HospitalInspections.org

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The facility failed to maintain the building construction type per code. Findings include:

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

A wood structure was observed attached to this building by the E.R. Entrance for the storage of lawn mowers

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2000 NFPA 101, 19.1.6.2 Health care occupancies shall be limited to the types of building construction shown in Table 19.1.6.2. (See 8.2.1.)Table 19.1.6.2 Construction Type Limitations
Construction Stories
Type
1 2 3 4 or
More
I(443) X X X X
I(332) X X X X
II(222) X X X X
II(111) X X* X* NP
II(000) X* X* NP NP
III(211) X* X* NP NP
III(200) X* NP NP NP
IV(2HH) X* X* NP NP
V(111) X* X* NP NP
V(000) X* NP NP NP
X: Permitted type of construction.
NP: Not permitted.
*Building requires automatic sprinkler protection. (See 19.3.5.1.)
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The facility failed to maintain the building construction type per code. Findings include:

During the survey, the following is an example of what was observed:
First Floor
Same Day Surgery entrance/exit foyer was missing part of the two hour fire barrier above the lay-in ceiling.

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2000 NFPA 101, 19.1.6.2 Health care occupancies shall be limited to the types of building construction shown in Table 19.1.6.2. (See 8.2.1.)
Table 19.1.6.2 Construction Type Limitations
Construction Stories
Type
1 2 3 4 or
More
I(443) X X X X
I(332) X X X X
II(222) X X X X
II(111) X X* X* NP
II(000) X* X* NP NP
III(211) X* X* NP NP
III(200) X* NP NP NP
IV(2HH) X* X* NP NP
V(111) X* X* NP NP
V(000) X* NP NP NP
X: Permitted type of construction.
NP: Not permitted.
*Building requires automatic sprinkler protection. (See 19.3.5.1.)
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The facility failed to provide corridor doors that would close and resist the passage of smoke. Findings include: During the survey, the following is an example of what was observed:


Patient Room 334 door failed to close tight in the frame, this surveyor could see into room when door was closed.
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NFPA 101, 19.3.6.3.1 Exception No.2. In the smoke compartments protected throughout by an approved, supervised automatic sprinkler system, doors in corridor walls shall be constructed to resist the passage of smoke and be provided with suitable means of keeping the doors closed.
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Item number 1 is a rewrite from 2009

The facility failed to maintain the corridor openings per code. Findings include:

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

First Floor
1. Dish Room corridor door was missing the door handle hardware - creating a hole

2. Admissions Supervisor's Office had a self- closing device on the corridor door, was being held open by a wedge

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2000 NFPA 101, 19.3.6.3.1 Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 13/4-in. (4.4-cm) thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke. Compliance with NFPA 80, Standard for Fire Doors and Fire Windows, shall not be required. Clearance between the bottom of the door and the floor covering not exceeding 1 in. (2.5 cm) shall be permitted for corridor doors.
2000 NFPA 101, 19.3.6.3.2 Doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door. Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.2.
2007 CMS - 2786R There is no impediment to the closing of the corridor doors.

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The facility failed to provide exit signs for the E.R. Suite per code. Findings include:

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

First Floor
E.R. Suite did not have exit signs for either exit access

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2000 NFPA 101, 7.10.1.4 Access to exits shall be marked by approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent to the occupants. Sign placement shall be such that no point in an exit access corridor is in excess of 100 ft (30 m) from the nearest externally illuminated sign and is not in excess of the marked rating for internally illuminated signs.
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The facility failed to maintain separation of hazardous areas. Findings include: During the survey, the following is an example of what was observed:

1. Unsealed penetrations around conduit, wiring, and at the end of two sleeve's, in the wall of the storage room located in the basement.


27382


First Floor - non sprinklered
2. Patient Financial Representative Office - corridor door had a self-closing device, but was being held open by a wedge
Second Floor - sprinkler coverage is provided
3. Patient Bath at room 207 was over 50 sq. ft., being used to store combustibles - the door did not have a self-closing device
4. Room across from room 205 was over 50 sq. ft., being used to store combustibles - the door did not have a self-closing device
5. Room across from room 213 was over 50 sq. ft., being used to store combustibles - the door did not have a self-closing device

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

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A) The facility failed to provide a readily accessible means of egress pathway at all times. Findings include: During the survey, the following is an example of what was observed:


Equipment was stored in the means of egress, at the Exit Discharge, for the Exit by the freight elevator in the basement.
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NFPA 101, 7.1.10.1 Means of egress shall be continuously maintained free of all obstructions or impediments for full instant use in case of fire or other emergencies.




27382

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

During the survey, the following is an example of what was observed:
Second Floor
1. The Linen Closet (across from room 235) the corridor door , when fully opened projected more than 7" into the corridor.

2. The Geri-Psych Nurses' Station had two "kill switches" for the magnetically locked doors - (1) "kill switch" released the stairwell door
(1) "kill switch" released the two sets of double corridor doors
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2000 NFPA 101, 7.2.1.4.4 During its swing, any door in a means of egress shall leave not less than one-half of the required width of an aisle, corridor, passageway, or landing unobstructed and shall not project more than 7 in. (17.8 cm) into the required width of an aisle, corridor, passageway, or landing, when fully open. Doors shall not open directly onto a stair without a landing. The landing shall have a width not less than the width of the door. (See 7.2.1.3.)
Alabama Department of Public Health, Technical Services Unit 08/23/20112. Locked egress doors: This hardware is locked all or part of the day.C. An emergency release switch, or "kill switch", shall be provided at the nearest nurse station, to disable locks on doors under control of that station. This release switch shall be capable of being reset only by key or special knowledge. This switch may release doors by means of a key only in psychiatric and infant units.
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The facility failed to maintain the two hour fire barrier per code. Findings include:

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

First Floor
The two hour fire barrier did not continue to the outside wall at the Same Day Surgery entrance/exit foyer

