HospitalInspections.org

Bldg A1 - Hospital
It was determined by observation during the course of the survey on July 30 to Aug 2, 2013 that the facility failed to maintain the fire protection features to the building structure in accordance with Life Safety Code section 19.1.6.2. This was evidenced by the following:

1.) The required fire tape was missing from a section of the gypsum drywall, approximately 18"x18", that had been used as an attic access hole in the Phone / Electrical Room.
This deficient practice could affect an indeterminate number of staff and visitors, located within this smoke compartment.
2.) The Radiology Generator Closet for the CT had two unsealed 3" diameter holes in the drywall ceiling at electrical penetrations.
This deficient practice could affect all of the six patient beds, as well as staff and visitors, located within this smoke compartment.
These sections of drywall must be reconstructed to maintain the integrity of the one-hour fire rating that the gypsum board ceiling assembly originally provided.

Each of the building structure deficiency items were discussed with the Plant Operations Manager during a tour of the facility.

Bldg. A5 - Granby Hospital
It was determined by observation during the course of the survey on July 30 to Aug 2, 2013 that the facility failed to maintain the fire protection features to the building structure in accordance with Life Safety Code section 18.1.6.2. This was evidenced by the following:

1.) The hospital facility was identified to be constructed as a Type II (000) structure, however, an exposed wood ceiling, wood truss system and wood beams were observed to be attached to the building structure located outside the facility and above the emergency entrance that is cause for the structure to be rated as Type V (000) construction.

Life Safety Code (2000) section 18.1.6.2 does not permit a New Healthcare Occupancy to be classified as Type V (000).

In accordance with NFPA 101 Section 8.2.1 states " Where the building or facility includes additions or connected structures of different construction types, the rating and classification of the structure shall be based on either of the following:
(1) Separate buildings if a 2-hour or greater vertically-aligned fire barrier wall in accordance with NFPA 221, Standard for Fire Walls and Fire Barrier Walls, exists between the portions of the building.
Exception: The requirement of 8.2.1(1) shall not apply to previously approved separations between buildings.
(2) The least fire-resistive type of construction of the connected portions, if no such separation is provided.

2.) The two hour rated fire barrier wall was observed with a minimum of four unsealed 3/4" diameter sleeve penetrations in the Prep / Recovery area near bay 1501 and 1506.

This deficient practice could affect each of the two residents, as well as staff and visitors, located within the smoke compartment or facility.

Each of the building structure deficiency items were discussed with the Plant Operations Manager during a tour of the facility.

Bldg. A5 - Granby Hospital
It was determined by observation during the course of the survey on July 30 to Aug 2, 2013 that the facility failed to provide proper smoke resistive separation between common use areas and the egress corridor in accordance with the Life Safety Code section 18.3.6.1. This was evidenced by the following:

The CT Control Room #1204 was determined to be an area open to the egress corridor. The sliding door to the corridor was without a positive latching mechanism.
This use area and corridor were protected by automatic (quick response) sprinklers. Only the corridor was protected by an automatic smoke detection system. This use area was not protected by an automatic smoke detection system.

The Life Safety Code section 18.3.6.1, exception #1 states: Smoke compartments protected throughout by an automatic sprinkler system shall be permitted to have spaces unlimited in size open to the corridor, provided that all the following criteria is met:
a) The space is not used for patient sleeping or treatment rooms.
b) The corridors onto which the spaces open are protected by an automatic smoke detection system, OR the smoke compartment where the space is located is protected throughout by quick response sprinklers.
c) The open space is protected by an automatic smoke detection system OR the entire space is arranged and located to allow direct supervision by staff from a nurse's station or similar space.
d) The space does not obstruct access to exits.

This deficient practice could affect an indeterminate number of staff and visitors located within this smoke compartment.

This corridor deficiency item was discussed with the Plant Operations Manager during a tour of the facility.

Bldg A1 - Hospital
It was determined by observation during the survey on July 30 to Aug 2, 2013that the facility failed to maintain two exits from each fire section of the building in accordance with section 19.2.4 the Life Safety Code. This was evidenced by the following:

The power sliding exit door located in the Foyer of the north wing and near the Radiology Suite would not swing to the fully open position when the electrical power was dropped and operated in the emergency exit mode. The bottom of the door was hitting / dragging on the tile floor.
This deficient practice could affect an indeterminate number of staff and visitors located within this smoke compartment.

This exit door deficiency item was discussed with the Plant Operations Manager during a tour of the facility.

Bldg A1 - Hospital
It was determined by record review during the course of the survey on July 30 to Aug 2, 2013 that documentation was not available on the required annual testing of battery operated emergency corridor, exit and task lighting unit that will be used to illuminate the means of egress and / or essential work space during a power outage in accordance with LSC section 19.2.9. This was evidenced by the following:

Maintenance staff stated that documentation either was not able to be retrieved from digital record storage, or was not available, regarding an annual 90 minute functional test conducted on each battery operated emergency lighting unit located at the facility. Battery operated emergency lighting units were observed at the emergency power supply system's generator location as well as at various light locations throughout the facility.
NOTE: The existing automatic transfer switch (ATS) location in the electrical / boiler room is currently capable of being illuminated by the shining of automotive headlights directly into the room. This access and capability must be maintained or a battery operated emergency lighting unit may be required at the ATS location.
This deficient practice could potentially affect 100% of the facility's patients, as well as staff and visitors, located within the facility.

This emergency lighting deficiency item was discussed with the Plant Operations Manager during a review of the facility's required documentation and during a tour of the facility.

Bldg. A5 - Granby Hospital
It was determined by record review during the course of the survey on July 30 to Aug 2, 2013 that documentation was not available on the required annual 90 minute testing of battery operated emergency corridor, exit and task lighting unit that will be used to illuminate the means of egress and / or essential work space during a power outage in accordance with LSC section 18.2.9. This was evidenced by the following:

Maintenance staff stated that documentation either was not able to be retrieved from digital record storage, or documentation was not available, regarding an annual 90 minute functional test conducted on each battery operated emergency lighting unit located at the facility. Battery operated emergency lighting units were observed at the emergency power supply system's generator location and at the automatic transfer switch as well as at various light locations throughout the facility.
This deficient practice could potentially affect 100% of the facility's patients, as well as staff and visitors, located within the facility.

This emergency lighting deficiency item was discussed with the Plant Operations Manager during a review of the facility's required documentation and during a tour of the facility.

