HospitalInspections.org

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

During the survey, the following is a example of what was observed:
1. The Gift shop corridor door was observed with the following:
a. No positive latching hardware
b. The corridor door had a self-closing device on it, but was impeded from closing by a toe stop
2. The Old Lab Records Storage Room, across from the time clock and behind the fire door did not have positive latching hardware

______________

2000 NFPA 101, 19.3.6.3.2 Doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door. Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.2.
2007 CMS - 2786R There is no impediment to the closing of the corridor doors.

.

The facility failed to provide separation of hazardous areas. Findings include:

During the survey the following are examples of what was observed:
1. The door was not provided with a self-closing device for the combustible storage room which is over 50 sq feet. This room is located by Purchasing.
2. The door was not provided with a self-closing device for the combustible storage room which is over 50 sq feet. This room is located by Respiratory.

_________

NFPA 101, 19.3.2.1 and 8.4.1 Hazardous areas to be provided with smoke-resisting partitions and doors when protection consists of an automatic extinguishing system. Doors shall be selfclosing with positive latching hardware.

.

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

During the survey, the following are examples of what was observed:
The following hazardous rooms were not separated from the rest of the facility:
1. File Storage Room in the Imaging Dept. was approximately 520 sq. ft. with combustibles
2. Environmental Services Room in the Imaging Dept. was approximately 108 sq. ft. with combustibles
a. The walls did not continue to the deck above, the ceiling is not part of rated ceiling assembly
b. The doors were not rated
c. The doors did not have self-closing devices

__________________

18.3.2.1 Any hazardous area shall be protected in accordance with Section 8.4. The areas described in Table 18.3.2.1 shall be protected as indicated.

.

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

During the survey, the following is an example of what was observed:
1. The medical records room door had more than one releasing mechanism ( deadbolt and handle).


27382


2. The Women's Staff Restroom corridor door by Dietary, was observed with a double sided keyed dead bolt

______________

2000 NFPA 101, 7.2.1.5.4 A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 in. (86 cm), and not more than 48 in. (122 cm), above the finished floor. Doors shall be operable with not more than one releasing operation.

2000 NFPA 101, 7.2.1.5.1 Doors shall be arranged to be opened readily from the egress side whenever the building is occupied. Locks, if provided, shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side.
.

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

During the survey, the following is an example of what was observed:
The four hour fire barrier at the connection of the nursing facility was observed with two unsealed two inch conduits; one was empty and the other had blue wires

______________

2000 NFPA 101, 8.2.3.2.4.2 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through fire barriers shall be protected as follows:
(1) The space between the penetrating item and the fire barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier.
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 fire barrier, the sleeve shall be solidly set in the fire barrier, 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 maintaining the fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) * Insulation and coverings for pipes and ducts shall not pass through the fire barrier unless one of the following conditions is met:
a. The material shall be capable of maintaining the fire resistance of the fire barrier.
b. The material shall be protected by an approved device that is designed for the specific purpose.
(4) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:a. It shall be made on either side of the fire barrier.b. It shall be made by an approved device that is designed for the specific purpose.
.

The facility failed to document staff participation in the fire drills. Findings include:

During the survey, the following is an example of what was observed:
Per documentation and interview the facility was not getting all staff to sign the participation sheets. The participation sheets for the drills conducted on 10/9/2013, and 12/20/2013, were blank.

____________

NFPA 101, 19.7.1.2 and 19.7.1.3 Drills shall include proper procedures, making sure all staff members participate.

NFPA 101, 19.7.1.2 Drills shall be conducted at least quarterly on each shift and at unexpected times under varied conditions on all shifts to simulate the unusual conditions occurring in case of fire.

.

The facility failed to document staff participation in the fire drills. Findings include:

During the survey, the following is an example of what was observed:
Per documentation and interview, the facility was not getting all staff to sign the participation sheets. The participation sheets for the drills conducted on 10/9/2013, and 12/20/2013, were blank.
___________

NFPA 101, 19.7.1.2 and 19.7.1.3 Drills shall include proper procedures, making sure all staff members participate.

NFPA 101, 19.7.1.2 Drills shall be conducted at least quarterly on each shift and at unexpected times under varied conditions on all shifts to simulate the unusual conditions occurring in case of fire.

.

Sprinkler coverage was observed during the survey not adequately provided. Findings include:

During the survey, the following is an example of what was observed:
A noncombustible overhang approximately 5' x 9' by the kitchen, observed to have combustible items stored under the overhang. Sprinkler coverage was not provided.

____________

1999 NFPA 13, 5-13.8 Sprinklers shall be installed under exterior combustible roofs or canopies exceeding four feet in width, or over areas where combustibles are stored.

.

The facility failed to perform the required maintenance of the facility sprinkler system. Findings include:

During the survey, the following is an example of what was observed:
The fire department connection was not provided with an identification sign.

