 03/08/2019 at 1:18 p.m., revealed the Garner Clinic had a fully automatic fire alarm system installed at the facility. The facility could not provide documentation of any semi-annual inspections and testing for the fire alarm system.

The Director of Facilities verified the documentation during the survey process.

Based on record review and interview, the facility did not assure that an adequate, complete policy is in place regarding the procedures to be taken in the event that the fire alarm system is out of service for more than four hours in any 24-hour period. Lack of complete written policies and procedures could result in staff failing to implement interim safety measures in the event of an emergency. This deficient practice affects all occupants of the building, including patients, staff, and visitors. The facility had a capacity of 25 and a census of 10 patients at the time of the survey.

Findings include:

Record review and interview on 03/07/2019 at 11:10 a.m. of the fire watch procedures for a fire alarm system outage in the facility's policy, revealed the policy did not state that the employee(s) assigned to the fire watch shall conduct "continuous" rounds of the facility. The policy stated rounds of less than or equal to 30 minutes would be conducted, but did not elaborate that those assigned would be on continuous watch.

The Director of Facilities verified the documentation at the time of the survey process.

Based on record review and interview, the facility failed to conduct the required biennial sensitivity testing of smoke detectors in accordance with National Fire Protection Association (NFPA) Standard 72, National Fire Alarm and Signaling Code, 2010 edition, 14.4.5.3.2. This deficient practice affects all occupants as this lack of testing would not ensure the sensitivity of the detectors was within the manufacturer's specification.

Findings include:

Record review and interview on 03/08/2019 at 1:18 p.m., revealed the Garner Clinic had a fully automatic fire alarm system installed in the facility. The facility was unable to provide documentation of required biennial sensitivity testing of smoke detectors in the building.

The Director of Facilities verified the documentation during the survey process.

Based on observations and interview, the facility did not ensure the building was protected throughout by an automatic sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition, 19.3.5.3 and NFPA 13, Standard for the Installation of Sprinkler Systems, 2010 edition, 8.1.1 and 8.5.5.3.1, by ensuring the facility is protected by sprinklers installed throughout the premises. This deficient practice has the potential of affecting the operation of the sprinkler system in the event of an emergency and could affect all occupants of the building. The facility had a capacity of 25 and a census of 10 patients at the time of the survey.

Findings include:

1. Observation on 03/07/2019 at 2:05 p.m., revealed the Sample Med Closet in the Britt Clinic did not contain a sprinkler head. The Clinical Director confirmed this observation at the time of discovery.

2. Observation on 03/07/2019 at 2:12 p.m., revealed the Supply Closet in the Orthopaedic Room in the Britt Clinic did not contain a sprinkler head. The Clinical Director confirmed this observation at the time of discovery.

Interview of the Director of Facilities revealed he thought the Britt Clinic may have undergone a renovation which added those closets and the sprinkler heads may not have been located in those newly enclosed spaces.

3. Observation on 03/08/2019 at 2:05 p.m., revealed the Materials Receiving Dock contained a full-sized overhead garage door to the outside. This door constitutes a fixed obstruction exceeding four feet wide when in the open position and did not contain a sprinkler head installed under the obstruction as required.

The Director of Facilities confirmed this observation at the time of discovery.

Based on record review, observation, and interview, the facility failed to inspect and maintain a complete automatic sprinkler system within the facility in accordance with the National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition, 9.7.5 and NFPA Standard 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 edition, 14.2, by not ensuring an internal inspection of the piping was conducted within the last five years. This deficient practice could affect all smoke compartments and occupants of the facility. The facility had a capacity of 25 and a census of 10 patients at the time of the survey.

Findings include:

1. Record review on 03/08/2019 at 9:51 a.m., of the facility's sprinkler system inspection reports, revealed the facility was unable to provide documentation of an internal obstruction assessment of piping and branch line conditions. Interview of the Director of Facilities revealed he contacted the sprinkler contractor, who stated they had not conducted one in the previous five years.

2. Observation on 03/08/2019 at 12:56 p.m., revealed the sprinkler head in the ceiling of the 2nd Floor Restroom south of the Nurses Station in Patient North was missing the escutcheon ring. This missing escutcheon ring could cause a delay or failure in the operation of the sprinkler head.

The Director of Facilities confirmed these findings at the time of the survey.