Bldg. A5 - Granby Hospital
It was determined by observation during the course of the survey on July 30 to Aug 2, 2013 that the facility failed to install / maintain the exit and directional signs that mark the means of egress within all areas of the facility in accordance with Life Safety Code section 18.2.10.1. This was evidenced by the following:

A directional exit sign was not visible from within the hallway of the OR suite while standing in the Sterile Storage / Soiled Utility Hall, or from OR #1 / Anesthesia Work Room.
This deficient practice could affect all of the staff and any patient located within this smoke compartment.

This exit sign deficiency item was discussed with the Plant Operations Manager during a tour of the facility.

Bldg A1 - Hospital
It was determined by documentation review and staff interview during the survey on July 30 to Aug 2, 2013, that the facility failed to hold a quarterly fire drill on each shift, as a minimum, in accordance with Life Safety Code section 19.7.1. This was evidenced by the following:

Fire drill records were not available for:
a) the night shift in the 2nd calendar quarter of 2013, and
b) the night shift in the 4th calendar quarter of 2012.
Staff stated that the facility operates using two 12 hour shifts per day from 6:00 to 6:00.

Fire drills held within the past 12 months were documented as occurred on:
6/26/2013 at 12:30 pm on Day shift
4/1/2013 at 4:00 pm on Day shift
3/27/2013 on Night shift
12/29/2012 on Day shift
9/10/2012 at 12:12 pm on Day shift
9/10/2012 at 9:05 pm on Night shift
6/14/2012 on Night shift
6/8/2012 on Day shift
This deficient practice has the potential to affect all residents, as well as staff and visitors, located within the facility.

Each of the fire drill deficiency items were discussed with the Plant Operations Manager during a review of the facility's required documentation.

Bldg. A5 - Granby Hospital
It was determined by documentation review and staff interview during the survey on July 30 to Aug 2, 2013, that the facility failed to hold a quarterly fire drill on each shift, as a minimum, in accordance with Life Safety Code section 18.7.1. This was evidenced by the following:

Fire drill records were not available for:
a) the night shift in the 2nd calendar quarter of 2013,
b) the day shift in the 1st calendar quarter of 2013,
c) the day shift in the 4th calendar quarter of 2012,
d) the night shift in the 4th calendar quarter of 2012,
e) the day shift in the 3rd calendar quarter of 2012.
Staff stated that the facility operates using two 12 hour shifts per day from 6:00 to 6:00.

Fire drills held within the past 12 months were documented as occurred on:
5/21/2013 on Day shift
4/2/2013 on Day shift
3/28/2013 on Night shift
9/30/2012 on Night shift
6/26/2012 on Day shift
6/25/2012 on Night shift

This deficient practice has the potential to affect all residents, as well as staff and visitors, located within the facility.

Each of the fire drill deficiency items were discussed with the Plant Operations Manager during a review of the facility's required documentation.

Bldg A1 - Hospital
It was determined by observation during the course of the survey on July 30 to Aug 2, 2013that the facility failed to maintain the fire alarm system to assure reliable operation in accordance with section 19.3.4 of the Life Safety Code and NFPA 72, National Fire Alarm Code. This was evidenced by the following:

The smoke detector located in the east corridor was loose and not mounted securely to the ceiling with up to a ?" gap between the top of the smoke detector and the drywall ceiling.
This deficient practice could affect all of the six patient beds, as well as staff and visitors, located within this smoke compartment.

This smoke detection and alarm system deficiency item was discussed with the Plant Operations Manager during a tour of the facility.

Bldg A1 - Hospital
It was determined by observation during the course of the survey on July 30 to Aug 2, 2013that the facility failed to provide a fire alarm and smoke detection system to assure reliable signal initiation and alarm notification in accordance with National Fire Protection Association (NFPA) 72, National Fire Alarm Code and the Life Safety Code. This was evidenced by the following:

The 5'6" wide by 30 feet long corridor to the Dining Room was observed to not be provided with smoke detection coverage.
This smoke detection and alarm system deficient practice could affect 100% of the facility's patients, as well as staff and visitors, located within this smoke compartment.

This deficiency was discussed with the Plant Operations Manager during a tour of the facility.

Bldg A1 - Hospital
It was determined by a review of records during the survey on July 30 to Aug 2, 2013, that the facility failed to properly maintain the smoke detection system in accordance with sections 19.3.4 and 9.6 of the Life Safety Code and NFPA 72, National Fire Alarm Code. This was evidenced by the following:

A review of the fire alarm/smoke detection system maintenance records indicated that current records (within the past 24 months) were not available on premises that documented the required sensitivity test for each smoke detector installed within the facility.
Sensitivity testing of each individual smoke detector is a part of the bi-annual routine service and inspection program and must be performed every two years on each smoke detector or per manufacturer's recommendations.
This deficient practice could affect 100% of the facility's patients, as well as staff and visitors, located within this smoke compartment or facility.

The sensitivity testing deficiency item was discussed with the Plant Operations Manager during a review of the facility's required documentation.

Bldg. A5 - Granby Hospital
It was determined by a review of records during the survey on July 30 to Aug 2, 2013, that the facility failed to properly maintain the smoke detection system in accordance with sections 19.3.4 and 9.6 of the Life Safety Code and NFPA 72 (1999 edition), National Fire Alarm Code. This was evidenced by the following:

A review of the fire alarm/smoke detection system maintenance records indicated that current records (within the past 12 months) were not available on premises that documented the required sensitivity test for each smoke detector installed within the facility. Records indicated that this facility had a new fire alarm/smoke detection system installed in approximately October 2011.
NFPA 72 Section 7-3.2.1 states "Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter.

This deficient practice could affect 100% of the facility's patients, as well as staff and visitors, located within this smoke compartment or facility.

The sensitivity testing deficiency item was discussed with the Plant Operations Manager during a review of the facility's required documentation.

Bldg. A5 - Granby Hospital
It was determined by observation during the survey on July 30 to Aug 2, 2013 that the facility failed to provide a complete coverage automatic fire sprinkler system, installed in accordance with NFPA Standard 13, Installation of Sprinkler Systems (and properly maintained in accordance with NFPA 25,) for all portions of the facility. This was evidenced by the following locations that were not protected by the fire sprinkler system:

1.) A combustible wood framed maintenance storage shed, approximately 5' x 8' x 8', was located on the outside of the facility and butted against the facility structure using the wall of the structure as a wall of the shed. The shed was not protected by the automatic sprinkler system.

2.) The facility failed to provide sprinkler protection to a combustible plastic film that covered the 10' x 14' expandable canopy frame that was attached to the building over the MRI Entrance / exit.
Note: documentation was not provided by the facility to prove that the fabric canopy in question meets the definition of either " non-combustible " or " limited-combustible, " and, therefore, must be sprinkler protected as required. NFPA 13, Installation of Sprinkler Systems, 5-13.8 states: Sprinklers shall be installed under exterior roofs or canopies exceeding 4 ft (1.2 m) in width. Exception: Sprinklers are permitted to be omitted where the canopy or roof is of noncombustible or limited combustible construction.

