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K52 [Fire Alarm Systems]

Observation and discussion with the Director, Plant Engineering Services and the Master Electrician between 8:30 am and 12:15 pm on 10/20/2011 revealed that certain requirements stipulated in NFPA 72 were not met.

Fire Alarm Control Panel

Connections to the light and power service shall be on a dedicated branch circuit(s). The circuit(s) and service shall be mechanically protected. Circuit disconnecting means shall have a red marking, shall be accessible only to authorized personnel, and shall be identified as FIRE ALARM CIRCUIT CONTROL. The location of the circuit disconnecting means shall be permanently identified at the fire alarm control unit [Re: NFPA 72, National Fire Alarm Code, 1999: ? 1-5.2.5.2.]

Findings: The FACP, located in the electrical room near the generator did not meet this requirement. Components located in the electrical rooms in Unit 300 and Unit 400 also failed to meet this requirement. The facility shall ensure that this requirement is met with the main FACP and all booster panels as well throughout the facility. [Surveyor 18604.]

Observation and discussion with the Director, Plant Engineering Services and the Master Electrician between 8:30 am and 12:15 pm on 10/20/2011 revealed that certain requirements stipulated in NFPA 13 were not met.

Identification Tags

All control, drain, and test connection valves shall be provided with permanently marked weatherproof metal or rigid plastic identification signs. The sign shall be secured with corrosion-resistant wire, chain, or other approved means [Re: NFPA 13, Installation of Sprinkler Systems, 1999: ? 3-8.3.]

Findings: The risers were observed and the required tags were not installed as required. The facility shall ensure that this requirement is met with all valves throughout the facility. [Surveyor 18604.]

Observation and discussion with the Director, Plant Engineering Services and the Master Electrician between 8:30 am and 12:15 pm on 10/20/2011 revealed that certain requirements stipulated in NFPA 90A and the State Licensing Rules were not met. . [Surveyor 18604.]

a. Filter Certification

Air filters shall be rated either as Class 1 or Class 2 in accordance with UL 900, Standard for Safety Air Filter Units [Re: NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, 1999: ?2-2.2.2.]

Findings: The Class of the filters utilized for the units was not affirmed. The facility shall ensure that the filter class is appropriate.

Observation and discussion with the Director, Plant Engineering Services between 8:30 am and 12:15 pm on 9/20/2011 revealed that certain requirements stipulated in NFPA 99 were not met.

Preferred Customer Status

The Department requires Letters of Preference for critical resources to be retained by the Facility for two items: fuel and water [Re: NFPA 99, Health Care Facilities, 1999: ?11-5.3.2.]

Findings: The letter of preference for fuel was not available for review. [Surveyor 18604]

Observation and discussion with the Director, Plant Engineering Services and the Master Electrician between 8:30 am and 12:15 pm on 10/20/2011 revealed that certain requirements stipulated in NFPA 70 and 99 were not met.

a. Three Branches Defined

It was extremely difficult to determine where the three required branches were installed in various electrical configurations.

Findings: It was difficult to determine compliance with the requirements for the Type I essential electrical system as defined in NFPA 99: 3-4.2.2.2. The facility shall ensure that this situation is mitigated by complying with the following three deficiencies. [Surveyor 18604.]

b. Functional Allocation

Specific requirements exist identifying the functions as they must be allocated to the critical branch [NFPA 70, National Electrical Code, 2002, ?517.33], life safety branch [NFPA 70, National Electrical Code, 2002, ?517.32], and the equipment system [NFPA 70, National Electrical Code, 2002, ?517.34].

Findings: During the survey, it was noted that the loads circuited by panelboards throughout the facility did not meet the requirements. The facility shall ensure that only the proper loads are circuited from the appropriate panelboards. [Surveyor 18604.]

c. Component Labels

All boxes and enclosures (including transfer switches, transformers, distribution panels, and panelboards) for emergency circuits shall be permanently marked so they will be readily identified as a component of an emergency circuit or system [Re: NFPA 70, NEC, 2002: 700.9(A).]