Based on record review, the facility did not assure that an adequate, complete policy is in place regarding the procedures to be taken in the event that the sprinkler system is out of service for more than 10 hours in any 24-hour period. Lack of complete written policies and procedures could result in staff failing to implement interim safety measures in the event of an emergency. This deficient practice affects all occupants of the building. The facility had a capacity of 25 and a census of 10 patients at the time of the survey.

Findings include:

Record review on 03/07/2019 at 11:12 a.m. of the fire watch procedures for a sprinkler system outage in the facility's outage policy, revealed the policy was incomplete in that it did not address and was missing the following information:

1. Assigning an impairment coordinator.

2. Tagging an impaired system that has been removed from service at each fire department connection and the system control valve indicating which system, or part thereof, has been removed from service.

3. Identifying equipment shall include, but shall not be limited to, the following:
(1) Sprinkler systems
(2) Standpipe systems
(3) Fire hose systems
(4) Underground fire service mains
(5) Fire pumps
(6) Water storage tanks
(7) Water spray fixed systems
(8) Foam-water systems
(9) Fire service control valves

4. All preplanned impairments shall be authorized by the impairment coordinator, who shall verify the following procedures have been implemented:
(1) The extent and expected duration of the impairment have been determined.
(2) The areas or buildings involved have been inspected and the increased risks determined.
(3) Recommendations have been submitted to management or the property owner or designated representative.
(4) The insurance carrier has been notified and its phone number.
(5) The supervisors in the areas to be affected have been notified.
(6) A tag impairment system has been implemented.
(7) All necessary tools and materials have been assembled on the impairment site.

5. Emergency impairments shall include, but are not limited to, system leakage, interruption of water supply, frozen or ruptured piping, and equipment failure.

6. When all impaired equipment is restored to normal working order, the impairment coordinator shall verify that the following procedures have been implemented:
(1) Any necessary inspections and tests have been conducted to verify that affected systems are operational. The appropriate chapter of this standard shall be consulted for guidance on the type of inspection and test required.
(2) Supervisors have been advised that protection is restored.
(3) The fire department has been advised that protection is restored.
(4) The insurance carrier, alarm company, State Fire Marshal's Office, and Iowa DIA have been advised that protection is restored.
(5) The impairment tag has been removed.

7. The policy stated fire watch rounds would be conducted less than or equal to every 30 minutes, but did not state that the rounds would be conducted continously.

The Director of Facilities verified the documentation at the time of the survey process.

Based on observations and interview, the facility failed to install portable fire extinguishers in accordance with National Fire Protection Association (NFPA) Standard 10, Standard for Portable Fire Extinguishers, 2010 edition, 6.1.3.8.1 by ensuring the top of the fire extinguisher is not more than five feet above the floor. This deficient practice affects two fire extinguishers in the facility. This facility had a capacity of 25 and a census of 10 patients at the time of the survey.

Findings include:

1. Observation on 03/08/2019 at 12:13 p.m., revealed the top of the fire extinguisher installed in a recessed wall cabinet in the Main Hallway was approximately 70 inches from the floor. Interview of the Director of Facilities revealed the cabinet was likely installed original to the building.

2. Observation on 03/08/2019 at 12:17 p.m., revealed the top of the fire extinguisher by the hand washing sink in the Kitchen was mounted approximately 65 inches from the floor.

The Director of Facilities verified these observations during the survey process.

Based on observation and testing, the facility did not ensure fire rated smoke barriers doors were maintained and positive latching in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, 8.3.3.1 and 4.6.12.3 and NFPA 80, Standard for Fire Doors and Other Opening Protectives, 2010 edition. This deficient practice affected two smoke zones in the Radiology Department. This facility had a capacity of 25 and a census of 10 patients at the time of the survey.

Findings include:

Observation and testing on 03/08/2019 at 11:55 a.m., revealed the east leaf of the double smoke barrier doors in the Radiology Department failed to positively latch within the door frame when tested. While smoke barrier doors are not required to contain latching hardware, because the door assembly is fire-rated and does contain positive latching hardware, the doors must be maintained as fire doors and be able to latch.

The Director of Facilities confirmed this finding at the time of discovery.

Based on observation and testing, it was determined the facility failed to maintain the building's electrical wiring system in accordance with National Fire Protection Association (NFPA) Standard 70, National Electrical Code, 2011 edition, 210.8, by not providing ground-fault circuit-interrupter protection for staff. This deficient practice could place all occupants in this room at risk in the event of a fire.

