HospitalInspections.org

A. Arizona Heart Hospital
Survey on April 10, 2013


Based on observation the facility failed to maintain the smoke/fire resistive rating of corridor walls.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.6.1, "Corridors shall be separated from all other areas by partitions complying with 19.3.6.2 through 19.3.6.5 (See also 19.2.5.9) (See all Exceptions) Section 19.3.6.2 "Corridor walls shall be continuous from the floor to the underside of the floor or roof deck above, through any concealed spaces, such as those above suspended ceilings, and through interstitial structural and mechanical spaces, and they shall have a fire resistance rating of not less than 1/2 hour." (See all Exceptions}.

Findings Include:

On April 10, 2013 the surveyor, accompanied by the Plant Director, Director, Environment of Care, Director of Quality and a Maintenance Technician observed the following:

1. Second Floor, Open penetration by elevator one, lobby
2. First floor, approximate one inch pipe penetration above Human Resources

During the exit conference on April 9th and 10th of 2013, the above findings were again acknowledged by the CEO, President, CNO, Regional Director Infection Control, Regional Director of Quality, Director, Environmental of Care(Vanguard) Director, Chief Clinical Officer, Director Lab/Respiratory, Director of Plant Operations.

Corridor walls must remain smoke tight/fire resistive to prevent smoke and heat from entering resident rooms. Smoke/heat will cause harm to the patients.

A. Phoenix Baptist Hospital
Survey on April 9, 2013

Based on observation the facility failed to maintain corridor doors to resist the passage of heat/smoke.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.6.3.1, 19.3.6.3.2, 19.3.6.3.3. Section 19. 19.3.6.3.1 "Doors protecting corridor openings shall be constructed to resist the passage of smoke. Clearance between the bottom of the door and the floor covering not exceeding 1 in. shall be permitted for corridor doors." Section 19.3.6.3.2 "Doors shall be provided with positive latching hardware. Roller latches shall be prohibited." Section 19.3.6.3.3 "Hold -open devices that release when the door is pushed or pulled shall be permitted."

Findings Include:

On April 9, 2013 the surveyor, accompanied by the Plant Director, Director, Environment of Care, Director of Quality and a Maintenance Technician observed that the following corridor doors would not tightly close when tested.

1. South Tower, Labor and Delivery third floor, twenty minute rated door tested three of three times will not positively latch, Door S-3-38

B. Arizona Heart Hospital
Survey on April 10, 2013

1. Second Floor, Room 239, door tested three of three times will not positively latch
2. First Floor, OR, Recovery/Isolation, four holes through the door by door handle

During the exit conference on April 9th and 10th of 2013, the above findings were again acknowledged by the CEO, President, CNO, Regional Director Infection Control, Regional Director of Quality, Director, Environmental of Care(Vanguard) Director, Chief Clinical Officer, Director Lab/Respiratory, Director of Plant Operations.

In time of a fire failing to protect patients from heat and smoke could cause harm to the patients.

A. Phoenix Baptist Hospital
Survey on April 9, 2013

Based on observation the facility did not maintain the integrity, smoke resistance, of doors in hazardous areas.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.3.2.1 requires that hazardous areas be separated and/or protected by one hour rated construction and automatic sprinklers. If protected by automatic sprinklers the walls and doors must be able to resist the passage of smoke. NFPA 80 "Fire Doors and Fire Windows" Chapter 2, Section 2-3.1.7 "The clearance between the edge of the door on the pull side and the frame, and the meeting edges of doors swinging in pairs on the pull side shall be 1/8 in. +/- 1/16 in for steel doors and shall not exceed 1/8 in. for wood doors.

Findings Include:

On April 9, 2013 the surveyor, accompanied by the Plant Director, Director, Environment of Care, Director of Quality and a Maintenance Technician observed the following doors would not tightly close when tested.