NFPA 13, defines Noncombustible as: A material that, in the form in which it is used and under the conditions anticipated, will not ignite, burn, support combustion, or release flammable vapors when subjected to fire or heat. Materials that are reported as passing ASTM E 136, Standard Test Method for Behavior of Materials in a Vertical Tube Furnace at 750?C, shall be considered noncombustible materials.

And, it defines Limited Combustible as: As applied to a building construction material, a material not complying with the definition of noncombustible material that, in the form in which it is used, has a potential heat value not exceeding 3500 Btu per lb (8141 kJ/kg) and complies with one of the following, (a) or (b). Materials subject to increase in combustibility or flame spread rating beyond the limits herein established through the effects of age, moisture, or other atmospheric condition shall be considered combustible. (a) Materials having a structural base of noncombustible material, with a surfacing not exceeding a thickness of 1/8 in. (3.2 mm) that has a flame spread rating not greater than 50. (b) Materials, in the form and thickness used, other than as described in (a), having neither a flame spread rating greater than 25 nor evidence of continued progressive combustion and of such composition that surfaces that would be exposed by cutting through the material on any plane would have neither a flame spread rating greater than 25 nor evidence of continued progressive combustion.

This deficient practice could affect 100% of the facility's patients, as well as staff and visitors, located within this smoke compartment or facility.

The sprinkler protection deficiency items were discussed with the Plant Operations Manager during a tour of the facility.

Bldg A2 - Admin Building
It was determined by observation during the course of the survey on July 30 to Aug 2, 2013 that the facility failed to maintain the automatic fire sprinkler system in accordance with NFPA 13, Installation of Sprinkler Systems and / or NFPA 25, Inspection, Testing and Maintenance of Water-Based Fire Protection Systems. This was evidenced by the following:

1.) The required escutcheon plates around sprinkler heads were missing or loose and not tight to the ceiling. In addition, this exposed the hole cut into the drywall ceiling for the sprinkler piping installation, with a substantial gap up to ?" around the circumference of the sprinkler piping, exposing the structural framing members and effecting thermal activation properties of the sprinkler heads. This was observed in:
a) the corridor outside the COO office,
b) the corridor outside the HR office,
c) in the Medical Records office,
d) in the Laundry Room,
e) in the Conference Room (2x).
An approved escutcheon plate that is compatible with the model of sprinkler head used must be maintained tightly in place to cover the hole in accordance with 1999 NFPA 13 section 3-2.7. The escutcheon plates used must be part of a listed sprinkler head assembly per 1999 NFPA 13 section 3-2.7.


2.) Air / water pressure gauges were not replaced, or recalibrated, every five (5) years in accordance with (1998) NFPA 25, section 2-3.2. The fire sprinkler riser was observed with two water pressure gauges located at the sprinkler system riser that were dated 2007.

3.) The automatic fire sprinkler system's three (3) water flow alarms and dry pipe low air pressure alarms were not tested timely and on a quarterly basis, with tamper switches tested on a semi-annual basis, as required and in accordance with NFPA 25 section 9-1. Fire alarm and Sprinkler system inspection records, dated July 8, 2013 documented the only testing of the water flow alarms and tamper switches during the past 12 month / annual inspection cycle. Maintenance staff stated that other documentation was not available regarding quarterly testing that should have been scheduled in a timely manner to take place in October, January and April (based on a July 8, 2013 annual inspection according to facility records).
An automatic fire sprinkler system is not a LSC requirement for an existing business occupancy, however, in accordance with (2000 edition) LSC section 4.6.12.2* states "Existing life safety features obvious to the public, if not required by the Code, shall be either maintained or removed."
Each of the fire sprinkler system deficient items could potentially affect 100% of the patients, as well as staff and visitors, located within the Administration Building.

These fire sprinkler system deficiency items were discussed with the Plant Operations Manager during a tour of the facility or during a review of the facility's required documentation.

Bldg. A5 - Granby Hospital
It was determined by observation during the course of the survey on July 30 to Aug 2, 2013 that the facility failed to maintain the automatic fire sprinkler system in accordance with LSC section 18.3.5 and NFPA 13, Installation of Sprinkler Systems and / or NFPA 25, Inspection, Testing and Maintenance of Water-Based Fire Protection Systems. This was evidenced by the following:

1.) Air / water pressure gauges were not replaced, or recalibrated, every five (5) years in accordance with (1998) NFPA 25, section 2-3.2. The base of the fire sprinkler riser, located in the Fire Riser Room, was observed with a water pressure gauge that was dated 2006.

2.) The automatic fire sprinkler system's water flow alarms and dry pipe low air pressure alarms were not tested timely and on a quarterly basis, with tamper switches tested on a semi-annual basis, as required and in accordance with NFPA 25 section 9-1. Fire alarm and Sprinkler system inspection records, dated July 8, 2013 documented the only testing of the water flow alarms and tamper switches during the past 12 month / annual inspection cycle. Maintenance staff stated that other documentation was not available regarding quarterly testing that should have been scheduled in a timely manner to take place in October, January and April (based on a July 8, 2013 annual inspection according to facility records).

Each of the fire sprinkler system deficient items could potentially affect 100% of the patients, as well as staff and visitors, located within the Administration Building.

These fire sprinkler system deficiency items were discussed with the Plant Operations Manager during a tour of the facility or during a review of the facility's required documentation.

Bldg A1 - Hospital
It was determined by record review and staff interview during the course of the survey on July 30 to Aug 2, 2013, the facility failed to perform and document the exercising of all fire and / or smoke dampers to verify they fully close, and latch if provided, with moving parts lubricated and fusible links replaced, as necessary, at least every six years, in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilation Systems; section 3-4.7 Maintenance. This was evidenced by the following:

A review of the facility's maintenance records and interview with maintenance staff indicated there were no current records on premises, or they could not be located, that documented that fire and / or smoke damper testing and maintenance was performed within the past six years as required.
Maintenance staff stated that fire / smoke dampers existed within the facility but was not aware of how many dampers there were.
This deficient practice could affect 100% of the facility's patients, as well as staff and visitors, located within the facility.

The fire damper deficiency item was discussed with the Plant Operations Manager during a review of the facility's required documentation.

