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Based on interview and record review, this facility failed to review and revise the Emergency Preparedness Plan policies and procedures. Several Forms and sections related to the facilities EPP were not included during the review.

Findings:

During record review on January 13, 2020, between 11:30 am and 4:00 PM, with the EH & Emergency Management Program Manager:

The following sections were missing from the Emergency Preparedness Plan and were listed in the Table of Contents:

1. Tab 2, Section a. - Form 4601 - Emergency Codes - This portion of the Plan was reviewed in January 2017, April 2017, December 2018 and April 2019.

2. Tab 9, Section a. - Form 4600 - Lost Patient Checklist - This portion of the Plan was reviewed in January 2015, September 2015, January 2016, May 2016, December 2016, April 2017, July 2017, April 2018 and April 2019.

3. Tab 11, Section a. - Form 1780 - Acute STEMI - This portion of the Plan was reviewed in July 2010, November 2012, August 2014, December 2016, July 10, 2017, November 2017, November 2018 and December 2018.

4. Tab 17, Sections b - i :
b. Communications Systems Failure
c. Electrical Power Failure
d. Room Conformance
e. Elevator Failure
f. Heating Ventilation/Air Conditioning Systems Failure
g. Medical Gas Supply Failure
h. Medical Surgical Vacuum Systems Failure
i. Water Sources Plumbing Systems/Equipment Failure
This portion of the Plan was reviewed in May 2003, March 2006, January 2010, March 2011, June 2012, July 2017, July 2018 and September 2019.

5. Tab 20, Section k. - Form 4612 - Notification Regarding Hazardous Material Incident Form - This portion of the Plan was reviewed in December 2016, April 2017, April 2018 and April 2019.

6. Tab 21, Section b. - Code Surge - This portion of the Plan was reviewed in December 2016, April 2017, April 2018, April 2019, and September 2019.

7. Tab 24, Section a. - Oxford County Regional Communications Center/Stephens Memorial Hospital Emergency Communications Guidelines - This portion of the Plan was reviewed in September 2019.

8. Tab 29, Section a. - Disaster Supply Inventory - This portion of the Plan was reviewed in September 2019.

9. Tab 32, Sections b and d :
b. Formalin Exposure Control Plan
d. Zero Tolerance Policy
This portion of the Plan was reviewed in September 2019.


These findings were confirmed with the EH & Emergency Management Program Manager the at the time of record review.

Based on interview and record review, the critical access hospital failed to ensure policy was maintained for the provision of subsistence needs for staff and patients, whether they evacuate or shelter in place. Alternate sources of energy to maintain temperatures to protect patient health and safety and for the safe and sanitary storage of provisions in Emergency Preparedness Plan.

Finding:

On 01/13/2020 between 10:30 AM and 4:30 PM, surveyors with the Emergency Management Program Manager present, observed the following:

1. A memorandum of understanding was not found that stated that in case of an emergency the facility would be guaranteed fuel delivery for heat.

The surveyor confirmed these observations with the Emergency Management Program Manager at the time of record review.

Based on interview and record review, the facility failed to develop and maintain an emergency preparedness training and testing program that is based on the emergency plan with annual review and updates if needed.

Findings:

On 01/13/2020 between 10:30 AM and 4:30 PM, surveyors with the Emergency Management Program Manager present, observed the following:

1. Training for the emergency preparedness plan was not in place for initial or annual training.
2. Testing documentation could not be verified for training on the emergency preparedness plan.

The surveyor confirmed these findings with the Emergency Management Program Manager at the time of record review.

Based on interview and record review, the facility failed to provide an Emergency preparedness training program annually for all employees and voluteers and initially for new hires.

Findings:

On 01/13/2020 between 10:30 AM and 4:30 PM, surveyors with the Emergency Management Program Manager present, observed the following:

1. Documentation of initial and annual emergency preparedness plan training documentation was not available.


The surveyor confirmed these findings with the Emergency Management Program Manager at the time of record review.

Based on interview and record review, the facility failed to ensure the emergency plan and corresponding policies and procedures were maintained for the provision of Emergency generator fuel, whether they evacuate or shelter in place. Hospitals that maintain an onsite fuel site to power emergency generators must have a plan for how it will keep emergency power systems operational in case of an emergency in the Emergency Preparedness Plan.

Finding:

On 01/13/2020 between 10:30 AM and 4:30 PM, surveyors with the Emergency Management Program Manager present, observed the following:

1 A memorandum of understanding was not available at the time of survey that stated that in case of an emergency the facility would be guaranteed fuel delivery for the generator.