Findings: The above listed components shall be labeled with the words " CRITICAL BRANCH " , " LIFE SAFETY BRANCH " or " EQUIPMENT BRANCH " to be readily identifiable as part of the Essential Electrical System. [Surveyor 18604.]

d. Circuit Directory

All circuits and circuit modifications shall be legibly identified as to purpose or use on a circuit directory located on the face or inside of the panel door in the case of a panelboard, and at each switch on a switchboard [Re: NFPA 70, National Electrical Code, 2002: ? 408.4.]

Findings: All circuit directories must be updated to be legible and meaningful. [Surveyor 18604.]

e. GenSet Amenities

No function other than those listed in (a) through (f) shall be connected to the life safety branch. The life safety branch of the emergency system shall supply power for the following lighting, receptacles, and equipment: ... ...(e) Generator Set Location. Task illumination battery charger for emergency battery-powered lighting unit(s) and selected receptacles at the generator set location [Re: NFPA 70, National Electrical Code, 1999: ?517-32(e).]

Findings: These amenities were not installed as required.

Observation and discussion with the Director, Plant Engineering Services and other staff personnel between 1 pm and 5:30 pm on 10/19/2011 revealed that certain requirements stipulated in NFPA 70 and the State Licensing Rules were not met.

a. Functional Allocation

Specific requirements exist identifying the functions as they must be allocated to the critical branch [NFPA 70, National Electrical Code, 2002, ?517.33], life safety branch [NFPA 70, National Electrical Code, 2002, ?517.32], and the equipment system [NFPA 70, National Electrical Code, 2002, ?517.34].

Findings: During the survey, it was noted that the loads circuited by panelboards throughout the facility did not meet this requirement. As an example, panelboard R1CPP1 provided power to loads commonly identified with different branches. Also panelboard LRE. The facility shall ensure that only the proper loads are circuited from the appropriate panelboards throughout the facility. [Surveyor 18604.]

b. Component Labels

All boxes and enclosures (including transfer switches, transformers, distribution panels, and panelboards) for emergency circuits shall be permanently marked so they will be readily identified as a component of an emergency circuit or system [Re: NFPA 70, NEC, 2002: 700.9(A).]

Findings: The above listed components shall be labeled with the words " CRITICAL BRANCH " , " LIFE SAFETY BRANCH " or " EQUIPMENT BRANCH " to be readily identifiable as part of the Essential Electrical System. [Surveyor 18604.]

c. Circuit Directory

All circuits and circuit modifications shall be legibly identified as to purpose or use on a circuit directory located on the face or inside of the panel door in the case of a panelboard, and at each switch on a switchboard [Re: NFPA 70, National Electrical Code, 2002: ? 408.4.]

Findings: All circuit directories must be updated to be legible and meaningful. [Surveyor 18604.]

d. Junction Box Cover

All pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use. Where metal covers are used, they shall comply with the grounding requirements of Section 250-110. An extension from the cover of an exposed box shall comply with Section 370-22, Exception [Re: NFPA 70, National Electrical Code, 1999: ? 370-28(d).]

Findings: A junction box was not covered above the lay in ceiling and double doors [2H11N] outside the laundry and gift shop. The facility shall install this cover and any others that are lacking. [Surveyor 1806.]


e. Normal Powered Receptacles

At least one receptacle at each patient treatment or procedure location shall be powered from the normal power panel [Re: 25 TAC HLR, 2007: ?133.162(d)(5)(H)(ii).]

Findings: The first floor CCU had no normal powered receptacles in the patient treatment locations. The facility shall devise plan to mitigate this deficiency. [Surveyor 18604.]

f. Red Receptacles Labeling

Emergency system receptacles at each patient bed location shall be identified and shall also indicate the panelboard and circuit number supplying them. [Re: NFPA 70, NEC, 2002: ? 517.19(a).]

Findings: Red receptacles without the required identifiers were noted in several locations. The facility shall devise a plan to mitigate this deficiency. [Surveyor 18604.]