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2000 NFPA 101, 8.2.2.2 Fire compartments shall be formed with fire barriers that are continuous from outside wall to outside wall, from one fire barrier to another, or a combination thereof, including continuity through all concealed spaces, such as those found above a ceiling, including interstitial spaces. Walls used as fire barriers shall comply with Chapter 3 of NFPA 221, Standard for Fire Walls and Fire Barrier Walls. The NFPA 221 limitation on percentage width of openings shall not apply.
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The facility failed to maintain the two hour fire barrier per code. Findings include:

During the survey, the following is an example of what was observed:
First Floor
The two hour fire barrier did not continue to the outside wall at the Same Day Surgery entrance/exit foyer

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2000 NFPA 101, 8.2.2.2 Fire compartments shall be formed with fire barriers that are continuous from outside wall to outside wall, from one fire barrier to another, or a combination thereof, including continuity through all concealed spaces, such as those found above a ceiling, including interstitial spaces. Walls used as fire barriers shall comply with Chapter 3 of NFPA 221, Standard for Fire Walls and Fire Barrier Walls. The NFPA 221 limitation on percentage width of openings shall not apply.
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The facility failed to provide continuous lighting for means of egress. Findings include: During the survey, the following are examples of what was observed:


1. The Exit Discharge lighting is controlled by a switch, for the Exit by Dietary First Floor.

2. The Exit Discharge lighting is controlled by a switch, for the Exit by the UPS Room First Floor.

3. The Exit Discharge lighting is controlled by a switch, for the old ER Exit First Floor.
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NFPA 101, 19.2.8 and 7.8.1.2 Illumination of means of egress shall be continuous.

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The facility failed to provide continuously illuminated exit signs. Findings include: During the survey, the following are examples of what was observed:


1. The Exit sign arrow was indicating wrong direction to the Exit in the basement near the bulb storage room.

2. The Exit sign was illuminated for the Exit in the Kitchen.
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NFPA 101, 7.10.5 Continuous illumination of exit signs.

Access to exits shall be marked by approved, readily visible signs in all cases where the exit or way to reach exit is not readily apparent. NFPA 101, 7.10.1.4.

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The facility failed to provide continuously illuminated exit signs. Findings include: During the survey, the following is an example of what was observed:

Two Exit signs were not illuminated for the Exits at the exit of the corridor, by Medical Records Storage Room.

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NFPA 101, 7.10.5 Continuous illumination of exit signs.
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The facility failed to provide a written fire evacuation plan per code. Findindings include:

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

The facility failed to provide a written fire evacuation plan that contained all eight items per code

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2000 NFPA 101, 19.7.2.2 A written health care occupancy fire safety plan shall provide for the following: (1)Use of alarms (2) Transmission of alarm to fire department (3) Response to alarms (4) Isolation of fire (5) Evacuation of immediate area (6) Evacuation of smoke compartment (7) Preparation of floors and building for evacuation (8) Extinguishment of fire
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The facility failed to provide a written fire evacuation plan per code. Findindings include:

During the survey, the following is an example of what was observed:
The facility failed to provide a written fire evacuation plan that contained all eight items per code

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2000 NFPA 101, 19.7.2.2 A written health care occupancy fire safety plan shall provide for the following: (1) Use of alarms (2) Transmission of alarm to fire department (3) Response to alarms (4) Isolation of fire (5) Evacuation of immediate area (6) Evacuation of smoke compartment (7) Preparation of floors and building for evacuation (8) Extinguishment of fire
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The facility failed to conduct fire drills per code. Findings include:


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

1. First Shift Third Quarter of 2012 did not have any signatures

2. Second Shift Second Quarter of 2012 - No Drill

3. Second Shift First Quarter of 2012 - No Time

4. Third Shift of Third Quarter of 2011 - No Drill

5. Not getting all staff to sign participation sheet, only the first responders

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

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

1. First Shift Third Quarter of 2012 did not have any signatures

2. Second Shift Second Quarter of 2012 - No Drill

3. Second Shift First Quarter of 2012 - No Time

4. Third Shift of Third Quarter of 2011 - No Drill

5. Not getting all staff to sign participation sheet, only the first responders

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

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

1. When the Auto Dialer was tested for phone line 1, failure was not indicated at the protected premise within the allotted four (4) minute time frame.

2. When the Auto Dialer was tested for phone line 2, failure was not indicated at the protected premise within the allotted four (4) minute time frame.

3. When the Auto Dialer was tested for Communication Failure, failure was not indicated at the protected premise within the allotted fifteen (15) minute time frame (5 minimum to 10 maximum attempts for signal transmission).


27382

4. The surveyor could not verify that the fire alarmsystem was on a dedicated circuit

5. While testing the fire alarm system phone lines (DACT):

a. The facility did not get a DACT trouble for line two
b. The facility did not get a DACT trouble for both phone lines (communication)

Second Floor
6. The surveyor could verify that the Geri-Psych doors released under loss of primary power to the fire alarm system

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NFPA 101 Sections 19.3.4.1 and 9.6. The indication shall be an audible and visual notification at location where it is likely to be heard in the facility.

1999 NFPA 72, 1-5.2.5.2 Connections to the light and power service shall be on a dedicated branch circuit(s). The circuit(s) and connections shall be mechanically protected. Circuit disconnecting means shall have a red marking, shall be accessible only to authorized personnel, and shall be identified as FIRE ALARM CIRCUIT CONTROL. The location of the circuit disconnecting means shall be permanently identified at the fire alarm control unit.

1999 NFPA 72, Table 7-2.2 b. Digital Alarm Communicator
Transmitter (DACT)
The primary line from the DACT shall be disconnected. Indication of the DACT trouble signal at the premises shall be verified as well as transmission to the supervising station within 4 minutes of detection of the fault.

The secondary means of transmission from the DACT shall be disconnected. Indication of the DACT trouble signal at the premises shall be verified as well as transmission to the supervising station within 4 minutes of detection of the fault.

