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The facility did not ensure that exit access is arranged so that exits are readily accessible at all times as defined in section 19.2.2.2.4 of the referenced, Life Safety Code.

On 05/07/13 at 2:00 PM the surveyor accompanied by the Director of Engineering observed that the egress path, from Psych/Behavioral Nursing Unit was equipped with more than 1 (one) locking arrangement that was equipped with a lock that required the use a key (a tool, or special knowledge) to disengage the mechanism and not meeting the requirements of section # 19.1.1.1.5 of the referenced Life Safety Code; i.e. sally port concept allowed in detention & correctional occupancies-not in healthcare

The facility did not ensure that emergency lighting of at least 1½-hour duration is provided in accordance with LSC 7.9 & 19.2.9.1.

On 05/07/13 at 9:50 AM, the surveyor was not provided with documentation from the Director of Engineering to indicate that that the battery backup emergency lights were tested for 90 minutes annually as required by the referenced, Life Safety Code; i.e. no records of annual testing for the Main Campus

1. The facility did not ensure that electrical power was provided to facility patient care and equipment in compliance with NFPA 70 , "National Electrical Code" and NFPA 99 "Health Care Facilities"

On 05/06/13 at 11:00 AM and other times throughout the day, the surveyor accompanied by the Director of Engineering observed that the facility was utilizing extension cords throughout the facility as a permanent primary source of power for electrically powered equipment (portable lap top work stations) not in compliance with the requirements of NFPA 70, " National Electrical Code" and NFPA 99 "Health Care Facilities " regarding the use of temporary power; i.e. certain types of work station tables have not been removed from service yet that depend on the extension cords

2. The facility did not ensure that electrical equipment used within health care facilities was being installed and used in accordance with the manufacturer requirements as required by section 9-2.1.7 of NFPA 99 " Health Care Facility ' s " .

On 05/06/13 at 10:15 AM and other times throughout the day, the surveyor accompanied by the Director of Engineering observed that the Fluid and Blanket warmers throughout the Operating Suites and other areas were not being maintained at temperatures consistent with the facility ' s policy and procedures and manufacturers requirements as required by NFPA 99 "Health Care Facility ' s " .;i.e. every fluid & blanket warmer that was inspected exceeded the temperatures listed on the policy-taped to the warmer(s)

3. The facility did not ensure that all employees are periodically instructed as to their duties during a fire emergency as required by NFPA 101 " Life Safety Code " 19.7.1 and annually as required in NFPA 99 " Health Care Facility ' s " section # 11-5.3.8.

On 05/07/13 at 10:40 AM, the surveyor was not provided with documentation from the Director of Engineering to indicate that all employees are in serviced annually as to their duties during a fire emergency; i.e. rosters indicate 39% of staff received such training in the last year.

4. The facility did not ensure that electrical receptacle outlets in-patient areas were being inspected at least annually as required in NFPA 99, " Health Care Facility ' s " .

On 05/07/13 at 10:30 AM, the surveyor was not provided with documentation from the Director of Engineering to indicate that all electrical receptacle outlets in patient areas are inspected annually as required in NFPA 99, " Health Care Facility ' s " , Section 3-3.3.3 and 3-3.4.2.3, and as part of the facility ' s preventive maintenance program;i.e. work orders indicate that a total of 1-hour was spent on receptacle testing in the last year and the tester unsure of when it was last done;

The facility did not ensure that generators are inspected weekly and exercised under load for 30 minutes per month as required by the referenced, Life Safety Code.

On 05/07/13 at 9:20 AM, the surveyor was not provided with documentation from the Director of Engineering to indicate that the generator was exercised at least once monthly, for a minimum of 30 minutes under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating or loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer, as required by section 6-4 of NFPA 110, " Standard for Emergency and Standby Power Systems "; i.e.no documentation that large, KW generator set is exercised annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of 2 continuous hours-generators 1, 2 & 3 had months of load testing where 30% of rated nameplate was not achieved.

