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Based on observation the facility failed to provide an acceptable enclosure a hazardous area.

The inspector observed while accompanied by the Plant Manager, the Survey Consultant, the Safety Officer, the Supervisor of Housekeeping, and the Contract Electrician during the hours of the inspection from 1:30 pm to 5:00 pm that there was a storage room off of O.R. #2 that had two doors that did not close properly.

Based on observation the facility failed to provide an acceptable fire escape route at the north stair.

The inspector observed while accompanied by the Plant Manager, the Survey Consultant, the Safety Officer, the Supervisor of Housekeeping, and the Contract Electrician during the hours of the inspection from 1:30 pm to 5:00 pm that there was a door at the top of the stair that was not rated and did not close properly.

Based on observation the facility failed to provide a complete fire sprinkler system.

The inspector observed while accompanied by the Plant Manager, the Survey Consultant, the Safety Officer, the Supervisor of Housekeeping, and the Contract Electrician during the hours of the inspection from 1:30 pm to 5:00 pm that there were ducts in AHU #1 room that were over 4 ft. wide that did not have sprinklers underneath. " Sprinklers shall be installed under fixed obstructions over 4 ft. wide such as ducts, decks, open grate flooring, cutting tables, and overhead doors. " - NFPA 13, 2002: 8.5.5.3.1.

Based on observation the facility failed to provide an acceptable medical gas enclosure and signage.

The inspector observed while accompanied by the Plant Manager, the Survey Consultant, the Safety Officer, the Supervisor of Housekeeping, and the Contract Electrician during the hours of the inspection from 1:30 pm to 5:00 pm that there was a truck parked closer than 20 ft. from the bulk oxygen storage location. Bollards must be placed to prevent any source of ignition from being adjacent to the storage. " Smoking, open flames, electric heating elements, and other sources of ignition shall be prohibited within storage locations and within 20 ft of outside storage locations. " - NFPA 99, 2002, 9.4.2(I). Also, the fenced in area was full of dry leaves that must be cleaned out. " Storage locations for oxygen and nitrous oxide shall be kept free of flammable materials. " - NFPA 99, 1999, 4-3.1.1.2(a)5.


In addition, the signage at the medical gas closet was incomplete. The medical gas closet shall have a door labeled with the following re. NFPA 99, 2002: 5.1.3.1.5.

CAUTION
Medical Gases
NO Smoking or Open Flame
Room may have Insufficient Oxygen
Open Door and Allow Room to Ventilate before Entering

Based on observation the facility failed to provide a history of records for grounding test of electrical receptacles per NFPA 99: 3-3.3.3. in patient care areas.

The inspector observed while accompanied by the Plant Manager, the Survey Consultant, the Safety Officer, the Supervisor of Housekeeping, and the Contract Electrician during the hours of the inspection from 1:30 pm to 5:00 pm that there were no records of receptacle testing in patient care areas.

NFPA 99, 1999, 3-3.4.2.3(a) states that testing shall be performed after initial installation, replacement or servicing of a device, and that additional testing shall be performed at intervals defined by documented performance data. If the facility has documented performance data for the electrical receptacles in all patient care areas then the schedule defined by this data will be acceptable. In the absence of the data the following schedule shall be maintained by the facility. Receptacle testing shall be performed in all general care areas every 12 months and in critical care areas every 6 months. (NFPA 99, 1984).

NFFA 99, 1999, 3-3.3.3 Receptacle Testing in Patient Care Areas
(a) The physical integrity of each receptacle shall be confirmed by visual inspection.
(b) The continuity of the grounding circuit in each electrical receptacle shall be verified.
(c) Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.
(d) The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz).


Based on observation the facility failed to provide an acceptable record of line isolation monitor tests.

The inspector observed while accompanied by the Plant Manager, the Survey Consultant, the Safety Officer, the Supervisor of Housekeeping, and the Contract Electrician during the hours of the inspection from 1:30 pm to 5:00 pm that there were no records of the 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. " - N.F.P.A. 99, 1999, 3-3.3.4.2

Based on observation the facility failed to provide a letter from a vendor for emergency fuel indicating that they have a preferred customer status.

The inspector observed while accompanied by the Plant Manager, the Survey Consultant, the Safety Officer, the Supervisor of Housekeeping, and the Contract Electrician during the hours of the inspection from 1:30 pm to 5:00 pm that there was not a letter for preferred customer status for emergency generator fuel.