Findings include:

Observation on 03/07/2019 at 1:33 p.m., revealed the Med Supply Room at the Kanawha Clinic contained an electrical outlet on the wall to the right of the sink that did not have ground-fault circuit-interrupter protection. The outlet did not shut off the power when tested.

The Clinical Director verified this observation during the survey process.

Based on record review and interview, the facility failed to provide a fire safety evacuation and relocation plan and procedure for the evacuation of the building's smoke zones directly affected by fire in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition, 19.7.1 and 19.7.2. This deficient practice affects all smoke zones, patients, staff, and visitors. The facility had a capacity of 25 and a census of 10 patients at the time of the survey.

Findings include:

Record review and interview on 03/08/2019 between 9:35 a.m. and 2:15 p.m., revealed the facility did not have a fire safety plan. The facility provided documentation of an evacuation plan that addressed partial evacuation, horizontal evacuation, vertical evacuation, complete patient evacuation, and patient removal, but the plan did not specifically address these procedures in the context of a fire response nor did it address these basic responses required of staff:

(1) Removal of all occupants directly involved with the fire emergency
(2) Transmission of an appropriate fire alarm signal to warn other building occupants and summon staff
(3) Confinement of the effects of the fire by closing doors to isolate the fire area
(4) Relocation of patients as detailed in the health care occupancy's fire safety plan.

Furthermore, the facility did not provide a policy including all elements as required of the following: use of alarms, transmission of alarms to the fire department, emergency phone call to the fire department, response to alarms, isolation of fire, evacuation of the immediate area, evacuation of a smoke compartment, and extinguishment of the fire.

The Director of Facilities confirmed the documentation during the survey process.

Based on record review and interview, the facility failed to conduct fire drills under varied conditions in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition, 19.7.1.6, for four of four quarters reviewed. This has the potential of affecting staff preparation and experience in providing for the protection of all patients in the event of a fire. The facility had a capacity of 25 and a census of 10 patients at the time of survey.

Findings include:

Record review and interview on 03/08/2019 at 10:05 a.m. of the facility's fire drill documentation, revealed first, second, and third shift drills were conducted at approximately the same time of day. Two first shift drills were conducted between 8:50 a.m. and 9:30 a.m.: on 08/05/2018 at 8:50 a.m. and 01/18/2019 at 9:30 a.m. Two second shift drills were conducted between 6:00 p.m. and 6:30 p.m.: on 06/19/2018 at 6:30 p.m. and 12/21/2018 at 6:05 p.m. Three third shift drills were conducted between 1:25 a.m. and 2:00 a.m.: on 05/25/2018 at 1:25 a.m., 09/25/2018 at 1:25 a.m., and 03/05/2019 at 2:00 a.m.

The Director of Facilities verified the documentation during the survey process.

Based on record review and interview, this facility is not providing proper documentation of inspection and testing of fire and/or smoke door assemblies in openings required to have a fire protection rating in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition, 8.3.3.1 and NFPA 80, Standard for Fire Doors and Other Opening Protectives, 5.2. This facility had a capacity of 25 and a census of 10 patients at the time of the survey.

Findings include:

Record review and interview on 03/08/2019 at 10:14 a.m., revealed the facility could not provide full documentation of annual inspection and testing of fire and/or smoke door assemblies within the facility. Documentation was provided for inspections of doors, but the documentation contained five points inspected and/or tested and did not contain verification of all 12 minimum items as required by code.

The Director of Facilities acknowledged this finding at the time of the survey.


NFPA 80 Standard for Fire Doors and Other Opening Protectives, 2010 edition, 5.2* Inspections.

5.2.1* Fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for inspection by the AHJ.

5.2.3 Functional Testing.

5.2.3.1 Functional testing of fire door and window assemblies shall be performed by individuals with knowledge and understanding of the operating components of the type of door being subject to testing.

5.2.3.2 Before testing, a visual inspection shall be performed to identify any damaged or missing parts that can create a hazard during testing or affect operation or resetting.

5.2.4.1 Fire door assemblies shall be visually inspected from both sides to assess the overall condition of door assembly.