Bldg A1 - Hospital
It was determined by observation during the survey on July 30 to Aug 2, 2013, that the facility failed to provide a piped-in medical gas system meeting the requirements of (1999) NFPA 99, Health Care Facilities. This was evidenced by the following:

A review of the medical gas system annual evaluation / inspection, test and maintenance records, provided by an independent medical gas system contractor to the facility, and dated January 2013, documented deficiency items that had not yet been corrected at the time of this survey, to include:

1.) Vacuum station outlet was provided without a shutoff zone valve in accordance with section 4-3.1.2.3(d). Locations are:
a) in the ER,
b) OR,
c) Nurse Office / Bird Room,
d) Laboratory,
e) Patient Room 1-2,
f) Patient Room 3-8, 10,
g) Patient room #9 (intensive care).
2.) A pressure / vacuum gage was not provided downstream from the zone valve, in accordance with section 4-3.1.2.3(d). Locations are:
a) in the ER,
b) OR,
c) Nurse Office / Bird Room,
d) Laboratory,
e) Patient Room 1-2,
f) Patient Room 3-8, 10,
g) Patient room #9 (intensive care)
h) Main hospital supply.

3.) Manual shut off valves in boxes shall be installed were they are visible and accessible at all times ... otherwise not hidden from plain view, in accordance with section 4-3.1.2.3(i). Locations are:
a) Patient Room 3-8, 10.

This deficient practice could potentially affect 100% of the patients located within this facility.

The medical gas system deficiency items were discussed with the Plant Operations Manager during a tour of the facility.

Bldg A1 - Hospital
It was determined by record review and staff interview during the course of the survey on July 30 to Aug 2, 2013 that the facility failed to properly maintain and test the emergency power source in accordance with LSC section 19.2.9, referenced section 7.9 and referenced (1999) NFPA 99 Health Care Facilities, section 3-4 for a Type I system and referenced NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6. This was evidenced by the following:

1.) Maintenance staff stated that documentation was not available for review regarding, at minimum, an annual inspection with required preventive maintenance conducted within the past 12 months, to the Emergency Power Supply System (EPSS), including the automatic transfer switch, by a properly trained, qualified, and certified company that performs maintenance, inspection and testing of the emergency generator secondary power supply system.

2.) Monthly load testing of the diesel powered Emergency Power Supply System (EPSS) was not conducted at 30% or greater of the EPSS nameplate rating in accordance with NFPA 110 section 6-4.2,. The facility's monthly load testing documentation, dated 6/24/2013, indicated that for the 155 Kilo-Watt EPS diesel generator, with the output of 212 volts with 3-phase amperage at 110 amps, 109 amps and 118 amps.
It was determined that the monthly load test of the generator must be operated to maintain a minimum of 127 amps for each of three phases for thirty minutes in order to achieve 30% of the EPS's nameplate rating.
Alternatively, an option to providing monthly load tests at 127 amps minimum is to provide an annual 2-hour load bank test in accordance with NFPA 110 and in conjunction with the (current) monthly load tests conducted under the existing available load.
Each of the EPSS deficient items could affect 100% of the patients, as well as all staff and any visitors, located within this facility.

The emergency power supply system deficiency items were discussed with the Plant Operations Manager during a review of the facility's required documentation.

Bldg. A5 - Granby Hospital
It was determined by record review and staff interview during the course of the survey on July 30 to Aug 2, 2013 that the facility failed to properly maintain and test the emergency power source in accordance with LSC section 18.2.9, referenced section 7.9 and referenced (1999) NFPA 99 Health Care Facilities, section 3-4 for a Type I system and referenced NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6. This was evidenced by the following:

1.) Maintenance staff stated that documentation was not available for review regarding, at minimum, an annual inspection with required preventive maintenance conducted within the past 12 months, to the Emergency Power Supply System (EPSS), including the automatic transfer switch, by a properly trained, qualified, and certified company that performs maintenance, inspection and testing of the emergency generator secondary power supply system.

2.) Monthly load testing of the diesel powered Emergency Power Supply System (EPSS) was not conducted at 30% or greater of the EPSS nameplate rating in accordance with NFPA 110 section 6-4.2. The facility's monthly load testing documentation, dated 4/9/2013, indicated that for the 230 Kilo-Watt EPS diesel generator, with the output of 286 volts with 3-phase amperage at 23 amps, 30 amps and 21 amps.
It was determined that the monthly load test of the generator must be operated to maintain a minimum of 139 amps for each of three phases for thirty minutes in order to achieve 30% of the EPS's nameplate rating.
Alternatively, an option to providing monthly load tests at 139 amps minimum is to provide an annual 2-hour load bank test in accordance with NFPA 110 and in conjunction with the (current) monthly load tests conducted under the existing available load.
Each of the EPSS deficient items could affect 100% of the patients, as well as all staff and any visitors, located within this facility.

The emergency power supply system deficiency items were discussed with the Plant Operations Manager during a review of the facility's required documentation.

Bldg A1 - Hospital
It was determined by observation and staff interview during the course of the survey on July 30 to Aug 2, 2013that the facility failed to provide and maintain a Type I emergency electrical system in accordance with NFPA 99 section 3-4.2.2.2(a).
This was evidenced by the following:

The electrical distribution system was not arranged properly to meet the specific requirements of a Type I essential emergency electrical system in accordance with NFPA 99 section 3-4.2.2. 2(a). The essential electrical system was identified as being arranged with the two required system panels, the emergency system and the equipment system. However, the emergency system panels were not identified as being further divided into the life safety branch and the critical branch. Only very specific functions are permitted to be placed on or connected to the Life Safety branch.
Panel board " ECA " was identified by a panel schedule to contain a list of circuits associated with the Fire Alarm system and Illumination of the Means of Egress that is required to be placed on the Life Safety branch, with a list of circuits associated with Nurse Call system, receptacles and task illumination located in patient care areas that are required to be placed on the Critical branch. Several circuits within the ECA panel board were not able to be evaluated offsite at this time for their appropriate placement either within the Life Safety branch or the Critical branch.
Likewise, panel board " ECB " was identified by a panel schedule to contain a list of circuits associated with the Fire Sprinkler system and Illumination of the Means of Egress that is required to be placed on the Life Safety branch, with a list of circuits associated with receptacles located in the Activity Room and Cardiac rehab areas, and lighting of OR, Sub-sterile room, Radiology and Activity areas that are required to be placed on the Critical branch or perhaps on the Equipment branch. Several circuits within the ECB panel board were not able to be evaluated offsite at this time for their appropriate placement either within the Life Safety branch or the Critical branch.
This deficient practice could affect 100% of the patients, as well as all staff and visitors, located within the hospital facility.

The distribution of the essential electrical system deficiency items were discussed with the CEO and the Plant Operations Manager during a tour of the facility.

