HospitalInspections.org

Repeat deficiency from the 2007 recertification survey.


The facility failed to provide a permitted construction type required by code. Findings include:

During the survey, the building construction type was observed to be Type II (000) with a partial automatic sprinkler and a corridor smoke detection system. The original plaster ceiling was observed not to be maintained throughout the building.

In 2007, the facility was granted a one year waiver to install the sprinkler system in the unsprinklered areas of the building. The wiaver expired in October 2008. The sprinkler installations were not made.

2000 NFPA 101, 19.1.6.2 Health care occupancies shall be limited to the types of building construction shown in Table 19.1.6.2. (See 8.2.1.)
Table 19.1.6.2 Construction Type Limitations
Construction Stories
Type
1 2 3 4 or
More
I(443) X X X X
I(332) X X X X
II(222) X X X X
II(111) X X* X* NP
II(000) X* X* NP NP
III(211) X* X* NP NP
III(200) X* NP NP NP
IV(2HH) X* X* NP NP
V(111) X* X* NP NP
V(000) X* NP NP NP
X: Permitted type of construction.
NP: Not permitted.
*Building requires automatic sprinkler protection. (See 19.3.5.1.)
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The facility failed to maintain the interior finish for exitways per code. Findings include:

During the survey, the unsprinklered Psychiatric Unit was observed with full height wood paneling on the corridor walls at the Nurse's Station and on the station itself. Per interview with the maintenance staff the interior finish classification was unknown.

2000 NFPA 101, 19.3.3.2 Interior wall and ceiling finish materials complying with 10.2.3 shall be permitted as follows:
(1) Existing materials - Class A or Class B
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The facility failed to provide corridor doors that would close and resist the passage of smoke. During the survey, the following are examples of what was observed in the non sprinklered portion of the building:

1. The corridor door to the Chapel failed to positive latch.
2. The door to the Manager Office which is located in the South Wing of the facility failed to positive latch.
3. The door to the Counselor Office, which is located in the South Wing of the facility, failed to positive latch.

NFPA 101, 19.3.6.3 In smoke compartments without a sprinkler system, doors in corridor walls shall be constructed to resist fire and the passage of smoke for at least twenty minutes.


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4. The Janitor's corridor door at Dining/B111 was not positive latching.
5. The Employees' Breakroom in the northwing, the corridor door was not positive latching.
6. The Janitor's corridor door in the northwing:
a. Did not have positive latching hardware
b. Had a hole in the door
7. Two sets of double doors on the corridor (closets used for storage) in the Psychriatric Office Area did not have astragals to resist the passage of smoke.

2000 NFPA 101, 19.3.6.3.1 Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 13/4-in. (4.4-cm) thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke. Compliance with NFPA 80, Standard for Fire Doors and Fire Windows, shall not be required. Clearance between the bottom of the door and the floor covering not exceeding 1 in. (2.5 cm) shall be permitted for corridor doors.
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Repeat deficiency from the 2007 recertification survey.



The facility failed to provide smoke barriers that would provide at least a half hour fire resistance rating. During the survey, the following are examples of what was observed:

A) In the non sprinklered areas of the building:

1. Unsealed penetrations around a group of wiring, in two separate locations, in the Smoke barrier, by Administration Business/Office.
2. Unsealed penetrations around a group of wiring, in two separate locations, in the Smoke Barrier, by Patient Room 120.


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3. The smoke barrier at the smoke doors by the Northwing Nurses' Station had several unsealed penetrations.

B) In areas with a sprinklered smoke compartment located adjacent to a non sprinklered compartment:

1. The smoke/fire barrier in the men's bathroom by Serving/B107:
a. Had unsealed penetrations
b. Was not sealed at the roof deck
2. The smoke/fire barrier in the corridor at the Janitor's Room/B114 had unsealed penetrations.
3. The smoke/fire barrier in the Dining Room side above the "Employees Only" door had an unsealed conduit and an unsealed penetration of a blue wire.
4. The smoke/fire barrier in the Northwing Employee Breakroom had an unsealed conduit.
5. The smoke/fire barrier outside of Labor and Delivery in the Northwing Chris's Storage, had an unsealed penetration.
6. The smoke/fire barrier in Labor and Delivery's Observation Room above the clock had two unsealed conduits.
7. The smoke/fire barrier in the bathroom in the Observation Room had unsealed penetrations and was not sealed at the roof deck on both the back and the right walls.

C) In the sprinklered areas of the building:

1. The smoke/fire barrier in the Outpatient Registration Office had unsealed conduit and penetration of a blue wire.

2000 NFPA 101, 8.3.2 Smoke barriers required by this Code shall be continuous from an outside wall to an outside wall, from a floor to a floor, or from a smoke barrier to a smoke barrier or a combination thereof. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces.
2000 NFPA 101, 8.3.6.1 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows: (1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions: a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke 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 smoke barrier, the sleeve shall be solidly set in the smoke 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 smoke resistance of the smoke barrier. b. It shall be protected by an approved device that is designed for the specific purpose. (3) 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 smoke barrier. b. It shall be made by an approved device that is designed for the specific purpose.

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Repeat deficiency from the 2007 recertification survey.



The facility failed to maintain the smoke doors per code. Findings include:

During the survey, the fire/smoke double doors at Labor and Delivery were observed with a gap greater than 1/8 inch between the meeting edges of the doors.

1999 NFPA 80,2-3.1.7 The clearance between the edge of the door on the pull side and the frame, and the meeting edges of doors swinging in pairs on the pull side shall be 1/8 in. ? 1/16 in. (3.18 mm ? 1.59 mm) for steel doors and shall not exceed 1/8 in. (3.18 mm) for wood doors.
2000 NFPA 101, 8.3.4.1 Doors in smoke barriers shall close the opening leaving only the minimum clearance necessary for proper operation and shall be without undercuts, louvers, or grilles.
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The facility failed to maintain separation of hazardous areas in the non sprinkered areas of the building. During the survey, the following are examples of what was observed:

1) Unsealed penetrations were observed, around a group of conduit, in the wall of the Storage Room, by the Lab.


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2) The Shred Room by the Dining Room approximately 70 sq. ft. was observed containing mostly combustible materials:
a. Did not have a self-closing device on the door
b. Had an unsealed penetration in the ceiling around the heat detector.

2000 NFPA 101, 19.3.2.1 Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing.

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The facility failed to provide continuous lighting for means of egress. During the survey, the following are examples of what was observed:

A) The Exit Discharge was observed to have single bulbed light fixture, at the following Exits:

1. The Exit for the South Wing.
2. The Exit located by Patient Room 120.

NFPA 101, 19.2.8 and 7.8.1.2 Illumination of means of egress shall be continuous.