The surveyor confirmed these findings with the Emergency Management Program Manager at the time of record review.

Based on observations and interviews the hospital failed to meet the requirements of the National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition for construction type and supporting construction for health care and/or other building occupancies. A 2-hour separation was not provided in accordance with section 8.2.1.3 in 8 of 8 areas.


Findings include:

Observation(s), Interview(s), and review of construction documents during a facility tour on January 13, 2020 between 12:00 PM and 4:00 PM with this surveyor along with the Plant Operations Director and a Maintenance worker.

1. The 2-hour separation wall located between the supply chain and basement hallway was penetrated by a 4 inch pipe going through wall. that was not protected by a firestop system or device in accordance with NFPA 221 (2012 edition), Standard for High Challenge Fire, section 4.9.2 Firestop Systems and Devices Required - Penetrations for cables, cable trays, conduit, pipes, tubes, combustible vents and exhaust vents, wires and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a fire barrier shall be protected by a fire stop system or device. This deficient practice could affect the 2 hour fire barrier wall of the facility.

2. The 2-hour separation located near West Wing Basement Doors hallway was penetrated by a 4 inch pipe going through wall as well as wire conduit that was not protected by a firestop system or device in accordance with NFPA 221 (2012 edition), Standard for High Challenge Fire, section 4.9.2 Firestop Systems and Devices Required - Penetrations for cables, cable trays, conduit, pipes, tubes, combustible vents and exhaust vents, wires and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a fire barrier shall be protected by a fire stop system or device. This deficient practice could affect the 2 hour fire barrier wall of the facility.

3. The 2-hour separation located near West Wing Basement Doors near Ramp was penetrated by a wire chase conduit that was not protected by a firestop system or device in accordance with NFPA 221 (2012 edition), Standard for High Challenge Fire, section 4.9.2 Firestop Systems and Devices Required - Penetrations for cables, cable trays, conduit, pipes, tubes, combustible vents and exhaust vents, wires and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a fire barrier shall be protected by a fire stop system or device. This deficient practice could affect the 2 hour fire barrier wall of the facility.

4. The 2-hour separation located near North Wing Doors near Administration was penetrated by numerous conduits and wires that were not protected by a firestop system or device in accordance with NFPA 221 (2012 edition), Standard for High Challenge Fire, section 4.9.2 Firestop Systems and Devices Required - Penetrations for cables, cable trays, conduit, pipes, tubes, combustible vents and exhaust vents, wires and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a fire barrier shall be protected by a fire stop system or device. This deficient practice could affect the 2 hour fire barrier wall of the facility.

5. The 2-hour separation located in Electrical Closet in Endo Hallway was penetrated by a large hole in the floor with conduits and wires that were not protected by a firestop system or device in accordance with NFPA 221 (2012 edition), Standard for High Challenge Fire, section 4.9.2 Firestop Systems and Devices Required - Penetrations for cables, cable trays, conduit, pipes, tubes, combustible vents and exhaust vents, wires and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a fire barrier shall be protected by a fire stop system or device. This deficient practice could affect the 2 hour fire barrier wall of the facility.

6. The 2-hour separation located in MRI Electrical Control Room had a large penetrated by a large missing piece of sheetrock in the wall that were not protected by a firestop system or device in accordance with NFPA 221 (2012 edition), Standard for High Challenge Fire, section 4.9.2 Firestop Systems and Devices Required - Penetrations for cables, cable trays, conduit, pipes, tubes, combustible vents and exhaust vents, wires and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a fire barrier shall be protected by a fire stop system or device. This deficient practice could affect the 2 hour fire barrier wall of the facility.





These findings were verified during observation and interview with the Director of Plant operations and Maintenance worker.

Based on observation and interview this surveyor on 1-13-2020 between 11:30 am and 4:00 PM, found a thumb turn/Dead bolt on 1 of 2 "EXIT" doors leading from the exterior court yard. Doors in the means of egress shall meet NFPA 101 LSC 2012 edition chapter 19/19.2, chapter 7/7.2.1.5


Findings:

1. The "EXIT door leading from the exterior court yard into the North Wing smoke compartment is equipped with a fully operational thumb turn dead bolt lock. This deficiency allows the "EXIT" door from the court yard to be locked from the inside of the facility and cannot be unlocked from the exterior of the building and could result in patients, employees and visitors being trapped outside during an emergency.
Locks shall be in accordance with chapter 7/7.2.1.5. Door leafs shall be shall be arranged to open readily from the egress side.