5.2.4.2 As a minimum, the following items shall be verified:

(1) No open holes or breaks exist in surfaces of either the door or frame.
(2) Glazing, vision light frames, and glazing beads are intact and securely fastened in place, if so
equipped.
(3) The door, frame, hinges, hardware, and noncombustible threshold are secured, aligned, and in
working order with no visible signs of damage.
(4) No parts are missing or broken.
(5) Door clearances do not exceed clearances listed in 4.8.4 and 6.3.1.7.
(6) The self-closing device is operational; that is, the active door completely closes when operated from the full open position.
(7) If a coordinator is installed, the inactive leaf closes before the active leaf.
(8) Latching hardware operates and secures the door when it is in the closed position.
(9) Auxiliary hardware items that interfere or prohibit operation are not installed on the door or frame.
(10) No field modifications to the door assembly have been performed that void the label.
(11) Gasketing and edge seals, where required, are inspected to verify their presence and integrity.

5.2.6 Inspection shall include an operational test for automatic-closing doors and windows to verify that the assembly will close under fire conditions.

5.2.9 Hardware shall be examined, and inoperative hardware, parts, or other defects shall be replaced without delay.

5.2.13.1 Door openings and the surrounding areas shall be kept clear of anything that could obstruct or interfere with the free operation of the door.

Based on record review and interview, the facility was unable to provide a documented risk assessment procedure designating the category of building systems in the health care facility as required by National Fire Protection Association (NFPA) Standard 99, Health Care Facilities Code, 2012 edition, Chapter 4. This deficient practice has the potential to affect all patients in the facility. The facility had a capacity of 25 and a census of 10 patients at the time of the survey.

Findings include:

Record review on 03/08/2019 at 11:15 a.m., revealed documentation could not be provided that qualified facility personnel followed a defined risk assessment procedure to determine the category of building systems. The results of the assessment procedure should be documented and records retained for review. Interview of the Director of Facilities revealed the facility's building systems are likely designed to meet system Category 1, but to his knowledge no documentation of a risk assessment was available for review.

The Director of Facilities acknowledged this finding during the survey.

Based on record review and interview, the facility was unable to provide a complete documented periodic maintenance program for the medical gas and vacuum systems and their subcomponents as appropriate to the equipment installed as required by National Fire Protection Association (NFPA) Standard 99, Health Care Facilities Code, 2012 edition, 5.1.14.2.2. This deficient practice has the potential to affect all patients in the facility. The facility had a capacity of 25 and a census of 10 patients at the time of the survey.

Findings include:

Record review and interview on 03/08/2019 at 11:25 a.m., revealed the facility could not provide documentation of a maintenance program for the facility's medical gas and vacuum systems that included all of the following:

(1) An inventory of medical gas and vacuum systems including at least all source subsystems, control valves, alarms, manufactured assemblies containing patient gases, and outlets.

(2) Scheduled inspections and maintenance for equipment and procedures established through the risk assessment of the facility and developed with consideration of the original equipment manufacturer recommendations.

(3) Documentation that persons maintaining the systems are qualified to perform the operations.

The Director of Facilities acknowledged these findings during the survey.

Based on record review and interview, the facility was unable to provide complete documentation of inspection and testing operations for the medical gas and vacuum systems and their subcomponents as appropriate to the equipment installed as required by National Fire Protection Association (NFPA) Standard 99, Health Care Facilities Code, 2012 edition, 5.1.14.2.3. This deficient practice has the potential to affect all patients in the facility. The facility had a capacity of 25 and a census of 10 patients at the time of the survey.

Findings include:

Record review on 03/08/2019 at 11:27 a.m., revealed the facility could not provide documentation of inspection or testing of all applicable elements required by the code as part of the facility's medical gas and vacuum systems maintenance plan. Interview of the Director of Facilities revealed facility staff conducted regular testing of the medical gas and vacuum systems alarms and an annual inspection of the central supply system bulk tanks by a qualified contractor was last conducted 02/26/2018. Documentation of each was provided.

The Director of Facilities acknowledged these findings during the survey.


