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Based on observations, the facility failed to maintain the fire resistance rating of 2-hour fire rated barriers in accordance with NFPA 101, 2000 Edition, Section 8.2.3.2.4.2¹. This deficiency affected 1 fire barrier & 2 lower level smoke compartments and 2 barriers & 4 upper level smoke compartments.

Findings include:

1. During an observation on 6/24/15 at 7:54 a.m., the following concerns were noted in the 2-hour rated wall by the radiation therapy oxygen storage room in the basement:
a.) An unsealed penetration around a conduit (which was previously sealed but the fire rated caulking was damaged).¹
b.) An unsealed hole in the wall approximately measuring two inches in diameter.¹
c.) An improperly sealed penetration around a blue communication cable measuring approximately two inches in diameter.¹

2. During an observation on 6/24/15 at 10:42 a.m., a two-inch unsealed conduit extended through the 2-hour rated wall on the upper level by the administration elevator. The open end of the conduit was not sealed.¹

3. During tan observation on 6/25/15 at 11:00 a.m., two open ended conduits and one duct extended through the 2-hour rated wall by the emergency department shower room.¹

¹ NFPA 101, 2000 Edition, Section 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.

Based on observations, the facility failed to properly seal vertical penetrations through the one hour floor/ceiling assembly between the basement monolithic ceiling and upper level per NFPA 101, 2000 Edition, Sections 19.3.1.1 and 8.2.5.2. The deficiency could affect 1 upper level smoke compartment and 1 lower level smoke compartment.

Findings include:

1. During an observation on 6/24/15 at 9:10 a.m., four pipe hanger penetrations extended through the ceiling surface in Heating, Ventilating, and Air Conditioning (HVAC) #1 room above HVAC #2 unit in the basement.¹ ²

2. During tan observation on 6/24/15 at 9:16 a.m., approximately four penetrations extended through the ceiling surface in the boiler room. One hole was above the autoclave; and four holes were above boiler #4.¹ ²

¹ NFPA 101, 2000 Edition, Section 19.3.1.1; Any vertical opening shall be enclosed or protected in accordance with 8.2.5. Where enclosure is provided, the construction shall have not less than a 1-hour fire resistance rating.

² NFPA 101, 2000 Edition, Section 8.2.5.2; Openings through floors, such as stairways, hoistways for elevators, dumbwaiters, and inclined and vertical conveyors; shaftways used for light, ventilation, or building services; or expansion joints and seismic joints used to allow structural movements shall be enclosed with fire barrier walls. Such enclosures shall be continuous from floor to floor or floor to roof. Openings shall be protected as appropriate for the fire resistance rating of the barrier.

Based on observations, the facility failed to maintain the corridor door in a protected stairwell per NFPA 80, 1999 Edition, Section 2-4.1.4¹. This deficiency could affect 2 smoke compartments on each level (lower and upper levels).

Findings include:

1. During an observation on 6/24/15 at 8:05 a.m., the corridor door to the stairwell outside the physical therapy did not latch and close when exercised three times. The door was located at the basement level and had a self-closure device.

2. During an observation on 6/24/15 at 11:40 a.m., the elevator corridor door in Acute Care did not latch and close when exercised three times. The bottom of the door dragged on the floor. The door had a self-closure device.

¹ NFPA 80 Standard for Fire Doors and Fire Windows, 1999 Edition, Section 2-4.1.4, All closing mechanisms shall be adjusted to overcome the resistance of the latch mechanism so that positive latching is achieved on each door operation.

Based on observation and interview, the facility failed to ensure all exit doors were readily available in a case of an emergency in accordance with NFPA 101, 2000 Edition, Section 7.1.10.1¹ This deficiency could affect 1 lower level smoke compartment.

Findings include:

During the observation on 6/23/15 at 4:55 p.m., the north exit door in the Surgical Suite, north of the Operating Room (OR)-3, was exercised. The door could not be opened. The door was taped at the bottom onto the threshold. Staff member A, director of support services, stated the exit was banned from use by the previous OR nursing director during her employment.

¹ NFPA 101, 2000 Edition, Section 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. Annex 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.

Based on observation and interview, the facility failed to conduct 30 second monthly and 90 minute annual tests on the battery powered emergency light fixtures in the surgical suite in accordance with NFPA 101, 2000 Edition, Section 7.9.3.¹ The deficiency could affect all staff and patients in the Surgery department smoke compartment.