1999 NFPA 72, 3-9.7.3 All exits connected in accordance with 3-9.7.1 shall unlock upon loss of the primary power to the fire alarm system serving the protected premises. The secondary power supply shall not be utilized to maintain these doors in the locked condition.
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The facility failed to provide a fire alarm system per code. Findings include:

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

1. The surveyor could not verify that the fire alarmsystem was on a dedicated circuit

2. While testing the fire alarm system phone lines (DACT):

a. The facility did not get a trouble for line two
b. The facility did not get a trouble for both phone lines (communication)

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1999 NFPA 72, Table 7-2.2
b. Digital Alarm Communicator Transmitter (DACT)
The primary line from the DACT shall be disconnected. Indication of the DACT trouble signal at the premises shall be verified as well as transmission to the supervising station within 4 minutes of detection of the fault.
The secondary means of transmission from the DACT shall be disconnected. Indication of the DACT trouble signal at the premises shall be verified as well as transmission to the supervising station within 4 minutes of detection of the fault.

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The facility failed to perform sensitivity testing of the smoke detectors. Findings include: During the survey, the following is an example of what was observed:

Documentation provided by the facility for sensitivity testing of the smoke detectors, conducted on 10/26/2010, failed to provide complete information concerning ranger of detectors, did not indicate if detectors passed or failed the test.

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Detector sensitivity shall be checked with one year after installation and
every alternate year thereafter per 72, 7-3.2.1. (Up to 5 years permitted under certain circumstances. See 7-3.2.1).
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The facility failed to perform sensitivity testing of the smoke detectors. Findings include: During the survey, the following is an example of what was observed:

Documentation provided by the facility for sensitivity testing of the smoke detectors, conducted on 10/26/2010, failed to provide complete information concerning ranger of detectors, did not indicate if detectors passed or failed the test.

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Detector sensitivity shall be checked with one year after installation and
every alternate year thereafter per 72, 7-3.2.1. (Up to 5 years permitted under certain circumstances. See 7-3.2.1).

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Sprinkler coverage was observed during the survey not adequately provided. Findings include: During the survey, the following are examples of what was observed:

1. A sprinkler had a bend deflector in Patient Room 320.

2. Ceiling tile missing in Nurses Lounge Third Floor.

3. Ceiling tile missing in Medi Prep Room Third Floor Nurses Station.

4. Escutcheon plate missing on a sprinkler at the Exit from same day surgery waiting room.

5. Ceiling tile had a large hole in the Physical Therapy.

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1999 NFPA 25, 2-2.1.1 and 2-4.1.2 Sprinklers that are painted, corroded or damaged shall be replaced with new listed sprinklers of the same characteristics, including orifice size, thermal response, and water distribution.

2000 NFPA 13, 3-2.7.2 Escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly.

NFPA 13 5-6., Sprinklers shall be arranged to be in compliance.

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The facility failed to perform the required maintenance of the facility sprinkler system. Findings include: During the survey, the following are examples of what was observed:

1. Fire department connection was not provided with sign for identification

2. Caps were missing on the fire department connection.

3. Quarterly inspection conducted on 5/31/12, noted deficiencies, two OSY 4" were corroded located in the basement. Also bad flow switch Third Floor Stairwell.

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NFPA 25, 1998 Edition, 9-7.1 Fire department connections shall be inspected quarterly. The inspection shall verify the following: (a) The fire department connections are visible and accessible. (b) Couplings or swivels are not damaged and rotate smoothly. (c) Plugs or caps are in place and undamaged. (d) Gaskets are in place and in good conition. (e) Identification signs are in place. (f) The check valve is not leaking. (g) The automatic drain valve is in place and operating properly.

NFPA 101,2000 Edition, 9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this code shall be inspected, tested, and maintained in accordance with NFPA 25, Standards for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

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The facility failed to provide required maintenance for fire extinguishers. Findings
include: During the survey, the following are examples of what was observed:

1. A fire extinguisher located in the boiler room was observed with the gauge needle in the discharge zone.

2. A fire extinguisher located by Patient room 320 was observed with the gauge needle in the discharge zone.

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1998 NFPA 10, 4-3.1 Fire extinguishers shall be inspected when placed in service and thereafter at approximately 30-day intervals.
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The facility failed to maintain the dietary hood. Findings include: During the survey, the following are examples of what was observed:

1. Filters had approximatley 1/4" gap between two sets.

2. Heavy build up of grease on filters.

3. Documentation not provided for cleaning of dietary hood.

4. Verification collar on the K-Extinguisher had 1/2003.

5. Documentation not provided for last hydrostatic test of cylinder for the dietary hood extinguishing system.

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NFPA 96, 3-2.3 Grease filters shall be listed and constructed of steel or listed equivalent material and shall be of rigid construction that will not distort or crush under normal operation, handling, and cleaning conditions. Filters shall be tight fitting and firmly held in place.

NFPA 96, 8-3.1.2 When a vent cleaning service is used, certificate showing date of inspection or cleaning shall be maintained on the premises. After cleaning is completed, the vent cleaning contractor shall place or display within the kitchen area a label indicating the date cleaned and the name of the servicing company. It shall also indicate areas not cleaned.

1998 NFPA 17, 9-5 Hydrostatic testing of the extinguishment cylinder shall not exceed 12 years.

1998 NFPA 10, 4-4.4.2 Each extinguisher that has been recharged shall have a "verification of service" collar around the neck, with perforations on dates.

1998 NFPA 10, 4-4-3 Tag on K- extinguisher indicated six year maintenance had not been performed.

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The facility failed to prohibit portable space heating devices per code. Findings include:

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

The Human Resources Office was observed with a portable space heating device (not in use)

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2000 NFPA 101, 19.7.8 Portable space-heating devices shall be prohibited in all health care occupancies.
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The facility failed to prohibit portable space heating devices per code. Findings include:

During the survey, the following are examples of what was observed:
The following rooms were observed with portable space heating devices:

Second Floor
1. Executive Housekeepers Office

2. Room 207

3. E.R. Doctors' Sleeping Room

4. Room 210

5. Sleep Lab. Tech. Support Room

First Floor

6. Coding room

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2000 NFPA 101, 19.7.8 Portable space-heating devices shall be prohibited in all health care occupancies.
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The facility failed to provide a readily accessible means of egress pathway at all times. Findings include: During the survey, the following is an example of what was observed:

Cans, signs, bldg materials, electrical materials, were stored in the corridor, by Medical records storage room.