Bldg A1 - Hospital
It was determined by observation during the course of the survey on July 30 to Aug 2, 2013 that the facility failed to maintain the fire protection features to the building structure in accordance with Life Safety Code section 19.1.6.2. This was evidenced by the following:

1.) The required fire tape was missing from a section of the gypsum drywall, approximately 18"x18", that had been used as an attic access hole in the Phone / Electrical Room.
This deficient practice could affect an indeterminate number of staff and visitors, located within this smoke compartment.
2.) The Radiology Generator Closet for the CT had two unsealed 3" diameter holes in the drywall ceiling at electrical penetrations.
This deficient practice could affect all of the six patient beds, as well as staff and visitors, located within this smoke compartment.
These sections of drywall must be reconstructed to maintain the integrity of the one-hour fire rating that the gypsum board ceiling assembly originally provided.

Each of the building structure deficiency items were discussed with the Plant Operations Manager during a tour of the facility.

Bldg. A5 - Granby Hospital
It was determined by observation during the course of the survey on July 30 to Aug 2, 2013 that the facility failed to maintain the fire protection features to the building structure in accordance with Life Safety Code section 18.1.6.2. This was evidenced by the following:

1.) The hospital facility was identified to be constructed as a Type II (000) structure, however, an exposed wood ceiling, wood truss system and wood beams were observed to be attached to the building structure located outside the facility and above the emergency entrance that is cause for the structure to be rated as Type V (000) construction.

Life Safety Code (2000) section 18.1.6.2 does not permit a New Healthcare Occupancy to be classified as Type V (000).

In accordance with NFPA 101 Section 8.2.1 states " Where the building or facility includes additions or connected structures of different construction types, the rating and classification of the structure shall be based on either of the following:
(1) Separate buildings if a 2-hour or greater vertically-aligned fire barrier wall in accordance with NFPA 221, Standard for Fire Walls and Fire Barrier Walls, exists between the portions of the building.
Exception: The requirement of 8.2.1(1) shall not apply to previously approved separations between buildings.
(2) The least fire-resistive type of construction of the connected portions, if no such separation is provided.

2.) The two hour rated fire barrier wall was observed with a minimum of four unsealed 3/4" diameter sleeve penetrations in the Prep / Recovery area near bay 1501 and 1506.

This deficient practice could affect each of the two residents, as well as staff and visitors, located within the smoke compartment or facility.

Each of the building structure deficiency items were discussed with the Plant Operations Manager during a tour of the facility.

Bldg. A5 - Granby Hospital
It was determined by observation during the course of the survey on July 30 to Aug 2, 2013 that the facility failed to provide proper smoke resistive separation between common use areas and the egress corridor in accordance with the Life Safety Code section 18.3.6.1. This was evidenced by the following:

The CT Control Room #1204 was determined to be an area open to the egress corridor. The sliding door to the corridor was without a positive latching mechanism.
This use area and corridor were protected by automatic (quick response) sprinklers. Only the corridor was protected by an automatic smoke detection system. This use area was not protected by an automatic smoke detection system.

The Life Safety Code section 18.3.6.1, exception #1 states: Smoke compartments protected throughout by an automatic sprinkler system shall be permitted to have spaces unlimited in size open to the corridor, provided that all the following criteria is met:
a) The space is not used for patient sleeping or treatment rooms.
b) The corridors onto which the spaces open are protected by an automatic smoke detection system, OR the smoke compartment where the space is located is protected throughout by quick response sprinklers.
c) The open space is protected by an automatic smoke detection system OR the entire space is arranged and located to allow direct supervision by staff from a nurse's station or similar space.
d) The space does not obstruct access to exits.

This deficient practice could affect an indeterminate number of staff and visitors located within this smoke compartment.

This corridor deficiency item was discussed with the Plant Operations Manager during a tour of the facility.

Bldg A1 - Hospital
It was determined by observation during the survey on July 30 to Aug 2, 2013that the facility failed to maintain two exits from each fire section of the building in accordance with section 19.2.4 the Life Safety Code. This was evidenced by the following:

The power sliding exit door located in the Foyer of the north wing and near the Radiology Suite would not swing to the fully open position when the electrical power was dropped and operated in the emergency exit mode. The bottom of the door was hitting / dragging on the tile floor.
This deficient practice could affect an indeterminate number of staff and visitors located within this smoke compartment.

This exit door deficiency item was discussed with the Plant Operations Manager during a tour of the facility.

Bldg A1 - Hospital
It was determined by record review during the course of the survey on July 30 to Aug 2, 2013 that documentation was not available on the required annual testing of battery operated emergency corridor, exit and task lighting unit that will be used to illuminate the means of egress and / or essential work space during a power outage in accordance with LSC section 19.2.9. This was evidenced by the following:

Maintenance staff stated that documentation either was not able to be retrieved from digital record storage, or was not available, regarding an annual 90 minute functional test conducted on each battery operated emergency lighting unit located at the facility. Battery operated emergency lighting units were observed at the emergency power supply system's generator location as well as at various light locations throughout the facility.
NOTE: The existing automatic transfer switch (ATS) location in the electrical / boiler room is currently capable of being illuminated by the shining of automotive headlights directly into the room. This access and capability must be maintained or a battery operated emergency lighting unit may be required at the ATS location.
This deficient practice could potentially affect 100% of the facility's patients, as well as staff and visitors, located within the facility.

This emergency lighting deficiency item was discussed with the Plant Operations Manager during a review of the facility's required documentation and during a tour of the facility.

Bldg. A5 - Granby Hospital
It was determined by record review during the course of the survey on July 30 to Aug 2, 2013 that documentation was not available on the required annual 90 minute testing of battery operated emergency corridor, exit and task lighting unit that will be used to illuminate the means of egress and / or essential work space during a power outage in accordance with LSC section 18.2.9. This was evidenced by the following:

Maintenance staff stated that documentation either was not able to be retrieved from digital record storage, or documentation was not available, regarding an annual 90 minute functional test conducted on each battery operated emergency lighting unit located at the facility. Battery operated emergency lighting units were observed at the emergency power supply system's generator location and at the automatic transfer switch as well as at various light locations throughout the facility.
This deficient practice could potentially affect 100% of the facility's patients, as well as staff and visitors, located within the facility.

This emergency lighting deficiency item was discussed with the Plant Operations Manager during a review of the facility's required documentation and during a tour of the facility.