1. Sixth Floor, Door 6-61, OR storage, rated door with a closing device blocked open by an impediment
2. Kitchen, Managers office/storage, no closing device, flammables/combustibles stored in room
3. Dry food storage, door tested three of three times, will not positively latch

During the exit conference on April 9th and 10th of 2013, the above findings were again acknowledged by the CEO, President, CNO, Regional Director Infection Control, Regional Director of Quality, Director, Environmental of Care(Vanguard) Director, Chief Clinical Officer, Director Lab/Respiratory, Director of Plant Operations.

Failing to prevent heat and smoke from spreading into the exit corridor will cause harm to patients.

B. Arizona Heart Hospital
Survey on April 10, 2013

Based on observation the facility failed to conduct the required fire drills.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.7.1.2 Fire exit 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."

Findings include:

On April 9, 2013 the surveyor, accompanied by the Plant Director, Director, Environment of Care, Director of Quality and a Maintenance Technician reviewed the facility's fire drill records. The surveyor noted there were no fire drill reports for First quarter second shift 2013.

During the exit conference on April 9th and 10th of 2013, the above findings were again acknowledged by the CEO, President, CNO, Regional Director Infection Control, Regional Director of Quality, Director, Environmental of Care(Vanguard) Director, Chief Clinical Officer, Director Lab/Respiratory, Director of Plant Operations.

Failure to train and drill the staff on fire procedures could result in harm to the patients.

A. Phoenix Baptist Hospital
Survey on April 9, 2013

Based on observation the facility failed to clean the kitchen exhaust hood system, filters and grease drip tray.

NFPA 101 Life Safety Code 2000, Chapter 19, Section 19.3.2.6 "Cooking facilities shall be protected in accordance with 9-2.3" Section 9-2.3 "Commercial cooking equipment shall be installed in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations." , Chapter 8, Section 8-3.1, " Hoods, grease removal devices, fans, ducts, and other appurtenances shall be cleaned to bare metal at frequent intervals prior to surfaces becoming heavily contaminated with grease or oily sludge".

Findings include:

On April 9, 2013 the surveyor, accompanied by the Plant Director, Director, Environment of Care, Director of Quality and a Maintenance Technician observed the kitchen exhaust system hood, filters and grease drip tray area had an excessive amount of grease buildup. The broiler grill cook area has one of seven filters with excessive grease build up. Staff interview stated filters cleaned on Saturday only.

During the exit conference on April 9th and 10th of 2013, the above findings were again acknowledged by the CEO, President, CNO, Regional Director Infection Control, Regional Director of Quality, Director, Environmental of Care(Vanguard) Director, Chief Clinical Officer, Director Lab/Respiratory, Director of Plant Operations.


Failing to keep the entire kitchen exhaust hood system clean from grease will cause a fire, which could cause damage to the kitchen and will cause harm to the patients.

A. Phoenix Baptist Hospital
Survey on April 9, 2013

Based on observation the facility failed to mount an electrical light switch five feet above the floor in the oxygen storage rooms and the facility failed to keep the oxygen bottles free of combustible/flammable materials.

NFPA 101 Life Safety Code, Chapter 19, Section 19.3.2.4 " Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities." NFPA 99 Chapter 8, Storage Requirements, Section 8-3.1.11.2 Storage for nonflammable gases less than 3000 cubic feet. (f) Electrical fixtures in storage locations shall meet 4-3.1.1.2 (a) 11d. Section 4-3.1.1.2 (a) 11(d) Ordinary electrical wall fixtures in supply rooms shall be installed in fixed locations not less than 5 ft. (1.5m) above the floor to avoid physical damage. Section 8-3.1.11 "Storage Requirements" Section 8-3.1.11.2 "Storage of nonflammable gases less than 3000 cubic. feet.." (a) "Storage locations shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limited-combustible construction, with doors (or gates outdoors) that can be secured against unauthorized entry. (c) "Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or incompatible materials by: (c) (2) A minimum distance of 5 ft. if the entire storage location is protected by an automatic sprinkler system..."