2. The "EXIT door leading from the employee entrance in the East/South smoke compartment is equipped with a fully operational thumb turn dead bolt lock. This deficiency allows the "EXIT" door from the East/South smoke compartment to be locked from the inside of the facility delaying the rapid egress of patients, visitors and staff.
Locks shall be in accordance with chapter 7/7.2.1.5. Door leafs shall be shall be arranged to open readily from the egress side.


This observation was confirmed during interview with the facility maintenance person.

This surveyor based on observation and interview on 1-13-2020 between 11:30 am and 4:00 PM, found the exit stairwell leading from the basement level near Materials Management to the first floor near the Emergency department did not have a continuous 1 hour exit stair enclosure as required by 7.2, 19.3.1.8. Fire doors located at the basement level did not latch and the hour hour fire barrier wall between Materials Management and the stairwell was compromised with through penetrations.

Findings:

1. A two hour fire rated wall makes up half of the fire rated stair enclosure, a set of double 90 minute fire rated doors located at the basement level in the two hour fire rated separation wall did not latch at the top or bottom when in the closed position. No latching plates were installed on the floor so, the door latching rods at the bottom of the door would not secure the doors in the closed position.
Latching rods for the top half of the door would not engage and secure the door when closed.

2. Material Management entry doors would not latch in when released from the magnetic hold open device because the stationary leaf requires manual latching. The stationary leaf shall either automatically latch when released or shall not be held open with the magnetic hold open device.

3. The one hour fire rated wall located between the Materials Management area and the stairwell was not continuous to the underside of the floor ceiling above and was not sealed with a fire stop system. Numerous penetrations (steel pipe, conduit, heat pipes, sprinkler piping, etc.) were found piercing the One hour without and visible fire stopping assemblies in place.

These findings were verified during observation and interview with the Director of Plant operations and Maintenance worker.

Based on observation and interview, this surveyor on 1-13-2020 between 11:30 am and 4:00 PM, the exterior court yard was not equipped with emergency lighting in accordance with NFPA 101 Life Safety Code 2012 edition chapter 19/19.2.8 and chapter 7/7.8


Finding:

1. The facilities court yard is open to the sky, but completely enclosed by walls with no exterior emergency lighting. Exterior emergency lighting for the exterior courtyard for safe egress could not be verified by the Director of Plant Operations when was asked.

The deficient practice could effect all patients,visitors and employees using the court yard area.


This observation was confirmed during interview with the facilities maintenance person.

Based on observation and interview, this surveyor on 1-13-2020 between 11:30 am and 4:00 PM, did observe the exterior court yard exit doors were not equipped with exit signs. The basement level exit signs are photoluminescent and require a certain light source specified by the manufacturer. Exit signs are required in accordance with NFPA 101 LSC 2012 edition chapter 19/19.2.10.1 section 7.10 through 7.10.8.3.1


Findings:

1. The court yard is not equipped with "EXIT" signs at either of it's two exits.

2. The exit signs located in the basement level of the facility had photoluminescent signs and the light source for the charging of these signs shall be in accordance with section 7.10.7.2 and manufacturer specifications. The light source for the signs could not be verified as compliant for these signs.

This observation was confirmed during interview with the facilities Director of Plant Operations and Maintenance worker.

Based on observation and interview, this surveyor on 1-13-2020 between 11:30 am and 4:00 PM, did observe Doctors sleeping room not equipped with a smoke detector. Smoke detection shall be installed in accordance with NFPA 101 LSC 2012 edition chapter 19.3 and section 9.6


Finding:

1. Doctor/Nurses sleeping room not equipped with a smoke detector.



This observation was confirmed during interview with the Director of Plant Operations.

K321 Hazardous Areas - Enclosure
This surveyor based on observation and interview on 1-13-2020 between 11:30 am and 4:00 PM, found the facility failed to ensure that hazardous areas were safeguarded in accordance with NFPA 101, Life Safety Code, section 19.3.2.1 in 3 hazardous areas of 26 hazardous areas inspected in the facility. A soiled linen room door would not close, a self-closing device was missing from the medical records storage room door between the EVS cart storage area and medical records area and the ventilator storage area door would not resist the passage of smoke.
This deficient practice could affect patients, employees and visitors of the facility. Deficient practices have the potential of allowing the passage of smoke and/or fire from the hazardous area(s) into adjacent areas.