B) The following Exit Discharge lighting was controlled by a switch:

1. The North Wing Exit.
2. The Exit by Endoscopy.

NFPA 101, 19.2.8 and 7.8.1.2 Illumination of means of egress shall be continuous.

Documentation was not provided during the survey, for the 30 second monthly, or 1.5 hour annual test of the Battery-Powered lights located in the Generator Set/Control Room.

NFPA 101, 7.9.3 A documented monthly test of battery-powered emergency lighting for at least 30 seconds, and an annual test for a duration of 1-1/2 hours, with equipment being fully operational for the duration of the test.

The facility failed to provide a complete evacuation plan per code. During the survey, the following is an example of what was observed:

The fire evacuation plan provided by the facility did not include the evacuation from an effected smoke compartment to an uneffected smoke compartment. The evacuation plan the facility provided was a complete evacuation plan.

2000 NFPA 101, 19.7.2.2 A written health care occupancy fire safety plan shall provide for the following:
(1) Use of alarms
(2) Transmission of alarm to fire department
(3) Response to alarms
(4) Isolation of fire
(5) Evacuation of immediate area
(6) Evacuation of smoke compartment
(7) Preparation of floors and building for evacuation
(8) Extinguishment of fire

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The facility failed to provide a complete evacuation plan per code. Findings include:

During the survey, the fire evacuation plan provided by the facility did not include the evacuation from an effected smoke compartment to an uneffected smoke compartment. The evacuation plan the facility provided was a complete evacuation plan.

2000 NFPA 101, 19.7.2.2 A written health care occupancy fire safety plan shall provide for the following:
(1) Use of alarms
(2) Transmission of alarm to fire department
(3) Response to alarms
(4) Isolation of fire
(5) Evacuation of immediate area
(6) Evacuation of smoke compartment
(7) Preparation of floors and building for evacuation
(8) Extinguishment of fire

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Repeat deficiency from the 2007 recertification survey.




The facility failed to conduct fire drills per code. During the survey, the following is an example of what was observed:

Based on interview and documentation, the facility has two shifts. The following is per documentation provided by the facility on fire drills for the year of 2010.

First Shift
No drill for the last quarter
No drill for the third quarter
06/10/10 - 1:00 pm
No drill for the first quarter

Second Shift
10/13/10 - 6:45 am - No signatures
No drill for the third quarter
No drill for the second quarter
01/31/10 - 2:00 am - Only two signatures

2000 NFPA 101, 19.7.1.2 Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
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Repeat deficiency from the 2007 recertification survey.



The facility failed to conduct fire drills per code. Findings include:

During the survey, per interview and documentation the facility has two shifts. The following documentation was provided by the facility for 2010 fire drills.

First Shift
No drill for the last quarter
No drill for the third quarter
06/10/10 - 1:00 pm
No drill for the first quarter

Second Shift
10/13/10 - 6:45 am - No signatures
No drill for the third quarter
No drill for the second quarter
01/31/10 - 2:00 am - Only two signatures

2000 NFPA 101, 19.7.1.2 Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
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The facility failed to perform the required maintenance of the facility sprinkler system. During the survey, the following are examples of what was observed:

A) The Fire Department Connection was obstructed by the AC Unit, connection is located by the Main Entrance of the facility.

NFPA 101,2000 Edition, 9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this code shall be inspected, tested, and maintained in accordance with NFPA 25, Standards for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

NFPA 25, 1998 Edition, 9-7.1 Fire department connections shall be inspected quarterly. The inspection shall verify the following:
(a) The fire department connections are visible and accessible.
(b) Couplings or swivels are not damaged and rotate smoothly.
(c) Plugs or caps are in place and undamaged.
(d) Gaskets are in place and in good condition.
(e) Identification signs are in place.
(f) The check valve is not leaking.
(g) The automatic drain valve is in place and operating properly.


B) Documentation provided by the facility, during the survey for the Quarterly Inspections of the Sprinkler Systems, failed to provide complete inspection reports. Based upon observation of documentation for inspection conducted on 2/18/2010 and 8/31/2010, only one of two sheets was provided.

NFPA 101, 4.6.12, and NFPA 25, 2-2 and Table 2-1 Requires an inspection every quarter (three months).


C) Documentation was not provided for the partial trip test, or the full flow trip test for the two dry risers.

NFPA 25,1998 Edition, 9-5.2.3 A partial flow trip test adequate to move the valve from its seat shall be conducted annually.
NFPA 25, 1998 Edition, 9-4.4.2.2.2 Every 3 years and whenever the system is altered, the dry pipe valve shall be trip tested with the control valve fully open and the quick-opening device, if provided, in service.

The facility failed to perform the required maintenance of the facility sprinkler system. During the survey, the following are examples of what was observed:

1) The Fire department Connection was obstructed by the AC Unit, connection is located by the Main Entrance of the facility.

NFPA 101,2000 Edition, 9.7.5 All automatic sprinkler and standpipe systems required by this code shall be inspected, tested, and maintained in accordance with NFPA 25, Standards for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

NFPA 25, 1998 Edition, 9-7.1 Fire department connections shall be inspected quarterly. The inspection shall verify the following:
(a) The fire department connections are visible and accessible.
(b) Couplings or swivels are not damaged and rotate smoothly.
(c) Plugs or caps are in place and undamaged.
(d) Gaskets are in place and in good condition.
(e) Identification signs are in place.
(f) The check valve is not leaking.
(g) The automatic drain valve is in place and operating properly.


2) Documentation provided by the facility during the survey for the Quarterly Inspections of the Sprinkler Systems, failed to provide complete inspection reports. Based upon observation of documentation, for inspection conducted on 2/18/2010, 8/31/2010, only one, of two sheets, were provided.

NFPA 101, 4.6.12, and NFPA 25, 2-2 and Table 2-1 Requires an inspection every quarter (three months).


3) Documentation was not provided for the partial trip test, or the full flow trip test for the two dry risers.

1998, NFPA 25, 9-5.2.3 A partial flow trip test adequate to move the valve from its seat shall be conducted annually.
1998, NFPA 25, 9-4.4.2.2.2 Every 3 years and whenever the system is altered, the dry pipe valve shall be trip tested with the control valve fully open and the quick-opening device, if provided, in service.

During the survey, this surveyor observed, in the Designated Smoking Area for the Psych Wing, trash cans (approximately seven) with paper bags used to line the inside of the cans. Discarded cigarette butts, and trash were observed in each can, a metal container for disposing of cigarette butts was not observed.

NFPA 101, 19.7.4 Ashtrays of noncombustible material and safe design, and metal self-closing containers for disposing of cigarette butts and ashes from ashtrays, shall be provided.