Findings Include:


On April 9, 2013 the surveyor, accompanied by the Plant Director, Director, Environment of Care, Director of Quality and a Maintenance Technician observed, the wall mounted electric light switch in room 270 was within sixty inches of eleven O2 E-type oxygen bottles, the room contained combustibles within sixty inches of the stored oxygen.

B. Arizona Heart Hospital
Survey on April 10, 2013

On April 10, 2013 the surveyor, accompanied by the Plant Director, Director, Environment of Care, Director of Quality and a Maintenance Technician observed, observed the following oxygen storage:

1. Second floor Case Manager office, 1 EO2 bottle stored by combustibles
2. Second floor, clean utility room, 2 EO2 empty bottle, six EO2 full bottles stored with combustible/flammables
3. Second floor Cath-Lab storage room, 1 EO2 bottle stored with combustibles
4. OR Core, 1 EO bottle stored by combustibles

During the exit conference on April 9th and 10th of 2013, the above findings were again acknowledged by the CEO, President, CNO, Regional Director Infection Control, Regional Director of Quality, Director, Environmental of Care(Vanguard) Director, Chief Clinical Officer, Director Lab/Respiratory, Director of Plant Operations.

Failing to mount a light switch five feet above the floor to prevent an accident/or possible fire could cause harm to the patients. Leaking oxygen could penetrate combustible materials and create an extreme fire hazard, which could cause harm to the patients. In an emergency, patients could be harmed if an empty medical gas cylinder was mistakenly taken from the storage area.

B. Arizona Heart Hospital
Survey on April 10, 2013

Based on record review and Staff interview the facility failed to document the required testing of the emergency generator.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.7.6 " Maintenance and Testing (See 4.6.12) Section 4.6.12.2 " Equipment requiring periodic testing or operation to ensure its maintenance shall be tested or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction." NFPA 99 "HEALTH CARE FACILITIES". Chapter 3, Section 3-5.4.1.1 (a) and Section 3-4.4.1.1 (b) "Generator sets shall be tested twelve (12) times a year... Generator sets serving emergency and equipment systems shall be in accordance with NFPA 110, Chapter 6, Section 6-4.1 "Level 1 and Level 2 EPSSs, including all appurtenant components shall be inspected weekly and shall be exercised under load at least monthly. NFPA 110, Chapter 6, Section 6-4.2 "Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes...
Chapter 3, Section 3-4.1.1.8. (Level/Type 1) "The generator sets shall have sufficient capacity to pick up the load and meet the minimum frequency and voltage stability requirements of the emergency system within 10 seconds after loss of normal power.
or Section 3-5.3.1 (Level/Type 2) "The emergency system shall be installed and connected to the alternate source of power specified in 3-4.1.1.2 and 3-4.1.1.3 so that all functions specified herein for the emergency system will be automatically restored to operation within 10 seconds after interruption of the normal source."

Findings Include:

On April 10, 2013 the surveyor, accompanied by the Plant Director, Director, Environment of Care, Director of Quality and a Maintenance Technician observed, reviewed the generator test records. The generators are inspected and exercised under load monthly and documented however, No documentation of weekly inspections were seen for the year of 2012 and the first quarter of 2013. During an interview of the Maintenance Staff the Staff member stated that they were not aware of the weekly documentation.

During the exit conference on April 9th and 10th of 2013, the above findings were again acknowledged by the CEO, President, CNO, Regional Director Infection Control, Regional Director of Quality, Director, Environmental of Care(Vanguard) Director, Chief Clinical Officer, Director Lab/Respiratory, Director of Plant Operations.

Failure to test the emergency generator under load, inspect weekly, and document time from normal power to emergency power could result in harm to patients during emergency system failures.