Findings:

1. Soiled linen room located within the EVS cart storage area; soiled linen room door would not close and latch when opened and released. The latching mechanism would not engage the strike because the door was hitting the frame.


2. Door leading from EVS storage to Medicals records requires a self-closing device in accordance with 19.3.2.1.3, 19.3.2.1.5 (7)

These findings were verified during observation with the Director of Plant operations and Maintenance worker.

3. Ventilator room door had a hole cut through the door approximately half way up the door . The hole measured approximately 2.5" high and 10" in length. The door wood no longer resist the passage of smoke in accordance with 19.3.2.1.2.

4. 7. Spray foam required to be removed in the Bio-Medical waste room. The deficient practice could affect flame spread as well as smoke production in the event of a fire.


These findings were verified during observation and interview with the Director of Plant operations.

Based on observations and interviews, the hospital failed to ensure that all areas of the hospital had sprinkler coverage throughout. Per NFPA 101 2012 EXISTING Nursing homes, and hospitals where required by construction type, are protected throughout by an approved automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. In Type I and II construction, alternative protection measures are permitted to be substituted for sprinkler protection in specific areas where state or local regulations prohibit sprinklers. In hospitals, sprinklers are not required in clothes closets of patient sleeping rooms where the area of the closet does not exceed 6 ft² and sprinkler coverage covers the closet footprint as required by NFPA 13, Standard for Installation of Sprinkler Systems. 19.3.5.1, 19.3.5.2, 19.3.5.3, 19.3.5.4, 19.3.5.5, 19.4.2, 19.3.5.10, 9.7, 9.7.1.1(1)

Finding:

1. On 11/13/2020 between 12:00 PM and 4:00 PM a surveyor with the Plant Operation Director and a Maintenance Worker observed the following:

a. Environmental Service Storage Closet had no sprinkler coverage.

b. Elevator Machine room in basement near boiler room had no sprinkler coverage.

c. Light bulb storage closet needs sprinkler coverage.

d. Medical / Surgical Unit employee bathroom entrance area needs sprinkler coverage.

e. X-Ray Room 1 and 2 as well as X-Ray control booth needs sprinkler coverage.

The surveyor confirmed these observations with the Plant Operation Director and a Maintenance Worker at the time of observation.

Based on observation this surveyor on 1-13-2020 between 11:30 am and 4:00 PM, did find sprinkler head escutcheon caps removed/missing from 2 of 2 areas. All sprinkler head components are required to be in place for proper sprinkler activation. NFPA 13 2010 edition chapter 6/6.2.7.2


Findings:


1. Sprinkler head escutcheon caps missing in the nurses station Med Surgical area.


2. Sprinkler head escutcheon caps missing in the utility area of the Med Surgical area.


This observation was confirmed during interview with the Director of Plant Operations.

Based on observation and interview, this surveyor on 1-13-2020 between 11:30 am and 4:00 PM, did found the Surgical Day Care (SDC) Room door would not resist the passage of smoke as required in accordance with 19.3.6.3. Kitchen doors do not latch as required by NFPA 101 LSC chapter 19/19.3.6.3.5
This deficiency has the ability to affect all patients, employees and visitors in the East/South smoke compartment located at the basement level.

Findings:

1. SDC corridor door had an approximately 2.5" x 10" opening cut into the door about midway of the door leaf. This hole rendered the door incapable of resisting the passage of smoke.

2. Kitchen corridor doors located on the basement level are required to latch. No approved latching device was located on these double doors that would prevent them from opening during a fire event.

3. Emergency department storage room door would not latch in the closed position.

This observation was confirmed during interview with the facilities Maintenance worker.

Based on observation, interview and record review, this facility failed to maintain documentation for the 6 year testing of the smoke and fire dampers per NFPA 101, Life Safety Code, 2012 Edition, Section 19.3.7.3 and Section 8.5.5.4.2 and NFPA 105, Standard for Smoke Door Assemblies and Other Opening Protectives, 2010 Edition, Section 6.5.2 throughout the building.

Finding:

During record review on January 13, 2020, between 11:30 AM and 4:00 PM, with the Director of Plant Operations:

Documentation could not be provided to indicate that the smoke and fire dampers have been tested in the last 6 years.

This finding was confirmed with Director of Plant Operations the at the time of record review.


40403

Based on observation, interview and record review, this facility failed to maintain documentation to indicate that all repairs and replacements have been made since the annual testing of the fire door assemblies on September 4-5, 2019 per NFPA 101, Life Safety Code, 2012 Edition, Section 19.7.6 and NFPA 80, Standard for Fire Doors and Other Opening Protectives, 2010 Edition, Section 5.2.1 throughout the building.