The facility failed to adequately perform testing and inspection of the dietary hood
extinguishment system. Findings include: During the survey, the following was observed:

A. Based upon observation of the documentation provided by the facility inspection of the Dietary Hood extinguishing system was conducted on 12/8/2009, 12/30/2010.

NFPA 17, 9-3 and 1998 NFPA 17a, 5-3 Require inspection and servicing at least every six months by properly trained and qualified persons.


The facility failed to maintain the dietary hood. Findings include:

B. The filters were not tight fitting or firmly held in place, approximately a half inch gap was between two of the filters.


NFPA 96, 3-2.3 Grease filters shall be listed and constructed of steel or listed equivalent material and shall be of rigid construction that will not distort or crush under normal operation, handling, and cleaning conditions. Filters shall be tight fitting and firmly held in place.


C. The provided documentation for the monthly inspection of the hood system was the inspection card attached to the pull station of the hood extinguishing system. This card was observed with space on the reverse side to date and initial each month an inspection was conducted by facility staff. This side of the inspection card was blank.

NFPA 17, 9-2.1- On a monthly basis, inspection shall be conducted in accordance with the manufacturer 's listed installation and maintenance manual or owner 's manual. As a minimum, this "quick check " or inspection shall include verification of the following:

(a) The extinguishing system is in its proper location.
(b) The manual actuators are unobstructed.
(c) The tamper indicators and seals are intact.
(d) The maintenance tag or certificate is in place.
(e) The system shows no physical damage or condition that might prevent operation.
(f) The pressure gauge(s), if provided, is in operable range.
(g) The nozzle blow-off caps, where provided, are intact and undamaged.
(h) Neither the protected equipment nor the hazard has been replaced, modified, or relocated.

The facility failed to maintain the curtains/draperies per code. Findings include:

During the survey, the facility could not provide flame resistant documentation on the curtains/draperies in the following nonsprinklered areas:
1. Patient Rooms in the Psychiatric Unit
2. The Bathroom at the Northwing Nurses' Station

2000 NFPA 101, 10.3.1 Where required by the applicable provisions of this Code, draperies, curtains, and other similar loosely hanging furnishings and decorations shall be flame resistant as demonstrated by testing in accordance with NFPA 701, Standard Methods of Fire Tests for Flame Propagation of Textiles and Films.

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The facility failed to provide proper storage of oxygen cylinders, and signage. During the survey, the following is an example of what was observed:

In the outside oxygen storage area, five unsecured oxygen cylinders were observed and signage for empty cylinders was not provided.


1999 NFPA 99, 8-3.1.11.2(g) Cylinders shall be secured from mechanical shock.


CGA G-4, 4.1.10, and 1999 NFPA 99, 4-3.5.2.2(b)2 and 4-5.5.2.2(b)2 Full and empty cylinders shall be stored separately with appropriate signage.

The facility failed to maintain the piped in medical gas system per code. During the survey, the following is an example of what was observed:

From documentation and interview, the last inspection on the piped medical gas system was 12/09/09. There were seven recommendations at this time. The facility could not provide documentation of repairs.

1999 NFPA 99, 4-3.5.2.3 Patient Gas Systems - Level 1.
(c) Maintenance programs in accordance with the manufacturers ' recommendations shall be established for the medical air compressor supply system as connected in each individual installation.

(g) A periodic testing procedure for nonflammable medical gas and related alarm systems shall be implemented.

(h) The test specified in 4-3.4.1.3(i) shall be conducted on the downstream portions of the medical gas piping system whenever a system is breached or whenever modifications are made or maintenance performed.

(i) * Periodic retesting of audible and visual alarm indicators shall be performed to determine that they are functioning properly, and records of the test shall be maintained until the next test.

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The facility failed to maintain the piped in medical gas system per code. Findings include:

During this 2/2/11 survey, documentation provided by the staff and based on interview, the last inspection on the piped medical gas system was 12/09/09. On the documentation provided, seven recommendations were noted on the report. The facility could not provide documentation of repairs.

1999 NFPA 99, 4-3.5.2.3 Patient Gas Systems - Level 1.
(c) Maintenance programs in accordance with the manufacturers' recommendations shall be established for the medical air compressor supply system as connected in each individual installation.

(g) A periodic testing procedure for nonflammable medical gas and related alarm systems shall be implemented.

(h) The test specified in 4-3.4.1.3(i) shall be conducted on the downstream portions of the medical gas piping system whenever a system is breached or whenever modifications are made or maintenance performed.

(i) * Periodic retesting of audible and visual alarm indicators shall be performed to determine that they are functioning properly, and records of the test shall be maintained until the next test.

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This is a repeat deficiency for the recertification survey in 2007.

The facility failed to provide a smoke venting system for the two windowless ORs per code. Findings include:

During the survey, the two windowless ORs (nonsprinklered) smoke venting system could not be verified. The two ORs were observed without smoke detectors in the rooms for a smoke venting system.

1999 NFPA 99, 5-4.1.2 Supply and exhaust systems for windowless anesthetizing locations shall be arranged to automatically vent smoke and products of combustion.
1999 NFPA 99, 5-4.1.3 Ventilating systems for anesthetizing locations shall be provided that automatically (a) prevent recirculation of smoke originating within the surgical suite and (b) prevent the circulation of smoke entering the system intake, without in either case interfering with the exhaust function of the system.
1999 NFPA 99, 5-4.1.4 The electric supply to the ventilating system shall be served by the equipment system of the essential electrical system specified in Chapter 3, "Electrical Systems."
1999 NFPA 99, 5-6.1.1 Ventilating and humidifying equipment for anesthetizing locations shall be kept in operable condition and be continually operating during surgical procedures (see A-5-4.1).

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Repeat deficiency from the 2007 recertification survey.




Facility failed to meet the requirements for the operation of the two generators. During the survey, the following are examples of what was observed:

Based upon observation and review of the documentation provided by the facility, the weekly inspections, and the 30 minutes load test for the Generators, were not being conducted. The documentation indicated the following:

A) Generator #1:
1. Load test was conducted on 4/15/2010, 5/21/2010, and 12/2010, 1/2011.
2. No weekly conducted on Third or Fourth week 6/2010.
3. No weekly conducted on Second, Third, or Fourth 8/2010.
4. No weekly conducted on Second, Third, or Fourth, 10/2010.
5. No weekly conducted First, Third, or Fourth, 11/2010.
6. No weekly conducted First, Second, 12/2010.
7. No weekly conducted for January 2011.