A. Phoenix Baptist Hospital
Survey on April 9, 2013

Based on observation the facility failed to provide a guard on the light bulb located in the supply closet and the facility failed to provide receptacle face plates.


NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.5.1, "Utilities shall comply with the provisions of Section 9.1, Section 9.1.2, "Electrical wiring and equipment installed shall be in accordance with NFPA 70 National Electrical Code." NEC, 1999, Article 110, Section 110-27 (b) Prevent Physical Damage. " In locations where electric equipment is likely to be exposed to physical damage, enclosures or guards shall be so arranged and of such strength as to prevent such damage" NEC, 1999, Article 410, Section 410-56 (e) Position of Receptacle Faces. "3. After installation, receptacle faces shall be flush with or project from faceplate of insulating material and shall project a minimum of 0.015 in. From metal faceplate. Faceplate shall be installed so as to completely cover the opening and seat against the mounting surface."


Findings Include:

On April 9, 2013 the surveyor, accompanied by the Plant Director, Director, Environment of Care, Director of Quality and a Maintenance Technician observed, the light bulbs were not protected from physical damage in the following areas:

1. S-3-32, two light bulbs no covers
2. second floor, two light units, four bulbs, no light covers, mechanize room by room 250

B. Arizona Heart Hospital
Survey on April 10, 2013

1. FD38 Dialysis/ICU storage, broken 110 outlet cover
2. Burnt 110 electrical outlet by surgical viewing


During the exit conference on April 9th and 10th of 2013, the above findings were again acknowledged by the CEO, President, CNO, Regional Director Infection Control, Regional Director of Quality, Director, Environmental of Care(Vanguard) Director, Chief Clinical Officer, Director Lab/Respiratory, Director of Plant Operations.


Failure to keep light guards on the light could cause accidental damage or possibly a fire, which could cause harm to the patients. Failing to repair broken receptacles and face plates may contribute to starting a fire by allowing the electrical wiring to short when an electrical appliance is plugged in or removed from the receptacle. A fire in the facility may cause harm to the patients.

A. Arizona Heart Hospital
Survey on April 10, 2013


Based on observation the facility failed to maintain the smoke/fire resistive rating of corridor walls.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.6.1, "Corridors shall be separated from all other areas by partitions complying with 19.3.6.2 through 19.3.6.5 (See also 19.2.5.9) (See all Exceptions) Section 19.3.6.2 "Corridor walls shall be continuous from the floor to the underside of the floor or roof deck above, through any concealed spaces, such as those above suspended ceilings, and through interstitial structural and mechanical spaces, and they shall have a fire resistance rating of not less than 1/2 hour." (See all Exceptions}.

Findings Include:

On April 10, 2013 the surveyor, accompanied by the Plant Director, Director, Environment of Care, Director of Quality and a Maintenance Technician observed the following:

1. Second Floor, Open penetration by elevator one, lobby
2. First floor, approximate one inch pipe penetration above Human Resources

During the exit conference on April 9th and 10th of 2013, the above findings were again acknowledged by the CEO, President, CNO, Regional Director Infection Control, Regional Director of Quality, Director, Environmental of Care(Vanguard) Director, Chief Clinical Officer, Director Lab/Respiratory, Director of Plant Operations.

Corridor walls must remain smoke tight/fire resistive to prevent smoke and heat from entering resident rooms. Smoke/heat will cause harm to the patients.

A. Phoenix Baptist Hospital
Survey on April 9, 2013

Based on observation the facility failed to maintain corridor doors to resist the passage of heat/smoke.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.6.3.1, 19.3.6.3.2, 19.3.6.3.3. Section 19. 19.3.6.3.1 "Doors protecting corridor openings shall be constructed to resist the passage of smoke. Clearance between the bottom of the door and the floor covering not exceeding 1 in. shall be permitted for corridor doors." Section 19.3.6.3.2 "Doors shall be provided with positive latching hardware. Roller latches shall be prohibited." Section 19.3.6.3.3 "Hold -open devices that release when the door is pushed or pulled shall be permitted."