Bldg. A5 - Granby Hospital
It was determined by observation during the course of the survey on July 30 to Aug 2, 2013 that the facility failed to install / maintain the exit and directional signs that mark the means of egress within all areas of the facility in accordance with Life Safety Code section 18.2.10.1. This was evidenced by the following:

A directional exit sign was not visible from within the hallway of the OR suite while standing in the Sterile Storage / Soiled Utility Hall, or from OR #1 / Anesthesia Work Room.
This deficient practice could affect all of the staff and any patient located within this smoke compartment.

This exit sign deficiency item was discussed with the Plant Operations Manager during a tour of the facility.

Bldg A1 - Hospital
It was determined by documentation review and staff interview during the survey on July 30 to Aug 2, 2013, that the facility failed to hold a quarterly fire drill on each shift, as a minimum, in accordance with Life Safety Code section 19.7.1. This was evidenced by the following:

Fire drill records were not available for:
a) the night shift in the 2nd calendar quarter of 2013, and
b) the night shift in the 4th calendar quarter of 2012.
Staff stated that the facility operates using two 12 hour shifts per day from 6:00 to 6:00.

Fire drills held within the past 12 months were documented as occurred on:
6/26/2013 at 12:30 pm on Day shift
4/1/2013 at 4:00 pm on Day shift
3/27/2013 on Night shift
12/29/2012 on Day shift
9/10/2012 at 12:12 pm on Day shift
9/10/2012 at 9:05 pm on Night shift
6/14/2012 on Night shift
6/8/2012 on Day shift
This deficient practice has the potential to affect all residents, as well as staff and visitors, located within the facility.

Each of the fire drill deficiency items were discussed with the Plant Operations Manager during a review of the facility's required documentation.

Bldg. A5 - Granby Hospital
It was determined by documentation review and staff interview during the survey on July 30 to Aug 2, 2013, that the facility failed to hold a quarterly fire drill on each shift, as a minimum, in accordance with Life Safety Code section 18.7.1. This was evidenced by the following:

Fire drill records were not available for:
a) the night shift in the 2nd calendar quarter of 2013,
b) the day shift in the 1st calendar quarter of 2013,
c) the day shift in the 4th calendar quarter of 2012,
d) the night shift in the 4th calendar quarter of 2012,
e) the day shift in the 3rd calendar quarter of 2012.
Staff stated that the facility operates using two 12 hour shifts per day from 6:00 to 6:00.

Fire drills held within the past 12 months were documented as occurred on:
5/21/2013 on Day shift
4/2/2013 on Day shift
3/28/2013 on Night shift
9/30/2012 on Night shift
6/26/2012 on Day shift
6/25/2012 on Night shift

This deficient practice has the potential to affect all residents, as well as staff and visitors, located within the facility.

Each of the fire drill deficiency items were discussed with the Plant Operations Manager during a review of the facility's required documentation.

Bldg A1 - Hospital
It was determined by observation during the course of the survey on July 30 to Aug 2, 2013that the facility failed to maintain the fire alarm system to assure reliable operation in accordance with section 19.3.4 of the Life Safety Code and NFPA 72, National Fire Alarm Code. This was evidenced by the following:

The smoke detector located in the east corridor was loose and not mounted securely to the ceiling with up to a ?" gap between the top of the smoke detector and the drywall ceiling.
This deficient practice could affect all of the six patient beds, as well as staff and visitors, located within this smoke compartment.

This smoke detection and alarm system deficiency item was discussed with the Plant Operations Manager during a tour of the facility.

Bldg A1 - Hospital
It was determined by observation during the course of the survey on July 30 to Aug 2, 2013that the facility failed to provide a fire alarm and smoke detection system to assure reliable signal initiation and alarm notification in accordance with National Fire Protection Association (NFPA) 72, National Fire Alarm Code and the Life Safety Code. This was evidenced by the following:

The 5'6" wide by 30 feet long corridor to the Dining Room was observed to not be provided with smoke detection coverage.
This smoke detection and alarm system deficient practice could affect 100% of the facility's patients, as well as staff and visitors, located within this smoke compartment.

This deficiency was discussed with the Plant Operations Manager during a tour of the facility.

Bldg A1 - Hospital
It was determined by a review of records during the survey on July 30 to Aug 2, 2013, that the facility failed to properly maintain the smoke detection system in accordance with sections 19.3.4 and 9.6 of the Life Safety Code and NFPA 72, National Fire Alarm Code. This was evidenced by the following:

A review of the fire alarm/smoke detection system maintenance records indicated that current records (within the past 24 months) were not available on premises that documented the required sensitivity test for each smoke detector installed within the facility.
Sensitivity testing of each individual smoke detector is a part of the bi-annual routine service and inspection program and must be performed every two years on each smoke detector or per manufacturer's recommendations.
This deficient practice could affect 100% of the facility's patients, as well as staff and visitors, located within this smoke compartment or facility.

The sensitivity testing deficiency item was discussed with the Plant Operations Manager during a review of the facility's required documentation.

Bldg. A5 - Granby Hospital
It was determined by a review of records during the survey on July 30 to Aug 2, 2013, that the facility failed to properly maintain the smoke detection system in accordance with sections 19.3.4 and 9.6 of the Life Safety Code and NFPA 72 (1999 edition), National Fire Alarm Code. This was evidenced by the following:

A review of the fire alarm/smoke detection system maintenance records indicated that current records (within the past 12 months) were not available on premises that documented the required sensitivity test for each smoke detector installed within the facility. Records indicated that this facility had a new fire alarm/smoke detection system installed in approximately October 2011.
NFPA 72 Section 7-3.2.1 states "Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter.

This deficient practice could affect 100% of the facility's patients, as well as staff and visitors, located within this smoke compartment or facility.

The sensitivity testing deficiency item was discussed with the Plant Operations Manager during a review of the facility's required documentation.

Bldg. A5 - Granby Hospital
It was determined by observation during the survey on July 30 to Aug 2, 2013 that the facility failed to provide a complete coverage automatic fire sprinkler system, installed in accordance with NFPA Standard 13, Installation of Sprinkler Systems (and properly maintained in accordance with NFPA 25,) for all portions of the facility. This was evidenced by the following locations that were not protected by the fire sprinkler system:

1.) A combustible wood framed maintenance storage shed, approximately 5' x 8' x 8', was located on the outside of the facility and butted against the facility structure using the wall of the structure as a wall of the shed. The shed was not protected by the automatic sprinkler system.

2.) The facility failed to provide sprinkler protection to a combustible plastic film that covered the 10' x 14' expandable canopy frame that was attached to the building over the MRI Entrance / exit.
Note: documentation was not provided by the facility to prove that the fabric canopy in question meets the definition of either " non-combustible " or " limited-combustible, " and, therefore, must be sprinkler protected as required. NFPA 13, Installation of Sprinkler Systems, 5-13.8 states: Sprinklers shall be installed under exterior roofs or canopies exceeding 4 ft (1.2 m) in width. Exception: Sprinklers are permitted to be omitted where the canopy or roof is of noncombustible or limited combustible construction.