B) Generator #2:
1. Load test was conducted on 1/2010, 2/2010, 3/12/2010, 6/11/2010, 7/16/2010, 11/2010, and 1/2011.
2. No weekly conducted first 1/2010.
3. No weekly conducted Second, Third 3/2010.
4. No weekly conducted Third, Fourth 6/2010.
5. No weekly conducted Second, Third, Fourth 8/2010.
6. No weekly conducted First, Third 10/2010.
7. No weekly conducted First, Third, Fourth 11/2010.
8. No weekly conducted First, Second 12/2010.
9. No weekly conducted Third, Fourth 1/2011.

NFPA 101, 19.2.9.1, 7.9 and NFPA 110, 6-4.1 Weekly inspection of the generator.

NFPA 110, 6-3.4 A written record of inspections, tests, exercising, operation, and repairs shall be maintained.

Exercised under load for 30 minutes per month NFPA 99, 3.4.4.1, NFPA 110, 8.4.2.

Repeat deficiency from the 2007 recertification survey.




Facility failed to meet the requirements for the operation of the two generators. During the survey, following are examples of what was observed:

Based upon observation and review of the documentation provided by the facility, the weekly inspections, and the 30 minutes load test for the generators were not being conducted. The documentation indicated the following:

A) Generator #1:
1. Load test was conducted on 4/15/2010, 5/21/2010, and 12/2010, 1/2011.
2. No weekly conducted on Third or Fourth week 6/2010.
3. No weekly conducted on Second, Third, or Fourth 8/2010.
4. No weekly conducted on Second, Third, or Fourth 10/2010.
5. No weekly conducted First, Third, or Fourth 11/2010.
6. No weekly conducted First, Second 12/2010.
7. No weekly conducted for January 2011.

B) Generator #2:
1. Load test was conducted on 1/2010, 2/2010, 3/12/2010, 6/11/2010, 7/16/2010, 11/2010 and 1/2011.
2. No weekly conducted first 1/2010.
3. No weekly conducted Second, Third 3/2010.
4. No weekly conducted Third, Fourth 6/2010.
5. No weekly conducted Second, Third, Fourth 8/2010.
6. No weekly conducted First, Third 10/2010.
7. No weekly conducted First, Third, Fourth 11/2010.
8. No weekly conducted First, Second 12/2010.
9. No weekly conducted Third, Fourth 1/2011.

NFPA 101, 19.2.9.1, 7.9 and NFPA 110, 6-4.1 Weekly inspection of the generator.

NFPA 110, 6-3.4 A written record of inspections, tests, exercising, operation, and repairs shall be maintained.

Exercised under load for 30 minutes per month NFPA 99, 3.4.4.1, NFPA 110, 8.4.2.

Facility failed to maintain the Type 1 EES. During the survey, the following are examples of what was observed:

A) During the survey, based upon observation and interview with Maintenance, the two generators were not provided with remote annunciator panels.

1999 NFPA 99, 3-4.1.1.15 A remote annunciator, storage battery powered, shall be provided to operate outside of the Generating Room in a location readily observed by operating personnel at a regular work station (see NFPA 70, National Electrical Code, Section 700-12.) The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows:
(a) Individual visual signals shall indicate the following:
1. When the emergency or auxiliary power source is operating to supply power to load
2. When the battery charger is malfunctioning
(b) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following:
1. Low lubricating oil pressure
2. Low water temperature (below those required in 3-4.1.1.9)
3. Excessive water temperature
4. Low fuel - when the main fuel storage tank contains less than a 3-hour operating supply
5. Overcrank (failed to start)
6. Overspeed
Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions in 3-4.1.1.15(a) and (b) occur, but need not display these conditions individually. [110: 3-5.5.2]

B) At the time of the survey, the transfer switches were not identified in Generator Set Control Room for Generator One or Two.

NFPA 70, 110-22 Identification of Disconnecting Means:
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.

Facility failed to maintain the Type 1 EES. During the survey, the following are examples of what was observed:

A) During the survey, based upon observation and interview with Maintenance, the two generators were not provided with remote annunciator panels.

1999 NFPA 99, 3-4.1.1.15 A remote annunciator, storage battery powered, shall be provided to operate outside of the Generating Room in a location readily observed by operating personnel at a regular work station (see NFPA 70, National Electrical Code, Section 700-12.) The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows:
(a) Individual visual signals shall indicate the following:
1. When the emergency or auxiliary power source is operating to supply power to load
2. When the battery charger is malfunctioning
(b) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following:
1. Low lubricating oil pressure
2. Low water temperature (below those required in 3-4.1.1.9)
3. Excessive water temperature
4. Low fuel - when the main fuel storage tank contains less than a 3-hour operating supply
5. Overcrank (failed to start)
6. Overspeed
Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions in 3-4.1.1.15(a) and (b) occur, but need not display these conditions individually. [110: 3-5.5.2]

B) At the time of the survey, the transfer switches were not identified in the Generator Set Control Room for Generator One or Two.

NFPA 70, 110-22 Identification of Disconnecting Means:
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.

The facility failed to maintain the electrical system per code. During the survey, the following are examples of what was observed:

A) Two Junction Boxes missing covers in the Air Handling Room behind Surgery.
B) Junction Box missing cover in the Boiler Room.

1999 NFPA 70, 370-25 and 410-12. Each box in completed installations to have a cover, face plate, or fixture canopy.


C) Extension cord in use without overcurrent protection in the Boiler Room.

1999 NFA 70, Article 240-4, and HFCA Transmittal Notice 22-99 prohibit the use of extension cords without overcurrent protection.


D) Boxes stored within three feet of the electrical panels in the Storage Room by the Lab.

1999 NFPA 70, Table 110-26(a) A minimum clearance of 3 feet shall be maintained in front of electrical panels and equipment operating at less than 600 volts.


E) Refrigerator and Microwave plugged into an overcurrent protector in the Ultrasound Room.

Appliances, such as air conditioners and refrigerators, shall plug directly into a receptacle. 1999 NFPA 70, 400-7 and 400-8, and HCFA Transmittal Notice
22-99.


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F) During the survey, no electrical receptacles were indicated as emergency receptacles in the two ORs.

1999 NFPA 70, 517-33
(a) Receptacle Identification. The receptacles or the faceplates for receptacles supplied by the critical branch shall have a distinctive color or marking so as to be readily recognizable.

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The facility failed to provide a complete fire watch per code. Findings include:

During the survey, the fire watch documentation provided by the facility did not include notifying the state agency (authority having jurisdiction - AHJ).

2000 NFPA 101, 9.6.1.8 Where a required, fire alarm system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service.
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Repeat deficiency from the 2007 recertification survey.


The facility failed to provide a permitted construction type required by code. Findings include:

During the survey, the building construction type was observed to be Type II (000) with a partial automatic sprinkler and a corridor smoke detection system. The original plaster ceiling was observed not to be maintained throughout the building.

