HospitalInspections.org

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The facility failed to maintain a corridor door per code. Findings include:

During the survey, the following is an example of what was observed:
Second Floor
The corridor door for room 272 was not positive latching. The lever action door handle on the patient room side was broken. The surveyor observed the plunger not working after the staff tried to fix it.

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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.
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The facility failed to maintain the one hour fire barrier for the atrium per code. Findings include:

During the survey, the following is an example of what was observed:
The one hour fire barrier for the Lobby atrium at the phone (above the lay-in ceiling) was observed with the following:
1. Several unsealed penetrations
2. Several unsealed conduit ends
3. Unsealed rockwool

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2000 NFPA 101, 8.2.5.6 Unless prohibited by Chapters 12 through 42, an atrium shall be permitted, provided that the following conditions are met:
(1) In other than existing, previously approved atria, atriums are separated from the adjacent spaces by fire barriers with not less than a 1-hour fire resistance rating with opening protectives for corridor walls. (See 8.2.3.2.3.1(2), Exception No. 1.)
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The facility failed to maintain the smoke barriers per code. Findings include: During the survey the following is an example of what was observed:

1. Unsealed penetrations around the beam in the Smoke Barrier, by Visitor Lounge Second Floor.


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Second Floor
2. The smoke barrier in room 262, above the closet, was observed:
a. Two unsealed penetrations at a bar joist's horizontal bridging
b. Wall was not sealed at the corrugated roof deck
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2000 NFPA 101, 8.2.4.4.1 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through smoke partitions shall be protected as follows: (1) The space between the penetrating item and the smoke partition shall meet one of the following conditions: a. It shall be filled with a material that is capable of limiting the transfer of smoke. b. It shall be protected by an approved device that is designed for the specific purpose. (2) Where the penetrating item uses a sleeve to penetrate the smoke partition, the sleeve shall be solidly set in the smoke partition, and the space between the item and the sleeve shall meet one of the following conditions: a. It shall be filled with a material that is capable of limiting the transfer of smoke. b. It shall be protected by an approved device that is designed for the specific purpose. (3) Where designs take transmission of vibrations into consideration, any vibration isolation shall meet one of the following conditions: a. It shall be made on either side of the smoke partitions. b. It shall be made by an approved device that is designed for the specific purpose.

2000 NFPA 101, 8.3.2 Smoke barriers required by this Code shall be continuous from an outside wall to an outside wall, from a floor to a floor, or from a smoke barrier to a smoke barrier or a combination thereof. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces.
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During the survey, the following are examples of observations during the testing of the fire alarm system to doors in the smoke barriers:

1. The following automatic smoke barrier doors (doors operated by power upon the approach of a person), failed to remain self closing. During initial activation of the fire alarm system the door mechanism released the doors to a closed position. The surveyor with maintenance personnel observed that these doors could be held open by the door mechanism at various degrees based on how much the doors was pushed to an open position while the fire alarm was still activated.
First Floor
a. At Endoscopy/Hospital separation wall
b. At Emergency Department entrance at the stairwell
Second Floor
c. At entrance to "Labor & Delivery 1 - 17" (at the nurses' station)
First Floor

2. The Manager's Office One South - the corridor door is in a one hour smoke barrier - did not have a self-closing device

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2000 NFPA 101, 19.3.7.6 Doors in smoke barriers shall comply with 8.3.4 and shall be self-closing or automatic-closing in accordance with 19.2.2.2.6. Such doors in smoke barriers shall not be required to swing with egress travel.

8.3.4.3* Doors in smoke barriers shall be self-closing or automatic-closing in accordance with 7.2.1.8 and shall comply with the provisions of 7.2.1.

7.2.1.9.2 Doors Required to Be Self-Closing.
Where doors are required to be self-closing and (1) are operated by power upon the approach of a person or (2) are provided with power-assisted manual operation, they shall be permitted in the means of egress under the following conditions: (1) Doors can be opened manually in accordance with 7.2.1.9.1 to allow egress travel in the event of power failure. (2) New doors remain in the closed position unless actuated or opened manually. (3) When actuated, new doors remain open for not more than 30 seconds. (4) Doors held open for any period of time close - and the power-assist mechanism ceases to function - upon operation of approved smoke detectors installed in such a way as to detect smoke on either side of the door opening in accordance with the provisions of NFPA 72, National Fire Alarm Code. (5) Doors required to be self-latching are either self-latching or become self-latching upon operation of approved smoke detectors per 7.2.1.9.2(4). (6) New power-assisted swinging doors comply with BHMA/ANSI A156.19, American National Standard for Power Assist and Low Energy Power Operated Doors.

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The facility failed to maintain the hazardous area per code. Findings include:

During the survey, the following is an example of what was observed:
Second Floor
The hallway storage room at Labor & Delivery was over 72 sq. ft. with combustibles, this room had sliding doors, that were not self-closing nor smoke resistive

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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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The facility failed to provide a reliable means of egress to the public way findings include: During the survey, the following are examples of what was observed.

1. The means of egress to the public way for the Exit One East, was blocked by a vehicle. The side walk ends at the parking space which blocks egress to the parking lot which is the public way.