Findings Include:

On April 9, 2013 the surveyor, accompanied by the Plant Director, Director, Environment of Care, Director of Quality and a Maintenance Technician observed that the following corridor doors would not tightly close when tested.

1. South Tower, Labor and Delivery third floor, twenty minute rated door tested three of three times will not positively latch, Door S-3-38

B. Arizona Heart Hospital
Survey on April 10, 2013

1. Second Floor, Room 239, door tested three of three times will not positively latch
2. First Floor, OR, Recovery/Isolation, four holes through the door by door handle

During the exit conference on April 9th and 10th of 2013, the above findings were again acknowledged by the CEO, President, CNO, Regional Director Infection Control, Regional Director of Quality, Director, Environmental of Care(Vanguard) Director, Chief Clinical Officer, Director Lab/Respiratory, Director of Plant Operations.

In time of a fire failing to protect patients from heat and smoke could cause harm to the patients.

A. Phoenix Baptist Hospital
Survey on April 9, 2013

Based on observation the facility did not maintain the integrity, smoke resistance, of doors in hazardous areas.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.3.2.1 requires that hazardous areas be separated and/or protected by one hour rated construction and automatic sprinklers. If protected by automatic sprinklers the walls and doors must be able to resist the passage of smoke. NFPA 80 "Fire Doors and Fire Windows" Chapter 2, Section 2-3.1.7 "The clearance between the edge of the door on the pull side and the frame, and the meeting edges of doors swinging in pairs on the pull side shall be 1/8 in. +/- 1/16 in for steel doors and shall not exceed 1/8 in. for wood doors.

Findings Include:

On April 9, 2013 the surveyor, accompanied by the Plant Director, Director, Environment of Care, Director of Quality and a Maintenance Technician observed the following doors would not tightly close when tested.

1. Sixth Floor, Door 6-61, OR storage, rated door with a closing device blocked open by an impediment
2. Kitchen, Managers office/storage, no closing device, flammables/combustibles stored in room
3. Dry food storage, door tested three of three times, will not positively latch

During the exit conference on April 9th and 10th of 2013, the above findings were again acknowledged by the CEO, President, CNO, Regional Director Infection Control, Regional Director of Quality, Director, Environmental of Care(Vanguard) Director, Chief Clinical Officer, Director Lab/Respiratory, Director of Plant Operations.

Failing to prevent heat and smoke from spreading into the exit corridor will cause harm to patients.

B. Arizona Heart Hospital
Survey on April 10, 2013

Based on observation the facility failed to conduct the required fire drills.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.7.1.2 Fire exit 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."

Findings include:

On April 9, 2013 the surveyor, accompanied by the Plant Director, Director, Environment of Care, Director of Quality and a Maintenance Technician reviewed the facility's fire drill records. The surveyor noted there were no fire drill reports for First quarter second shift 2013.

During the exit conference on April 9th and 10th of 2013, the above findings were again acknowledged by the CEO, President, CNO, Regional Director Infection Control, Regional Director of Quality, Director, Environmental of Care(Vanguard) Director, Chief Clinical Officer, Director Lab/Respiratory, Director of Plant Operations.

Failure to train and drill the staff on fire procedures could result in harm to the patients.

A. Phoenix Baptist Hospital
Survey on April 9, 2013

Based on observation the facility failed to clean the kitchen exhaust hood system, filters and grease drip tray.

NFPA 101 Life Safety Code 2000, Chapter 19, Section 19.3.2.6 "Cooking facilities shall be protected in accordance with 9-2.3" Section 9-2.3 "Commercial cooking equipment shall be installed in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations." , Chapter 8, Section 8-3.1, " Hoods, grease removal devices, fans, ducts, and other appurtenances shall be cleaned to bare metal at frequent intervals prior to surfaces becoming heavily contaminated with grease or oily sludge".