In 2007, the facility was granted a one year waiver to install the sprinkler system in the unsprinklered areas of the building. The wiaver expired in October 2008. The sprinkler installations were not made.

2000 NFPA 101, 19.1.6.2 Health care occupancies shall be limited to the types of building construction shown in Table 19.1.6.2. (See 8.2.1.)
Table 19.1.6.2 Construction Type Limitations
Construction Stories
Type
1 2 3 4 or
More
I(443) X X X X
I(332) X X X X
II(222) X X X X
II(111) X X* X* NP
II(000) X* X* NP NP
III(211) X* X* NP NP
III(200) X* NP NP NP
IV(2HH) X* X* NP NP
V(111) X* X* NP NP
V(000) X* NP NP NP
X: Permitted type of construction.
NP: Not permitted.
*Building requires automatic sprinkler protection. (See 19.3.5.1.)
.

The facility failed to maintain the interior finish for exitways per code. Findings include:

During the survey, the unsprinklered Psychiatric Unit was observed with full height wood paneling on the corridor walls at the Nurse's Station and on the station itself. Per interview with the maintenance staff the interior finish classification was unknown.

2000 NFPA 101, 19.3.3.2 Interior wall and ceiling finish materials complying with 10.2.3 shall be permitted as follows:
(1) Existing materials - Class A or Class B
.

The facility failed to provide corridor doors that would close and resist the passage of smoke. During the survey, the following are examples of what was observed in the non sprinklered portion of the building:

1. The corridor door to the Chapel failed to positive latch.
2. The door to the Manager Office which is located in the South Wing of the facility failed to positive latch.
3. The door to the Counselor Office, which is located in the South Wing of the facility, failed to positive latch.

NFPA 101, 19.3.6.3 In smoke compartments without a sprinkler system, doors in corridor walls shall be constructed to resist fire and the passage of smoke for at least twenty minutes.


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4. The Janitor's corridor door at Dining/B111 was not positive latching.
5. The Employees' Breakroom in the northwing, the corridor door was not positive latching.
6. The Janitor's corridor door in the northwing:
a. Did not have positive latching hardware
b. Had a hole in the door
7. Two sets of double doors on the corridor (closets used for storage) in the Psychriatric Office Area did not have astragals to resist the passage of smoke.

2000 NFPA 101, 19.3.6.3.1 Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 13/4-in. (4.4-cm) thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke. Compliance with NFPA 80, Standard for Fire Doors and Fire Windows, shall not be required. Clearance between the bottom of the door and the floor covering not exceeding 1 in. (2.5 cm) shall be permitted for corridor doors.
.

Repeat deficiency from the 2007 recertification survey.



The facility failed to provide smoke barriers that would provide at least a half hour fire resistance rating. During the survey, the following are examples of what was observed:

A) In the non sprinklered areas of the building:

1. Unsealed penetrations around a group of wiring, in two separate locations, in the Smoke barrier, by Administration Business/Office.
2. Unsealed penetrations around a group of wiring, in two separate locations, in the Smoke Barrier, by Patient Room 120.


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3. The smoke barrier at the smoke doors by the Northwing Nurses' Station had several unsealed penetrations.

B) In areas with a sprinklered smoke compartment located adjacent to a non sprinklered compartment:

1. The smoke/fire barrier in the men's bathroom by Serving/B107:
a. Had unsealed penetrations
b. Was not sealed at the roof deck
2. The smoke/fire barrier in the corridor at the Janitor's Room/B114 had unsealed penetrations.
3. The smoke/fire barrier in the Dining Room side above the "Employees Only" door had an unsealed conduit and an unsealed penetration of a blue wire.
4. The smoke/fire barrier in the Northwing Employee Breakroom had an unsealed conduit.
5. The smoke/fire barrier outside of Labor and Delivery in the Northwing Chris's Storage, had an unsealed penetration.
6. The smoke/fire barrier in Labor and Delivery's Observation Room above the clock had two unsealed conduits.
7. The smoke/fire barrier in the bathroom in the Observation Room had unsealed penetrations and was not sealed at the roof deck on both the back and the right walls.

C) In the sprinklered areas of the building:

1. The smoke/fire barrier in the Outpatient Registration Office had unsealed conduit and penetration of a blue wire.

2000 NFPA 101, 8.3.2 Smoke barriers required by this Code shall be continuous from an outside wall to an outside wall, from a floor to a floor, or from a smoke barrier to a smoke barrier or a combination thereof. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces.
2000 NFPA 101, 8.3.6.1 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows: (1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions: a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke 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 smoke barrier, the sleeve shall be solidly set in the smoke 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 smoke resistance of the smoke barrier. b. It shall be protected by an approved device that is designed for the specific purpose. (3) 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 smoke barrier. b. It shall be made by an approved device that is designed for the specific purpose.

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Repeat deficiency from the 2007 recertification survey.



The facility failed to maintain the smoke doors per code. Findings include:

During the survey, the fire/smoke double doors at Labor and Delivery were observed with a gap greater than 1/8 inch between the meeting edges of the doors.

1999 NFPA 80,2-3.1.7 The clearance between the edge of the door on the pull side and the frame, and the meeting edges of doors swinging in pairs on the pull side shall be 1/8 in. ? 1/16 in. (3.18 mm ? 1.59 mm) for steel doors and shall not exceed 1/8 in. (3.18 mm) for wood doors.
2000 NFPA 101, 8.3.4.1 Doors in smoke barriers shall close the opening leaving only the minimum clearance necessary for proper operation and shall be without undercuts, louvers, or grilles.
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The facility failed to maintain separation of hazardous areas in the non sprinkered areas of the building. During the survey, the following are examples of what was observed:

1) Unsealed penetrations were observed, around a group of conduit, in the wall of the Storage Room, by the Lab.


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2) The Shred Room by the Dining Room approximately 70 sq. ft. was observed containing mostly combustible materials:
a. Did not have a self-closing device on the door
b. Had an unsealed penetration in the ceiling around the heat detector.

2000 NFPA 101, 19.3.2.1 Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing.

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The facility failed to provide continuous lighting for means of egress. During the survey, the following are examples of what was observed:

A) The Exit Discharge was observed to have single bulbed light fixture, at the following Exits:

1. The Exit for the South Wing.
2. The Exit located by Patient Room 120.

NFPA 101, 19.2.8 and 7.8.1.2 Illumination of means of egress shall be continuous.


B) The following Exit Discharge lighting was controlled by a switch:

1. The North Wing Exit.
2. The Exit by Endoscopy.

NFPA 101, 19.2.8 and 7.8.1.2 Illumination of means of egress shall be continuous.