2. The means of egress to the public way for the Exit by MRI, was obstructed by a vehicle. The side walk ends at the parking space which obstructed clear wide for egress to the parking lot.
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NFPA 101, 7.1.10.1 Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

NFPA 101, A.7.1.10.1 *A proper means of egress allows unobstructed travel at all times. Any type of barrier including, but not limited to, the accumulations of snow and ice in those climates subject to such accumulations is an impediment to free movement in the means of egress.

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The facility failed to provide protection of openings in fire barriers to limit the spread of fire and restrict the movement of smoke from one side of the fire barrier to the other. Findings include: During the survey, the following is an example of what was observed:

Unsealed penetrations at the deck in the one hour barrier, at Outpatients Services First Floor.
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NFPA 101, 19.2.2.5 and 7.2.4.3 Openings in fire barriers shall be constructed to limit the spread of fire and restrict the movement of smoke from one side of the fire barrier to the other.

The facility failed to conduct fire drills at unexpected times and under varying conditions to test and evaluate the efficiency, knowledge, and response of institutional personnel in implementing the facility fire emergency plan. Findings include:

During the survey, the following are examples of what was observed:
1. Per documentation provided by maintenance staff, facility failed to illustrate that all facility personnel are familiar with the signals and emergency action required under varied conditions during fire drills. Per interview with facility maintenance staff, staff confirmed that documentation provided of fire drill participation did not include names of all staff in the facility at the time of the fire drills.

2. Per documentation not holding fire drills at unexpected times under varying conditions

First Shift
10/19/2012 - 12:47 pm
07/27/2012 - 12:58 pm
05/25/2012 - 1:45 pm
03/29/2012 - 2:35 pm
Second Shift
09/12/2012 - 3:10 pm
06/14/2012 - 3:25 pm
01/20/2012 - 3:01 pm
Third Shift
09/20/2012 - 4:45 am
06/22/2012 - 5:00 am
02/16/2012 - 5:00 am
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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.
2000 NFPA 101, 4.7.2* Emergency egress and relocation drills, where required by Chapters 11 through 42 or the authority having jurisdiction, shall be held with sufficient frequency to familiarize occupants with the drill procedure and to establish conduct of the drill as a matter of routine. Drills shall include suitable procedures to ensure that all persons subject to the drill participate.

2000 NFPA 101, 4.7.5* Drills shall be held at expected and unexpected times and under varying conditions to simulate the unusual conditions that can occur in an actual emergency.
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The facility failed to maintain the fire alarm system per code. Findings include:

During the survey, the following are examples of what was observed:
Second Floor
1. C-section OR # 3 - when the smoke detector in this room was tested, the fire alarm panel indicated that the smoke detector in C-section OR # 1 was in alarm
2. When the primary power to the fire alarm was removed - delayed egress door 2E failed to be delayed egress, there was no alarm and the door failed to release within thirty seconds. When the code was entered the door did release

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2000 NFPA 101, 9.6.7.2 Alarm annunciation at the control center shall be by means of audible and visible indicators.
2000 NFPA 101, 9.6.1.4 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.
2000 NFPA 101, 7.2.1.6.1 Approved, listed, delayed-egress locks shall be permitted to be installed on doors serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system in accordance with Section 9.6, or an approved, supervised automatic sprinkler system in accordance with Section 9.7, and where permitted in Chapters 12 through 42, provided that the following criteria are met. (c) An irreversible process shall release the lock within 15 seconds upon application of a force to the release device required in 7.2.1.5.4 that shall not be required to exceed 15 lbf (67 N) nor be required to be continuously applied for more than 3 seconds. The initiation of the release process shall activate an audible signal in the vicinity of the door. Once the door lock has been released by the application of force to the releasing device, relocking shall be by manual means only. Exception: Where approved by the authority having jurisdiction, a delay not exceeding 30 seconds shall be permitted. (d) * On the door adjacent to the release device, there shall be a readily visible, durable sign in letters not less than 1 in. (2.5 cm) high and not less than 1/8 in. (0.3 cm) in stroke width on a contrasting background that reads as follows:
PUSH UNTIL ALARM SOUNDS
DOOR CAN BE OPENED IN 15 SECONDS
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The facility failed to provide complete sprinkler coverage to all parts of the facility.
Findings include: During the survey, the following are examples of what was observed:


1. Ceiling tiles missing in CT Exam Room.

2. Escutcheon plate missing on a sprinkler in the cooler located outside near kitchen.

3. Escutcheon plate missing on a sprinkler in the cover parking area near Emergency Room.

4. Sprinkler coverage not provided in the Tel/Com Room across from Clinical Operations Manager Surgery Office.

5. Sprinkler coverage not provided in the cooler located in the Kitchen.

6. Sprinkler coverage not provided in the freezer located in the Kitchen.


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Second Floor
7. Telecommunications Closet across from room 248 was observed without automatic sprinkler coverage
8. Hydraulic elevators # 3 and # 4 were observed without sprinkler protection at the bottom of the shaft. Documentation provided by the facility did not indicate that the hydraulic fluid was "not combustible".
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2000 NFPA 19.3.5.1 Sprinkler protection shall be provide throughout the facility in accordance with
section 9.7.

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

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.