___________

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 condition.
(e) Identification signs are in place.
(f) The check valve is not leaking.
(g) The automatic drain valve is in place and operating properly.

.
The facility failed to perform the required maintenance of the facility sprinkler system. Findings include:

During the survey, the following is an example of what was observed:
The fire department connection was not provided with an identification sign.

______________

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 condition.
(e) Identification signs are in place.
(f) The check valve is not leaking.
(g) The automatic drain valve is in place and operating properly.

.

The facility failed to maintain the dietary hood. Findings include:

During the survey, the following is an example of what was observed:
1. The caulk for the seams in the dietary hood was loose at three differ locations.
2. The k-extinguisher was not provided with a placard.

_________________

NFPA 96, 2-1.2 Internal hood joints, seams, filter support frames, and appendages attached inside the hood need not be welded but shall be sealed or otherwise made grease tight.


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.

.

The facility failed to maintain the means of egress per code. Findings include:

During the survey, the following is an example of what was observed:
The West Exit, across from Infection Control ended in the grass.

_____________

2000 NFPA 101, 7.1.6.4 Walking surfaces shall be slip resistant under foreseeable conditions. The walking surface of each element in the means of egress shall be uniformly slip resistant along the natural path of travel.

2000 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.
.

The facility failed to provide proper storage of oxygen cylinders. Findings include:

During the survey, the following are examples of what was observed:
1. Empty and full signage was not provided for the oxygen cylinder storage area located outside of the facility.


27382

2. The "Dialysis Room" had one unsecured oxygen cylinder

_________________

CGA G-4, 4.1.10, and 1999 NFPA 99, 4-3.5.2.2(b)2 and 4-5.5.2.2(b)2 Full and empty cylinders shall be stored separately, with appropriate signage.

1999 NFPA 99, 4-3.5.2.1 Gases in Cylinders and Liquefied Gases in Containers - Level 1.
(a) * Handling of Gases. Administrative authorities shall provide regulations to ensure that standards for safe practice in the specifications for cylinders; marking of cylinders, regulators, and valves; and cylinder connections have been met by vendors of cylinders containing compressed gases supplied to the facility.
(b) Special Precautions - Oxygen Cylinders and Manifolds. Great care shall be exercised in handling oxygen to prevent contact of oxygen under pressure with oils, greases, organic lubricants, rubber, or other materials of an organic nature. The following regulations, based on those of the CGA Pamphlet G-4, Oxygen, shall be observed:
27. Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.
.

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

During the survey, the following is an example of what was observed:
The surveyors could not verify that the two O.R.s had a smoke venting system

_______________

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).
.

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

During the survey, the following are examples of what was observed:
1. Battery-powered lighting at the generator equipment and controls was not provided as observed during the survey.


27382

2. Per documentation and interview with maintenance staff, the facility was not testing the line isolation monitors

_____________

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


1999 NFPA 99, 3-3.3.4.2 Line Isolation Monitor Tests.
The proper functioning of each line isolation monitor (LIM) circuit shall be ensured by the following:
(a) The LIM circuit shall be tested after installation, and prior to being placed in service, by successively grounding each line of the energized distribution system through a resistor of 200 V ohms, where V = measured line voltage. The visual and audible alarms [see 3-3.2.2.3(b)] shall be activated.
(b) The LIM circuit shall be tested at intervals of not more than 1 month by actuating the LIM test switch [see 3-3.2.2.3(f)]. For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months. Actuation of the test switch shall activate both visual and audible alarm indicators.
(c) After any repair or renovation to an electrical distribution system and at intervals of not more than 6 months, the LIM circuit shall be tested in accordance with paragraph (a) above and only when the circuit is not otherwise in use. For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months.
.

The facility failed to provide the required transfer switch set up per code. Findings include:

During the survey, the following is an example of what was observed:
The generator was not divided into the critical branch, life safety branch and the equipment branch. Per the Maintenance Director a new generator, 300 kw, with new transfer switch was installed in 1998.

____________

1999 Edition of NFPA 99, 3-4.2.2.2, 3-5.2.2 type 1 EES and type 11 EES ref each branch of emergency system shall have one or more transfer switches, based on demand on the essential electrical system.

.

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

During the survey, the following are examples of what was observed:
1. Microwave was plugged into an overcurrent protection device in the respiratory break room.
2. Broken cover on an electrical outlet in the Director Office Respiratory.
3. A printer was plugged into an extension cord, the cord was then plugged into one of the emergency outlet in the Lab.


