HospitalInspections.org

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The facility failed to maintain the smoke barriers per code. Findings include:

During the survey, the following are examples of what was observed:

1. Smoke barrier at smoke doors by the Business Office had two unsealed conduit ends

2. Smoke barrier in Business Office had an unsealed penetration just inside the door

3. Smoke barrier I.C.U. Waiting Room had an unsealed conduit end with a black wire

4. Smoke barrier at Admissions had two unsealed conduit ends:
a. One with two red wires
b. One with green, tan and white wires

5. Smoke door to Outpatient Admissions did not close

6. Smoke barrier in Nurse Manager's Officehad one unsealed conduit end with a tan wire

7. E.R. Bay One had two unsealed conduit ends:

a. One with a white wire
b. One with a tan wire

8. Smoke barrier at E.R. deskhad two unsealed conduit ends

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2000 NFPA 101, 8.2.4.4.1 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through smoke partitions shall be protected as follows: (1) The space between the penetrating item and the smoke partition shall meet one of the following conditions: a. It shall be filled with a material that is capable of limiting the transfer of smoke. b. It shall be protected by an approved device that is designed for the specific purpose. (2) Where the penetrating item uses a sleeve to penetrate the smoke partition, the sleeve shall be solidly set in the smoke partition, and the space between the item and the sleeve shall meet one of the following conditions: a. It shall be filled with a material that is capable of limiting the transfer of smoke. b. It shall be protected by an approved device that is designed for the specific purpose. (3) Where designs take transmission of vibrations into consideration, any vibration isolation shall meet one of the following conditions: a. It shall be made on either side of the smoke partitions. b. It shall be made by an approved device that is designed for the specific purpose.
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The facility failed to maintain a hazardous area per code. Findings include:

During the survey, the following is an example of what was observed:

The Supply Room for the O.R. the door to Centril Sterile had a self-closing device on it, but was being held open by a wire

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2000 NFPA 101, 19.3.2.1 Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing.

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The facility failed to maintain the exit access per code. Findings include:

During the survey, the following is an example of what was observed:

The Storage Room between rooms 501 and 502, the corridor door when fully opened projected more than 7" into the corridor.
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2000 NFPA 101, 7.2.1.4.4 During its swing, any door in a means of egress shall leave not less than one-half of the required width of an aisle, corridor, passageway, or landing unobstructed and shall not project more than 7 in. (17.8 cm) into the required width of an aisle, corridor, passageway, or landing, when fully open. Doors shall not open directly onto a stair without a landing. The landing shall have a width not less than the width of the door. (See 7.2.1.3.)
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The facility failed to maintain the fire barrier per code. Findings include:

During the survey, the following is an example of what was observed:

The fire barrier at Administration had two unsealed conduit ends.

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2000 NFPA 101, 8.2.3.2.4.2 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through fire barriers shall be protected as follows: (1) The space between the penetrating item and the fire barrier shall meet one of the following conditions: a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier. b. It shall be protected by an approved device that is designed for the specific purpose. (2) Where the penetrating item uses a sleeve to penetrate the fire barrier, the sleeve shall be solidly set in the fire barrier, and the space between the item and the sleeve shall meet one of the following conditions: a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier. b. It shall be protected by an approved device that is designed for the specific purpose. (3) * Insulation and coverings for pipes and ducts shall not pass through the fire barrier unless one of the following conditions is met: a. The material shall be capable of maintaining the fire resistance of the fire barrier. b. The material shall be protected by an approved device that is designed for the specific purpose. (4) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions: a. It shall be made on either side of the fire barrier. b. It shall be made by an approved device that is designed for the specific purpose.
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The facility failed to conduct fire drills per code. Findings include:

During the survey, the following is an example of what was observed:

Per documentation and interview the facility was not having all staff to sign the participation sheet

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2000 NFPA 101, 19.7.1.2 Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
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The facility failed to provide a fire alarm system per code. Findings include:

During the survey, the following is an example of what was observed:

While testing the fire alarm system, it was observed that there was no audible or visual device in the Administration Compartment

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2000 NFPA 101, 9.6.3.1 Occupant notification shall provide signal notification to alert occupants of fire or other emergency as required by other sections of this Code.