1999 NFPA 13, 5-13.6.1 Sidewall spray sprinklers shall be installed at the bottom of each elevator hoistway not more than 2 ft (0.61 m) above the floor of the pit.
Exception: For enclosed, noncombustible elevator shafts that do not contain combustible hydraulic fluids, the sprinklers at the bottom of the shaft are not required.
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The facility failed to comply with the required maintenance of the facility sprinkler system. During the survey, the following are examples of what was observed:


1. The fire department connections were not provided with an identification sign.

2. Documentation was not provided for the 5 year replacement or calibration for sprinkler system gauges.
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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.

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 25, Table 2-1 Summary of Sprinkler System Inspection, Testing, and Maintenance

NFPA 25, 9-2.8.2: Gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge. Gauges not accurate to within 3 percent of the full scale shall be recalibrated or replaced.

NFPA 25, 9-2.8.1: Gauges shall be inspected monthly to verify that they are in good condition and that normal pressure is being maintained. Exception: When other sections of this standard have different frequency requirements for specific gauges.

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The facility failed provide the required clearance between the bottom of the fire extinguisher and the floor. Findings
include: During the survey, the following is an example of what was observed:

The K-extinguisher in the kitchen was sitting on the floor not mounted on the wall.
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1998 NFPA 10, 1-6.10 Fire extinguishers weighting not more than 40 lb. (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. Fire extinguishers having a gross weight greater than 40 lb. (18.14 kg) (except wheeled types) shall be so installed that the top of the fire extinguisher is not more than 31/2 ft (1.07 m) above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 in. (10.2 cm).
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Facility failed to maintain the protection for the cooking area per NFPA standards. The following is an example of what was observed:

During the survey, the K-extinguisher in the kitchen was not provided with a placard.
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NFPA 96 7-2.1.1 A placard identifying the use of the extinguisher as a secondary backup means to the automatic fire suppression system shall be conspicuously placed near each portable fire extinguisher in the cooking area.

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The facility failed to prohibit the use of a portable space-heating device per code. Findings include:

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

A portable wire coil space-heating device was observed plugged into an electrical outlet
in the second floor North Manager's Office located in the smoke compartment encompassing the Nursery.
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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 maintain anesthetizing locations per code. Findings include:

During the survey, the following are examples of what was observed:
First Floor
1. All six of the windowless ORs were observed without the following:
a. Battery back-up lighting
b. "Supply and exhaust systems to automatically vent smoke and products of combustion"

Second Floor
2. The windowless C-section ORs # 2 & # 3 were observed without the following:
a. Battery back-up lighting
b. "Supply and exhaust systems to automatically vent smoke and products of combustion"

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1999 NFPA 99, 3-3.2.1.2 All Patient Care Areas.
5. Wiring in Anesthetizing Locations.
e. Battery-Powered Emergency Lighting Units. One or more battery-powered emergency lighting units shall be provided in accordance with NFPA 70, National Electrical Code, Section 700-12(e).
1999 NFPA 99, 5-4.1.2 Supply and exhaust systems for windowless anesthetizing locations shall be arranged to automatically vent smoke and products of combustion.
1999 NFPA 99, 5-4.1.3 Ventilating systems for anesthetizing locations shall be provided that automatically (a) prevent recirculation of smoke originating within the surgical suite and (b) prevent the circulation of smoke entering the system intake, without in either case interfering with the exhaust function of the system.
1999 NFPA 99, 5-4.1.4 The electric supply to the ventilating system shall be served by the equipment system of the essential electrical system specified in Chapter 3, " Electrical Systems. "
1999 NFPA 99, 5-6.1.1 Ventilating and humidifying equipment for anesthetizing locations shall be kept in operable condition and be continually operating during surgical procedures (see A-5-4.1).
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1. The facility failed to maintain the emergency lighting per code. Findings include:

During the survey, the following is an example of what was observed:
a. The facility failed to provide documentation of the annual testing of the emergency lighting
b. Per staff, the facility is only testing the emergency lighting for one hour annually

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2000 NFPA 101, 39.2.9.1 Emergency lighting shall be provided in accordance with Section 7.9 in any building where any one of the following conditions exists: (1) The building is two or more stories in height above the level of exit discharge. (2) The occupancy is subject to 100 or more occupants above or below the level of exit discharge. (3) The occupancy is subject to 1000 or more total occupants.

2000 NFPA 101, 7.9.3 A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 1/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction

2. The facility failed to provide documentation of inspections and testing on the following systems. Findings include:

During the survey, the following are examples of what was observed:
a. Review of all documentation was conducted on the afternoon of the second day of the survey. The documentation for the annual inspection of the fire alarm system was not provided. Information was requested by the Vice President of facilities, but was not provided for this surveyor before the exit interview on the third day. No promises were made by this surveyor to accept documentation after the surveyor had completed the survey and left the facility.
b. Review of all documentation was conducted on the afternoon of the second day of the survey. The documentation for the inspection of the sprinkler system was not provided. Information was requested by the Vice President of facilities, but was not provided for this surveyor before the exit interview on the third day. No promises were made by this surveyor to accept documentation after the surveyor had completed the survey and left the facility.

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NFPA 101, 9.6.1.4 The fire alarm system to be installed, tested, and maintained in accordance with the requirements of NFPA 70 and NFPA 72.