Finding:

During record review on January 13, 2020, between 11:30 am and 4:00 PM, with the Director of Plant Operations:

Per the annual inspection of the fire door assemblies in September 2019, documentation was not provided that indicated the 72 fire doors that were found deficient by an outside contractor were repaired or replaced.

This finding was confirmed with Director of Plant Operations the at the time of record review.

Based on observation, interview and record review, this facility failed to maintain documentation to indicate that the 65 Maintenance Deficiencies and 89 Compliance Deficiencies noted on the 2019 Medical Gas Testing and Evaluation per NFPA 99, Health Care Facilities Code, 2012 Edition, Section 5.1 and Section 9.3.7.5.3.3. throughout the building. The Director of Plant Operations confirmed that the following deficiencies have not been documented as being repaired and have not been scheduled to be repaired.

Findings:

During record review on January 13, 2020, between 11:30am and 4:00pm, with the Director of Plant Operations:

The following deficiencies were noted in the 2019 Medical Gas Testing and Evaluation dated January 4, 2019 from the testing completed on January 2, 2019:


Maintenance Deficiencies


Oxygen zone valves leak at the flange in the following areas:
1. Surgical Services - left of the OR entrance
2. Medical Surgical East - across from the Inpatient Physical Rehab


Vacuum inlets leak in the following areas:
1. Surgical Services - Operating Room 1 on column 2
2. Surgical Services - Operating Room 2 on column 1
3. Surgical Services - Operating Room 2 on column 2
4. Surgical Services - PACU Bay 1 - 1st vacuum
5. Surgical Services - PACU Bay 2 - 1st vacuum
6. Surgical Services - PACU Bay 3 - 1st vacuum
7. Surgical Services - Operating Room 3 - 2nd vacuum
8. Surgical Services - ASU Bay 5 - 3rd vacuum
9. Surgical Services - Blood Gas
10. ICU - ICU 102 - 2nd vacuum
11. ICU - ICU 103 - 1st vacuum
12. ICU - ICU 104 - 2nd vacuum
13. Medical Surgical East - Room 122 - 1st vacuum
14. Medical Surgical East - Room 122 - 2nd vacuum
15. Medical Surgical East - Room 126 - 1st vacuum
16. Medical Surgical East - Room 126 - 2nd vacuum
17. Medical Surgical East - Room 127 - 1st vacuum
18. Medical Surgical East - Room 127 - 2nd vacuum
19. Medical Surgical East - Room 128 - 2nd vacuum
20. Medical Surgical East - Room 130 - 1st vacuum
21. Medical Surgical East - Room 131 - 1st vacuum
22. Medical Surgical East - Room 140 - 1st vacuum
23. Medical Surgical East - Room 144 - 1st vacuum
24. Medical Surgical East - Room 144 - 2nd vacuum
25. Medical Surgical East - Room 146 - 2nd vacuum
26. Medical Surgical East - Room 148 - 1st vacuum
27. Medical Surgical East - Oncology Nurse Practitioner - 1st vacuum
28. Medical Surgical East - Oncology Nurse Practitioner - 2nd vacuum
29. Emergency - Room E
30. Radiology - X Ray 1
31. Radiology - X Ray 2
32. Radiology - CT Scan


Medical air outlets leak in the following areas:
1. Surgical Services - Operating Room 1 - 1st outlet on column 2
2. Surgical Services - Operating Room 1 - 2nd outlet on column 2
3. ICU - ICU 102
4. ICU - ICU 104
5. Medical Surgical East - Room 128
6. Medical Surgical East - Room 131 - from the back assembly
7. Medical Surgical East - Room 132
8. Medical Surgical East - Room 142 - 1st outlet


Oxygen outlets leak in the following areas:
1. Surgical Services - Operating Room 3 - 1st outlet
2. Surgical Services - ASU Bay 5 - 3rd outlet
3. Medical Surgical East - Room 124 - 1st outlet
4. Medical Surgical East - Room 130 - 1st outlet - from the back assembly
5. Medical Surgical East - Room 140 - 1st outlet
6. Medical Surgical East - Room 140 - 2nd outlet
7. Medical Surgical East - Room 146 - 2nd outlet - from the back assembly
8. Medical Surgical East - Room 152 - 1st outlet
9. Medical Surgical East - Room 152 - 2nd outlet - from the back assembly
10. Radiology - CT Scan


Oxygen outlets drop psig in the following areas:
1. Surgical Services - Operating Room 3 - 1st outlet drops 40 psig at 2.0 scfm
2. Radiology - CT Scan - drops 20 psig at 3.5 scfm


Medical air zone valves leaks at the stem and/or flange in the following areas:
1. ICU - across from ICU 2 - leaks at the stem and flange
2. Medical Surgical East - across from Inpatient Physical Rehab - leaks at the flange


The particulate sample taken from ICU 104, even though it passed NFPA criteria for weight, was visibly soiled.