27382

4. The "Dialysis Room" had a refrigerator plugged into a surge protector (extension cord)
________________

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

1999 NFPA 70, 370-25 and 410-12. Each box in completed installations to have a cover, face plate, or fixture canopy.

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

During the survey, the following is a example of what was observed:
1. The Gift shop corridor door was observed with the following:
a. No positive latching hardware
b. The corridor door had a self-closing device on it, but was impeded from closing by a toe stop
2. The Old Lab Records Storage Room, across from the time clock and behind the fire door did not have positive latching hardware

______________

2000 NFPA 101, 19.3.6.3.2 Doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door. Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.2.
2007 CMS - 2786R There is no impediment to the closing of the corridor doors.

.

The facility failed to provide separation of hazardous areas. Findings include:

During the survey the following are examples of what was observed:
1. The door was not provided with a self-closing device for the combustible storage room which is over 50 sq feet. This room is located by Purchasing.
2. The door was not provided with a self-closing device for the combustible storage room which is over 50 sq feet. This room is located by Respiratory.

_________

NFPA 101, 19.3.2.1 and 8.4.1 Hazardous areas to be provided with smoke-resisting partitions and doors when protection consists of an automatic extinguishing system. Doors shall be selfclosing with positive latching hardware.

.

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

During the survey, the following are examples of what was observed:
The following hazardous rooms were not separated from the rest of the facility:
1. File Storage Room in the Imaging Dept. was approximately 520 sq. ft. with combustibles
2. Environmental Services Room in the Imaging Dept. was approximately 108 sq. ft. with combustibles
a. The walls did not continue to the deck above, the ceiling is not part of rated ceiling assembly
b. The doors were not rated
c. The doors did not have self-closing devices

__________________

18.3.2.1 Any hazardous area shall be protected in accordance with Section 8.4. The areas described in Table 18.3.2.1 shall be protected as indicated.

.

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

During the survey, the following is an example of what was observed:
1. The medical records room door had more than one releasing mechanism ( deadbolt and handle).


27382


2. The Women's Staff Restroom corridor door by Dietary, was observed with a double sided keyed dead bolt

______________

2000 NFPA 101, 7.2.1.5.4 A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 in. (86 cm), and not more than 48 in. (122 cm), above the finished floor. Doors shall be operable with not more than one releasing operation.

2000 NFPA 101, 7.2.1.5.1 Doors shall be arranged to be opened readily from the egress side whenever the building is occupied. Locks, if provided, shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side.
.

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

During the survey, the following is an example of what was observed:
The four hour fire barrier at the connection of the nursing facility was observed with two unsealed two inch conduits; one was empty and the other had blue wires

______________

2000 NFPA 101, 8.2.3.2.4.2 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through fire barriers shall be protected as follows:
(1) The space between the penetrating item and the fire barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier.
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 fire barrier, the sleeve shall be solidly set in the fire barrier, 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 maintaining the fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) * Insulation and coverings for pipes and ducts shall not pass through the fire barrier unless one of the following conditions is met:
a. The material shall be capable of maintaining the fire resistance of the fire barrier.
b. The material shall be protected by an approved device that is designed for the specific purpose.
(4) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:a. It shall be made on either side of the fire barrier.b. It shall be made by an approved device that is designed for the specific purpose.
.

The facility failed to document staff participation in the fire drills. Findings include:

During the survey, the following is an example of what was observed:
Per documentation and interview the facility was not getting all staff to sign the participation sheets. The participation sheets for the drills conducted on 10/9/2013, and 12/20/2013, were blank.

____________

NFPA 101, 19.7.1.2 and 19.7.1.3 Drills shall include proper procedures, making sure all staff members participate.

NFPA 101, 19.7.1.2 Drills shall be conducted at least quarterly on each shift and at unexpected times under varied conditions on all shifts to simulate the unusual conditions occurring in case of fire.

.

The facility failed to document staff participation in the fire drills. Findings include:

During the survey, the following is an example of what was observed:
Per documentation and interview, the facility was not getting all staff to sign the participation sheets. The participation sheets for the drills conducted on 10/9/2013, and 12/20/2013, were blank.
___________

NFPA 101, 19.7.1.2 and 19.7.1.3 Drills shall include proper procedures, making sure all staff members participate.

NFPA 101, 19.7.1.2 Drills shall be conducted at least quarterly on each shift and at unexpected times under varied conditions on all shifts to simulate the unusual conditions occurring in case of fire.

.

Sprinkler coverage was observed during the survey not adequately provided. Findings include:

During the survey, the following is an example of what was observed:
A noncombustible overhang approximately 5' x 9' by the kitchen, observed to have combustible items stored under the overhang. Sprinkler coverage was not provided.

____________

1999 NFPA 13, 5-13.8 Sprinklers shall be installed under exterior combustible roofs or canopies exceeding four feet in width, or over areas where combustibles are stored.

.

The facility failed to perform the required maintenance of the facility sprinkler system. Findings include:

During the survey, the following is an example of what was observed:
The fire department connection was not provided with an identification sign.