2000 NFPA 101, 9.6.3.2 Notification shall be provided by audible and visible signals in accordance with 9.6.3.3 through 9.6.3.12.

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The facility failed to maintain the automatic sprinkler system per code. Findings include:

During the survey, the following are examples of what was observed:

1. The following locations had missing escutcheon plates:

a. Storage in the O.R. Suite, next to Clean Utility
b. Dietary General's Office

2. The automatic sprinkler head in the C.T. Room over the C.T. had heavy foreign materials on it.

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1999 NFPA 13, 3-2.7.2 Escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly.
1998 NFPA 25, 2-2.1.1 Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.
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The facility failed to maintain the designated smoking area per code. Findings include:

During the survey, the following is an example of what was observed:

The facility failed to provide a metal container with a self-closing cover at the designated smoking area

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2000 NFPA 101, 19.7.4 Smoking regulations shall be adopted and shall include not less than the following provisions: (1) Smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such areas shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking. (2) Smoking by patients classified as not responsible shall be prohibited. (3) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted. (4) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted.
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The facility failed to prohibit portable space heating devices per code. Findings include:

During the survey, the following is an example of what was observed:

The CFO's Office had a portable space heating device in it

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2000 NFPA 101, 19.7.8 Portable space-heating devices shall be prohibited in all health care occupancies.
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The facility failed to maintain the med gas alarm panels per code. Findings include:

During the survey, the following is an example of what was observed:

The Outpatient Surgery med. gas panel gave no audible alarm when tested

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1999 NFPA 99, 4-3.1.2.2 Gas Warning Systems. (a) * General. 1. All local, master, and area alarm panels used for medical gas systems shall provide the following: a. Separate visual indicators for each condition monitored b. Cancelable audible indication of an alarm condition. The audible indicator shall produce a minimum of 80 dBA measured at 3 ft (1 m). A second indicated condition occurring while the alarm is silenced shall reinitiate the audible signal c. A means to visually indicate a lamp or LED failure 2. Local, master, and area alarms shall indicate visually and audibly if a. The monitored condition occurs b. The wiring to the sensor or switch is disconnected 3. Each local, master, and area alarm panel shall be labeled for its area of surveillance (e.g., O2, vacuum, medical air), etc., and room(s) served. Each indicator shall be separately labeled indicating the condition monitored. 4. Where multiple panels are intended to indicate the same condition(s): a. At least one panel shall be connected directly to the sensor(s) or switch(es). b. Both master alarms required by 4-3.1.2.2(b)2 shall be connected by dedicated wiring directly to the sensor(s) or switch(es). c. Other panels shall be permitted to be connected through indirect means such as data transmission lines provided that such indirect means are fully supervised and failure of such indirect transmissions is indicated at all panels so connected. 5. Local, master, and area alarms shall be powered from the life safety branch of the emergency system as described in Chapter 3, " Electrical Systems. " 6. All pressure switches, pressure gauges, and pressure-sensing devices downstream of the source valve shall be provided with a gas specific demand check fitting to facilitate servicing, testing, or replacement. 7. The responsible authority of the facility shall ensure that all labeling of alarms, where room numbers or designations are used, is accurate and up-to-date. 8. All wiring from switch or sensors shall be supervised or protected as required by Section 517-30(c)(3) of NFPA 70, National Electrical Code, for emergency system circuits. 9. A centralized computer (e.g., a building management system) shall not substitute for any required medical gas alarm panel, but shall be permitted to be used to supplement the medical gas alarm system. (b) Master Alarms. 1. A master alarm system shall be provided to monitor the operation and condition of the source of supply, the reserve (if any), and the pressure of the main lines of all medical gas piping systems. 2. The master alarm system shall consist of two or more alarm panels located in two separate locations. One panel shall be located in the principal working area of the individual responsible for the maintenance of the medical gas piping systems and one or more panels shall be located to assure continuous surveillance during the working hours of the facility (e.g., the telephone switchboard, security office, or other continuously staffed location). 3. Each master alarm panel shall include visual indicators for each of the following conditions: a. * A separate indicator shall be provided for all systems supplied by a manifold or an alternating-type bulk system that has as part of its normal operation a changeover from one portion of the operating supply to another portion. It shall indicate when, or just before, this changeover occurs. b. * Where a manifold or bulk supply consists of one or more units that continuously supply the piping system while another unit remains as the reserve supply and operates only in case of an emergency, it shall be indicated separately for each system when, or just before, this changeover occurs. c. * Where check valves are not provided for each cylinder lead of the reserve supply for a manifold or bulk supply system, it shall be indicated separately for each system when the reserve supply is reduced to one average day ' s supply. If check valves are provided in each cylinder lead, this signal is not required. d. When a cryogenic liquid storage unit is used as a reserve for a bulk supply system, it shall be indicated separately for each system when the contents of the reserve is reduced to one average day ' s supply and when the gas pressure available in the reserve unit is reduced below the pressure required to function properly. e. * It shall be indicated separately for each medical gas piping system when the pressure in the main line increases 20 percent or decreases 20 percent from the normal operating pressure. The actuating switch for these signals shall be installed in the main line immediately downstream (on the piping distributing side) of the main line shutoff valve or the source valve if the main line shutoff valve is not required. f. Each of the individual alarms required in 4-3.1.2.2(d)1 shall be indicated. This shall be either by a separate indicator for each condition monitored or with a single indicator labeled " Medical Air System Fault " or similar wording and that indicates when any of the conditions monitored occurs. g. A separate indicator shall be provided for dew point per 4-3.1.2.2(d)2. (c) Area Alarms. 1. Area alarms shall be provided for each medical gas piping system supplying anesthetizing locations and other vital life support and critical care areas such as postanaesthesia recovery, intensive care units, coronary care units. 2. Area alarm panels shall be located at the nurses ' station or other location that will provide for responsible surveillance. 3. * Area alarms shall indicate if the pressure in the local line increases 20 percent or decreases 20 percent from normal line pressure. 4. * Actuating switches or sensors for critical care areas shall be placed in the individual line supplying each such specific area. No valve, other than valves located in areas accessible only to authorized personnel, shall intervene between the sensor or switch and the outlets intended to be monitored by the alarm. 5. * Actuating switches or sensors for anesthetizing areas shall be placed in the individual line supplying each such specific area with the individual room shutoff valve being the only one between the actuating switch and the outlets. (d) Local Alarms. 1. An indicator shall be provided for each of the individual alarms required in 4-3.1.1.9 at the air compressor site. These indicators shall comply with 4-3.1.2.2(a)1, 2, and 3 and shall be grouped together in a single location (e.g., in an alarm panel or with the system controls). 2. Dew point for medical air shall be monitored and alarmed per 4-3.1.1.9(i) to indicate a line pressure dew point above 39?F (3.9?C). 3. Carbon monoxide for medical air shall be monitored and alarmed per 4-3.1.1.9(i) to indicate a level above 10 ppm. (e) Pressure Gauges for Gases. The scale range of positive pressure analog gauges shall be such that the normal reading falls within the middle 50 percent of the scale. The scale range of digital gauges shall be not more than two times the working pressure. The rated accuracy of pressure gauges used for testing shall be one percent (full scale) or better at the point of reading. Pressure gauges shall be in compliance with ANSI/ASME B-40.1, Gauges, Pressure Indicating Dial-Type, Elastic Elements. 1. * A pressure gauge shall be installed in the main line adjacent to the actuating switch required in 4-3.1.2.2(b)3e. It shall be appropriately labeled and shall be readily visible from a standing position. 2. * An appropriately identified pressure gauge, connected to the line being monitored, shall be installed at each area alarm panel location. It shall be appropriately labeled and shall be readily visible from a standing position.
1999 NFPA 99, 4-4.1 Piped Gas Systems (Source and Distribution). Level 2 piped gas systems shall conform to the requirements for Level 1 piped gas systems. Exception No. 4: One alarm panel that complies with 4-3.1.2.2(b)3a, b, c, and d, and with 4-3.1.2.2(c)2 and 5, shall be permitted.
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The facility failed to provide signs indicating the transferring of oxygen per code. Findings include:

During the survey, the following is an example of what was observed:

The facility failed to provide signage indicating the transferring of oxygen

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1999 NFPA 99, 8-6.2.5.2 Transferring of liquid oxygen from one container to another shall be accomplished at a location specifically designated for the transferring that is as follows: (a) Separated from any portion of a facility wherein patients are housed, examined, or treated by a separation of a fire barrier of 1-hour fire-resistive construction; and (b) The area is mechanically ventilated, is sprinklered, and has ceramic or concrete flooring; and (c) The area is posted with signs indicating that transferring is occurring, and that smoking in the immediate area is not permitted.
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The facility failed to maintain the electrical wiring and equipment per code. Findings include:

During the survey, the following are examples of what was observed:

1. Doctor's Office/Consultaion Room in the O.R. Suite had a refrigerator plugged into a surge protector

2. CFO's Office had an adding machine plugged into an extension cord

3. Radiologists' Room had a homemade extension cord plugged into a surge protector, plugged into another extension cord

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1999 NFPA 70, 400-7 and 400-8, and HCFA Transmittal Notice 22-99 The 1984 edition of the National Electric Code restricts the use of extension cords to temporary short term uses. It is the policy of HCFA to prohibit non-circuit breaker protected extension cords in health care. The limited use of circuit breaker protected power strips is acceptable, provided the current is limited to 15 amps or less, and no major appliances such as air conditioners, refrigerators, or heating units are connected to the power strip.

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The facility failed to maintain the smoke barriers per code. Findings include:

During the survey, the following are examples of what was observed:

1. Smoke barrier at smoke doors by the Business Office had two unsealed conduit ends

2. Smoke barrier in Business Office had an unsealed penetration just inside the door

3. Smoke barrier I.C.U. Waiting Room had an unsealed conduit end with a black wire

4. Smoke barrier at Admissions had two unsealed conduit ends:
a. One with two red wires
b. One with green, tan and white wires

5. Smoke door to Outpatient Admissions did not close

6. Smoke barrier in Nurse Manager's Officehad one unsealed conduit end with a tan wire

7. E.R. Bay One had two unsealed conduit ends:

a. One with a white wire
b. One with a tan wire

8. Smoke barrier at E.R. deskhad two unsealed conduit ends

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2000 NFPA 101, 8.2.4.4.1 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through smoke partitions shall be protected as follows: (1) The space between the penetrating item and the smoke partition shall meet one of the following conditions: a. It shall be filled with a material that is capable of limiting the transfer of smoke. b. It shall be protected by an approved device that is designed for the specific purpose. (2) Where the penetrating item uses a sleeve to penetrate the smoke partition, the sleeve shall be solidly set in the smoke partition, and the space between the item and the sleeve shall meet one of the following conditions: a. It shall be filled with a material that is capable of limiting the transfer of smoke. b. It shall be protected by an approved device that is designed for the specific purpose. (3) Where designs take transmission of vibrations into consideration, any vibration isolation shall meet one of the following conditions: a. It shall be made on either side of the smoke partitions. b. It shall be made by an approved device that is designed for the specific purpose.
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The facility failed to maintain a hazardous area per code. Findings include:

During the survey, the following is an example of what was observed:

The Supply Room for the O.R. the door to Centril Sterile had a self-closing device on it, but was being held open by a wire

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2000 NFPA 101, 19.3.2.1 Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing.