Vacuum inlets have a low flow in the following areas:
1. ICU - ICU 103 - low flow of 1.5 scfm
2. Medical Surgical East - Room 126- low flow of 1.0 scfm
3. Radiology - CT Scan - low flow of 1.5 scfm


Master Alarms and Sources have the following pressure alarm deficiencies:
1. Oxygen Supply System - During the master alarm testing, the high pressure alarmed at 70 psig and needs to be adjusted to 60 psig.
2. Medical Air Compressor - During the master alarm testing, the high pressure alarmed did not alarm at 100 psig and the low pressure alarmed at 16 psig. Both alarms need to be adjusted to 60 psig and 40 psig accordingly.
3. Nitrous Oxide Manifold - During the master alarm testing, the low pressure alarmed at 36 psig and needs to be adjusted to 42 psig.


Medical Air Compressor has a leak located at the beginning of the pipeline upstream of the flexible connection.


The Nitrous Oxide Manifold right bank ready light is out that needs to be replaced.


Compliance Deficiencies


A pressure/vacuum indicator shall be provided on the station outlet/inlet side of each zone valve per NFPA 99, Health Care Facilities Code, 2012 Edition, Section 5.1.4.8.3 and is not in the following areas:
1. Surgical Services - left of OR 1
2. Surgical Services - right of OR 2
3. Surgical Services - left of OR entrance
4. ICU - across from ICU 2
5. Medical Surgical East - across from Inpatient Physical Rehab
6. Medical Surgical North - right of Medical Surgical North Entrance
7. Radiology - left of X-Ray entrance


Piping shall be labeled by stenciling or adhesive markers that identify the patient gas, support gas, or the vacuum and include the gas or system color code per NFPA 99, Health Care Facilities Code, 2012 Edition, Section 5.1.11.1.1 (2) and are not in the following areas:
1. Surgical Services - medical air zone valve located left of OR 1
2. Surgical Services - WAGD label needed on vacuum zone valve
3. Surgical Services - medical air zone valve located right of OR 2
4. Surgical Services - vacuum zone right of OR 2
5. Surgical Services - WAGD label needed on vacuum zone valve
6. Surgical Services - medical air zone valve located left of OR entrance
7. ICU - medical air zone valve across from ICU 2
8. Medical Surgical East - medical air zone valve and placard across from Inpatient Physical Rehab
9. Women's Imaging/Endo - vacuum and medical air zone valves across from Women's Imaging Consultation
10. Master Alarms and Sources - Vacuum Pump (New) - PVC piping in OR corridor
11. Master Alarms and Sources - Vacuum Pump (Old)


Each station outlet/inlet for medical gases or vacuums shall be gas specific per NFPA 99, Health Care Facilities Code, 2012 Edition, Section 5.1.5.1 and WAGD networks shall provide a WAGD inlet in all locations where nitrous oxide or halogenated anesthetic gas is intended to be administered per NFPA 99, Health Care Facilities Code, 2012 Edition, Section 5.1.5.16.1 (1) and does not in the following areas:
1. Surgical Services - both evacuation inlets in OR 1 are not gas specific with WAGD connections
2. Surgical Services - both evacuation inlets in OR 2 are not gas specific with WAGD connections


Color and pressure requirements shall be in accordance with Table 5.1.11 per NFPA 99, Health Care Facilities Code, 2012 Edition, Section 5.1.11 and station outlets and inlets shall be identified as to the name or chemical symbol for the specific medical gas or vacuum provided per NFPA 99, Health Care Facilities Code, 2012 Edition, Section 5.1.11.3.1 and do not in the following areas:
1. Surgical Services - all outlets in OR 1
2. Surgical Services - all outlets in OR 2
3. Surgical Services - all outlets in PACU Bays
4. Surgical Services - all outlets in OR 3
5. Surgical Services - Blood Gas
6. ICU - all outlets in this department
7. Medical Surgical East - all outlets in this department
8. Medical Surgical North - all outlets in this department


