HospitalInspections.org

Fire Drill Records

Findings:
The inspector observed, while accompanied by the CEO and Maintenance Director, during the hours of the inspection from 2:45 PM to 5:00 PM on 07/13/2016 that there were the following issues:

A) Based on an interview with staff the facility failed to conduct fire drill with confirmation of transmission of fire alarm signal.

The Standard:
Fire drills in ambulatory health care facilities shall include the transmission of fire alarm signal and simulation of emergency fire conditions. - NFPA 101, Life Safety Code. U.S.A.: NFPA; 2003: 20.7.1.4

Receptacle Testing in Patient Care Areas

Findings:
The inspector observed, while accompanied by the CEO and Maintenance Director, during the hours of the inspection from 2:45 PM to 5:00 PM on 07/13/2016 that there were the following issues:

1) Based on observation the facility failed to provide records of documentation of receptacle testing in patient care areas for the last three years, in order to ensure that there was no lapse in regular safety preventative maintenance. Facility is to maintain a history of records for receptacle testing per NFPA 99: 3-3.3.3. in patient care areas dating back from the present at least 3 years which includes performance data (such as impedance, ground potentials, retention force of the grounding blade of each electrical receptacle).

The Standard:
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).

Testing Intervals. (a) The facility shall establish policies and protocols for the type of test and intervals of testing for each appliance. (b) All appliances used in patient care areas shall be tested in accordance with 7-5.1.3 or 7-5.2.2.1 before being put into service for the first time and after repair or modification. Patient-care-related electrical appliances shall be retested at intervals determined by their normal location or area of normal use, but not exceeding the intervals listed below: General care areas - 12 months; critical care areas - 6 months; wet locations - 6 months. - NFPA 99, 1999, 7-6.2.1.2

Fire Drill Records

Findings:
The inspector observed, while accompanied by the CEO and Maintenance Director, during the hours of the inspection from 2:45 PM to 5:00 PM on 07/13/2016 that there were the following issues:

A) Based on an interview with staff the facility failed to conduct fire drill with confirmation of transmission of fire alarm signal.

The Standard:
Fire drills in ambulatory health care facilities shall include the transmission of fire alarm signal and simulation of emergency fire conditions. - NFPA 101, Life Safety Code. U.S.A.: NFPA; 2003: 20.7.1.4

Receptacle Testing in Patient Care Areas

Findings:
The inspector observed, while accompanied by the CEO and Maintenance Director, during the hours of the inspection from 2:45 PM to 5:00 PM on 07/13/2016 that there were the following issues:

1) Based on observation the facility failed to provide records of documentation of receptacle testing in patient care areas for the last three years, in order to ensure that there was no lapse in regular safety preventative maintenance. Facility is to maintain a history of records for receptacle testing per NFPA 99: 3-3.3.3. in patient care areas dating back from the present at least 3 years which includes performance data (such as impedance, ground potentials, retention force of the grounding blade of each electrical receptacle).

The Standard:
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).

Testing Intervals. (a) The facility shall establish policies and protocols for the type of test and intervals of testing for each appliance. (b) All appliances used in patient care areas shall be tested in accordance with 7-5.1.3 or 7-5.2.2.1 before being put into service for the first time and after repair or modification. Patient-care-related electrical appliances shall be retested at intervals determined by their normal location or area of normal use, but not exceeding the intervals listed below: General care areas - 12 months; critical care areas - 6 months; wet locations - 6 months. - NFPA 99, 1999, 7-6.2.1.2