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NFPA 101, 7.1.10.1 Means of egress shall be continuously maintained free of all obstructions or impediments for full instant use in case of fire or other emergencies.

S&C Transmittal #99-94. Corridors must be maintained free of all furniture and other items. Items are considered stored in the corridor if they are not both used and moved at least once every half hour.
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The facility failed to provide a readily accessible means of egress pathway at all times. Findings include: During the survey, the following is an example of what was observed:

Doors, tables, beds, equipment was stored in the corridor throughout the basement.

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NFPA 101, 7.1.10.1 Means of egress shall be continuously maintained free of all obstructions or impediments for full instant use in case of fire or other emergencies.

S&C Transmittal #99-94. Corridors must be maintained free of all furniture and other items. Items are considered stored in the corridor if they are not both used and moved at least once every half hour.

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The facility failed to provide proper storage of oxygen cylinders. Findings include: During the survey, the following is an example of what was observed:


One unsecured oxygen cylinder in the Recovery Room same day surgery.

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1999 NFPA 99, 8-3.1.11.2(g) Cylinders shall be secured from mechanical shock.

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The facility failed to maintain the piped in medical gas system per code. Findings include:

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

The facility had not corrected all items from the 09/15/2011 report on the medical gas system.

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1999 NFPA 99, 4-3.5.2.3 Patient Gas Systems - Level 1.
(a) * Piping systems shall not be used for the distribution of flammable anesthetic gases. (b) Nonflammable medical gas systems used to supply gases for respiratory therapy shall be installed in accordance with 4-3.1 of this chapter. (c) Maintenance programs in accordance with the manufacturers ' recommendations shall be established for the medical air compressor supply system as connected in each individual installation. (d) * The responsible authority of the facility shall establish procedures to ensure that all signal warnings are promptly evaluated and that all necessary measures are taken to reestablish the proper functions of the medical gas system. (e) Piping systems for gases shall not be used as a grounding electrode. (f) The facility shall have the capability and organization to implement a plan to cope with a complete loss of any medical gas system. (g) A periodic testing procedure for nonflammable medical gas and related alarm systems shall be implemented. (h) The test specified in 4-3.4.1.3(i) shall be conducted on the downstream portions of the medical gas piping system whenever a system is breached or whenever modifications are made or maintenance performed. (i) * Periodic retesting of audible and visual alarm indicators shall be performed to determine that they are functioning properly, and records of the test shall be maintained until the next test.

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The facility failed to maintain the piped in medical gas system per code. Findings include:

During the survey, the following is an example of what was observed:
The facility had not corrected all items from the 09/15/2011 report on the medical gas system.

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1999 NFPA 99, 4-3.5.2.3 Patient Gas Systems - Level 1.
(a) * Piping systems shall not be used for the distribution of flammable anesthetic gases.
(b) Nonflammable medical gas systems used to supply gases for respiratory therapy shall be installed in accordance with 4-3.1 of this chapter. (c) Maintenance programs in accordance with the manufacturers ' recommendations shall be established for the medical air compressor supply system as connected in each individual installation.
(d) * The responsible authority of the facility shall establish procedures to ensure that all signal warnings are promptly evaluated and that all necessary measures are taken to reestablish the proper functions of the medical gas system. (e) Piping systems for gases shall not be used as a grounding electrode. (f) The facility shall have the capability and organization to implement a plan to cope with a complete loss of any medical gas system.
(g) A periodic testing procedure for nonflammable medical gas and related alarm systems shall be implemented. (h) The test specified in 4-3.4.1.3(i) shall be conducted on the downstream portions of the medical gas piping system whenever a system is breached or whenever modifications are made or maintenance performed. (i) * Periodic retesting of audible and visual alarm indicators shall be performed to determine that they are functioning properly, and records of the test shall be maintained until the next test.

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During the survey, battery-powered lighting was not provided at the generator equipment and controls room.

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1999 NFPA 99, 3-6.1.1 and 3-4.1.1.4, and 1999 NFPA 110, 5-3.1 The Level 1 or Level 2 EPS equipment location shall be provided with battery-powered emergency lighting.

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During the survey, battery-powered lighting was not provided at the generator equipment and controls room.

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1999 NFPA 99, 3-6.1.1 and 3-4.1.1.4, and 1999 NFPA 110, 5-3.1 The Level 1 or Level 2 EPS equipment location shall be provided with battery-powered emergency lighting.
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The facility failed to provide approved electrical utilities. Findings include: During the survey, the following are examples of what was observed:


1. Junction box was missing the cover for #1 boiler shutdown.

2. Junction boxes missing the covers in the AC Room in the basement.

3. Two junction boxes missing the covers in the Mechanical Room under the ER.

4. Two junction boxes missing the covers in the AC Room basement control mri.

5. Exposed wiring in junction box mechanical room below the financial office.

6. Exposed wiring on a cord from a light in generator control room.

7. Boxes stored in front of the electrical panels generator control room.

8. Microwave plugged into a surg protector in the Nurses Lounge Third Floor.

9. Microwave plugged into an extension cord in the Laundry Room located in the basement.

10. Overcurrent plugged into an overcurrent proection device in Materials Handler Office.

11. Overcurrent plugged into an overcurrent protection device in the service room first floor.
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1999 NFPA 70, 370-25 and 410-12. Each box in completed installations to have a cover, face plate, or fixture canopy.

Appliances, such as air conditioners and refrigerators, microwaves, shall plug directly into a receptacle. 1999 NFPA 70, 400-7 and 400-8, and HCFA Transmittal Notice 22-99.

NFPA 101, 19.5.1 Utilities shall comply with NFPA 101, 9.1. Electrical utilities shall comply with 1999 NFPA 70, National Electrical Code.




