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Based on observation the facility had improperly made opaque the windows in the smoke barrier doors.

Smoke barriers shall be constructed to provide at least a one-half hour fire resistance rating and constructed in accordance with 8.3. Smoke barriers shall be permitted to terminate at an atrium wall. Windows shall be protected by fire-rated glazing or by wired glass panels and steel frames. A minimum of two separate compartments shall be provided on each floor. Dampers shall not be required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air conditioning systems.19.3.7.3, 19.3.7.5, 19.1.6.3, 19.1.6.4

Based on observation the facility failed to adequately secure the medical gas tanks.

" Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over. " - NFPA 99, 1999: 4-3.1.1.1.

Based on observation the facility failed to provide documentation of Electrical Power Distribution and Grounding Systems testing reports.


Receptacle Testing in Patient Care Areas - NFFA 99, 1999, 3-3.3.3

(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).

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. Since data is not typically available from the manufacturer, the facility may document the failure rates of the receptacles and provide a testing schedule that will safeguard their patients. This shall be done by the Safety Committee, approved by the Governing Board, and written into the safety policies and procedures. H.L.R. 2007, §133.142. Until this assessment has been done, receptacle testing shall be performed in all general care areas every 12 months and in critical care areas every 6 months. (NFPA 99, 1984).

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

the facility was not conducting receptacle testing at all. The facility sited the 2012 edition of NFPA 99, 6.3.4.1.3 as justification for not doing the testing. This reference addresses non hospital grade receptacles and does not apply to this situation.

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Based on observation the facility was improperly using the electrical rooms for storage.

" 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)

" Dedicated Equipment Space: All switchboards, panelboards, distribution boards, and motor control centers shall be located in dedicated spaces and protected from damage. " - NFPA 70, 2002, 110.26(F)

Based on observation the facility failed to properly label the emergency receptacles.

Cover Plates: In critical care areas, emergency system receptacles must be labeled to indicate the panel board and circuit number supplying them in accordance with NFPA 70, 1999: 517-19(a). The identification label shall be permanent either by engraving the cover plates or permanent adhesive engraved laminated labels.

Based on observation the facility had improperly made opaque the windows in the smoke barrier doors.

Smoke barriers shall be constructed to provide at least a one-half hour fire resistance rating and constructed in accordance with 8.3. Smoke barriers shall be permitted to terminate at an atrium wall. Windows shall be protected by fire-rated glazing or by wired glass panels and steel frames. A minimum of two separate compartments shall be provided on each floor. Dampers shall not be required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air conditioning systems.19.3.7.3, 19.3.7.5, 19.1.6.3, 19.1.6.4

Based on observation the facility failed to adequately secure the medical gas tanks.

" Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over. " - NFPA 99, 1999: 4-3.1.1.1.

Based on observation the facility failed to provide documentation of Electrical Power Distribution and Grounding Systems testing reports.


Receptacle Testing in Patient Care Areas - NFFA 99, 1999, 3-3.3.3

(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).

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. Since data is not typically available from the manufacturer, the facility may document the failure rates of the receptacles and provide a testing schedule that will safeguard their patients. This shall be done by the Safety Committee, approved by the Governing Board, and written into the safety policies and procedures. H.L.R. 2007, §133.142. Until this assessment has been done, receptacle testing shall be performed in all general care areas every 12 months and in critical care areas every 6 months. (NFPA 99, 1984).

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

the facility was not conducting receptacle testing at all. The facility sited the 2012 edition of NFPA 99, 6.3.4.1.3 as justification for not doing the testing. This reference addresses non hospital grade receptacles and does not apply to this situation.

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Based on observation the facility was improperly using the electrical rooms for storage.

" 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)

" Dedicated Equipment Space: All switchboards, panelboards, distribution boards, and motor control centers shall be located in dedicated spaces and protected from damage. " - NFPA 70, 2002, 110.26(F)

Based on observation the facility failed to properly label the emergency receptacles.

Cover Plates: In critical care areas, emergency system receptacles must be labeled to indicate the panel board and circuit number supplying them in accordance with NFPA 70, 1999: 517-19(a). The identification label shall be permanent either by engraving the cover plates or permanent adhesive engraved laminated labels.