NFPA 13, defines Noncombustible as: A material that, in the form in which it is used and under the conditions anticipated, will not ignite, burn, support combustion, or release flammable vapors when subjected to fire or heat. Materials that are reported as passing ASTM E 136, Standard Test Method for Behavior of Materials in a Vertical Tube Furnace at 750?C, shall be considered noncombustible materials.

And, it defines Limited Combustible as: As applied to a building construction material, a material not complying with the definition of noncombustible material that, in the form in which it is used, has a potential heat value not exceeding 3500 Btu per lb (8141 kJ/kg) and complies with one of the following, (a) or (b). Materials subject to increase in combustibility or flame spread rating beyond the limits herein established through the effects of age, moisture, or other atmospheric condition shall be considered combustible. (a) Materials having a structural base of noncombustible material, with a surfacing not exceeding a thickness of 1/8 in. (3.2 mm) that has a flame spread rating not greater than 50. (b) Materials, in the form and thickness used, other than as described in (a), having neither a flame spread rating greater than 25 nor evidence of continued progressive combustion and of such composition that surfaces that would be exposed by cutting through the material on any plane would have neither a flame spread rating greater than 25 nor evidence of continued progressive combustion.

This deficient practice could affect 100% of the facility's patients, as well as staff and visitors, located within this smoke compartment or facility.

The sprinkler protection deficiency items were discussed with the Plant Operations Manager during a tour of the facility.

Bldg A2 - Admin Building
It was determined by observation during the course of the survey on July 30 to Aug 2, 2013 that the facility failed to maintain the automatic fire sprinkler system in accordance with NFPA 13, Installation of Sprinkler Systems and / or NFPA 25, Inspection, Testing and Maintenance of Water-Based Fire Protection Systems. This was evidenced by the following:

1.) The required escutcheon plates around sprinkler heads were missing or loose and not tight to the ceiling. In addition, this exposed the hole cut into the drywall ceiling for the sprinkler piping installation, with a substantial gap up to ?" around the circumference of the sprinkler piping, exposing the structural framing members and effecting thermal activation properties of the sprinkler heads. This was observed in:
a) the corridor outside the COO office,
b) the corridor outside the HR office,
c) in the Medical Records office,
d) in the Laundry Room,
e) in the Conference Room (2x).
An approved escutcheon plate that is compatible with the model of sprinkler head used must be maintained tightly in place to cover the hole in accordance with 1999 NFPA 13 section 3-2.7. The escutcheon plates used must be part of a listed sprinkler head assembly per 1999 NFPA 13 section 3-2.7.


2.) Air / water pressure gauges were not replaced, or recalibrated, every five (5) years in accordance with (1998) NFPA 25, section 2-3.2. The fire sprinkler riser was observed with two water pressure gauges located at the sprinkler system riser that were dated 2007.

3.) The automatic fire sprinkler system's three (3) water flow alarms and dry pipe low air pressure alarms were not tested timely and on a quarterly basis, with tamper switches tested on a semi-annual basis, as required and in accordance with NFPA 25 section 9-1. Fire alarm and Sprinkler system inspection records, dated July 8, 2013 documented the only testing of the water flow alarms and tamper switches during the past 12 month / annual inspection cycle. Maintenance staff stated that other documentation was not available regarding quarterly testing that should have been scheduled in a timely manner to take place in October, January and April (based on a July 8, 2013 annual inspection according to facility records).
An automatic fire sprinkler system is not a LSC requirement for an existing business occupancy, however, in accordance with (2000 edition) LSC section 4.6.12.2* states "Existing life safety features obvious to the public, if not required by the Code, shall be either maintained or removed."
Each of the fire sprinkler system deficient items could potentially affect 100% of the patients, as well as staff and visitors, located within the Administration Building.

These fire sprinkler system deficiency items were discussed with the Plant Operations Manager during a tour of the facility or during a review of the facility's required documentation.

Bldg. A5 - Granby Hospital
It was determined by observation during the course of the survey on July 30 to Aug 2, 2013 that the facility failed to maintain the automatic fire sprinkler system in accordance with LSC section 18.3.5 and NFPA 13, Installation of Sprinkler Systems and / or NFPA 25, Inspection, Testing and Maintenance of Water-Based Fire Protection Systems. This was evidenced by the following:

1.) Air / water pressure gauges were not replaced, or recalibrated, every five (5) years in accordance with (1998) NFPA 25, section 2-3.2. The base of the fire sprinkler riser, located in the Fire Riser Room, was observed with a water pressure gauge that was dated 2006.

2.) The automatic fire sprinkler system's water flow alarms and dry pipe low air pressure alarms were not tested timely and on a quarterly basis, with tamper switches tested on a semi-annual basis, as required and in accordance with NFPA 25 section 9-1. Fire alarm and Sprinkler system inspection records, dated July 8, 2013 documented the only testing of the water flow alarms and tamper switches during the past 12 month / annual inspection cycle. Maintenance staff stated that other documentation was not available regarding quarterly testing that should have been scheduled in a timely manner to take place in October, January and April (based on a July 8, 2013 annual inspection according to facility records).

Each of the fire sprinkler system deficient items could potentially affect 100% of the patients, as well as staff and visitors, located within the Administration Building.

These fire sprinkler system deficiency items were discussed with the Plant Operations Manager during a tour of the facility or during a review of the facility's required documentation.

Bldg A1 - Hospital
It was determined by record review and staff interview during the course of the survey on July 30 to Aug 2, 2013, the facility failed to perform and document the exercising of all fire and / or smoke dampers to verify they fully close, and latch if provided, with moving parts lubricated and fusible links replaced, as necessary, at least every six years, in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilation Systems; section 3-4.7 Maintenance. This was evidenced by the following:

A review of the facility's maintenance records and interview with maintenance staff indicated there were no current records on premises, or they could not be located, that documented that fire and / or smoke damper testing and maintenance was performed within the past six years as required.
Maintenance staff stated that fire / smoke dampers existed within the facility but was not aware of how many dampers there were.
This deficient practice could affect 100% of the facility's patients, as well as staff and visitors, located within the facility.

The fire damper deficiency item was discussed with the Plant Operations Manager during a review of the facility's required documentation.