1999 NFPA 72, 1-6.3 Records.
A complete, unalterable record of the tests and operations of each system shall be kept until the next test and for 1 year thereafter. The record shall be available for examination and, if required, reported to the authority having jurisdiction. Archiving of records by any means shall be permitted if hard copies of the records can be provided promptly when requested.
Exception: If off-premises monitoring is provided, records of all signals, tests, and operations recorded at the supervising station shall be maintained for not less than 1 year.


NFPA 101, 4.6.12, and NFPA 25, 2-2 and Table 2-1 Requires an inspection every quarter (three months).

1998 NFPA 25, 1-8* Records.
Records of inspections, tests, and maintenance of the system and its components shall be made available to the authority having jurisdiction upon request. Typical records include, but are not limited to, valve inspections; flow, drain, and pump tests; and trip tests of dry pipe, deluge, and preaction valves.

1. The facility failed to maintain the hazardous area per code. Findings include:

During the survey, the following is an example of what was observed:
First Floor
Human Resources - Personnel File Room was observed to be over 140 sq. ft. with combustibles, the door to this room did not have a self-closing device. This room had closeable lateral file cabinets. This room was observed with no one in it and several of the lateral file cabinets had been left open.

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2000 NFPA 101, 39.3.2.1* Hazardous areas including, but not limited to, areas used for general storage, boiler or furnace rooms, and maintenance shops that include woodworking and painting areas shall be protected in accordance with Section 8.4.


HCFA Transmittal 40-93 It is the intent of the code that (smoke-resisting) separation be provided even in a sprinklered hazardous area. "Where the sprinkler option is used, the (hazardous) areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be equipped with self- or automatic closers and be positive latching."

2. The facility failed to maintain the emergency lighting per code. Findings include:

During the survey, the following is an example of what was observed:
a. The facility failed to provide documentation of the monthly and annual testing of the emergency lighting
b. Per staff, the facility is only testing the emergency lighting for one hour annually

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2000 NFPA 101, 39.2.9.1 Emergency lighting shall be provided in accordance with Section 7.9 in any building where any one of the following conditions exists: (1) The building is two or more stories in height above the level of exit discharge. (2) The occupancy is subject to 100 or more occupants above or below the level of exit discharge. (3) The occupancy is subject to 1000 or more total occupants.

2000 NFPA 101, 7.9.3 A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 1/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

3. The facility failed to maintain the exit sign per code. Findings include:

During the survey, the following is an example of what was observed:
First Floor
The exit sign in the Senior Volunteer Services Suite was observed not to be illuminated

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2000 NFPA 101, 39.2.10 Means of egress shall have signs in accordance with Section 7.10.

2000 NFPA 101, 7.10.5.2 Every sign required to be illuminated by 7.10.6.3 and 7.10.7 shall be continuously illuminated as required under the provisions of Section 7.8.

4. The facility failed to maintain the fire extinguisher per code. Findings include:

During the survey, the following is an example of what was observed:
First Floor
The fire extinguisher in the Administration Conference Room was observed to be mounted approximately 6' -0" above the finish floor

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2000 NFPA 101, 39.3.5 Portable fire extinguishers shall be provided in every business occupancy in accordance with 9.7.4.1. (See also Section 39.4.)
2000 NFPA 101, 9.7.4.1 Where required by the provisions of another section of this Code, portable fire extinguishers shall be installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.
1998 NFPA 10, 1-6.10 Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. Fire extinguishers having a gross weight greater than 40 lb (18.14 kg) (except wheeled types) shall be so installed that the top of the fire extinguisher is not more than 31/2 ft (1.07 m) above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 in. (10.2 cm).

1. The facility failed to maintain the hazardous area per code. Findings include:

During the survey, the following is an example of what was observed:
The Ultrasound Storage Room was observed to be over 50 sq. ft. with combustibles (Christmas and other holiday decorations, etc.), the door to this room did not have a self-closing device

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2000 NFPA 101, 39.3.2.1* Hazardous areas including, but not limited to, areas used for general storage, boiler or furnace rooms, and maintenance shops that include woodworking and painting areas shall be protected in accordance with Section 8.4.


HCFA Transmittal 40-93 It is the intent of the code that (smoke-resisting) separation be provided even in a sprinklered hazardous area. "Where the sprinkler option is used, the (hazardous) areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be equipped with self- or automatic closers and be positive latching."

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

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

Second Floor - the generator room, the emergency battery back-up light did not illuminate when tested
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1999 NFPA 110, 5-3.1 The Level 1 or Level 2 EPS equipment location shall be provided with battery-powered emergency lighting. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch.
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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. An overcurrent protection cord was plugged into an overcurrent multiple outlet device in the Tel/Com Room on the first floor.

2. Equipment was stored in front of the electrical panel in CT Exam Room.


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3. First Floor - Security Office had a microwave plugged into a surge protector, The staff removed the surge protector, this left the microwave unplugged. According to the staff the facility will get an electrical company to install an electrical outlet for the microwave.

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NFPA 101 Life Safety Code (Sec. 19-5.1) utilities shall comply with NFPA 101 (Sec. 9-1.) . Electrical shall comply with the NFPA 70 National Electrical Code. NEC 400-7(b) Requires each flexible cord to "be energized from a receptacle outlet."

1999 NFPA 70, Table 110-34(a) A minimum clearance of 3 feet, up to 8 feet, shall be maintained in front of electrical panels and equipment operating at more than 600 volts.