Documentation was not provided during the survey, for the 30 second monthly, or 1.5 hour annual test of the Battery-Powered lights located in the Generator Set/Control Room.

NFPA 101, 7.9.3 A documented monthly test of battery-powered emergency lighting for at least 30 seconds, and an annual test for a duration of 1-1/2 hours, with equipment being fully operational for the duration of the test.

The facility failed to provide a complete evacuation plan per code. During the survey, the following is an example of what was observed:

The fire evacuation plan provided by the facility did not include the evacuation from an effected smoke compartment to an uneffected smoke compartment. The evacuation plan the facility provided was a complete evacuation plan.

2000 NFPA 101, 19.7.2.2 A written health care occupancy fire safety plan shall provide for the following:
(1) Use of alarms
(2) Transmission of alarm to fire department
(3) Response to alarms
(4) Isolation of fire
(5) Evacuation of immediate area
(6) Evacuation of smoke compartment
(7) Preparation of floors and building for evacuation
(8) Extinguishment of fire

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The facility failed to provide a complete evacuation plan per code. Findings include:

During the survey, the fire evacuation plan provided by the facility did not include the evacuation from an effected smoke compartment to an uneffected smoke compartment. The evacuation plan the facility provided was a complete evacuation plan.

2000 NFPA 101, 19.7.2.2 A written health care occupancy fire safety plan shall provide for the following:
(1) Use of alarms
(2) Transmission of alarm to fire department
(3) Response to alarms
(4) Isolation of fire
(5) Evacuation of immediate area
(6) Evacuation of smoke compartment
(7) Preparation of floors and building for evacuation
(8) Extinguishment of fire

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Repeat deficiency from the 2007 recertification survey.




The facility failed to conduct fire drills per code. During the survey, the following is an example of what was observed:

Based on interview and documentation, the facility has two shifts. The following is per documentation provided by the facility on fire drills for the year of 2010.

First Shift
No drill for the last quarter
No drill for the third quarter
06/10/10 - 1:00 pm
No drill for the first quarter

Second Shift
10/13/10 - 6:45 am - No signatures
No drill for the third quarter
No drill for the second quarter
01/31/10 - 2:00 am - Only two signatures

2000 NFPA 101, 19.7.1.2 Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
.

Repeat deficiency from the 2007 recertification survey.



The facility failed to conduct fire drills per code. Findings include:

During the survey, per interview and documentation the facility has two shifts. The following documentation was provided by the facility for 2010 fire drills.

First Shift
No drill for the last quarter
No drill for the third quarter
06/10/10 - 1:00 pm
No drill for the first quarter

Second Shift
10/13/10 - 6:45 am - No signatures
No drill for the third quarter
No drill for the second quarter
01/31/10 - 2:00 am - Only two signatures

2000 NFPA 101, 19.7.1.2 Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
.

The facility failed to perform the required maintenance of the facility sprinkler system. During the survey, the following are examples of what was observed:

A) The Fire Department Connection was obstructed by the AC Unit, connection is located by the Main Entrance of the facility.

NFPA 101,2000 Edition, 9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this code shall be inspected, tested, and maintained in accordance with NFPA 25, Standards for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

NFPA 25, 1998 Edition, 9-7.1 Fire department connections shall be inspected quarterly. The inspection shall verify the following:
(a) The fire department connections are visible and accessible.
(b) Couplings or swivels are not damaged and rotate smoothly.
(c) Plugs or caps are in place and undamaged.
(d) Gaskets are in place and in good condition.
(e) Identification signs are in place.
(f) The check valve is not leaking.
(g) The automatic drain valve is in place and operating properly.


B) Documentation provided by the facility, during the survey for the Quarterly Inspections of the Sprinkler Systems, failed to provide complete inspection reports. Based upon observation of documentation for inspection conducted on 2/18/2010 and 8/31/2010, only one of two sheets was provided.

NFPA 101, 4.6.12, and NFPA 25, 2-2 and Table 2-1 Requires an inspection every quarter (three months).


C) Documentation was not provided for the partial trip test, or the full flow trip test for the two dry risers.

NFPA 25,1998 Edition, 9-5.2.3 A partial flow trip test adequate to move the valve from its seat shall be conducted annually.
NFPA 25, 1998 Edition, 9-4.4.2.2.2 Every 3 years and whenever the system is altered, the dry pipe valve shall be trip tested with the control valve fully open and the quick-opening device, if provided, in service.

The facility failed to perform the required maintenance of the facility sprinkler system. During the survey, the following are examples of what was observed:

1) The Fire department Connection was obstructed by the AC Unit, connection is located by the Main Entrance of the facility.

NFPA 101,2000 Edition, 9.7.5 All automatic sprinkler and standpipe systems required by this code shall be inspected, tested, and maintained in accordance with NFPA 25, Standards for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

NFPA 25, 1998 Edition, 9-7.1 Fire department connections shall be inspected quarterly. The inspection shall verify the following:
(a) The fire department connections are visible and accessible.
(b) Couplings or swivels are not damaged and rotate smoothly.
(c) Plugs or caps are in place and undamaged.
(d) Gaskets are in place and in good condition.
(e) Identification signs are in place.
(f) The check valve is not leaking.
(g) The automatic drain valve is in place and operating properly.


2) Documentation provided by the facility during the survey for the Quarterly Inspections of the Sprinkler Systems, failed to provide complete inspection reports. Based upon observation of documentation, for inspection conducted on 2/18/2010, 8/31/2010, only one, of two sheets, were provided.

NFPA 101, 4.6.12, and NFPA 25, 2-2 and Table 2-1 Requires an inspection every quarter (three months).


3) Documentation was not provided for the partial trip test, or the full flow trip test for the two dry risers.

1998, NFPA 25, 9-5.2.3 A partial flow trip test adequate to move the valve from its seat shall be conducted annually.
1998, NFPA 25, 9-4.4.2.2.2 Every 3 years and whenever the system is altered, the dry pipe valve shall be trip tested with the control valve fully open and the quick-opening device, if provided, in service.

During the survey, this surveyor observed, in the Designated Smoking Area for the Psych Wing, trash cans (approximately seven) with paper bags used to line the inside of the cans. Discarded cigarette butts, and trash were observed in each can, a metal container for disposing of cigarette butts was not observed.

NFPA 101, 19.7.4 Ashtrays of noncombustible material and safe design, and metal self-closing containers for disposing of cigarette butts and ashes from ashtrays, shall be provided.

The facility failed to adequately perform testing and inspection of the dietary hood
extinguishment system. Findings include: During the survey, the following was observed:

A. Based upon observation of the documentation provided by the facility inspection of the Dietary Hood extinguishing system was conducted on 12/8/2009, 12/30/2010.