Findings include:

During an observation on 6/23/15 at 4:10 p.m., surgery rooms 1, 2, and 3 lacked battery powered emergency light fixtures.

Review of the facility floor plans reflected all three surgery rooms were actually equipped with A14 battery pack light fixtures.

During an interview on 6/24/15 at 7:10 a.m., staff member A, director of support services, stated they were not aware of the "battery packs" in surgery rooms. He stated he did not think the battery packed light fixtures were ever tested since the installation.

¹ NFPA 101, 2000 Edition, Section 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 11/2 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.

Based on observation, the facility failed to ensure the automatic sprinkler system was inspected and maintained by preventing gaps forming around the sprinkler heads and escutcheon rings, and by maintaining proper ceiling assemblies per NFPA 25, 1998 Edition, Section 2.2.1.1. These deficiencies may affect 4 smoke compartments at the lower level and 5 smoke compartment at the upper level.

Findings include:

1. During an observation on 6/24/15 at 8:10 a.m., the sprinkler head had shifted down from the ceiling surface exposing a gap in the ceiling tile in Old Surgery above the sink.¹

2. During an observation on 6/24/15 at 8:27 a.m., the sprinkler head pipe had shifted away from the wall under the stairs in the Acute Care stairwell, exposing a gap in the wall surface at the lower level.¹

3. During an observation on 6/24/15 at 8:34 a.m., the sprinkler head pipe had shifted away from the ceiling in the dietary housekeeping closet, exposing a gap in the ceiling surface.¹

4. During an observation on 6/24/15 at 8:46 a.m., two sprinkler head pipes had shifted away from the ceiling in the dietary corridor just outside the main entrance to the kitchen, exposing gaps in the ceiling surface.¹

5. During an observation on 6/24/15 at 8:56 a.m., the following concerns were observed in Purchasing:
a) a water pipe extended through the ceiling tile exposing a gap in the ceiling assembly in the west wall of Purchasing.¹
b) the sprinkler head pipe had shifted away from the ceiling above the B-C shelving, exposing a gap in the ceiling surface.¹

6. During an observation on 6/24/15 at 10:35 a.m., a ceiling tile was off its tract in the IS room in Administration.¹

7. During an observation on 6/24/15 at 11:10 a.m., the sprinkler head pipe had shifted away from the ceiling in the Acute Care staff bathroom on the upper level, exposing a gap in the ceiling surface.¹

8. During an observation on 6/24/15 at 11:25 a.m., the sprinkler head pipe had shifted away from the ceiling in Intensive care Unit outside room 112 on the upper level, exposing a gap in the ceiling surface.¹

These disruptions in the ceiling assemblies could delay the activation time of the automatic sprinkler system.¹

¹ NFPA 13 Standard for the Installation of Sprinklers Systems,1999 Edition, Section 5.1.1; The requirements for spacing, location, and position of sprinklers shall be based on the following principles:
(1) Sprinklers installed throughout the premises
(2) Sprinklers located so as not to exceed maximum protection area per sprinkler
(3) Sprinklers positioned and located so as to provide satisfactory performance with respect to activation time and distribution
Exception No. 1: For locations permitting omission of sprinklers, see 5-13.1, 5-13.2, and 5-13.9.
Exception No. 2: When sprinklers are specifically tested and test results demonstrate that deviations from clearance requirements to structural members do not impair the ability of the sprinkler to control or suppress a fire, their positioning and locating in accordance with the test results shall be permitted.

Based on observation, the facility failed to ensure proper sign was posted in areas where oxygen was used or stored per NFPA 101, 2000 Edition, Section 19.3.2.4 and NFPA 99, 1999 Edition, Section 8.3.1.11.3. The deficiency could affect 1 lower level smoke compartment.

Findings include:

During an observation on 6/24/15 at 8:18 a.m., the durable medical equipment storage area contained "empty" oxygen cylinders (47 E size and approximately 110 C size). Total oxygen storage would be 9 cubic feet (cu. ft.) per C size and 24 cu. ft. per E size compressed gas cylinders or (110 x 9) + (47 x 24) = 2,118 cu. ft of oxygen. The corridor door lacked a sign cautioning of the oxidizing gas storage.¹

¹ NFPA 99 Standard for Health Care Facilities, 1999 Edition, section 8-3.1.11.3 Signs; A precautionary sign, readable from a distance of 5 ft (1.5 m), shall be conspicuously displayed on each door or gate of the storage room or enclosure. The sign shall include the following wording as a minimum:

CAUTION
OXIDIZING GAS(ES) STORED WITHIN
NO SMOKING

Based on observations, the facility failed to maintain the electrical system and/or its components in accordance with the Centers for Medicare and Medicaid Services (CMS) Policy S&C-14-46-LSC, and NFPA 70, 1999 Edition, Articles 110-22 and 110-26(a). These deficiencies could affect one compartment in the basement and one compartment in the upper level.