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 a corridor door per code. Findings include:

During the survey, the following is an example of what was observed:
Second Floor
The corridor door for room 272 was not positive latching. The lever action door handle on the patient room side was broken. The surveyor observed the plunger not working after the staff tried to fix it.

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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.
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The facility failed to maintain the one hour fire barrier for the atrium per code. Findings include:

During the survey, the following is an example of what was observed:
The one hour fire barrier for the Lobby atrium at the phone (above the lay-in ceiling) was observed with the following:
1. Several unsealed penetrations
2. Several unsealed conduit ends
3. Unsealed rockwool

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2000 NFPA 101, 8.2.5.6 Unless prohibited by Chapters 12 through 42, an atrium shall be permitted, provided that the following conditions are met:
(1) In other than existing, previously approved atria, atriums are separated from the adjacent spaces by fire barriers with not less than a 1-hour fire resistance rating with opening protectives for corridor walls. (See 8.2.3.2.3.1(2), Exception No. 1.)
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The facility failed to maintain the smoke barriers per code. Findings include: During the survey the following is an example of what was observed:

1. Unsealed penetrations around the beam in the Smoke Barrier, by Visitor Lounge Second Floor.


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Second Floor
2. The smoke barrier in room 262, above the closet, was observed:
a. Two unsealed penetrations at a bar joist's horizontal bridging
b. Wall was not sealed at the corrugated roof deck
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2000 NFPA 101, 8.2.4.4.1 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through smoke partitions shall be protected as follows: (1) The space between the penetrating item and the smoke partition shall meet one of the following conditions: a. It shall be filled with a material that is capable of limiting the transfer of smoke. b. It shall be protected by an approved device that is designed for the specific purpose. (2) Where the penetrating item uses a sleeve to penetrate the smoke partition, the sleeve shall be solidly set in the smoke partition, and the space between the item and the sleeve shall meet one of the following conditions: a. It shall be filled with a material that is capable of limiting the transfer of smoke. b. It shall be protected by an approved device that is designed for the specific purpose. (3) Where designs take transmission of vibrations into consideration, any vibration isolation shall meet one of the following conditions: a. It shall be made on either side of the smoke partitions. b. It shall be made by an approved device that is designed for the specific purpose.

2000 NFPA 101, 8.3.2 Smoke barriers required by this Code shall be continuous from an outside wall to an outside wall, from a floor to a floor, or from a smoke barrier to a smoke barrier or a combination thereof. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces.
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During the survey, the following are examples of observations during the testing of the fire alarm system to doors in the smoke barriers:

1. The following automatic smoke barrier doors (doors operated by power upon the approach of a person), failed to remain self closing. During initial activation of the fire alarm system the door mechanism released the doors to a closed position. The surveyor with maintenance personnel observed that these doors could be held open by the door mechanism at various degrees based on how much the doors was pushed to an open position while the fire alarm was still activated.
First Floor
a. At Endoscopy/Hospital separation wall
b. At Emergency Department entrance at the stairwell
Second Floor
c. At entrance to "Labor & Delivery 1 - 17" (at the nurses' station)
First Floor

2. The Manager's Office One South - the corridor door is in a one hour smoke barrier - did not have a self-closing device

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2000 NFPA 101, 19.3.7.6 Doors in smoke barriers shall comply with 8.3.4 and shall be self-closing or automatic-closing in accordance with 19.2.2.2.6. Such doors in smoke barriers shall not be required to swing with egress travel.

8.3.4.3* Doors in smoke barriers shall be self-closing or automatic-closing in accordance with 7.2.1.8 and shall comply with the provisions of 7.2.1.

7.2.1.9.2 Doors Required to Be Self-Closing.
Where doors are required to be self-closing and (1) are operated by power upon the approach of a person or (2) are provided with power-assisted manual operation, they shall be permitted in the means of egress under the following conditions: (1) Doors can be opened manually in accordance with 7.2.1.9.1 to allow egress travel in the event of power failure. (2) New doors remain in the closed position unless actuated or opened manually. (3) When actuated, new doors remain open for not more than 30 seconds. (4) Doors held open for any period of time close - and the power-assist mechanism ceases to function - upon operation of approved smoke detectors installed in such a way as to detect smoke on either side of the door opening in accordance with the provisions of NFPA 72, National Fire Alarm Code. (5) Doors required to be self-latching are either self-latching or become self-latching upon operation of approved smoke detectors per 7.2.1.9.2(4). (6) New power-assisted swinging doors comply with BHMA/ANSI A156.19, American National Standard for Power Assist and Low Energy Power Operated Doors.

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The facility failed to maintain the hazardous area per code. Findings include:

During the survey, the following is an example of what was observed:
Second Floor
The hallway storage room at Labor & Delivery was over 72 sq. ft. with combustibles, this room had sliding doors, that were not self-closing nor smoke resistive

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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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The facility failed to provide a reliable means of egress to the public way findings include: During the survey, the following are examples of what was observed.

1. The means of egress to the public way for the Exit One East, was blocked by a vehicle. The side walk ends at the parking space which blocks egress to the parking lot which is the public way.

