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K902 GAS AND VACUUM PIPED SYSTEMS - OTHER
List in the REMARKS section, any NFPA 99 Chapter 5 Gas and Vacuum Systems requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567. Chapter 5 (NFPA 99)

Two Entry/Exits

NFPA 99, 2012 :5.1.3.3.2* Design and Construction. Locations for central supply systems and the storage of positive-pressure gases shall meet the following requirements:
These are general requirements.
(1) They shall be constructed with access to move cylinders, equipment, and so forth, in and out of the location on hand trucks complying with 11.4.3.1.1.
(2) They shall be secured with lockable doors or gates or otherwise secured.
(3) If outdoors, they shall be provided with an enclosure (wall or fencing) constructed of noncombustible materials with a minimum of two entry/exits.

Based on observation the facility failed to provide two entry/exits in the oxygen farm Tanks area.

The inspector observed, while accompanied by the Director of Plant Operation and Safety Officer during the hours of the inspection from 2:00 pm to 6:00 pm on 2/13/2024 that the facility oxygen farm tank area did not have two entry or exits per the code (3) above.

Based on observation the facility failed to provide a risk assessment for the medical gas system.

The inspector observed, while accompanied by the Director of Plant Operation and Safety Officer during the hours of the inspection from 2:00 pm to 6:00 pm on 2/13/2024 that the facility had not done a risk assessment to determine the medical gas supply failure likelihood to cause major injury or death.

Based on observation the facility failed to provide a risk assessment for the medical gas system.


The inspector observed, while accompanied by the Director of Plant Operation and Safety Officer during the hours of the inspection from 2:00 pm to 6:00 pm on 2/13/2024 that the facility had not done a risk assessment to determine the procedures and schedule for testing the medical gas system.

Generator Manual Kill Switch

"All installations shall have a remote manual stop station of a type to prevent inadvertent or unintentional operation located outside the room housing the prime mover, where so installed, or elsewhere on the premises where the prime mover is located outside the building" - NFPA 110, 2010, 5.6.5.6* Note: "For systems located outdoors, the manual shutdown should be located external to the weatherproof enclosure and should be appropriately identified." A.5.6.5.6.


Based on observation the facility failed to provide adequate generator safety features.


The inspector observed, while accompanied by the Director of Plant Operation and Safety Officer during the hours of the inspection from 2:00 pm to 6:00 pm on 2/13/2024 that the facility had a generator kill switch installed outside the generator enclosure but in a locked location. The kill switch shall be at a location with unfettered access.

Segregation of the Essential Electrical System (General)
Type 1 EES

The critical system shall serve functions related to patient care. - NFPA 99, 2012,
6.4.2.2.4.1 The critical branch shall be permitted to be subdivided into two or more branches.

6.4.2.2.4.2 The critical branch shall supply power for task illumination, fixed equipment, select receptacles, and select power circuits serving the following areas and functions related to patient care:

(1) Critical care areas that utilize anesthetizing gases, task illumination, select receptacles, and fixed equipment
(2) Isolated power systems in special environments
(3) Task illumination and select receptacles in the following:
(a) Patient care rooms, including infant nurseries, selected acute nursing areas, psychiatric bed areas (omit receptacles), and ward treatment rooms
(b) Medication preparation areas
(c) Pharmacy dispensing areas
(d) Nurses' stations (unless adequately lighted by corridor luminaires)
(4) Additional specialized patient care task illumination and receptacles, where needed
(5) Nurse call systems
(6) Blood, bone, and tissue banks
(7) Telephone equipment rooms and closets
(8) Task illumination, select receptacles, and select power circuits for the following areas:
(a) General care beds with at least one duplex receptacles per patient bedroom, and task illumination as required by the governing body of the health care facility
(b) Angiographic labs
(c) Cardiac catheterization labs
(d) Coronary care units
(e) Hemodialysis rooms or areas
(f) Emergency room treatment areas (select)
(g) Human physiology labs
(h) Intensive care units
(i) Postoperative recovery rooms (select)
(9) Additional task illumination, receptacles, and select power circuits needed for effective facility operation, including single-phase fractional horsepower motors, which are permitted to be connected to the critical branch.



Based on observation the facility failed to provide correct Essential Electrical System separation.


The inspector observed, while accompanied by the Director of Plant Operation and Safety Officer during the hours of the inspection from 2:00 pm to 6:00 pm on 2/13/2024 that the lights in the following areas are powered from the normal branch instead of the critical branch:
1. The Pre-Ops restroom.
2. All the ICU patient restrooms.
3. Nourishment area light and add a critical receptacle for Ice Maker.
4. Medical Surgical suite, all the patient rooms and restrooms lights are on normal branch. It shall be on critical branch.

Based on observation the facility failed to provide adequate maintenance and testing.


The inspector observed, while accompanied by the Director of Plant Operation and Safety Officer during the hours of the inspection from 2:00 pm to 6:00 pm on 2/13/2024 that there were the following issues:
1. That the required annual receptacles testing was not being performed.
2. No records of where, type of repair performed and date of electrical maintenance and required tests performed in all the patient care areas.

Based on observation the facility failed to provide a Type I electrical system.


The inspector observed, while accompanied by the Director of Plant Operation and Safety Officer during the hours of the inspection from 2:00 pm to 6:00 pm on 2/13/2024 that the facility electrical system was not "Type I" Essential Electrical System (EES) as required for Ambulatory Surgery Centers. Provide Life Safety, Critical and Equipment Panels per the code.

Based on observation the facility failed to provide all the required documentation for the essential electrical system maintenance.


The inspector observed, while accompanied by the Director of Plant Operation and Safety Officer during the hours of the inspection from 2:00 pm to 6:00 pm on 2/13/2024 that there were:
1. There was no record of 36-month load bank test being performed.
2. There was no record of the main and feeder circuit breakers being inspected annually.
3. There were no records of maintenance and testing of the EES system being catalogued.

Based on observation the facility failed to provide adequate training check of the service technicians.


The inspector observed, while accompanied by the Director of Plant Operation and Safety Officer during the hours of the inspection from 2:00 pm to 6:00 pm on 2/13/2024 that the facility failed to check the training record of the technicians calibrating the center medical equipment.

Based on observation the facility failed to provide adequate medical gas equipment testing.


The inspector observed, while accompanied by the Director of Plant Operation and Safety Officer during the hours of the inspection from 2:00 pm to 6:00 pm on 2/13/2024 that the facility had no scheduled maintenance program for medical gas equipment.