NFPA 99, Health Care Facilities Code, 2012 edition, 5.1.14.2.3.1 General. The elements in 5.1.14.2.2.2 through 5.1.15 shall be inspected or tested as part of the maintenance program as follows:

(1)*Medical air source, as follows:
(a) Room temperature
(b) Shaft seal condition
(c) Filter condition
(d) Presence of hydrocarbons
(e) Room ventilation
(f) Water quality, if so equipped
(g) Intake location
(h) Carbon monoxide monitor calibration
(i) Air purity
(j) Dew point
(2)*Medical vacuum source - exhaust location
(3) WAGD source - exhaust location
(4)*Instrument air source - filter condition
(5)*Manifold sources (including systems complying with 5.1.3.5.10, 5.1.3.5.11, 5.1.3.5.12, and 5.1.3.5.13), as follows:
(a) Ventilation
(b) Enclosure labeling
(6) Bulk cryogenic liquid source inspected in accordance with NFPA 55, Compressed Gases and Cryogenic Fluids Code
(7) Final line regulation for all positive pressure systems - delivery pressure
(8)*Valves - labeling
(9)*Alarms and warning systems-lamp and audio operation
(10) Alarms and warning systems, as follows:
(a) Master alarm signal operation
(b) Area alarm signal operation
(c) Local alarm signal operation
(11)*Station outlets/inlets, as follows:
(a) Flow
(b) Labeling
(c) Latching/delatching
(d) Leaks

Based on record review, observations, and interview, the facility failed to maintain complete documentation of the inspections, tests, exercising, and operation of the emergency generator power supplies as required by National Fire Protection Association (NFPA) Standard 110, Standard for Emergency and Standby Power Systems, 2010 edition, 8.3.4; did not ensure the emergency generators for the building were properly equipped with a remote manual stop mechanism in accordance with NFPA Standard 110, 2010 edition, 5.6.5.6; could not provide documentation showing the emergency generator power supplies were exercised as required by NFPA Standard 110, 2010 edition, 8.4.2; and failed to maintain and test essential electrical system (EES) circuitry as required by NFPA Standard 99, Health Care Facilities Code, 2012 edition, 6.4.4.1.2 and 6.4.4.2. These deficient practices affect all smoke compartments of the building and all occupants. The facility had a capacity of 25 and a census of 10 patients at the time of the survey.

Findings include:

1. Record review and interview on 03/07/2019 at 11:55 a.m., revealed the facility failed to maintain proper documentation of monthly load tests for the facility's emergency generators. The facility had not documented the generator meter start and stop times for either of the facility's two generators during any monthly 30-minute load test.

2. Record review and interview on 03/07/2019 at 12:00 p.m., revealed the facility could not provide any documentation for the south emergency generator weekly visual inspection during the fourth week of September 2018.

3. Observations and interview on 03/08/2019 at 1:15 p.m., revealed neither of the facility's two emergency generators were equipped with a remote manual stop mechanism (emergency shut-off) external to the weatherproof enclosure. Both of the emergency stops were located internal to the generators' housings and on the control panels.

NFPA 110, Standard for Emergency and Standby Power Systems,
2010 edition, 5.6.5.6

5.6.5.6* All installations shall have a remote manual stop station
of a type to prevent inadvertent or unintentional operation located
outside the room housing the prime mover, where so installed,
or elsewhere on the premises where the prime mover is
located outside the building.

5.6.5.6.1 The remote manual stop station shall be labeled.

A.5.6.5.6 For systems located outdoors, the manual shutdown
should be located external to the weatherproof enclosure
and should be appropriately identified.

4. Record review on 03/08/2019 at 1:18 p.m. of the monthly 30-minute load tests for the facility's two diesel-powered emergency generators, revealed neither generator appeared to be operating at the necessary 30 percent load for any month and the facility could not provide the minimum operating conditions required to ensure the diesel generators are exercised at not less than 30 percent of the EPS nameplate rating. Each generator was three-phase and had nameplate listed ratings of 500 kW. The documented amperages and voltages for all months resulted in calculated load percentages well below 30%. Additionally, the facility was unable to provide documentation of annual load bank tests conducted in lieu of the monthly requirements. Interview of the Director of Facilities revealed the generators' control screens show the load percentages they are running at, so the facility thought they were in monthly compliance with one of the generators. For the other generator, the Director of Facilities thought a load bank had been conducted on it, but verified with the testing company one had not been conducted within the previous year.

5. Record review and interview on 03/08/2019 at 10:25 a.m., revealed the facility provided documentation of inspection of the components of the essential electrical system (EES) main and feeder circuit breakers, but was unable to provide record of exercising or explain the facility's process included mechanically tripping and resetting the main and feeder circuit breakers.

The Director of Maintenance acknowledged these findings during the survey process.