NFPA 17, 9-3 and 1998 NFPA 17a, 5-3 Require inspection and servicing at least every six months by properly trained and qualified persons.


The facility failed to maintain the dietary hood. Findings include:

B. The filters were not tight fitting or firmly held in place, approximately a half inch gap was between two of the filters.


NFPA 96, 3-2.3 Grease filters shall be listed and constructed of steel or listed equivalent material and shall be of rigid construction that will not distort or crush under normal operation, handling, and cleaning conditions. Filters shall be tight fitting and firmly held in place.


C. The provided documentation for the monthly inspection of the hood system was the inspection card attached to the pull station of the hood extinguishing system. This card was observed with space on the reverse side to date and initial each month an inspection was conducted by facility staff. This side of the inspection card was blank.

NFPA 17, 9-2.1- On a monthly basis, inspection shall be conducted in accordance with the manufacturer 's listed installation and maintenance manual or owner 's manual. As a minimum, this "quick check " or inspection shall include verification of the following:

(a) The extinguishing system is in its proper location.
(b) The manual actuators are unobstructed.
(c) The tamper indicators and seals are intact.
(d) The maintenance tag or certificate is in place.
(e) The system shows no physical damage or condition that might prevent operation.
(f) The pressure gauge(s), if provided, is in operable range.
(g) The nozzle blow-off caps, where provided, are intact and undamaged.
(h) Neither the protected equipment nor the hazard has been replaced, modified, or relocated.

The facility failed to maintain the curtains/draperies per code. Findings include:

During the survey, the facility could not provide flame resistant documentation on the curtains/draperies in the following nonsprinklered areas:
1. Patient Rooms in the Psychiatric Unit
2. The Bathroom at the Northwing Nurses' Station

2000 NFPA 101, 10.3.1 Where required by the applicable provisions of this Code, draperies, curtains, and other similar loosely hanging furnishings and decorations shall be flame resistant as demonstrated by testing in accordance with NFPA 701, Standard Methods of Fire Tests for Flame Propagation of Textiles and Films.

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The facility failed to provide proper storage of oxygen cylinders, and signage. During the survey, the following is an example of what was observed:

In the outside oxygen storage area, five unsecured oxygen cylinders were observed and signage for empty cylinders was not provided.


1999 NFPA 99, 8-3.1.11.2(g) Cylinders shall be secured from mechanical shock.


CGA G-4, 4.1.10, and 1999 NFPA 99, 4-3.5.2.2(b)2 and 4-5.5.2.2(b)2 Full and empty cylinders shall be stored separately with appropriate signage.

The facility failed to maintain the piped in medical gas system per code. During the survey, the following is an example of what was observed:

From documentation and interview, the last inspection on the piped medical gas system was 12/09/09. There were seven recommendations at this time. The facility could not provide documentation of repairs.

1999 NFPA 99, 4-3.5.2.3 Patient Gas Systems - Level 1.
(c) Maintenance programs in accordance with the manufacturers ' recommendations shall be established for the medical air compressor supply system as connected in each individual installation.

(g) A periodic testing procedure for nonflammable medical gas and related alarm systems shall be implemented.

(h) The test specified in 4-3.4.1.3(i) shall be conducted on the downstream portions of the medical gas piping system whenever a system is breached or whenever modifications are made or maintenance performed.

(i) * Periodic retesting of audible and visual alarm indicators shall be performed to determine that they are functioning properly, and records of the test shall be maintained until the next test.

.

The facility failed to maintain the piped in medical gas system per code. Findings include:

During this 2/2/11 survey, documentation provided by the staff and based on interview, the last inspection on the piped medical gas system was 12/09/09. On the documentation provided, seven recommendations were noted on the report. The facility could not provide documentation of repairs.

1999 NFPA 99, 4-3.5.2.3 Patient Gas Systems - Level 1.
(c) Maintenance programs in accordance with the manufacturers' recommendations shall be established for the medical air compressor supply system as connected in each individual installation.

(g) A periodic testing procedure for nonflammable medical gas and related alarm systems shall be implemented.

(h) The test specified in 4-3.4.1.3(i) shall be conducted on the downstream portions of the medical gas piping system whenever a system is breached or whenever modifications are made or maintenance performed.

(i) * Periodic retesting of audible and visual alarm indicators shall be performed to determine that they are functioning properly, and records of the test shall be maintained until the next test.

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This is a repeat deficiency for the recertification survey in 2007.

The facility failed to provide a smoke venting system for the two windowless ORs per code. Findings include:

During the survey, the two windowless ORs (nonsprinklered) smoke venting system could not be verified. The two ORs were observed without smoke detectors in the rooms for a smoke venting system.

1999 NFPA 99, 5-4.1.2 Supply and exhaust systems for windowless anesthetizing locations shall be arranged to automatically vent smoke and products of combustion.
1999 NFPA 99, 5-4.1.3 Ventilating systems for anesthetizing locations shall be provided that automatically (a) prevent recirculation of smoke originating within the surgical suite and (b) prevent the circulation of smoke entering the system intake, without in either case interfering with the exhaust function of the system.
1999 NFPA 99, 5-4.1.4 The electric supply to the ventilating system shall be served by the equipment system of the essential electrical system specified in Chapter 3, "Electrical Systems."
1999 NFPA 99, 5-6.1.1 Ventilating and humidifying equipment for anesthetizing locations shall be kept in operable condition and be continually operating during surgical procedures (see A-5-4.1).

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During the survey, the Battery-Powered Light in the Generator Set/Control Room was observed to be inoperable.

1999 NFPA 99, 3-6.1.1 and 3-4.1.1.4, and 1999 NFPA 110, 5-3.1 The Level 1 or Level 2 EPS equipment location shall be provided with battery-powered emergency lighting.

Repeat deficiency from the 2007 recertification survey.




Facility failed to meet the requirements for the operation of the two generators. During the survey, the following are examples of what was observed:

Based upon observation and review of the documentation provided by the facility, the weekly inspections, and the 30 minutes load test for the Generators, were not being conducted. The documentation indicated the following:

A) Generator #1:
1. Load test was conducted on 4/15/2010, 5/21/2010, and 12/2010, 1/2011.
2. No weekly conducted on Third or Fourth week 6/2010.
3. No weekly conducted on Second, Third, or Fourth 8/2010.
4. No weekly conducted on Second, Third, or Fourth, 10/2010.
5. No weekly conducted First, Third, or Fourth, 11/2010.
6. No weekly conducted First, Second, 12/2010.
7. No weekly conducted for January 2011.