___________

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 condition.
(e) Identification signs are in place.
(f) The check valve is not leaking.
(g) The automatic drain valve is in place and operating properly.

.
The facility failed to perform the required maintenance of the facility sprinkler system. Findings include:

During the survey, the following is an example of what was observed:
The fire department connection was not provided with an identification sign.

______________

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 condition.
(e) Identification signs are in place.
(f) The check valve is not leaking.
(g) The automatic drain valve is in place and operating properly.

.

The facility failed to maintain the dietary hood. Findings include:

During the survey, the following is an example of what was observed:
1. The caulk for the seams in the dietary hood was loose at three differ locations.
2. The k-extinguisher was not provided with a placard.

_________________

NFPA 96, 2-1.2 Internal hood joints, seams, filter support frames, and appendages attached inside the hood need not be welded but shall be sealed or otherwise made grease tight.


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.

.

The facility failed to maintain the means of egress per code. Findings include:

During the survey, the following is an example of what was observed:
The West Exit, across from Infection Control ended in the grass.

_____________

2000 NFPA 101, 7.1.6.4 Walking surfaces shall be slip resistant under foreseeable conditions. The walking surface of each element in the means of egress shall be uniformly slip resistant along the natural path of travel.

2000 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.
.

The facility failed to provide proper storage of oxygen cylinders. Findings include:

During the survey, the following are examples of what was observed:
1. Empty and full signage was not provided for the oxygen cylinder storage area located outside of the facility.


27382

2. The "Dialysis Room" had one unsecured oxygen cylinder

_________________

CGA G-4, 4.1.10, and 1999 NFPA 99, 4-3.5.2.2(b)2 and 4-5.5.2.2(b)2 Full and empty cylinders shall be stored separately, with appropriate signage.

1999 NFPA 99, 4-3.5.2.1 Gases in Cylinders and Liquefied Gases in Containers - Level 1.
(a) * Handling of Gases. Administrative authorities shall provide regulations to ensure that standards for safe practice in the specifications for cylinders; marking of cylinders, regulators, and valves; and cylinder connections have been met by vendors of cylinders containing compressed gases supplied to the facility.
(b) Special Precautions - Oxygen Cylinders and Manifolds. Great care shall be exercised in handling oxygen to prevent contact of oxygen under pressure with oils, greases, organic lubricants, rubber, or other materials of an organic nature. The following regulations, based on those of the CGA Pamphlet G-4, Oxygen, shall be observed:
27. Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.
.

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

During the survey, the following is an example of what was observed:
The surveyors could not verify that the two O.R.s had a smoke venting system

_______________

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).
.

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

During the survey, the following are examples of what was observed:
1. Battery-powered lighting at the generator equipment and controls was not provided as observed during the survey.


27382

2. Per documentation and interview with maintenance staff, the facility was not testing the line isolation monitors

_____________

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


1999 NFPA 99, 3-3.3.4.2 Line Isolation Monitor Tests.
The proper functioning of each line isolation monitor (LIM) circuit shall be ensured by the following:
(a) The LIM circuit shall be tested after installation, and prior to being placed in service, by successively grounding each line of the energized distribution system through a resistor of 200 V ohms, where V = measured line voltage. The visual and audible alarms [see 3-3.2.2.3(b)] shall be activated.
(b) The LIM circuit shall be tested at intervals of not more than 1 month by actuating the LIM test switch [see 3-3.2.2.3(f)]. For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months. Actuation of the test switch shall activate both visual and audible alarm indicators.
(c) After any repair or renovation to an electrical distribution system and at intervals of not more than 6 months, the LIM circuit shall be tested in accordance with paragraph (a) above and only when the circuit is not otherwise in use. For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months.
.

The facility failed to provide the required transfer switch set up per code. Findings include:

During the survey, the following is an example of what was observed:
The generator was not divided into the critical branch, life safety branch and the equipment branch. Per the Maintenance Director a new generator, 300 kw, with new transfer switch was installed in 1998.

____________

1999 Edition of NFPA 99, 3-4.2.2.2, 3-5.2.2 type 1 EES and type 11 EES ref each branch of emergency system shall have one or more transfer switches, based on demand on the essential electrical system.

.

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

During the survey, the following are examples of what was observed:
1. Microwave was plugged into an overcurrent protection device in the respiratory break room.
2. Broken cover on an electrical outlet in the Director Office Respiratory.
3. A printer was plugged into an extension cord, the cord was then plugged into one of the emergency outlet in the Lab.


27382

4. The "Dialysis Room" had a refrigerator plugged into a surge protector (extension cord)
________________

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

1999 NFPA 70, 370-25 and 410-12. Each box in completed installations to have a cover, face plate, or fixture canopy.