K52 [Fire Alarm Systems]

Observation and discussion with the Director, Plant Engineering Services and the Master Electrician between 8:30 am and 12:15 pm on 10/20/2011 revealed that certain requirements stipulated in NFPA 72 were not met.

Fire Alarm Control Panel

Connections to the light and power service shall be on a dedicated branch circuit(s). The circuit(s) and service shall be mechanically protected. Circuit disconnecting means shall have a red marking, shall be accessible only to authorized personnel, and shall be identified as FIRE ALARM CIRCUIT CONTROL. The location of the circuit disconnecting means shall be permanently identified at the fire alarm control unit [Re: NFPA 72, National Fire Alarm Code, 1999: ? 1-5.2.5.2.]

Findings: The FACP, located in the electrical room near the generator did not meet this requirement. Components located in the electrical rooms in Unit 300 and Unit 400 also failed to meet this requirement. The facility shall ensure that this requirement is met with the main FACP and all booster panels as well throughout the facility. [Surveyor 18604.]

Observation and discussion with the Director, Plant Engineering Services and the Master Electrician between 8:30 am and 12:15 pm on 10/20/2011 revealed that certain requirements stipulated in NFPA 13 were not met.

Identification Tags

All control, drain, and test connection valves shall be provided with permanently marked weatherproof metal or rigid plastic identification signs. The sign shall be secured with corrosion-resistant wire, chain, or other approved means [Re: NFPA 13, Installation of Sprinkler Systems, 1999: ? 3-8.3.]

Findings: The risers were observed and the required tags were not installed as required. The facility shall ensure that this requirement is met with all valves throughout the facility. [Surveyor 18604.]

Observation and discussion with the Director, Plant Engineering Services and the Master Electrician between 8:30 am and 12:15 pm on 10/20/2011 revealed that certain requirements stipulated in NFPA 90A and the State Licensing Rules were not met. . [Surveyor 18604.]

a. Filter Certification

Air filters shall be rated either as Class 1 or Class 2 in accordance with UL 900, Standard for Safety Air Filter Units [Re: NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, 1999: ?2-2.2.2.]

Findings: The Class of the filters utilized for the units was not affirmed. The facility shall ensure that the filter class is appropriate.

Observation and discussion with the Director, Plant Engineering Services between 8:30 am and 12:15 pm on 9/20/2011 revealed that certain requirements stipulated in NFPA 99 were not met.

Preferred Customer Status

The Department requires Letters of Preference for critical resources to be retained by the Facility for two items: fuel and water [Re: NFPA 99, Health Care Facilities, 1999: ?11-5.3.2.]

Findings: The letter of preference for fuel was not available for review. [Surveyor 18604]

Observation and discussion with the Director, Plant Engineering Services and the Master Electrician between 8:30 am and 12:15 pm on 10/20/2011 revealed that certain requirements stipulated in NFPA 70 and 99 were not met.

a. Three Branches Defined

It was extremely difficult to determine where the three required branches were installed in various electrical configurations.

Findings: It was difficult to determine compliance with the requirements for the Type I essential electrical system as defined in NFPA 99: 3-4.2.2.2. The facility shall ensure that this situation is mitigated by complying with the following three deficiencies. [Surveyor 18604.]

b. Functional Allocation

Specific requirements exist identifying the functions as they must be allocated to the critical branch [NFPA 70, National Electrical Code, 2002, ?517.33], life safety branch [NFPA 70, National Electrical Code, 2002, ?517.32], and the equipment system [NFPA 70, National Electrical Code, 2002, ?517.34].

Findings: During the survey, it was noted that the loads circuited by panelboards throughout the facility did not meet the requirements. The facility shall ensure that only the proper loads are circuited from the appropriate panelboards. [Surveyor 18604.]

c. Component Labels

All boxes and enclosures (including transfer switches, transformers, distribution panels, and panelboards) for emergency circuits shall be permanently marked so they will be readily identified as a component of an emergency circuit or system [Re: NFPA 70, NEC, 2002: 700.9(A).]

