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Type 1 EES & Gen Anesthesia/Life Support, Generator Maintenance re 110, Gen Set Light & Receptacle

Findings:
The inspector observed, while accompanied by the Maintenance, during the hours of the inspection from 7:30 AM to 10:00 AM on 07/14/2016 that there were the following issues:

A) There was no light with at least 90 minutes battery backup at generator set location.
B) There was no receptacle powered by the life safety branch of the emergency system at generator set location.
C) During testing of the generator startup, the generator annunciator panel status indicator LED did not change to reflect the status of the generator operation.

The Standard:
"Generator Set Location: Task illumination, battery charger for emergency battery-powered lighting unit(s), and selected receptacles at the generator set location and essential electrical system transfer switch locations. " - NFPA 99, Health Care Facilities Code. U.S.A.: NFPA; 2002: 4.4.2.2.2.2.(5).

Electrical Room

Findings:
The inspector observed, while accompanied by the Maintenance, during the hours of the inspection from 7:30 AM to 10:00 AM on 07/14/2016 that there were the following issues:

A) The electrical room which housed the master distribution panel, ATS(s), and boiler had been used as storage for defunct equipments, construction materials, and rubbish, which limited clear space for accessing electrical panels and contributed to hazard of contents.

The Standard:
Clear Spaces. Working space required by this section shall not be used for storage. When normally enclosed live parts are exposed for inspection or servicing, the working space, if in a passageway or general open space, shall be suitably guarded. - NFPA 70, 2002, 110.26(B)

Fuel and Water Preferred Customer Status

Findings:
The inspector observed, while accompanied by the Maintenance, during the hours of the inspection from 7:30 AM to 10:00 AM on 07/14/2016 that there were the following issues:

A) Based on observation the facility failed to provide letters from vendors for emergency fuel and water.

The Standard:
" Continuity of Essential Building Systems. When designated by the emergency preparedness management plan to provide continuous service in a disaster or emergency, health care facilities shall establish contingency plans for the continuity of essential building systems, as applicable: (a) Electricity, (b) Water, (c) Ventilation, (d) Fire protection systems, (e) Fuel sources, (f) Medical gas and vacuum systems (if applicable), (g) Communications systems. " - NFPA 99, 1999, 11-5.3.2

Type 1 EES & Gen Anesthesia/Life Support, Generator Maintenance re 110, Gen Set Light & Receptacle

Findings:
The inspector observed, while accompanied by the Maintenance, during the hours of the inspection from 7:30 AM to 10:00 AM on 07/14/2016 that there were the following issues:

A) There was no light with at least 90 minutes battery backup at generator set location.
B) There was no receptacle powered by the life safety branch of the emergency system at generator set location.
C) During testing of the generator startup, the generator annunciator panel status indicator LED did not change to reflect the status of the generator operation.

The Standard:
"Generator Set Location: Task illumination, battery charger for emergency battery-powered lighting unit(s), and selected receptacles at the generator set location and essential electrical system transfer switch locations. " - NFPA 99, Health Care Facilities Code. U.S.A.: NFPA; 2002: 4.4.2.2.2.2.(5).

Electrical Room

Findings:
The inspector observed, while accompanied by the Maintenance, during the hours of the inspection from 7:30 AM to 10:00 AM on 07/14/2016 that there were the following issues:

A) The electrical room which housed the master distribution panel, ATS(s), and boiler had been used as storage for defunct equipments, construction materials, and rubbish, which limited clear space for accessing electrical panels and contributed to hazard of contents.

The Standard:
Clear Spaces. Working space required by this section shall not be used for storage. When normally enclosed live parts are exposed for inspection or servicing, the working space, if in a passageway or general open space, shall be suitably guarded. - NFPA 70, 2002, 110.26(B)

Fuel and Water Preferred Customer Status

Findings:
The inspector observed, while accompanied by the Maintenance, during the hours of the inspection from 7:30 AM to 10:00 AM on 07/14/2016 that there were the following issues:

A) Based on observation the facility failed to provide letters from vendors for emergency fuel and water.

The Standard:
" Continuity of Essential Building Systems. When designated by the emergency preparedness management plan to provide continuous service in a disaster or emergency, health care facilities shall establish contingency plans for the continuity of essential building systems, as applicable: (a) Electricity, (b) Water, (c) Ventilation, (d) Fire protection systems, (e) Fuel sources, (f) Medical gas and vacuum systems (if applicable), (g) Communications systems. " - NFPA 99, 1999, 11-5.3.2