27382

Second Floor
12. Room 210 had a portable heating device plugged into an extension cord

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

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The facility failed to maintain the electrical wiring and equipment per code. Findings include:

During the survey, the following are examples of what was observed:
First Floor
1. Conference Room had a surge protector plugged into an extension cord in use

2. Radiology Breakroom had a microwave plugged into a multi outlet extension cord

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

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The facility failed to maintain the building construction type per code. Findings include:

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

A wood structure was observed attached to this building by the E.R. Entrance for the storage of lawn mowers

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2000 NFPA 101, 19.1.6.2 Health care occupancies shall be limited to the types of building construction shown in Table 19.1.6.2. (See 8.2.1.)Table 19.1.6.2 Construction Type Limitations
Construction Stories
Type
1 2 3 4 or
More
I(443) X X X X
I(332) X X X X
II(222) X X X X
II(111) X X* X* NP
II(000) X* X* NP NP
III(211) X* X* NP NP
III(200) X* NP NP NP
IV(2HH) X* X* NP NP
V(111) X* X* NP NP
V(000) X* NP NP NP
X: Permitted type of construction.
NP: Not permitted.
*Building requires automatic sprinkler protection. (See 19.3.5.1.)
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The facility failed to maintain the building construction type per code. Findings include:

During the survey, the following is an example of what was observed:
First Floor
Same Day Surgery entrance/exit foyer was missing part of the two hour fire barrier above the lay-in ceiling.

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2000 NFPA 101, 19.1.6.2 Health care occupancies shall be limited to the types of building construction shown in Table 19.1.6.2. (See 8.2.1.)
Table 19.1.6.2 Construction Type Limitations
Construction Stories
Type
1 2 3 4 or
More
I(443) X X X X
I(332) X X X X
II(222) X X X X
II(111) X X* X* NP
II(000) X* X* NP NP
III(211) X* X* NP NP
III(200) X* NP NP NP
IV(2HH) X* X* NP NP
V(111) X* X* NP NP
V(000) X* NP NP NP
X: Permitted type of construction.
NP: Not permitted.
*Building requires automatic sprinkler protection. (See 19.3.5.1.)
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The facility failed to provide corridor doors that would close and resist the passage of smoke. Findings include: During the survey, the following is an example of what was observed:


Patient Room 334 door failed to close tight in the frame, this surveyor could see into room when door was closed.
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NFPA 101, 19.3.6.3.1 Exception No.2. In the smoke compartments protected throughout by an approved, supervised automatic sprinkler system, doors in corridor walls shall be constructed to resist the passage of smoke and be provided with suitable means of keeping the doors closed.
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Item number 1 is a rewrite from 2009

The facility failed to maintain the corridor openings per code. Findings include:

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

First Floor
1. Dish Room corridor door was missing the door handle hardware - creating a hole

2. Admissions Supervisor's Office had a self- closing device on the corridor door, was being held open by a wedge

___________________

2000 NFPA 101, 19.3.6.3.1 Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 13/4-in. (4.4-cm) thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke. Compliance with NFPA 80, Standard for Fire Doors and Fire Windows, shall not be required. Clearance between the bottom of the door and the floor covering not exceeding 1 in. (2.5 cm) shall be permitted for corridor doors.
2000 NFPA 101, 19.3.6.3.2 Doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door. Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.2.
2007 CMS - 2786R There is no impediment to the closing of the corridor doors.

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The facility failed to provide exit signs for the E.R. Suite per code. Findings include:

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

First Floor
E.R. Suite did not have exit signs for either exit access

____________________
2000 NFPA 101, 7.10.1.4 Access to exits shall be marked by approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent to the occupants. Sign placement shall be such that no point in an exit access corridor is in excess of 100 ft (30 m) from the nearest externally illuminated sign and is not in excess of the marked rating for internally illuminated signs.
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The facility failed to maintain separation of hazardous areas. Findings include: During the survey, the following is an example of what was observed:

1. Unsealed penetrations around conduit, wiring, and at the end of two sleeve's, in the wall of the storage room located in the basement.


27382


First Floor - non sprinklered
2. Patient Financial Representative Office - corridor door had a self-closing device, but was being held open by a wedge
Second Floor - sprinkler coverage is provided
3. Patient Bath at room 207 was over 50 sq. ft., being used to store combustibles - the door did not have a self-closing device
4. Room across from room 205 was over 50 sq. ft., being used to store combustibles - the door did not have a self-closing device
5. Room across from room 213 was over 50 sq. ft., being used to store combustibles - the door did not have a self-closing device

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

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A) The facility failed to provide a readily accessible means of egress pathway at all times. Findings include: During the survey, the following is an example of what was observed:


Equipment was stored in the means of egress, at the Exit Discharge, for the Exit by the freight elevator in the basement.
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NFPA 101, 7.1.10.1 Means of egress shall be continuously maintained free of all obstructions or impediments for full instant use in case of fire or other emergencies.




27382

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

During the survey, the following is an example of what was observed:
Second Floor
1. The Linen Closet (across from room 235) the corridor door , when fully opened projected more than 7" into the corridor.

2. The Geri-Psych Nurses' Station had two "kill switches" for the magnetically locked doors - (1) "kill switch" released the stairwell door
(1) "kill switch" released the two sets of double corridor doors
___________________
2000 NFPA 101, 7.2.1.4.4 During its swing, any door in a means of egress shall leave not less than one-half of the required width of an aisle, corridor, passageway, or landing unobstructed and shall not project more than 7 in. (17.8 cm) into the required width of an aisle, corridor, passageway, or landing, when fully open. Doors shall not open directly onto a stair without a landing. The landing shall have a width not less than the width of the door. (See 7.2.1.3.)
Alabama Department of Public Health, Technical Services Unit 08/23/20112. Locked egress doors: This hardware is locked all or part of the day.C. An emergency release switch, or "kill switch", shall be provided at the nearest nurse station, to disable locks on doors under control of that station. This release switch shall be capable of being reset only by key or special knowledge. This switch may release doors by means of a key only in psychiatric and infant units.
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The facility failed to maintain the two hour fire barrier per code. Findings include:

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

First Floor
The two hour fire barrier did not continue to the outside wall at the Same Day Surgery entrance/exit foyer

______________________
2000 NFPA 101, 8.2.2.2 Fire compartments shall be formed with fire barriers that are continuous from outside wall to outside wall, from one fire barrier to another, or a combination thereof, including continuity through all concealed spaces, such as those found above a ceiling, including interstitial spaces. Walls used as fire barriers shall comply with Chapter 3 of NFPA 221, Standard for Fire Walls and Fire Barrier Walls. The NFPA 221 limitation on percentage width of openings shall not apply.
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The facility failed to maintain the two hour fire barrier per code. Findings include:

During the survey, the following is an example of what was observed:
First Floor
The two hour fire barrier did not continue to the outside wall at the Same Day Surgery entrance/exit foyer

______________________
2000 NFPA 101, 8.2.2.2 Fire compartments shall be formed with fire barriers that are continuous from outside wall to outside wall, from one fire barrier to another, or a combination thereof, including continuity through all concealed spaces, such as those found above a ceiling, including interstitial spaces. Walls used as fire barriers shall comply with Chapter 3 of NFPA 221, Standard for Fire Walls and Fire Barrier Walls. The NFPA 221 limitation on percentage width of openings shall not apply.
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The facility failed to provide continuous lighting for means of egress. Findings include: During the survey, the following are examples of what was observed:


1. The Exit Discharge lighting is controlled by a switch, for the Exit by Dietary First Floor.

2. The Exit Discharge lighting is controlled by a switch, for the Exit by the UPS Room First Floor.

3. The Exit Discharge lighting is controlled by a switch, for the old ER Exit First Floor.
------------------------------------
NFPA 101, 19.2.8 and 7.8.1.2 Illumination of means of egress shall be continuous.

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The facility failed to provide continuously illuminated exit signs. Findings include: During the survey, the following are examples of what was observed:


1. The Exit sign arrow was indicating wrong direction to the Exit in the basement near the bulb storage room.

2. The Exit sign was illuminated for the Exit in the Kitchen.
-------------------------------------
NFPA 101, 7.10.5 Continuous illumination of exit signs.

Access to exits shall be marked by approved, readily visible signs in all cases where the exit or way to reach exit is not readily apparent. NFPA 101, 7.10.1.4.

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The facility failed to provide continuously illuminated exit signs. Findings include: During the survey, the following is an example of what was observed:

Two Exit signs were not illuminated for the Exits at the exit of the corridor, by Medical Records Storage Room.

______________________
NFPA 101, 7.10.5 Continuous illumination of exit signs.
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The facility failed to provide a written fire evacuation plan per code. Findindings include:

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

The facility failed to provide a written fire evacuation plan that contained all eight items per code

_____________________
2000 NFPA 101, 19.7.2.2 A written health care occupancy fire safety plan shall provide for the following: (1)Use of alarms (2) Transmission of alarm to fire department (3) Response to alarms (4) Isolation of fire (5) Evacuation of immediate area (6) Evacuation of smoke compartment (7) Preparation of floors and building for evacuation (8) Extinguishment of fire
.

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The facility failed to provide a written fire evacuation plan per code. Findindings include:

During the survey, the following is an example of what was observed:
The facility failed to provide a written fire evacuation plan that contained all eight items per code

_____________________

2000 NFPA 101, 19.7.2.2 A written health care occupancy fire safety plan shall provide for the following: (1) Use of alarms (2) Transmission of alarm to fire department (3) Response to alarms (4) Isolation of fire (5) Evacuation of immediate area (6) Evacuation of smoke compartment (7) Preparation of floors and building for evacuation (8) Extinguishment of fire
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The facility failed to conduct fire drills per code. Findings include:


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

1. First Shift Third Quarter of 2012 did not have any signatures

2. Second Shift Second Quarter of 2012 - No Drill

3. Second Shift First Quarter of 2012 - No Time

4. Third Shift of Third Quarter of 2011 - No Drill

5. Not getting all staff to sign participation sheet, only the first responders

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

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The facility failed to conduct fire drills per code. Findings include:

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

1. First Shift Third Quarter of 2012 did not have any signatures

2. Second Shift Second Quarter of 2012 - No Drill

3. Second Shift First Quarter of 2012 - No Time

4. Third Shift of Third Quarter of 2011 - No Drill

5. Not getting all staff to sign participation sheet, only the first responders

____________________

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

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

1. When the Auto Dialer was tested for phone line 1, failure was not indicated at the protected premise within the allotted four (4) minute time frame.

2. When the Auto Dialer was tested for phone line 2, failure was not indicated at the protected premise within the allotted four (4) minute time frame.

3. When the Auto Dialer was tested for Communication Failure, failure was not indicated at the protected premise within the allotted fifteen (15) minute time frame (5 minimum to 10 maximum attempts for signal transmission).


27382

4. The surveyor could not verify that the fire alarmsystem was on a dedicated circuit

5. While testing the fire alarm system phone lines (DACT):

a. The facility did not get a DACT trouble for line two
b. The facility did not get a DACT trouble for both phone lines (communication)

Second Floor
6. The surveyor could verify that the Geri-Psych doors released under loss of primary power to the fire alarm system

________________________
NFPA 101 Sections 19.3.4.1 and 9.6. The indication shall be an audible and visual notification at location where it is likely to be heard in the facility.

1999 NFPA 72, 1-5.2.5.2 Connections to the light and power service shall be on a dedicated branch circuit(s). The circuit(s) and connections shall be mechanically protected. Circuit disconnecting means shall have a red marking, shall be accessible only to authorized personnel, and shall be identified as FIRE ALARM CIRCUIT CONTROL. The location of the circuit disconnecting means shall be permanently identified at the fire alarm control unit.

1999 NFPA 72, Table 7-2.2 b. Digital Alarm Communicator
Transmitter (DACT)
The primary line from the DACT shall be disconnected. Indication of the DACT trouble signal at the premises shall be verified as well as transmission to the supervising station within 4 minutes of detection of the fault.

The secondary means of transmission from the DACT shall be disconnected. Indication of the DACT trouble signal at the premises shall be verified as well as transmission to the supervising station within 4 minutes of detection of the fault.