Findings include:

1. During an observation on 6/23/15 at 4:25 p.m., a refrigerator was plugged into a power strip in the imaging manager's office. High load devices shall not be plugged into power strips.¹

2. During on observation on 6/23/15 at 4:58 p.m., the following concerns were noted in electrical panels 2C5L and 2C4L outside of the post-anesthesia care unit:
a.) Circuit breakers 33-41 in electrical panel 2C5L were marked as spares on the panel directory, but they were in on position.²
b.) Circuit breakers 31-33 and 30-40 in electrical panel 2C4L were marked as spares on the panel directory, but they were in on position.²

3. During an observation on 6/23/15 at 5:01 p.m., a power strip was balanced on a trash can in the Doctor's dictation room in the basement.¹

4. During an observation on 6/24/15 at 9:20 a.m., several items were stored on the floor in front of the generator transfer switch and an electrical panel (ELS1) in the Information Services phone room in the lower level.³

5. During an observation on 6/24/15 at 11:32 a.m., a night stand was placed directly in front of the electrical panel in the Acute Care staff bathroom.³

¹ CMS Survey & Certification Policy S&C-14-46-LSC Categorical Waiver for Power Strips Use in Patient Care Areas, Issued 9/26/14.

² NFPA 70, 1999 Edition, Article 110-22, Each disconnecting means required by this Code for motors and appliances, and each service, feeder, or branch circuit at the point where it originates, shall be legibly marked to indicate its purpose unless located and arranged so the purpose is evident. The marking shall be of sufficient durability to withstand the environment involved.

³ NFPA 70 National Electric Code, 1999 Edition, Article 110-26 Spaces About Electrical Equipment; 110-26. Spaces About Electrical Equipment; Sufficient access and working space shall be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment. Enclosures housing electrical apparatus that are controlled by lock and key shall be considered accessible to qualified persons.
(a) Working Space. Working space for equipment operating at 600 volts, nominal, or less to ground and likely to require examination, adjustment, servicing, or maintenance while energized shall comply with the dimensions of (1), (2), and (3) or as required or permitted elsewhere in this Code.
(1) Depth of Working Space. The depth of the working space in the direction of access to live parts shall not be less than indicated in Table 110-26(a). Distances shall be measured from the live parts if such are exposed or from the enclosure front or opening if such are enclosed.
Exception No. 1: Working space shall not be required in back or sides of assemblies, such as dead-front switchboards or motor control centers, where there are no renewable or adjustable parts, such as fuses or switches, on the back or sides and where all connections are accessible from locations other than the back or sides. Where rear access is required to work on de-energized parts on the back of enclosed equipment, a minimum working space of 30 in. (762 mm) horizontally shall be provided.
Exception No. 2: By special permission, smaller spaces shall be permitted where all uninsulated parts are at a voltage no greater than 30 volts rms, 42 volts peak, or 60 volts dc.
Exception No. 3: In existing buildings where electrical equipment is being replaced, Condition 2 working clearance shall be permitted between dead-front switchboards, panelboards, or motor control centers located across the aisle from each other where conditions of maintenance and supervision ensure that written procedures have been adopted to prohibit equipment on both sides of the aisle from being open at the same time and qualified persons who are authorized will service the installation.
Table 110-26(a). Working Spaces

Minimum Clear Distance (ft)
Nominal Voltage to Ground Condition 1 Condition 2 Condition 3
0-150 3 3 3
151-600 3 3 1/2 4

Notes:
1. For SI units, 1 ft = 0.3048 m.
2. Where the conditions are as follows:
Condition 1 - Exposed live parts on one side and no live or grounded parts on the other side of the working space, or exposed live parts on both sides effectively guarded by suitable wood or other insulating materials. Insulated wire or insulated busbars operating at not over 300 volts to ground shall not be considered live parts.
Condition 2 - Exposed live parts on one side and grounded parts on the other side. Concrete, brick, or tile walls shall be considered as grounded.
Condition 3 - Exposed live parts on both sides of the work space (not guarded as provided in Condition 1) with the operator between.