Based on observation the facility failed to provide an acceptable enclosure a hazardous area.

The inspector observed while accompanied by the Plant Manager, the Survey Consultant, the Safety Officer, the Supervisor of Housekeeping, and the Contract Electrician during the hours of the inspection from 1:30 pm to 5:00 pm that there was a storage room off of O.R. #2 that had two doors that did not close properly.

Based on observation the facility failed to provide an acceptable fire escape route at the north stair.

The inspector observed while accompanied by the Plant Manager, the Survey Consultant, the Safety Officer, the Supervisor of Housekeeping, and the Contract Electrician during the hours of the inspection from 1:30 pm to 5:00 pm that there was a door at the top of the stair that was not rated and did not close properly.

Based on observation the facility failed to provide a complete fire sprinkler system.

The inspector observed while accompanied by the Plant Manager, the Survey Consultant, the Safety Officer, the Supervisor of Housekeeping, and the Contract Electrician during the hours of the inspection from 1:30 pm to 5:00 pm that there were ducts in AHU #1 room that were over 4 ft. wide that did not have sprinklers underneath. " Sprinklers shall be installed under fixed obstructions over 4 ft. wide such as ducts, decks, open grate flooring, cutting tables, and overhead doors. " - NFPA 13, 2002: 8.5.5.3.1.

Based on observation the facility failed to provide an acceptable medical gas enclosure and signage.

The inspector observed while accompanied by the Plant Manager, the Survey Consultant, the Safety Officer, the Supervisor of Housekeeping, and the Contract Electrician during the hours of the inspection from 1:30 pm to 5:00 pm that there was a truck parked closer than 20 ft. from the bulk oxygen storage location. Bollards must be placed to prevent any source of ignition from being adjacent to the storage. " Smoking, open flames, electric heating elements, and other sources of ignition shall be prohibited within storage locations and within 20 ft of outside storage locations. " - NFPA 99, 2002, 9.4.2(I). Also, the fenced in area was full of dry leaves that must be cleaned out. " Storage locations for oxygen and nitrous oxide shall be kept free of flammable materials. " - NFPA 99, 1999, 4-3.1.1.2(a)5.


In addition, the signage at the medical gas closet was incomplete. The medical gas closet shall have a door labeled with the following re. NFPA 99, 2002: 5.1.3.1.5.

CAUTION
Medical Gases
NO Smoking or Open Flame
Room may have Insufficient Oxygen
Open Door and Allow Room to Ventilate before Entering

Based on observation the facility failed to provide a history of records for grounding test of electrical receptacles per NFPA 99: 3-3.3.3. in patient care areas.

The inspector observed while accompanied by the Plant Manager, the Survey Consultant, the Safety Officer, the Supervisor of Housekeeping, and the Contract Electrician during the hours of the inspection from 1:30 pm to 5:00 pm that there were no records of receptacle testing in patient care areas.

NFPA 99, 1999, 3-3.4.2.3(a) states that testing shall be performed after initial installation, replacement or servicing of a device, and that additional testing shall be performed at intervals defined by documented performance data. If the facility has documented performance data for the electrical receptacles in all patient care areas then the schedule defined by this data will be acceptable. In the absence of the data the following schedule shall be maintained by the facility. Receptacle testing shall be performed in all general care areas every 12 months and in critical care areas every 6 months. (NFPA 99, 1984).

NFFA 99, 1999, 3-3.3.3 Receptacle Testing in Patient Care Areas
(a) The physical integrity of each receptacle shall be confirmed by visual inspection.
(b) The continuity of the grounding circuit in each electrical receptacle shall be verified.
(c) Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.
(d) The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz).


Based on observation the facility failed to provide an acceptable record of line isolation monitor tests.

The inspector observed while accompanied by the Plant Manager, the Survey Consultant, the Safety Officer, the Supervisor of Housekeeping, and the Contract Electrician during the hours of the inspection from 1:30 pm to 5:00 pm that there were no records of the 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. " - N.F.P.A. 99, 1999, 3-3.3.4.2

Based on observation the facility failed to provide a letter from a vendor for emergency fuel indicating that they have a preferred customer status.

The inspector observed while accompanied by the Plant Manager, the Survey Consultant, the Safety Officer, the Supervisor of Housekeeping, and the Contract Electrician during the hours of the inspection from 1:30 pm to 5:00 pm that there was not a letter for preferred customer status for emergency generator fuel.