Findings: The above listed components shall be labeled with the words " CRITICAL BRANCH " , " LIFE SAFETY BRANCH " or " EQUIPMENT BRANCH " to be readily identifiable as part of the Essential Electrical System. [Surveyor 18604.]

d. Circuit Directory

All circuits and circuit modifications shall be legibly identified as to purpose or use on a circuit directory located on the face or inside of the panel door in the case of a panelboard, and at each switch on a switchboard [Re: NFPA 70, National Electrical Code, 2002: ? 408.4.]

Findings: All circuit directories must be updated to be legible and meaningful. [Surveyor 18604.]

e. GenSet Amenities

No function other than those listed in (a) through (f) shall be connected to the life safety branch. The life safety branch of the emergency system shall supply power for the following lighting, receptacles, and equipment: ... ...(e) Generator Set Location. Task illumination battery charger for emergency battery-powered lighting unit(s) and selected receptacles at the generator set location [Re: NFPA 70, National Electrical Code, 1999: ?517-32(e).]

Findings: These amenities were not installed as required.

Observation and discussion with the Director, Plant Engineering Services and other staff personnel between 1 pm and 5:30 pm on 10/19/2011 revealed that certain requirements stipulated in NFPA 70 and the State Licensing Rules were not met.

a. Functional Allocation

Specific requirements exist identifying the functions as they must be allocated to the critical branch [NFPA 70, National Electrical Code, 2002, ?517.33], life safety branch [NFPA 70, National Electrical Code, 2002, ?517.32], and the equipment system [NFPA 70, National Electrical Code, 2002, ?517.34].

Findings: During the survey, it was noted that the loads circuited by panelboards throughout the facility did not meet this requirement. As an example, panelboard R1CPP1 provided power to loads commonly identified with different branches. Also panelboard LRE. The facility shall ensure that only the proper loads are circuited from the appropriate panelboards throughout the facility. [Surveyor 18604.]

b. Component Labels

All boxes and enclosures (including transfer switches, transformers, distribution panels, and panelboards) for emergency circuits shall be permanently marked so they will be readily identified as a component of an emergency circuit or system [Re: NFPA 70, NEC, 2002: 700.9(A).]

Findings: The above listed components shall be labeled with the words " CRITICAL BRANCH " , " LIFE SAFETY BRANCH " or " EQUIPMENT BRANCH " to be readily identifiable as part of the Essential Electrical System. [Surveyor 18604.]

c. Circuit Directory

All circuits and circuit modifications shall be legibly identified as to purpose or use on a circuit directory located on the face or inside of the panel door in the case of a panelboard, and at each switch on a switchboard [Re: NFPA 70, National Electrical Code, 2002: ? 408.4.]

Findings: All circuit directories must be updated to be legible and meaningful. [Surveyor 18604.]

d. Junction Box Cover

All pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use. Where metal covers are used, they shall comply with the grounding requirements of Section 250-110. An extension from the cover of an exposed box shall comply with Section 370-22, Exception [Re: NFPA 70, National Electrical Code, 1999: ? 370-28(d).]

Findings: A junction box was not covered above the lay in ceiling and double doors [2H11N] outside the laundry and gift shop. The facility shall install this cover and any others that are lacking. [Surveyor 1806.]


e. Normal Powered Receptacles

At least one receptacle at each patient treatment or procedure location shall be powered from the normal power panel [Re: 25 TAC HLR, 2007: ?133.162(d)(5)(H)(ii).]

Findings: The first floor CCU had no normal powered receptacles in the patient treatment locations. The facility shall devise plan to mitigate this deficiency. [Surveyor 18604.]

f. Red Receptacles Labeling

Emergency system receptacles at each patient bed location shall be identified and shall also indicate the panelboard and circuit number supplying them. [Re: NFPA 70, NEC, 2002: ? 517.19(a).]

Findings: Red receptacles without the required identifiers were noted in several locations. The facility shall devise a plan to mitigate this deficiency. [Surveyor 18604.]