Based on observations, the facility failed to maintain the fire resistance rating of 2-hour fire rated barriers in accordance with NFPA 101, 2000 Edition, Section 8.2.3.2.4.2¹. This deficiency affected 1 fire barrier & 2 lower level smoke compartments and 2 barriers & 4 upper level smoke compartments.

Findings include:

1. During an observation on 6/24/15 at 7:54 a.m., the following concerns were noted in the 2-hour rated wall by the radiation therapy oxygen storage room in the basement:
a.) An unsealed penetration around a conduit (which was previously sealed but the fire rated caulking was damaged).¹
b.) An unsealed hole in the wall approximately measuring two inches in diameter.¹
c.) An improperly sealed penetration around a blue communication cable measuring approximately two inches in diameter.¹

2. During an observation on 6/24/15 at 10:42 a.m., a two-inch unsealed conduit extended through the 2-hour rated wall on the upper level by the administration elevator. The open end of the conduit was not sealed.¹

3. During tan observation on 6/25/15 at 11:00 a.m., two open ended conduits and one duct extended through the 2-hour rated wall by the emergency department shower room.¹

¹ NFPA 101, 2000 Edition, Section 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.

Based on observations, the facility failed to properly seal vertical penetrations through the one hour floor/ceiling assembly between the basement monolithic ceiling and upper level per NFPA 101, 2000 Edition, Sections 19.3.1.1 and 8.2.5.2. The deficiency could affect 1 upper level smoke compartment and 1 lower level smoke compartment.

Findings include:

1. During an observation on 6/24/15 at 9:10 a.m., four pipe hanger penetrations extended through the ceiling surface in Heating, Ventilating, and Air Conditioning (HVAC) #1 room above HVAC #2 unit in the basement.¹ ²

2. During tan observation on 6/24/15 at 9:16 a.m., approximately four penetrations extended through the ceiling surface in the boiler room. One hole was above the autoclave; and four holes were above boiler #4.¹ ²

¹ NFPA 101, 2000 Edition, Section 19.3.1.1; Any vertical opening shall be enclosed or protected in accordance with 8.2.5. Where enclosure is provided, the construction shall have not less than a 1-hour fire resistance rating.

² NFPA 101, 2000 Edition, Section 8.2.5.2; Openings through floors, such as stairways, hoistways for elevators, dumbwaiters, and inclined and vertical conveyors; shaftways used for light, ventilation, or building services; or expansion joints and seismic joints used to allow structural movements shall be enclosed with fire barrier walls. Such enclosures shall be continuous from floor to floor or floor to roof. Openings shall be protected as appropriate for the fire resistance rating of the barrier.

Based on observations, the facility failed to maintain the corridor door in a protected stairwell per NFPA 80, 1999 Edition, Section 2-4.1.4¹. This deficiency could affect 2 smoke compartments on each level (lower and upper levels).

Findings include:

1. During an observation on 6/24/15 at 8:05 a.m., the corridor door to the stairwell outside the physical therapy did not latch and close when exercised three times. The door was located at the basement level and had a self-closure device.

2. During an observation on 6/24/15 at 11:40 a.m., the elevator corridor door in Acute Care did not latch and close when exercised three times. The bottom of the door dragged on the floor. The door had a self-closure device.

¹ NFPA 80 Standard for Fire Doors and Fire Windows, 1999 Edition, Section 2-4.1.4, All closing mechanisms shall be adjusted to overcome the resistance of the latch mechanism so that positive latching is achieved on each door operation.

Based on observation and interview, the facility failed to ensure all exit doors were readily available in a case of an emergency in accordance with NFPA 101, 2000 Edition, Section 7.1.10.1¹ This deficiency could affect 1 lower level smoke compartment.

Findings include:

During the observation on 6/23/15 at 4:55 p.m., the north exit door in the Surgical Suite, north of the Operating Room (OR)-3, was exercised. The door could not be opened. The door was taped at the bottom onto the threshold. Staff member A, director of support services, stated the exit was banned from use by the previous OR nursing director during her employment.

¹ NFPA 101, 2000 Edition, Section 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. Annex 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.

Based on observation and interview, the facility failed to conduct 30 second monthly and 90 minute annual tests on the battery powered emergency light fixtures in the surgical suite in accordance with NFPA 101, 2000 Edition, Section 7.9.3.¹ The deficiency could affect all staff and patients in the Surgery department smoke compartment.