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The facility failed to maintain the exit access per code. Findings include:

During the survey, the following is an example of what was observed:

The Storage Room between rooms 501 and 502, the corridor door when fully opened projected more than 7" into the corridor.
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2000 NFPA 101, 7.2.1.4.4 During its swing, any door in a means of egress shall leave not less than one-half of the required width of an aisle, corridor, passageway, or landing unobstructed and shall not project more than 7 in. (17.8 cm) into the required width of an aisle, corridor, passageway, or landing, when fully open. Doors shall not open directly onto a stair without a landing. The landing shall have a width not less than the width of the door. (See 7.2.1.3.)
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The facility failed to maintain the fire barrier per code. Findings include:

During the survey, the following is an example of what was observed:

The fire barrier at Administration had two unsealed conduit ends.

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2000 NFPA 101, 8.2.3.2.4.2 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through fire barriers shall be protected as follows: (1) The space between the penetrating item and the fire barrier shall meet one of the following conditions: a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier. b. It shall be protected by an approved device that is designed for the specific purpose. (2) Where the penetrating item uses a sleeve to penetrate the fire barrier, the sleeve shall be solidly set in the fire barrier, and the space between the item and the sleeve shall meet one of the following conditions: a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier. b. It shall be protected by an approved device that is designed for the specific purpose. (3) * Insulation and coverings for pipes and ducts shall not pass through the fire barrier unless one of the following conditions is met: a. The material shall be capable of maintaining the fire resistance of the fire barrier. b. The material shall be protected by an approved device that is designed for the specific purpose. (4) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions: a. It shall be made on either side of the fire barrier. b. It shall be made by an approved device that is designed for the specific purpose.
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The facility failed to conduct fire drills per code. Findings include:

During the survey, the following is an example of what was observed:

Per documentation and interview the facility was not having all staff to sign the participation sheet

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2000 NFPA 101, 19.7.1.2 Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
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The facility failed to provide a fire alarm system per code. Findings include:

During the survey, the following is an example of what was observed:

While testing the fire alarm system, it was observed that there was no audible or visual device in the Administration Compartment

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2000 NFPA 101, 9.6.3.1 Occupant notification shall provide signal notification to alert occupants of fire or other emergency as required by other sections of this Code.

2000 NFPA 101, 9.6.3.2 Notification shall be provided by audible and visible signals in accordance with 9.6.3.3 through 9.6.3.12.

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The facility failed to maintain the automatic sprinkler system per code. Findings include:

During the survey, the following are examples of what was observed:

1. The following locations had missing escutcheon plates:

a. Storage in the O.R. Suite, next to Clean Utility
b. Dietary General's Office

2. The automatic sprinkler head in the C.T. Room over the C.T. had heavy foreign materials on it.

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1999 NFPA 13, 3-2.7.2 Escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly.
1998 NFPA 25, 2-2.1.1 Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.
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The facility failed to maintain the designated smoking area per code. Findings include:

During the survey, the following is an example of what was observed:

The facility failed to provide a metal container with a self-closing cover at the designated smoking area

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2000 NFPA 101, 19.7.4 Smoking regulations shall be adopted and shall include not less than the following provisions: (1) Smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such areas shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking. (2) Smoking by patients classified as not responsible shall be prohibited. (3) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted. (4) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted.
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The facility failed to prohibit portable space heating devices per code. Findings include:

During the survey, the following is an example of what was observed:

The CFO's Office had a portable space heating device in it

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2000 NFPA 101, 19.7.8 Portable space-heating devices shall be prohibited in all health care occupancies.
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The facility failed to maintain the med gas alarm panels per code. Findings include:

During the survey, the following is an example of what was observed:

The Outpatient Surgery med. gas panel gave no audible alarm when tested

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1999 NFPA 99, 4-3.1.2.2 Gas Warning Systems. (a) * General. 1. All local, master, and area alarm panels used for medical gas systems shall provide the following: a. Separate visual indicators for each condition monitored b. Cancelable audible indication of an alarm condition. The audible indicator shall produce a minimum of 80 dBA measured at 3 ft (1 m). A second indicated condition occurring while the alarm is silenced shall reinitiate the audible signal c. A means to visually indicate a lamp or LED failure 2. Local, master, and area alarms shall indicate visually and audibly if a. The monitored condition occurs b. The wiring to the sensor or switch is disconnected 3. Each local, master, and area alarm panel shall be labeled for its area of surveillance (e.g., O2, vacuum, medical air), etc., and room(s) served. Each indicator shall be separately labeled indicating the condition monitored. 4. Where multiple panels are intended to indicate the same condition(s): a. At least one panel shall be connected directly to the sensor(s) or switch(es). b. Both master alarms required by 4-3.1.2.2(b)2 shall be connected by dedicated wiring directly to the sensor(s) or switch(es). c. Other panels shall be permitted to be connected through indirect means such as data transmission lines provided that such indirect means are fully supervised and failure of such indirect transmissions is indicated at all panels so connected. 5. Local, master, and area alarms shall be powered from the life safety branch of the emergency system as described in Chapter 3, " Electrical Systems. " 6. All pressure switches, pressure gauges, and pressure-sensing devices downstream of the source valve shall be provided with a gas specific demand check fitting to facilitate servicing, testing, or replacement. 7. The responsible authority of the facility shall ensure that all labeling of alarms, where room numbers or designations are used, is accurate and up-to-date. 8. All wiring from switch or sensors shall be supervised or protected as required by Section 517-30(c)(3) of NFPA 70, National Electrical Code, for emergency system circuits. 9. A centralized computer (e.g., a building management system) shall not substitute for any required medical gas alarm panel, but shall be permitted to be used to supplement the medical gas alarm system. (b) Master Alarms. 1. A master alarm system shall be provided to monitor the operation and condition of the source of supply, the reserve (if any), and the pressure of the main lines of all medical gas piping systems. 2. The master alarm system shall consist of two or more alarm panels located in two separate locations. One panel shall be located in the principal working area of the individual responsible for the maintenance of the medical gas piping systems and one or more panels shall be located to assure continuous surveillance during the working hours of the facility (e.g., the telephone switchboard, security office, or other continuously staffed location). 3. Each master alarm panel shall include visual indicators for each of the following conditions: a. * A separate indicator shall be provided for all systems supplied by a manifold or an alternating-type bulk system that has as part of its normal operation a changeover from one portion of the operating supply to another portion. It shall indicate when, or just before, this changeover occurs. b. * Where a manifold or bulk supply consists of one or more units that continuously supply the piping system while another unit remains as the reserve supply and operates only in case of an emergency, it shall be indicated separately for each system when, or just before, this changeover occurs. c. * Where check valves are not provided for each cylinder lead of the reserve supply for a manifold or bulk supply system, it shall be indicated separately for each system when the reserve supply is reduced to one average day ' s supply. If check valves are provided in each cylinder lead, this signal is not required. d. When a cryogenic liquid storage unit is used as a reserve for a bulk supply system, it shall be indicated separately for each system when the contents of the reserve is reduced to one average day ' s supply and when the gas pressure available in the reserve unit is reduced below the pressure required to function properly. e. * It shall be indicated separately for each medical gas piping system when the pressure in the main line increases 20 percent or decreases 20 percent from the normal operating pressure. The actuating switch for these signals shall be installed in the main line immediately downstream (on the piping distributing side) of the main line shutoff valve or the source valve if the main line shutoff valve is not required. f. Each of the individual alarms required in 4-3.1.2.2(d)1 shall be indicated. This shall be either by a separate indicator for each condition monitored or with a single indicator labeled " Medical Air System Fault " or similar wording and that indicates when any of the conditions monitored occurs. g. A separate indicator shall be provided for dew point per 4-3.1.2.2(d)2. (c) Area Alarms. 1. Area alarms shall be provided for each medical gas piping system supplying anesthetizing locations and other vital life support and critical care areas such as postanaesthesia recovery, intensive care units, coronary care units. 2. Area alarm panels shall be located at the nurses ' station or other location that will provide for responsible surveillance. 3. * Area alarms shall indicate if the pressure in the local line increases 20 percent or decreases 20 percent from normal line pressure. 4. * Actuating switches or sensors for critical care areas shall be placed in the individual line supplying each such specific area. No valve, other than valves located in areas accessible only to authorized personnel, shall intervene between the sensor or switch and the outlets intended to be monitored by the alarm. 5. * Actuating switches or sensors for anesthetizing areas shall be placed in the individual line supplying each such specific area with the individual room shutoff valve being the only one between the actuating switch and the outlets. (d) Local Alarms. 1. An indicator shall be provided for each of the individual alarms required in 4-3.1.1.9 at the air compressor site. These indicators shall comply with 4-3.1.2.2(a)1, 2, and 3 and shall be grouped together in a single location (e.g., in an alarm panel or with the system controls). 2. Dew point for medical air shall be monitored and alarmed per 4-3.1.1.9(i) to indicate a line pressure dew point above 39?F (3.9?C). 3. Carbon monoxide for medical air shall be monitored and alarmed per 4-3.1.1.9(i) to indicate a level above 10 ppm. (e) Pressure Gauges for Gases. The scale range of positive pressure analog gauges shall be such that the normal reading falls within the middle 50 percent of the scale. The scale range of digital gauges shall be not more than two times the working pressure. The rated accuracy of pressure gauges used for testing shall be one percent (full scale) or better at the point of reading. Pressure gauges shall be in compliance with ANSI/ASME B-40.1, Gauges, Pressure Indicating Dial-Type, Elastic Elements. 1. * A pressure gauge shall be installed in the main line adjacent to the actuating switch required in 4-3.1.2.2(b)3e. It shall be appropriately labeled and shall be readily visible from a standing position. 2. * An appropriately identified pressure gauge, connected to the line being monitored, shall be installed at each area alarm panel location. It shall be appropriately labeled and shall be readily visible from a standing position.
1999 NFPA 99, 4-4.1 Piped Gas Systems (Source and Distribution). Level 2 piped gas systems shall conform to the requirements for Level 1 piped gas systems. Exception No. 4: One alarm panel that complies with 4-3.1.2.2(b)3a, b, c, and d, and with 4-3.1.2.2(c)2 and 5, shall be permitted.
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The facility failed to provide signs indicating the transferring of oxygen per code. Findings include:

During the survey, the following is an example of what was observed:

The facility failed to provide signage indicating the transferring of oxygen

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1999 NFPA 99, 8-6.2.5.2 Transferring of liquid oxygen from one container to another shall be accomplished at a location specifically designated for the transferring that is as follows: (a) Separated from any portion of a facility wherein patients are housed, examined, or treated by a separation of a fire barrier of 1-hour fire-resistive construction; and (b) The area is mechanically ventilated, is sprinklered, and has ceramic or concrete flooring; and (c) The area is posted with signs indicating that transferring is occurring, and that smoking in the immediate area is not permitted.
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The facility failed to maintain the electrical wiring and equipment per code. Findings include:

During the survey, the following are examples of what was observed:

1. Doctor's Office/Consultaion Room in the O.R. Suite had a refrigerator plugged into a surge protector

2. CFO's Office had an adding machine plugged into an extension cord

3. Radiologists' Room had a homemade extension cord plugged into a surge protector, plugged into another extension cord

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1999 NFPA 70, 400-7 and 400-8, and HCFA Transmittal Notice 22-99 The 1984 edition of the National Electric Code restricts the use of extension cords to temporary short term uses. It is the policy of HCFA to prohibit non-circuit breaker protected extension cords in health care. The limited use of circuit breaker protected power strips is acceptable, provided the current is limited to 15 amps or less, and no major appliances such as air conditioners, refrigerators, or heating units are connected to the power strip.