The facility did not ensure that exit access is arranged so that exits are readily accessible at all times as defined in section 19.2.2.2.4 of the referenced, Life Safety Code.

On 05/07/13 at 2:00 PM the surveyor accompanied by the Director of Engineering observed that the egress path, from Psych/Behavioral Nursing Unit was equipped with more than 1 (one) locking arrangement that was equipped with a lock that required the use a key (a tool, or special knowledge) to disengage the mechanism and not meeting the requirements of section # 19.1.1.1.5 of the referenced Life Safety Code; i.e. sally port concept allowed in detention & correctional occupancies-not in healthcare

The facility did not ensure that emergency lighting of at least 1½-hour duration is provided in accordance with LSC 7.9 & 19.2.9.1.

On 05/07/13 at 9:50 AM, the surveyor was not provided with documentation from the Director of Engineering to indicate that that the battery backup emergency lights were tested for 90 minutes annually as required by the referenced, Life Safety Code; i.e. no records of annual testing for the Main Campus

1. The facility did not ensure that electrical power was provided to facility patient care and equipment in compliance with NFPA 70 , "National Electrical Code" and NFPA 99 "Health Care Facilities"

On 05/06/13 at 11:00 AM and other times throughout the day, the surveyor accompanied by the Director of Engineering observed that the facility was utilizing extension cords throughout the facility as a permanent primary source of power for electrically powered equipment (portable lap top work stations) not in compliance with the requirements of NFPA 70, " National Electrical Code" and NFPA 99 "Health Care Facilities " regarding the use of temporary power; i.e. certain types of work station tables have not been removed from service yet that depend on the extension cords

2. The facility did not ensure that electrical equipment used within health care facilities was being installed and used in accordance with the manufacturer requirements as required by section 9-2.1.7 of NFPA 99 " Health Care Facility ' s " .

On 05/06/13 at 10:15 AM and other times throughout the day, the surveyor accompanied by the Director of Engineering observed that the Fluid and Blanket warmers throughout the Operating Suites and other areas were not being maintained at temperatures consistent with the facility ' s policy and procedures and manufacturers requirements as required by NFPA 99 "Health Care Facility ' s " .;i.e. every fluid & blanket warmer that was inspected exceeded the temperatures listed on the policy-taped to the warmer(s)

3. The facility did not ensure that all employees are periodically instructed as to their duties during a fire emergency as required by NFPA 101 " Life Safety Code " 19.7.1 and annually as required in NFPA 99 " Health Care Facility ' s " section # 11-5.3.8.

On 05/07/13 at 10:40 AM, the surveyor was not provided with documentation from the Director of Engineering to indicate that all employees are in serviced annually as to their duties during a fire emergency; i.e. rosters indicate 39% of staff received such training in the last year.

4. The facility did not ensure that electrical receptacle outlets in-patient areas were being inspected at least annually as required in NFPA 99, " Health Care Facility ' s " .

On 05/07/13 at 10:30 AM, the surveyor was not provided with documentation from the Director of Engineering to indicate that all electrical receptacle outlets in patient areas are inspected annually as required in NFPA 99, " Health Care Facility ' s " , Section 3-3.3.3 and 3-3.4.2.3, and as part of the facility ' s preventive maintenance program;i.e. work orders indicate that a total of 1-hour was spent on receptacle testing in the last year and the tester unsure of when it was last done;

The facility did not ensure that generators are inspected weekly and exercised under load for 30 minutes per month as required by the referenced, Life Safety Code.

On 05/07/13 at 9:20 AM, the surveyor was not provided with documentation from the Director of Engineering to indicate that the generator was exercised at least once monthly, for a minimum of 30 minutes under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating or loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer, as required by section 6-4 of NFPA 110, " Standard for Emergency and Standby Power Systems "; i.e.no documentation that large, KW generator set is exercised annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of 2 continuous hours-generators 1, 2 & 3 had months of load testing where 30% of rated nameplate was not achieved.