Findings include:

On April 9, 2013 the surveyor, accompanied by the Plant Director, Director, Environment of Care, Director of Quality and a Maintenance Technician observed the kitchen exhaust system hood, filters and grease drip tray area had an excessive amount of grease buildup. The broiler grill cook area has one of seven filters with excessive grease build up. Staff interview stated filters cleaned on Saturday only.

During the exit conference on April 9th and 10th of 2013, the above findings were again acknowledged by the CEO, President, CNO, Regional Director Infection Control, Regional Director of Quality, Director, Environmental of Care(Vanguard) Director, Chief Clinical Officer, Director Lab/Respiratory, Director of Plant Operations.


Failing to keep the entire kitchen exhaust hood system clean from grease will cause a fire, which could cause damage to the kitchen and will cause harm to the patients.

A. Phoenix Baptist Hospital
Survey on April 9, 2013

Based on observation the facility failed to mount an electrical light switch five feet above the floor in the oxygen storage rooms and the facility failed to keep the oxygen bottles free of combustible/flammable materials.

NFPA 101 Life Safety Code, Chapter 19, Section 19.3.2.4 " Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities." NFPA 99 Chapter 8, Storage Requirements, Section 8-3.1.11.2 Storage for nonflammable gases less than 3000 cubic feet. (f) Electrical fixtures in storage locations shall meet 4-3.1.1.2 (a) 11d. Section 4-3.1.1.2 (a) 11(d) Ordinary electrical wall fixtures in supply rooms shall be installed in fixed locations not less than 5 ft. (1.5m) above the floor to avoid physical damage. Section 8-3.1.11 "Storage Requirements" Section 8-3.1.11.2 "Storage of nonflammable gases less than 3000 cubic. feet.." (a) "Storage locations shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limited-combustible construction, with doors (or gates outdoors) that can be secured against unauthorized entry. (c) "Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or incompatible materials by: (c) (2) A minimum distance of 5 ft. if the entire storage location is protected by an automatic sprinkler system..."

Findings Include:


On April 9, 2013 the surveyor, accompanied by the Plant Director, Director, Environment of Care, Director of Quality and a Maintenance Technician observed, the wall mounted electric light switch in room 270 was within sixty inches of eleven O2 E-type oxygen bottles, the room contained combustibles within sixty inches of the stored oxygen.

B. Arizona Heart Hospital
Survey on April 10, 2013

On April 10, 2013 the surveyor, accompanied by the Plant Director, Director, Environment of Care, Director of Quality and a Maintenance Technician observed, observed the following oxygen storage:

1. Second floor Case Manager office, 1 EO2 bottle stored by combustibles
2. Second floor, clean utility room, 2 EO2 empty bottle, six EO2 full bottles stored with combustible/flammables
3. Second floor Cath-Lab storage room, 1 EO2 bottle stored with combustibles
4. OR Core, 1 EO bottle stored by combustibles

During the exit conference on April 9th and 10th of 2013, the above findings were again acknowledged by the CEO, President, CNO, Regional Director Infection Control, Regional Director of Quality, Director, Environmental of Care(Vanguard) Director, Chief Clinical Officer, Director Lab/Respiratory, Director of Plant Operations.

Failing to mount a light switch five feet above the floor to prevent an accident/or possible fire could cause harm to the patients. Leaking oxygen could penetrate combustible materials and create an extreme fire hazard, which could cause harm to the patients. In an emergency, patients could be harmed if an empty medical gas cylinder was mistakenly taken from the storage area.