Findings include:

During an observation on 6/23/15 at 4:10 p.m., surgery rooms 1, 2, and 3 lacked battery powered emergency light fixtures.

Review of the facility floor plans reflected all three surgery rooms were actually equipped with A14 battery pack light fixtures.

During an interview on 6/24/15 at 7:10 a.m., staff member A, director of support services, stated they were not aware of the "battery packs" in surgery rooms. He stated he did not think the battery packed light fixtures were ever tested since the installation.

¹ NFPA 101, 2000 Edition, Section 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 11/2 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.

Based on observation, the facility failed to ensure the automatic sprinkler system was inspected and maintained by preventing gaps forming around the sprinkler heads and escutcheon rings, and by maintaining proper ceiling assemblies per NFPA 25, 1998 Edition, Section 2.2.1.1. These deficiencies may affect 4 smoke compartments at the lower level and 5 smoke compartment at the upper level.

Findings include:

1. During an observation on 6/24/15 at 8:10 a.m., the sprinkler head had shifted down from the ceiling surface exposing a gap in the ceiling tile in Old Surgery above the sink.¹

2. During an observation on 6/24/15 at 8:27 a.m., the sprinkler head pipe had shifted away from the wall under the stairs in the Acute Care stairwell, exposing a gap in the wall surface at the lower level.¹

3. During an observation on 6/24/15 at 8:34 a.m., the sprinkler head pipe had shifted away from the ceiling in the dietary housekeeping closet, exposing a gap in the ceiling surface.¹

4. During an observation on 6/24/15 at 8:46 a.m., two sprinkler head pipes had shifted away from the ceiling in the dietary corridor just outside the main entrance to the kitchen, exposing gaps in the ceiling surface.¹

5. During an observation on 6/24/15 at 8:56 a.m., the following concerns were observed in Purchasing:
a) a water pipe extended through the ceiling tile exposing a gap in the ceiling assembly in the west wall of Purchasing.¹
b) the sprinkler head pipe had shifted away from the ceiling above the B-C shelving, exposing a gap in the ceiling surface.¹

6. During an observation on 6/24/15 at 10:35 a.m., a ceiling tile was off its tract in the IS room in Administration.¹

7. During an observation on 6/24/15 at 11:10 a.m., the sprinkler head pipe had shifted away from the ceiling in the Acute Care staff bathroom on the upper level, exposing a gap in the ceiling surface.¹

8. During an observation on 6/24/15 at 11:25 a.m., the sprinkler head pipe had shifted away from the ceiling in Intensive care Unit outside room 112 on the upper level, exposing a gap in the ceiling surface.¹

These disruptions in the ceiling assemblies could delay the activation time of the automatic sprinkler system.¹

¹ NFPA 13 Standard for the Installation of Sprinklers Systems,1999 Edition, Section 5.1.1; The requirements for spacing, location, and position of sprinklers shall be based on the following principles:
(1) Sprinklers installed throughout the premises
(2) Sprinklers located so as not to exceed maximum protection area per sprinkler
(3) Sprinklers positioned and located so as to provide satisfactory performance with respect to activation time and distribution
Exception No. 1: For locations permitting omission of sprinklers, see 5-13.1, 5-13.2, and 5-13.9.
Exception No. 2: When sprinklers are specifically tested and test results demonstrate that deviations from clearance requirements to structural members do not impair the ability of the sprinkler to control or suppress a fire, their positioning and locating in accordance with the test results shall be permitted.

Based on observation, the facility failed to ensure proper sign was posted in areas where oxygen was used or stored per NFPA 101, 2000 Edition, Section 19.3.2.4 and NFPA 99, 1999 Edition, Section 8.3.1.11.3. The deficiency could affect 1 lower level smoke compartment.

Findings include:

During an observation on 6/24/15 at 8:18 a.m., the durable medical equipment storage area contained "empty" oxygen cylinders (47 E size and approximately 110 C size). Total oxygen storage would be 9 cubic feet (cu. ft.) per C size and 24 cu. ft. per E size compressed gas cylinders or (110 x 9) + (47 x 24) = 2,118 cu. ft of oxygen. The corridor door lacked a sign cautioning of the oxidizing gas storage.¹

¹ NFPA 99 Standard for Health Care Facilities, 1999 Edition, section 8-3.1.11.3 Signs; A precautionary sign, readable from a distance of 5 ft (1.5 m), shall be conspicuously displayed on each door or gate of the storage room or enclosure. The sign shall include the following wording as a minimum:

CAUTION
OXIDIZING GAS(ES) STORED WITHIN
NO SMOKING

Based on observations, the facility failed to maintain the electrical system and/or its components in accordance with the Centers for Medicare and Medicaid Services (CMS) Policy S&C-14-46-LSC, and NFPA 70, 1999 Edition, Articles 110-22 and 110-26(a). These deficiencies could affect one compartment in the basement and one compartment in the upper level.