2. The means of egress to the public way for the Exit by MRI, was obstructed by a vehicle. The side walk ends at the parking space which obstructed clear wide for egress to the parking lot.
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NFPA 101, 7.1.10.1 Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

NFPA 101, A.7.1.10.1 *A proper means of egress allows unobstructed travel at all times. Any type of barrier including, but not limited to, the accumulations of snow and ice in those climates subject to such accumulations is an impediment to free movement in the means of egress.

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The facility failed to provide protection of openings in fire barriers to limit the spread of fire and restrict the movement of smoke from one side of the fire barrier to the other. Findings include: During the survey, the following is an example of what was observed:

Unsealed penetrations at the deck in the one hour barrier, at Outpatients Services First Floor.
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NFPA 101, 19.2.2.5 and 7.2.4.3 Openings in fire barriers shall be constructed to limit the spread of fire and restrict the movement of smoke from one side of the fire barrier to the other.

The facility failed to conduct fire drills at unexpected times and under varying conditions to test and evaluate the efficiency, knowledge, and response of institutional personnel in implementing the facility fire emergency plan. Findings include:

During the survey, the following are examples of what was observed:
1. Per documentation provided by maintenance staff, facility failed to illustrate that all facility personnel are familiar with the signals and emergency action required under varied conditions during fire drills. Per interview with facility maintenance staff, staff confirmed that documentation provided of fire drill participation did not include names of all staff in the facility at the time of the fire drills.

2. Per documentation not holding fire drills at unexpected times under varying conditions

First Shift
10/19/2012 - 12:47 pm
07/27/2012 - 12:58 pm
05/25/2012 - 1:45 pm
03/29/2012 - 2:35 pm
Second Shift
09/12/2012 - 3:10 pm
06/14/2012 - 3:25 pm
01/20/2012 - 3:01 pm
Third Shift
09/20/2012 - 4:45 am
06/22/2012 - 5:00 am
02/16/2012 - 5:00 am
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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.
2000 NFPA 101, 4.7.2* Emergency egress and relocation drills, where required by Chapters 11 through 42 or the authority having jurisdiction, shall be held with sufficient frequency to familiarize occupants with the drill procedure and to establish conduct of the drill as a matter of routine. Drills shall include suitable procedures to ensure that all persons subject to the drill participate.

2000 NFPA 101, 4.7.5* Drills shall be held at expected and unexpected times and under varying conditions to simulate the unusual conditions that can occur in an actual emergency.
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The facility failed to maintain the fire alarm system per code. Findings include:

During the survey, the following are examples of what was observed:
Second Floor
1. C-section OR # 3 - when the smoke detector in this room was tested, the fire alarm panel indicated that the smoke detector in C-section OR # 1 was in alarm
2. When the primary power to the fire alarm was removed - delayed egress door 2E failed to be delayed egress, there was no alarm and the door failed to release within thirty seconds. When the code was entered the door did release

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2000 NFPA 101, 9.6.7.2 Alarm annunciation at the control center shall be by means of audible and visible indicators.
2000 NFPA 101, 9.6.1.4 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.
2000 NFPA 101, 7.2.1.6.1 Approved, listed, delayed-egress locks shall be permitted to be installed on doors serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system in accordance with Section 9.6, or an approved, supervised automatic sprinkler system in accordance with Section 9.7, and where permitted in Chapters 12 through 42, provided that the following criteria are met. (c) An irreversible process shall release the lock within 15 seconds upon application of a force to the release device required in 7.2.1.5.4 that shall not be required to exceed 15 lbf (67 N) nor be required to be continuously applied for more than 3 seconds. The initiation of the release process shall activate an audible signal in the vicinity of the door. Once the door lock has been released by the application of force to the releasing device, relocking shall be by manual means only. Exception: Where approved by the authority having jurisdiction, a delay not exceeding 30 seconds shall be permitted. (d) * On the door adjacent to the release device, there shall be a readily visible, durable sign in letters not less than 1 in. (2.5 cm) high and not less than 1/8 in. (0.3 cm) in stroke width on a contrasting background that reads as follows:
PUSH UNTIL ALARM SOUNDS
DOOR CAN BE OPENED IN 15 SECONDS
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The facility failed to provide complete sprinkler coverage to all parts of the facility.
Findings include: During the survey, the following are examples of what was observed:


1. Ceiling tiles missing in CT Exam Room.

2. Escutcheon plate missing on a sprinkler in the cooler located outside near kitchen.

3. Escutcheon plate missing on a sprinkler in the cover parking area near Emergency Room.

4. Sprinkler coverage not provided in the Tel/Com Room across from Clinical Operations Manager Surgery Office.

5. Sprinkler coverage not provided in the cooler located in the Kitchen.

6. Sprinkler coverage not provided in the freezer located in the Kitchen.


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Second Floor
7. Telecommunications Closet across from room 248 was observed without automatic sprinkler coverage
8. Hydraulic elevators # 3 and # 4 were observed without sprinkler protection at the bottom of the shaft. Documentation provided by the facility did not indicate that the hydraulic fluid was "not combustible".
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2000 NFPA 19.3.5.1 Sprinkler protection shall be provide throughout the facility in accordance with
section 9.7.

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

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.