1999 NFPA 72, 3-9.7.3 All exits connected in accordance with 3-9.7.1 shall unlock upon loss of the primary power to the fire alarm system serving the protected premises. The secondary power supply shall not be utilized to maintain these doors in the locked condition.
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The facility failed to provide a fire alarm system per code. Findings include:

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

1. The surveyor could not verify that the fire alarmsystem was on a dedicated circuit

2. While testing the fire alarm system phone lines (DACT):

a. The facility did not get a trouble for line two
b. The facility did not get a trouble for both phone lines (communication)

________________________
1999 NFPA 72, Table 7-2.2
b. Digital Alarm Communicator Transmitter (DACT)
The primary line from the DACT shall be disconnected. Indication of the DACT trouble signal at the premises shall be verified as well as transmission to the supervising station within 4 minutes of detection of the fault.
The secondary means of transmission from the DACT shall be disconnected. Indication of the DACT trouble signal at the premises shall be verified as well as transmission to the supervising station within 4 minutes of detection of the fault.

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The facility failed to perform sensitivity testing of the smoke detectors. Findings include: During the survey, the following is an example of what was observed:

Documentation provided by the facility for sensitivity testing of the smoke detectors, conducted on 10/26/2010, failed to provide complete information concerning ranger of detectors, did not indicate if detectors passed or failed the test.

______________________
Detector sensitivity shall be checked with one year after installation and
every alternate year thereafter per 72, 7-3.2.1. (Up to 5 years permitted under certain circumstances. See 7-3.2.1).
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The facility failed to perform sensitivity testing of the smoke detectors. Findings include: During the survey, the following is an example of what was observed:

Documentation provided by the facility for sensitivity testing of the smoke detectors, conducted on 10/26/2010, failed to provide complete information concerning ranger of detectors, did not indicate if detectors passed or failed the test.

_______________________
Detector sensitivity shall be checked with one year after installation and
every alternate year thereafter per 72, 7-3.2.1. (Up to 5 years permitted under certain circumstances. See 7-3.2.1).

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Sprinkler coverage was observed during the survey not adequately provided. Findings include: During the survey, the following are examples of what was observed:

1. A sprinkler had a bend deflector in Patient Room 320.

2. Ceiling tile missing in Nurses Lounge Third Floor.

3. Ceiling tile missing in Medi Prep Room Third Floor Nurses Station.

4. Escutcheon plate missing on a sprinkler at the Exit from same day surgery waiting room.

5. Ceiling tile had a large hole in the Physical Therapy.

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1999 NFPA 25, 2-2.1.1 and 2-4.1.2 Sprinklers that are painted, corroded or damaged shall be replaced with new listed sprinklers of the same characteristics, including orifice size, thermal response, and water distribution.

2000 NFPA 13, 3-2.7.2 Escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly.

NFPA 13 5-6., Sprinklers shall be arranged to be in compliance.

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The facility failed to perform the required maintenance of the facility sprinkler system. Findings include: During the survey, the following are examples of what was observed:

1. Fire department connection was not provided with sign for identification

2. Caps were missing on the fire department connection.

3. Quarterly inspection conducted on 5/31/12, noted deficiencies, two OSY 4" were corroded located in the basement. Also bad flow switch Third Floor Stairwell.

________________
NFPA 25, 1998 Edition, 9-7.1 Fire department connections shall be inspected quarterly. The inspection shall verify the following: (a) The fire department connections are visible and accessible. (b) Couplings or swivels are not damaged and rotate smoothly. (c) Plugs or caps are in place and undamaged. (d) Gaskets are in place and in good conition. (e) Identification signs are in place. (f) The check valve is not leaking. (g) The automatic drain valve is in place and operating properly.

NFPA 101,2000 Edition, 9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this code shall be inspected, tested, and maintained in accordance with NFPA 25, Standards for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

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The facility failed to provide required maintenance for fire extinguishers. Findings
include: During the survey, the following are examples of what was observed:

1. A fire extinguisher located in the boiler room was observed with the gauge needle in the discharge zone.

2. A fire extinguisher located by Patient room 320 was observed with the gauge needle in the discharge zone.

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1998 NFPA 10, 4-3.1 Fire extinguishers shall be inspected when placed in service and thereafter at approximately 30-day intervals.
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The facility failed to maintain the dietary hood. Findings include: During the survey, the following are examples of what was observed:

1. Filters had approximatley 1/4" gap between two sets.

2. Heavy build up of grease on filters.

3. Documentation not provided for cleaning of dietary hood.

4. Verification collar on the K-Extinguisher had 1/2003.

5. Documentation not provided for last hydrostatic test of cylinder for the dietary hood extinguishing system.

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NFPA 96, 3-2.3 Grease filters shall be listed and constructed of steel or listed equivalent material and shall be of rigid construction that will not distort or crush under normal operation, handling, and cleaning conditions. Filters shall be tight fitting and firmly held in place.

NFPA 96, 8-3.1.2 When a vent cleaning service is used, certificate showing date of inspection or cleaning shall be maintained on the premises. After cleaning is completed, the vent cleaning contractor shall place or display within the kitchen area a label indicating the date cleaned and the name of the servicing company. It shall also indicate areas not cleaned.

1998 NFPA 17, 9-5 Hydrostatic testing of the extinguishment cylinder shall not exceed 12 years.

1998 NFPA 10, 4-4.4.2 Each extinguisher that has been recharged shall have a "verification of service" collar around the neck, with perforations on dates.

1998 NFPA 10, 4-4-3 Tag on K- extinguisher indicated six year maintenance had not been performed.

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The facility failed to prohibit portable space heating devices per code. Findings include:

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

The Human Resources Office was observed with a portable space heating device (not in use)

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2000 NFPA 101, 19.7.8 Portable space-heating devices shall be prohibited in all health care occupancies.
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The facility failed to prohibit portable space heating devices per code. Findings include:

During the survey, the following are examples of what was observed:
The following rooms were observed with portable space heating devices:

Second Floor
1. Executive Housekeepers Office

2. Room 207

3. E.R. Doctors' Sleeping Room

4. Room 210

5. Sleep Lab. Tech. Support Room

First Floor

6. Coding room

______________
2000 NFPA 101, 19.7.8 Portable space-heating devices shall be prohibited in all health care occupancies.
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The facility failed to provide a readily accessible means of egress pathway at all times. Findings include: During the survey, the following is an example of what was observed:

Cans, signs, bldg materials, electrical materials, were stored in the corridor, by Medical records storage room.