Findings include:

1. During an observation on 6/23/15 at 4:25 p.m., a refrigerator was plugged into a power strip in the imaging manager's office. High load devices shall not be plugged into power strips.¹

2. During on observation on 6/23/15 at 4:58 p.m., the following concerns were noted in electrical panels 2C5L and 2C4L outside of the post-anesthesia care unit:
a.) Circuit breakers 33-41 in electrical panel 2C5L were marked as spares on the panel directory, but they were in on position.²
b.) Circuit breakers 31-33 and 30-40 in electrical panel 2C4L were marked as spares on the panel directory, but they were in on position.²

3. During an observation on 6/23/15 at 5:01 p.m., a power strip was balanced on a trash can in the Doctor's dictation room in the basement.¹

4. During an observation on 6/24/15 at 9:20 a.m., several items were stored on the floor in front of the generator transfer switch and an electrical panel (ELS1) in the Information Services phone room in the lower level.³

5. During an observation on 6/24/15 at 11:32 a.m., a night stand was placed directly in front of the electrical panel in the Acute Care staff bathroom.³

¹ CMS Survey & Certification Policy S&C-14-46-LSC Categorical Waiver for Power Strips Use in Patient Care Areas, Issued 9/26/14.

² NFPA 70, 1999 Edition, Article 110-22, Each disconnecting means required by this Code for motors and appliances, and each service, feeder, or branch circuit at the point where it originates, shall be legibly marked to indicate its purpose unless located and arranged so the purpose is evident. The marking shall be of sufficient durability to withstand the environment involved.

³ NFPA 70 National Electric Code, 1999 Edition, Article 110-26 Spaces About Electrical Equipment; 110-26. Spaces About Electrical Equipment; Sufficient access and working space shall be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment. Enclosures housing electrical apparatus that are controlled by lock and key shall be considered accessible to qualified persons.
(a) Working Space. Working space for equipment operating at 600 volts, nominal, or less to ground and likely to require examination, adjustment, servicing, or maintenance while energized shall comply with the dimensions of (1), (2), and (3) or as required or permitted elsewhere in this Code.
(1) Depth of Working Space. The depth of the working space in the direction of access to live parts shall not be less than indicated in Table 110-26(a). Distances shall be measured from the live parts if such are exposed or from the enclosure front or opening if such are enclosed.
Exception No. 1: Working space shall not be required in back or sides of assemblies, such as dead-front switchboards or motor control centers, where there are no renewable or adjustable parts, such as fuses or switches, on the back or sides and where all connections are accessible from locations other than the back or sides. Where rear access is required to work on de-energized parts on the back of enclosed equipment, a minimum working space of 30 in. (762 mm) horizontally shall be provided.
Exception No. 2: By special permission, smaller spaces shall be permitted where all uninsulated parts are at a voltage no greater than 30 volts rms, 42 volts peak, or 60 volts dc.
Exception No. 3: In existing buildings where electrical equipment is being replaced, Condition 2 working clearance shall be permitted between dead-front switchboards, panelboards, or motor control centers located across the aisle from each other where conditions of maintenance and supervision ensure that written procedures have been adopted to prohibit equipment on both sides of the aisle from being open at the same time and qualified persons who are authorized will service the installation.
Table 110-26(a). Working Spaces

Minimum Clear Distance (ft)
Nominal Voltage to Ground Condition 1 Condition 2 Condition 3
0-150 3 3 3
151-600 3 3 1/2 4

Notes:
1. For SI units, 1 ft = 0.3048 m.
2. Where the conditions are as follows:
Condition 1 - Exposed live parts on one side and no live or grounded parts on the other side of the working space, or exposed live parts on both sides effectively guarded by suitable wood or other insulating materials. Insulated wire or insulated busbars operating at not over 300 volts to ground shall not be considered live parts.
Condition 2 - Exposed live parts on one side and grounded parts on the other side. Concrete, brick, or tile walls shall be considered as grounded.
Condition 3 - Exposed live parts on both sides of the work space (not guarded as provided in Condition 1) with the operator between.