Zone valve boxes shall not be installed behind a normally open or normally closed doors or otherwise hidden from plain view per NFPA 99, Health Care Facilities Code, 2012 Edition, Section 5.1.4.8.5 and are in the following areas:
1. Surgical Services - left of OR entrance
2. Medical Surgical East - across from Inpatient Physical Rehab
3. Radiology - left of X-Ray entrance


Shutoff valves shall be identified with the room or area served per NFPA 99, Health Care Facilities Code, 2012 Edition, Section 5.1.11.2.1 (2) and are not in the following areas;
1. Surgical Services - nitrous oxide zone valve to the left of OR entrance
2. Surgical Services - medical air zone valve to the left of OR entrance


WAGD shall be installed where nitrous oxide or halogenated anesthetic gas is intended to be administered per NFPA 99, Health Care Facilities Code, 2012 Edition, Section 5.1.5.16 and are not in Surgical Services OR 3.


Area alarms shall be labeled for the area of their surveillance per NFPA 99, Health Care Facilities Code, 2012 Edition, Section 5.1.9.1 (7) and Section 5.1.11.4 and are not for the Medical Surgical East nurse's station medical air module.


New or replacement zone valves shall consist of of three pieces permitting in-line serviceability per NFPA 99, Health Care Facilities Code, 2012 Edition, Section 5.1.4.3. and are not in the following areas:
1. Medical Surgical North - oxygen zone valve - right of Medical Surgical North Entrance
2. Master Alarms and Sources - Vacuum Pump (New)


All station outlets/inlets shall be supplied through a zone valve per per NFPA 99, Health Care Facilities Code, 2012 Edition, Section 5.1.4.8 and are not in Medical Surgical North for all vacuum inlets.


The medical-surgical vacuum and WAGD systems shall not be used for nonmedical applications per NFPA 99, Health Care Facilities Code, 2012 Edition, Section 5.1.14.1.4 and is not in the Women's Imaging/Endo Scope Room.


Medical air sources shall be used only for air in the application of human respiration and calibration of medical devices for respiratory application per NFPA 99, Health Care Facilities Code, 2012 Edition, Section 5.1.3.6.2 and is not in the Women's Imaging/Endo Scope Room.


Outdoor locations for central supply systems and the storage of positive-pressure gases shall be provided with an enclosure constructed of noncombustible materials with a minimum of two entry/exits per NFPA 99, Health Care Facilities Code, 2012 Edition, Section 5.1.3.3.2 (3) and is not for the Bulk Cryogenic Liquid System.


A shutoff valve shall be placed at the immediate connection of each source system to the piped distribution system to allow the entire source, including all accessory devices, to be isolated from the facility per NFPA 99, Health Care Facilities Code, 2012 Edition, Section 5.1.4.4. and is not in the following areas:
1. Master Alarms and Sources - Oxygen Supply System
2. Master Alarms and Sources - Medical Air Compressor
3. Master Alarms and Sources - Vacuum Pump (Old)


Main line valves shall be labeled with the name or chemical symbol for the specific medical gas or vacuum system and caution to not close or open the valve except in emergency per NFPA 99, Health Care Facilities Code, 2012 Edition, Section 5.1.4.5.3, Section 5.1.11.2.1 (1) and Section 5.1.11.2.1 (3) and are not for the Oxygen Supply System.


New or replacement check valves shall not have threaded connections per NFPA 99, Health Care Facilities Code, 2012 Edition, Section 5.1.4.11 (4) and do in the following areas:
1. Master Alarms and Sources - Oxygen Supply System - oxygen in-line check valve for the main piping
2. Master Alarms and Sources - Emergency Oxygen Supply Connection - oxygen in-line check valve for the emergency piping


The scale range of positive pressure analog indicators shall be such that the normal operating pressure is within the middle third of the total range per NFPA 99, Health Care Facilities Code, 2012 Edition, Section 5.1.8.1.3 and is not in the following areas:
1. Master Alarms and Sources - Oxygen Supply System - Pressure indicator adjacent to the oxygen high/low pressure switch is a 0-200 psig gauge which does not have the normal operating pressure within the middle third of the total range.
2. Master Alarms and Sources - Nitrous Oxide Manifold - Pressure indicator adjacent to the nitrous oxide high/low pressure switch is a 0-200 psig gauge which does not have the normal operating pressure within the middle third of the total range.