1999 NFPA 13, 5-13.6.1 Sidewall spray sprinklers shall be installed at the bottom of each elevator hoistway not more than 2 ft (0.61 m) above the floor of the pit.
Exception: For enclosed, noncombustible elevator shafts that do not contain combustible hydraulic fluids, the sprinklers at the bottom of the shaft are not required.
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The facility failed to comply with the required maintenance of the facility sprinkler system. During the survey, the following are examples of what was observed:


1. The fire department connections were not provided with an identification sign.

2. Documentation was not provided for the 5 year replacement or calibration for sprinkler system gauges.
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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.

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 25, Table 2-1 Summary of Sprinkler System Inspection, Testing, and Maintenance

NFPA 25, 9-2.8.2: Gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge. Gauges not accurate to within 3 percent of the full scale shall be recalibrated or replaced.

NFPA 25, 9-2.8.1: Gauges shall be inspected monthly to verify that they are in good condition and that normal pressure is being maintained. Exception: When other sections of this standard have different frequency requirements for specific gauges.

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The facility failed provide the required clearance between the bottom of the fire extinguisher and the floor. Findings
include: During the survey, the following is an example of what was observed:

The K-extinguisher in the kitchen was sitting on the floor not mounted on the wall.
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1998 NFPA 10, 1-6.10 Fire extinguishers weighting not more than 40 lb. (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. Fire extinguishers having a gross weight greater than 40 lb. (18.14 kg) (except wheeled types) shall be so installed that the top of the fire extinguisher is not more than 31/2 ft (1.07 m) above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 in. (10.2 cm).
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Facility failed to maintain the protection for the cooking area per NFPA standards. The following is an example of what was observed:

During the survey, the K-extinguisher in the kitchen was not provided with a placard.
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NFPA 96 7-2.1.1 A placard identifying the use of the extinguisher as a secondary backup means to the automatic fire suppression system shall be conspicuously placed near each portable fire extinguisher in the cooking area.

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The facility failed to prohibit the use of a portable space-heating device per code. Findings include:

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

A portable wire coil space-heating device was observed plugged into an electrical outlet
in the second floor North Manager's Office located in the smoke compartment encompassing the Nursery.
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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 maintain anesthetizing locations per code. Findings include:

During the survey, the following are examples of what was observed:
First Floor
1. All six of the windowless ORs were observed without the following:
a. Battery back-up lighting
b. "Supply and exhaust systems to automatically vent smoke and products of combustion"

Second Floor
2. The windowless C-section ORs # 2 & # 3 were observed without the following:
a. Battery back-up lighting
b. "Supply and exhaust systems to automatically vent smoke and products of combustion"

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1999 NFPA 99, 3-3.2.1.2 All Patient Care Areas.
5. Wiring in Anesthetizing Locations.
e. Battery-Powered Emergency Lighting Units. One or more battery-powered emergency lighting units shall be provided in accordance with NFPA 70, National Electrical Code, Section 700-12(e).
1999 NFPA 99, 5-4.1.2 Supply and exhaust systems for windowless anesthetizing locations shall be arranged to automatically vent smoke and products of combustion.
1999 NFPA 99, 5-4.1.3 Ventilating systems for anesthetizing locations shall be provided that automatically (a) prevent recirculation of smoke originating within the surgical suite and (b) prevent the circulation of smoke entering the system intake, without in either case interfering with the exhaust function of the system.
1999 NFPA 99, 5-4.1.4 The electric supply to the ventilating system shall be served by the equipment system of the essential electrical system specified in Chapter 3, " Electrical Systems. "
1999 NFPA 99, 5-6.1.1 Ventilating and humidifying equipment for anesthetizing locations shall be kept in operable condition and be continually operating during surgical procedures (see A-5-4.1).
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1. The facility failed to maintain the emergency lighting per code. Findings include:

During the survey, the following is an example of what was observed:
a. The facility failed to provide documentation of the annual testing of the emergency lighting
b. Per staff, the facility is only testing the emergency lighting for one hour annually

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2000 NFPA 101, 39.2.9.1 Emergency lighting shall be provided in accordance with Section 7.9 in any building where any one of the following conditions exists: (1) The building is two or more stories in height above the level of exit discharge. (2) The occupancy is subject to 100 or more occupants above or below the level of exit discharge. (3) The occupancy is subject to 1000 or more total occupants.

2000 NFPA 101, 7.9.3 A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 1/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction

2. The facility failed to provide documentation of inspections and testing on the following systems. Findings include:

During the survey, the following are examples of what was observed:
a. Review of all documentation was conducted on the afternoon of the second day of the survey. The documentation for the annual inspection of the fire alarm system was not provided. Information was requested by the Vice President of facilities, but was not provided for this surveyor before the exit interview on the third day. No promises were made by this surveyor to accept documentation after the surveyor had completed the survey and left the facility.
b. Review of all documentation was conducted on the afternoon of the second day of the survey. The documentation for the inspection of the sprinkler system was not provided. Information was requested by the Vice President of facilities, but was not provided for this surveyor before the exit interview on the third day. No promises were made by this surveyor to accept documentation after the surveyor had completed the survey and left the facility.

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NFPA 101, 9.6.1.4 The fire alarm system to be installed, tested, and maintained in accordance with the requirements of NFPA 70 and NFPA 72.

