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Provide a placard placed conspicuously near the Class "K" fire extinguisher after June 30, 1998. Placard to read: "Fire protection system shall be activated prior to using fire extinguisher." NFPA 10: 4.3.2.2

This STANDARD is not being met, as evidenced by: Based on observation during the Survey on the morning of 11/20/2013, with the hospital's Plant Operations Director, the required placard was not observed.

Written report on Disaster Drills. Each organizational entity shall implement one or more specific responses of the emergency management plan at least semiannually. At least one semiannual drill shall rehearse mass casualty response for health care facilities with emergency services, disaster receiving stations, or both. NFPA 99, 12.3.3.9 Drills

This STANDARD is not met as evidenced by: Based on observations during the review of required maintenance logs, on the morning of 11/20/2013, the facility failed to supply written reports on Disaster Drills.


Letters indicating preferred customer status in case of emergency situation for water and fuel source. When designated by the emergency management plan to provide continuous service in a disaster or emergency, health care facilities shall establish contingency plans for the continuity of essential building systems, as applicable: (2) water; and, (5) fuel sources. NFPA 99, 12.3.3.2 Continuity of Essential Building Systems

This STANDARD is not met as evidence by: Based on observations during the review of required maintenance logs, on the morning of 11/20/2013, the facility failed to supply letters indicating preferred customer status for water and fuel.


Receptacle Testing in Patient Care Areas (NFPA 99: 4.3.3.2). The physical integrity of each receptacle shall be confirmed by visual inspection. The continuity of the grounding circuit in each electrical receptacle shall be verified. Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed. The retention force of the ground blade of each electrical receptacle (except for locking-type receptacles) shall be not less than 115 g (4 oz). NFPA99: 4.3.3.2.1 - 4.3.3.2.4

Testing intervals for hospital grade receptacles in patient care areas shall be performed after initial installation, replacement, or servicing of the device (NFPA 99: 4.3.4.1.1). Additional testing shall be performed at intervals defined by documented performance data (NFPA 99: 4.3.4.1.2) - semi-annually. Receptacles not listed as hospital-grade shall be tested at intervals not exceeding 12 months (NFPA 99: 4.3.4.1.3).

A review of documentation, during the facility survey on the morning of 11/20/2013, revealed that no information on electrical receptacle testing was being kept in facility records/logs.

Emergency system receptacles shall be identified and shall also indicate the panelboard and circuit number supplying them. NFPA 70: 517-19

This STANDARD is not being met, as evidenced by: Based on observation during the Survey on the morning of 11/20/2013, with the hospital's Plant Operations Director, numerous emergency system electrical receptacles in patient care areas did not have non-removable labels identifying the electrical panelboard and circuit number supplying them.

Provide a placard placed conspicuously near the Class "K" fire extinguisher after June 30, 1998. Placard to read: "Fire protection system shall be activated prior to using fire extinguisher." NFPA 10: 4.3.2.2

This STANDARD is not being met, as evidenced by: Based on observation during the Survey on the morning of 11/20/2013, with the hospital's Plant Operations Director, the required placard was not observed.

Written report on Disaster Drills. Each organizational entity shall implement one or more specific responses of the emergency management plan at least semiannually. At least one semiannual drill shall rehearse mass casualty response for health care facilities with emergency services, disaster receiving stations, or both. NFPA 99, 12.3.3.9 Drills

This STANDARD is not met as evidenced by: Based on observations during the review of required maintenance logs, on the morning of 11/20/2013, the facility failed to supply written reports on Disaster Drills.


Letters indicating preferred customer status in case of emergency situation for water and fuel source. When designated by the emergency management plan to provide continuous service in a disaster or emergency, health care facilities shall establish contingency plans for the continuity of essential building systems, as applicable: (2) water; and, (5) fuel sources. NFPA 99, 12.3.3.2 Continuity of Essential Building Systems

This STANDARD is not met as evidence by: Based on observations during the review of required maintenance logs, on the morning of 11/20/2013, the facility failed to supply letters indicating preferred customer status for water and fuel.


Receptacle Testing in Patient Care Areas (NFPA 99: 4.3.3.2). The physical integrity of each receptacle shall be confirmed by visual inspection. The continuity of the grounding circuit in each electrical receptacle shall be verified. Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed. The retention force of the ground blade of each electrical receptacle (except for locking-type receptacles) shall be not less than 115 g (4 oz). NFPA99: 4.3.3.2.1 - 4.3.3.2.4

Testing intervals for hospital grade receptacles in patient care areas shall be performed after initial installation, replacement, or servicing of the device (NFPA 99: 4.3.4.1.1). Additional testing shall be performed at intervals defined by documented performance data (NFPA 99: 4.3.4.1.2) - semi-annually. Receptacles not listed as hospital-grade shall be tested at intervals not exceeding 12 months (NFPA 99: 4.3.4.1.3).

A review of documentation, during the facility survey on the morning of 11/20/2013, revealed that no information on electrical receptacle testing was being kept in facility records/logs.

Emergency system receptacles shall be identified and shall also indicate the panelboard and circuit number supplying them. NFPA 70: 517-19

This STANDARD is not being met, as evidenced by: Based on observation during the Survey on the morning of 11/20/2013, with the hospital's Plant Operations Director, numerous emergency system electrical receptacles in patient care areas did not have non-removable labels identifying the electrical panelboard and circuit number supplying them.