_______________________
NFPA 101, 7.1.10.1 Means of egress shall be continuously maintained free of all obstructions or impediments for full instant use in case of fire or other emergencies.

S&C Transmittal #99-94. Corridors must be maintained free of all furniture and other items. Items are considered stored in the corridor if they are not both used and moved at least once every half hour.
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The facility failed to provide a readily accessible means of egress pathway at all times. Findings include: During the survey, the following is an example of what was observed:

Doors, tables, beds, equipment was stored in the corridor throughout the basement.

_______________________
NFPA 101, 7.1.10.1 Means of egress shall be continuously maintained free of all obstructions or impediments for full instant use in case of fire or other emergencies.

S&C Transmittal #99-94. Corridors must be maintained free of all furniture and other items. Items are considered stored in the corridor if they are not both used and moved at least once every half hour.

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The facility failed to provide proper storage of oxygen cylinders. Findings include: During the survey, the following is an example of what was observed:


One unsecured oxygen cylinder in the Recovery Room same day surgery.

____________________
1999 NFPA 99, 8-3.1.11.2(g) Cylinders shall be secured from mechanical shock.

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The facility failed to maintain the piped in medical gas system per code. Findings include:

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

The facility had not corrected all items from the 09/15/2011 report on the medical gas system.

____________________
1999 NFPA 99, 4-3.5.2.3 Patient Gas Systems - Level 1.
(a) * Piping systems shall not be used for the distribution of flammable anesthetic gases. (b) Nonflammable medical gas systems used to supply gases for respiratory therapy shall be installed in accordance with 4-3.1 of this chapter. (c) Maintenance programs in accordance with the manufacturers ' recommendations shall be established for the medical air compressor supply system as connected in each individual installation. (d) * The responsible authority of the facility shall establish procedures to ensure that all signal warnings are promptly evaluated and that all necessary measures are taken to reestablish the proper functions of the medical gas system. (e) Piping systems for gases shall not be used as a grounding electrode. (f) The facility shall have the capability and organization to implement a plan to cope with a complete loss of any medical gas system. (g) A periodic testing procedure for nonflammable medical gas and related alarm systems shall be implemented. (h) The test specified in 4-3.4.1.3(i) shall be conducted on the downstream portions of the medical gas piping system whenever a system is breached or whenever modifications are made or maintenance performed. (i) * Periodic retesting of audible and visual alarm indicators shall be performed to determine that they are functioning properly, and records of the test shall be maintained until the next test.

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The facility failed to maintain the piped in medical gas system per code. Findings include:

During the survey, the following is an example of what was observed:
The facility had not corrected all items from the 09/15/2011 report on the medical gas system.

____________________
1999 NFPA 99, 4-3.5.2.3 Patient Gas Systems - Level 1.
(a) * Piping systems shall not be used for the distribution of flammable anesthetic gases.
(b) Nonflammable medical gas systems used to supply gases for respiratory therapy shall be installed in accordance with 4-3.1 of this chapter. (c) Maintenance programs in accordance with the manufacturers ' recommendations shall be established for the medical air compressor supply system as connected in each individual installation.
(d) * The responsible authority of the facility shall establish procedures to ensure that all signal warnings are promptly evaluated and that all necessary measures are taken to reestablish the proper functions of the medical gas system. (e) Piping systems for gases shall not be used as a grounding electrode. (f) The facility shall have the capability and organization to implement a plan to cope with a complete loss of any medical gas system.
(g) A periodic testing procedure for nonflammable medical gas and related alarm systems shall be implemented. (h) The test specified in 4-3.4.1.3(i) shall be conducted on the downstream portions of the medical gas piping system whenever a system is breached or whenever modifications are made or maintenance performed. (i) * Periodic retesting of audible and visual alarm indicators shall be performed to determine that they are functioning properly, and records of the test shall be maintained until the next test.

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During the survey, battery-powered lighting was not provided at the generator equipment and controls room.

__________________
1999 NFPA 99, 3-6.1.1 and 3-4.1.1.4, and 1999 NFPA 110, 5-3.1 The Level 1 or Level 2 EPS equipment location shall be provided with battery-powered emergency lighting.

.
During the survey, battery-powered lighting was not provided at the generator equipment and controls room.

______________________
1999 NFPA 99, 3-6.1.1 and 3-4.1.1.4, and 1999 NFPA 110, 5-3.1 The Level 1 or Level 2 EPS equipment location shall be provided with battery-powered emergency lighting.
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The facility failed to provide approved electrical utilities. Findings include: During the survey, the following are examples of what was observed:


1. Junction box was missing the cover for #1 boiler shutdown.

2. Junction boxes missing the covers in the AC Room in the basement.

3. Two junction boxes missing the covers in the Mechanical Room under the ER.

4. Two junction boxes missing the covers in the AC Room basement control mri.

5. Exposed wiring in junction box mechanical room below the financial office.

6. Exposed wiring on a cord from a light in generator control room.

7. Boxes stored in front of the electrical panels generator control room.

8. Microwave plugged into a surg protector in the Nurses Lounge Third Floor.

9. Microwave plugged into an extension cord in the Laundry Room located in the basement.

10. Overcurrent plugged into an overcurrent proection device in Materials Handler Office.

11. Overcurrent plugged into an overcurrent protection device in the service room first floor.
____________________
1999 NFPA 70, 370-25 and 410-12. Each box in completed installations to have a cover, face plate, or fixture canopy.

Appliances, such as air conditioners and refrigerators, microwaves, shall plug directly into a receptacle. 1999 NFPA 70, 400-7 and 400-8, and HCFA Transmittal Notice 22-99.

NFPA 101, 19.5.1 Utilities shall comply with NFPA 101, 9.1. Electrical utilities shall comply with 1999 NFPA 70, National Electrical Code.




27382

Second Floor
12. Room 210 had a portable heating device plugged into an extension cord

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

.
The facility failed to maintain the electrical wiring and equipment per code. Findings include:

During the survey, the following are examples of what was observed:
First Floor
1. Conference Room had a surge protector plugged into an extension cord in use

2. Radiology Breakroom had a microwave plugged into a multi outlet extension cord

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