B) Generator #2:
1. Load test was conducted on 1/2010, 2/2010, 3/12/2010, 6/11/2010, 7/16/2010, 11/2010, and 1/2011.
2. No weekly conducted first 1/2010.
3. No weekly conducted Second, Third 3/2010.
4. No weekly conducted Third, Fourth 6/2010.
5. No weekly conducted Second, Third, Fourth 8/2010.
6. No weekly conducted First, Third 10/2010.
7. No weekly conducted First, Third, Fourth 11/2010.
8. No weekly conducted First, Second 12/2010.
9. No weekly conducted Third, Fourth 1/2011.

NFPA 101, 19.2.9.1, 7.9 and NFPA 110, 6-4.1 Weekly inspection of the generator.

NFPA 110, 6-3.4 A written record of inspections, tests, exercising, operation, and repairs shall be maintained.

Exercised under load for 30 minutes per month NFPA 99, 3.4.4.1, NFPA 110, 8.4.2.

Repeat deficiency from the 2007 recertification survey.




Facility failed to meet the requirements for the operation of the two generators. During the survey, following are examples of what was observed:

Based upon observation and review of the documentation provided by the facility, the weekly inspections, and the 30 minutes load test for the generators were not being conducted. The documentation indicated the following:

A) Generator #1:
1. Load test was conducted on 4/15/2010, 5/21/2010, and 12/2010, 1/2011.
2. No weekly conducted on Third or Fourth week 6/2010.
3. No weekly conducted on Second, Third, or Fourth 8/2010.
4. No weekly conducted on Second, Third, or Fourth 10/2010.
5. No weekly conducted First, Third, or Fourth 11/2010.
6. No weekly conducted First, Second 12/2010.
7. No weekly conducted for January 2011.

B) Generator #2:
1. Load test was conducted on 1/2010, 2/2010, 3/12/2010, 6/11/2010, 7/16/2010, 11/2010 and 1/2011.
2. No weekly conducted first 1/2010.
3. No weekly conducted Second, Third 3/2010.
4. No weekly conducted Third, Fourth 6/2010.
5. No weekly conducted Second, Third, Fourth 8/2010.
6. No weekly conducted First, Third 10/2010.
7. No weekly conducted First, Third, Fourth 11/2010.
8. No weekly conducted First, Second 12/2010.
9. No weekly conducted Third, Fourth 1/2011.

NFPA 101, 19.2.9.1, 7.9 and NFPA 110, 6-4.1 Weekly inspection of the generator.

NFPA 110, 6-3.4 A written record of inspections, tests, exercising, operation, and repairs shall be maintained.

Exercised under load for 30 minutes per month NFPA 99, 3.4.4.1, NFPA 110, 8.4.2.

Facility failed to maintain the Type 1 EES. During the survey, the following are examples of what was observed:

A) During the survey, based upon observation and interview with Maintenance, the two generators were not provided with remote annunciator panels.

1999 NFPA 99, 3-4.1.1.15 A remote annunciator, storage battery powered, shall be provided to operate outside of the Generating Room in a location readily observed by operating personnel at a regular work station (see NFPA 70, National Electrical Code, Section 700-12.) The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows:
(a) Individual visual signals shall indicate the following:
1. When the emergency or auxiliary power source is operating to supply power to load
2. When the battery charger is malfunctioning
(b) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following:
1. Low lubricating oil pressure
2. Low water temperature (below those required in 3-4.1.1.9)
3. Excessive water temperature
4. Low fuel - when the main fuel storage tank contains less than a 3-hour operating supply
5. Overcrank (failed to start)
6. Overspeed
Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions in 3-4.1.1.15(a) and (b) occur, but need not display these conditions individually. [110: 3-5.5.2]

B) At the time of the survey, the transfer switches were not identified in Generator Set Control Room for Generator One or Two.

NFPA 70, 110-22 Identification of Disconnecting Means:
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.

Facility failed to maintain the Type 1 EES. During the survey, the following are examples of what was observed:

A) During the survey, based upon observation and interview with Maintenance, the two generators were not provided with remote annunciator panels.

1999 NFPA 99, 3-4.1.1.15 A remote annunciator, storage battery powered, shall be provided to operate outside of the Generating Room in a location readily observed by operating personnel at a regular work station (see NFPA 70, National Electrical Code, Section 700-12.) The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows:
(a) Individual visual signals shall indicate the following:
1. When the emergency or auxiliary power source is operating to supply power to load
2. When the battery charger is malfunctioning
(b) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following:
1. Low lubricating oil pressure
2. Low water temperature (below those required in 3-4.1.1.9)
3. Excessive water temperature
4. Low fuel - when the main fuel storage tank contains less than a 3-hour operating supply
5. Overcrank (failed to start)
6. Overspeed
Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions in 3-4.1.1.15(a) and (b) occur, but need not display these conditions individually. [110: 3-5.5.2]

B) At the time of the survey, the transfer switches were not identified in the Generator Set Control Room for Generator One or Two.

NFPA 70, 110-22 Identification of Disconnecting Means:
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.

The facility failed to maintain the electrical system per code. During the survey, the following are examples of what was observed:

A) Two Junction Boxes missing covers in the Air Handling Room behind Surgery.
B) Junction Box missing cover in the Boiler Room.

1999 NFPA 70, 370-25 and 410-12. Each box in completed installations to have a cover, face plate, or fixture canopy.


C) Extension cord in use without overcurrent protection in the Boiler Room.

1999 NFA 70, Article 240-4, and HFCA Transmittal Notice 22-99 prohibit the use of extension cords without overcurrent protection.


D) Boxes stored within three feet of the electrical panels in the Storage Room by the Lab.

1999 NFPA 70, Table 110-26(a) A minimum clearance of 3 feet shall be maintained in front of electrical panels and equipment operating at less than 600 volts.


E) Refrigerator and Microwave plugged into an overcurrent protector in the Ultrasound Room.

Appliances, such as air conditioners and refrigerators, shall plug directly into a receptacle. 1999 NFPA 70, 400-7 and 400-8, and HCFA Transmittal Notice
22-99.


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F) During the survey, no electrical receptacles were indicated as emergency receptacles in the two ORs.

1999 NFPA 70, 517-33
(a) Receptacle Identification. The receptacles or the faceplates for receptacles supplied by the critical branch shall have a distinctive color or marking so as to be readily recognizable.

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The facility failed to provide a complete fire watch per code. Findings include:

During the survey, the fire watch documentation provided by the facility did not include notifying the state agency (authority having jurisdiction - AHJ).

2000 NFPA 101, 9.6.1.8 Where a required, fire alarm system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service.
.

The facility failed to provide a complete fire watch per code. Findings include:

During the survey, the fire watch documentation provided by the facility did not include notifying the state agency (authority having jurisdiction - AHJ).

2000 NFPA 101, 9.6.1.8 Where a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service.
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