Pressure/vacuum indicators shall be readable from a standing position per NFPA 99, Health Care Facilities Code, 2012 Edition, Section 5.1.8.2.1 and are not in the following areas:
1. Master Alarms and Sources - Oxygen Supply System - adjacent to the oxygen high/low pressure switch
2. Master Alarms and Sources - Nitrous Oxide Manifold - adjacent to the nitrous high/low pressure switch
3. Master Alarms and Sources - Vacuum Pump (New) - adjacent to the vacuum low switch


All pressure-sensing devices and main line pressure gauges downstream of the source valves shall be provided with a gas- specific demand check fitting to facilitate service testing or replacement per NFPA 99, Health Care Facilities Code, 2012 Edition, Section 5.1.8.2.3 and are not for Medical Air Compressor final line gauge.


Positive pressure patient gas systems, medical support gas systems, vacuum systems and WAGD systems shall have all turns, offsets, and other changes in direction made using fittings or techniques appropriate per NFPA 99, Health Care Facilities Code, 2012 Edition, Section 5.1.10.3.1 and are not in the following areas:
1. Master Alarms and Sources - Medical Air Compressor -intake piping is soft-soldered
2. Master Alarms and Sources - Nitrous Oxide Manifold - pressure relief piping is soft-soldered
3. Master Alarms and Sources - Vacuum Pump (New) - main piping in the shell space is soft-soldered
4. Master Alarms and Sources - Vacuum Pump (New) - exhaust piping is soft-soldered
5. Master Alarms and Sources - Vacuum Pump (Old) - main piping is soft-soldered
6. Master Alarms and Sources - Vacuum Pump (Old) - exhaust piping is soft-soldered


The medical air intake shall be located a minimum of 25 ft from ventilating system exhausts, fuel storage vents, combustion vents, plumbing vents, vacuum and WAGD discharges or areas that can collect vehicular exhausts or noxious fumes per NFPA 99, Health Care Facilities Code, 2012 Edition, Section 5.1.3.6.3.12 (B) and is not for the Medical Air Compressor.


Indoor locations for central supply systems and the storage of positive-pressure gases shall be constructed and use interior finishes of noncombustible or limited-combustible materials such that all walls, floors, ceilings, and doors are of a minimum 1-hour resistance rating per NFPA 99, Health Care Facilities Code, 2012 Edition, Section 5.1.3.3.2 (4) and is not for the Nitrous Oxide Manifold.


Locations containing positive-pressure gases other than oxygen and medical air shall have their door labeled per NFPA 99, Health Care Facilities Code, 2012 Edition, Section 5.1.3.1.8. and it is not for the Nitrous Oxide Manifold.


Mechanical exhaust inlets shall be unobstructed and shall draw air from within 1 ft of the floor and adjacent to the cylinder or containers per NFPA 99, Health Care Facilities Code, 2012 Edition, Section 9.3.7.5.3.3 and is not for the Nitrous Oxide Manifold.


When vented outside, relief valve vent lines shall in any manner that will distinguish them from the medical gas pipeline per NFPA 99, Health Care Facilities Code, 2012 Edition, Section 5.1.3.5.6.4 and does not for the Nitrous Oxide Manifold.


The alarm indications shall originate from sensors installed in the main lines immediately downstream of the source valves per NFPA 99, Health Care Facilities Code, 2012 Edition, Section 5.1.9.2.5. and is not for the following areas:
1. Master Alarms and Sources - Nitrous Oxide Manifold - high/low pressure switch
2. Master Alarms and Sources - Vacuum Pump (New) - vacuum low switch


Piping for vacuum systems shall be constructed of hard-drawn seamless copper tube or stainless steel tube per NFPA 99, Health Care Facilities Code, 2012 Edition, Section 5.1.10.2.1. and is not for the Vacuum Pump (New).


Pressure/vacuum indicators shall be provided adjacent to the alarm-initiating device for source main line pressure and vacuum alarms in the master alarm system per NFPA 99, Health Care Facilities Code, 2012 Edition, Section 5.1.8.2.2 (1) and is not for the Vacuum Pump (Old).


A master alarm system shall be provided to monitor the operation and condition of the source of supply, the reserve source, and the pressure in the main lines of each medical gas and vacuum piping system per NFPA 99, Health Care Facilities Code, 2012 Edition, Section 5.1.9.2. and is not for the Vacuum Pump (Old).



Inspection Report is attached.

These findings were confirmed with Director of Plant Operations the at the time of record review.