Bldg A1 - Hospital
It was determined by observation during the survey on July 30 to Aug 2, 2013, that the facility failed to provide a piped-in medical gas system meeting the requirements of (1999) NFPA 99, Health Care Facilities. This was evidenced by the following:

A review of the medical gas system annual evaluation / inspection, test and maintenance records, provided by an independent medical gas system contractor to the facility, and dated January 2013, documented deficiency items that had not yet been corrected at the time of this survey, to include:

1.) Vacuum station outlet was provided without a shutoff zone valve in accordance with section 4-3.1.2.3(d). Locations are:
a) in the ER,
b) OR,
c) Nurse Office / Bird Room,
d) Laboratory,
e) Patient Room 1-2,
f) Patient Room 3-8, 10,
g) Patient room #9 (intensive care).
2.) A pressure / vacuum gage was not provided downstream from the zone valve, in accordance with section 4-3.1.2.3(d). Locations are:
a) in the ER,
b) OR,
c) Nurse Office / Bird Room,
d) Laboratory,
e) Patient Room 1-2,
f) Patient Room 3-8, 10,
g) Patient room #9 (intensive care)
h) Main hospital supply.

3.) Manual shut off valves in boxes shall be installed were they are visible and accessible at all times ... otherwise not hidden from plain view, in accordance with section 4-3.1.2.3(i). Locations are:
a) Patient Room 3-8, 10.

This deficient practice could potentially affect 100% of the patients located within this facility.

The medical gas system deficiency items were discussed with the Plant Operations Manager during a tour of the facility.

Bldg A1 - Hospital
It was determined by record review and staff interview during the course of the survey on July 30 to Aug 2, 2013 that the facility failed to properly maintain and test the emergency power source in accordance with LSC section 19.2.9, referenced section 7.9 and referenced (1999) NFPA 99 Health Care Facilities, section 3-4 for a Type I system and referenced NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6. This was evidenced by the following:

1.) Maintenance staff stated that documentation was not available for review regarding, at minimum, an annual inspection with required preventive maintenance conducted within the past 12 months, to the Emergency Power Supply System (EPSS), including the automatic transfer switch, by a properly trained, qualified, and certified company that performs maintenance, inspection and testing of the emergency generator secondary power supply system.

2.) Monthly load testing of the diesel powered Emergency Power Supply System (EPSS) was not conducted at 30% or greater of the EPSS nameplate rating in accordance with NFPA 110 section 6-4.2,. The facility's monthly load testing documentation, dated 6/24/2013, indicated that for the 155 Kilo-Watt EPS diesel generator, with the output of 212 volts with 3-phase amperage at 110 amps, 109 amps and 118 amps.
It was determined that the monthly load test of the generator must be operated to maintain a minimum of 127 amps for each of three phases for thirty minutes in order to achieve 30% of the EPS's nameplate rating.
Alternatively, an option to providing monthly load tests at 127 amps minimum is to provide an annual 2-hour load bank test in accordance with NFPA 110 and in conjunction with the (current) monthly load tests conducted under the existing available load.
Each of the EPSS deficient items could affect 100% of the patients, as well as all staff and any visitors, located within this facility.

The emergency power supply system deficiency items were discussed with the Plant Operations Manager during a review of the facility's required documentation.

Bldg. A5 - Granby Hospital
It was determined by record review and staff interview during the course of the survey on July 30 to Aug 2, 2013 that the facility failed to properly maintain and test the emergency power source in accordance with LSC section 18.2.9, referenced section 7.9 and referenced (1999) NFPA 99 Health Care Facilities, section 3-4 for a Type I system and referenced NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6. This was evidenced by the following:

1.) Maintenance staff stated that documentation was not available for review regarding, at minimum, an annual inspection with required preventive maintenance conducted within the past 12 months, to the Emergency Power Supply System (EPSS), including the automatic transfer switch, by a properly trained, qualified, and certified company that performs maintenance, inspection and testing of the emergency generator secondary power supply system.

2.) Monthly load testing of the diesel powered Emergency Power Supply System (EPSS) was not conducted at 30% or greater of the EPSS nameplate rating in accordance with NFPA 110 section 6-4.2. The facility's monthly load testing documentation, dated 4/9/2013, indicated that for the 230 Kilo-Watt EPS diesel generator, with the output of 286 volts with 3-phase amperage at 23 amps, 30 amps and 21 amps.
It was determined that the monthly load test of the generator must be operated to maintain a minimum of 139 amps for each of three phases for thirty minutes in order to achieve 30% of the EPS's nameplate rating.
Alternatively, an option to providing monthly load tests at 139 amps minimum is to provide an annual 2-hour load bank test in accordance with NFPA 110 and in conjunction with the (current) monthly load tests conducted under the existing available load.
Each of the EPSS deficient items could affect 100% of the patients, as well as all staff and any visitors, located within this facility.

The emergency power supply system deficiency items were discussed with the Plant Operations Manager during a review of the facility's required documentation.

Bldg A1 - Hospital
It was determined by observation and staff interview during the course of the survey on July 30 to Aug 2, 2013that the facility failed to provide and maintain a Type I emergency electrical system in accordance with NFPA 99 section 3-4.2.2.2(a).
This was evidenced by the following:

The electrical distribution system was not arranged properly to meet the specific requirements of a Type I essential emergency electrical system in accordance with NFPA 99 section 3-4.2.2. 2(a). The essential electrical system was identified as being arranged with the two required system panels, the emergency system and the equipment system. However, the emergency system panels were not identified as being further divided into the life safety branch and the critical branch. Only very specific functions are permitted to be placed on or connected to the Life Safety branch.
Panel board " ECA " was identified by a panel schedule to contain a list of circuits associated with the Fire Alarm system and Illumination of the Means of Egress that is required to be placed on the Life Safety branch, with a list of circuits associated with Nurse Call system, receptacles and task illumination located in patient care areas that are required to be placed on the Critical branch. Several circuits within the ECA panel board were not able to be evaluated offsite at this time for their appropriate placement either within the Life Safety branch or the Critical branch.
Likewise, panel board " ECB " was identified by a panel schedule to contain a list of circuits associated with the Fire Sprinkler system and Illumination of the Means of Egress that is required to be placed on the Life Safety branch, with a list of circuits associated with receptacles located in the Activity Room and Cardiac rehab areas, and lighting of OR, Sub-sterile room, Radiology and Activity areas that are required to be placed on the Critical branch or perhaps on the Equipment branch. Several circuits within the ECB panel board were not able to be evaluated offsite at this time for their appropriate placement either within the Life Safety branch or the Critical branch.
This deficient practice could affect 100% of the patients, as well as all staff and visitors, located within the hospital facility.

The distribution of the essential electrical system deficiency items were discussed with the CEO and the Plant Operations Manager during a tour of the facility.