B. Arizona Heart Hospital
Survey on April 10, 2013

Based on record review and Staff interview the facility failed to document the required testing of the emergency generator.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.7.6 " Maintenance and Testing (See 4.6.12) Section 4.6.12.2 " Equipment requiring periodic testing or operation to ensure its maintenance shall be tested or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction." NFPA 99 "HEALTH CARE FACILITIES". Chapter 3, Section 3-5.4.1.1 (a) and Section 3-4.4.1.1 (b) "Generator sets shall be tested twelve (12) times a year... Generator sets serving emergency and equipment systems shall be in accordance with NFPA 110, Chapter 6, Section 6-4.1 "Level 1 and Level 2 EPSSs, including all appurtenant components shall be inspected weekly and shall be exercised under load at least monthly. NFPA 110, Chapter 6, Section 6-4.2 "Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes...
Chapter 3, Section 3-4.1.1.8. (Level/Type 1) "The generator sets shall have sufficient capacity to pick up the load and meet the minimum frequency and voltage stability requirements of the emergency system within 10 seconds after loss of normal power.
or Section 3-5.3.1 (Level/Type 2) "The emergency system shall be installed and connected to the alternate source of power specified in 3-4.1.1.2 and 3-4.1.1.3 so that all functions specified herein for the emergency system will be automatically restored to operation within 10 seconds after interruption of the normal source."

Findings Include:

On April 10, 2013 the surveyor, accompanied by the Plant Director, Director, Environment of Care, Director of Quality and a Maintenance Technician observed, reviewed the generator test records. The generators are inspected and exercised under load monthly and documented however, No documentation of weekly inspections were seen for the year of 2012 and the first quarter of 2013. During an interview of the Maintenance Staff the Staff member stated that they were not aware of the weekly documentation.

During the exit conference on April 9th and 10th of 2013, the above findings were again acknowledged by the CEO, President, CNO, Regional Director Infection Control, Regional Director of Quality, Director, Environmental of Care(Vanguard) Director, Chief Clinical Officer, Director Lab/Respiratory, Director of Plant Operations.

Failure to test the emergency generator under load, inspect weekly, and document time from normal power to emergency power could result in harm to patients during emergency system failures.

A. Phoenix Baptist Hospital
Survey on April 9, 2013

Based on observation the facility failed to provide a guard on the light bulb located in the supply closet and the facility failed to provide receptacle face plates.


NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.5.1, "Utilities shall comply with the provisions of Section 9.1, Section 9.1.2, "Electrical wiring and equipment installed shall be in accordance with NFPA 70 National Electrical Code." NEC, 1999, Article 110, Section 110-27 (b) Prevent Physical Damage. " In locations where electric equipment is likely to be exposed to physical damage, enclosures or guards shall be so arranged and of such strength as to prevent such damage" NEC, 1999, Article 410, Section 410-56 (e) Position of Receptacle Faces. "3. After installation, receptacle faces shall be flush with or project from faceplate of insulating material and shall project a minimum of 0.015 in. From metal faceplate. Faceplate shall be installed so as to completely cover the opening and seat against the mounting surface."


Findings Include:

On April 9, 2013 the surveyor, accompanied by the Plant Director, Director, Environment of Care, Director of Quality and a Maintenance Technician observed, the light bulbs were not protected from physical damage in the following areas:

1. S-3-32, two light bulbs no covers
2. second floor, two light units, four bulbs, no light covers, mechanize room by room 250

B. Arizona Heart Hospital
Survey on April 10, 2013

1. FD38 Dialysis/ICU storage, broken 110 outlet cover
2. Burnt 110 electrical outlet by surgical viewing


During the exit conference on April 9th and 10th of 2013, the above findings were again acknowledged by the CEO, President, CNO, Regional Director Infection Control, Regional Director of Quality, Director, Environmental of Care(Vanguard) Director, Chief Clinical Officer, Director Lab/Respiratory, Director of Plant Operations.


Failure to keep light guards on the light could cause accidental damage or possibly a fire, which could cause harm to the patients. Failing to repair broken receptacles and face plates may contribute to starting a fire by allowing the electrical wiring to short when an electrical appliance is plugged in or removed from the receptacle. A fire in the facility may cause harm to the patients.