1999 NFPA 72, 1-6.3 Records.
A complete, unalterable record of the tests and operations of each system shall be kept until the next test and for 1 year thereafter. The record shall be available for examination and, if required, reported to the authority having jurisdiction. Archiving of records by any means shall be permitted if hard copies of the records can be provided promptly when requested.
Exception: If off-premises monitoring is provided, records of all signals, tests, and operations recorded at the supervising station shall be maintained for not less than 1 year.


NFPA 101, 4.6.12, and NFPA 25, 2-2 and Table 2-1 Requires an inspection every quarter (three months).

1998 NFPA 25, 1-8* Records.
Records of inspections, tests, and maintenance of the system and its components shall be made available to the authority having jurisdiction upon request. Typical records include, but are not limited to, valve inspections; flow, drain, and pump tests; and trip tests of dry pipe, deluge, and preaction valves.

1. The facility failed to maintain the hazardous area per code. Findings include:

During the survey, the following is an example of what was observed:
First Floor
Human Resources - Personnel File Room was observed to be over 140 sq. ft. with combustibles, the door to this room did not have a self-closing device. This room had closeable lateral file cabinets. This room was observed with no one in it and several of the lateral file cabinets had been left open.

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2000 NFPA 101, 39.3.2.1* Hazardous areas including, but not limited to, areas used for general storage, boiler or furnace rooms, and maintenance shops that include woodworking and painting areas shall be protected in accordance with Section 8.4.


HCFA Transmittal 40-93 It is the intent of the code that (smoke-resisting) separation be provided even in a sprinklered hazardous area. "Where the sprinkler option is used, the (hazardous) areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be equipped with self- or automatic closers and be positive latching."

2. The facility failed to maintain the emergency lighting per code. Findings include:

During the survey, the following is an example of what was observed:
a. The facility failed to provide documentation of the monthly and annual testing of the emergency lighting
b. Per staff, the facility is only testing the emergency lighting for one hour annually

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2000 NFPA 101, 39.2.9.1 Emergency lighting shall be provided in accordance with Section 7.9 in any building where any one of the following conditions exists: (1) The building is two or more stories in height above the level of exit discharge. (2) The occupancy is subject to 100 or more occupants above or below the level of exit discharge. (3) The occupancy is subject to 1000 or more total occupants.

2000 NFPA 101, 7.9.3 A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 1/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

3. The facility failed to maintain the exit sign per code. Findings include:

During the survey, the following is an example of what was observed:
First Floor
The exit sign in the Senior Volunteer Services Suite was observed not to be illuminated

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2000 NFPA 101, 39.2.10 Means of egress shall have signs in accordance with Section 7.10.

2000 NFPA 101, 7.10.5.2 Every sign required to be illuminated by 7.10.6.3 and 7.10.7 shall be continuously illuminated as required under the provisions of Section 7.8.

4. The facility failed to maintain the fire extinguisher per code. Findings include:

During the survey, the following is an example of what was observed:
First Floor
The fire extinguisher in the Administration Conference Room was observed to be mounted approximately 6' -0" above the finish floor

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2000 NFPA 101, 39.3.5 Portable fire extinguishers shall be provided in every business occupancy in accordance with 9.7.4.1. (See also Section 39.4.)
2000 NFPA 101, 9.7.4.1 Where required by the provisions of another section of this Code, portable fire extinguishers shall be installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.
1998 NFPA 10, 1-6.10 Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. Fire extinguishers having a gross weight greater than 40 lb (18.14 kg) (except wheeled types) shall be so installed that the top of the fire extinguisher is not more than 31/2 ft (1.07 m) above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 in. (10.2 cm).

1. The facility failed to maintain the hazardous area per code. Findings include:

During the survey, the following is an example of what was observed:
The Ultrasound Storage Room was observed to be over 50 sq. ft. with combustibles (Christmas and other holiday decorations, etc.), the door to this room did not have a self-closing device

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2000 NFPA 101, 39.3.2.1* Hazardous areas including, but not limited to, areas used for general storage, boiler or furnace rooms, and maintenance shops that include woodworking and painting areas shall be protected in accordance with Section 8.4.


HCFA Transmittal 40-93 It is the intent of the code that (smoke-resisting) separation be provided even in a sprinklered hazardous area. "Where the sprinkler option is used, the (hazardous) areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be equipped with self- or automatic closers and be positive latching."

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

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

Second Floor - the generator room, the emergency battery back-up light did not illuminate when tested
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1999 NFPA 110, 5-3.1 The Level 1 or Level 2 EPS equipment location shall be provided with battery-powered emergency lighting. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch.
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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. An overcurrent protection cord was plugged into an overcurrent multiple outlet device in the Tel/Com Room on the first floor.

2. Equipment was stored in front of the electrical panel in CT Exam Room.


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3. First Floor - Security Office had a microwave plugged into a surge protector, The staff removed the surge protector, this left the microwave unplugged. According to the staff the facility will get an electrical company to install an electrical outlet for the microwave.

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NFPA 101 Life Safety Code (Sec. 19-5.1) utilities shall comply with NFPA 101 (Sec. 9-1.) . Electrical shall comply with the NFPA 70 National Electrical Code. NEC 400-7(b) Requires each flexible cord to "be energized from a receptacle outlet."

1999 NFPA 70, Table 110-34(a) A minimum clearance of 3 feet, up to 8 feet, shall be maintained in front of electrical panels and equipment operating at more than 600 volts.

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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