HospitalInspections.org

The inspector observed, while accompanied by the Human Resource Director during the hours of the inspection from 1:00 pm to 4:15 pm on 4/27/2016 that there were the following issues. In the main electrical room, there were numerous penetrations that were not properly sealed with a firestop sealant. The rated walls above the double doors failed to have the sprinkler penetrations and data line penetrations sealed by firestop systems.

''Penetrations for cables, cable trays, conduits, pipes, tubes, combustion vents and exhaust vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a fire barrier shall be protected by a firestop system or device.'' - NFPA 101, 2003, 8.3.5.1.

The inspector observed, while accompanied by the Human Resource Director during the hours of the inspection from 1:00 pm to 4:15 pm on 4/27/2016 that there were the following issues. Fire alarm pull stations was missing at main entrance to hospital. These fire alarm pull stations should be within five feet of the exits.

A fire alarm system with approved component, devices or equipment installed according to NFPA 72, National Fire Alarm Code to provide effective warning of fire in any part of the building. Activation of the complete fire alarm system shall be by manual fire alarm initiation, automatic detection or extinguishing system operation. Pull stations in patient sleeping areas, may be omitted provided that manual pull stations are within 200 ft of nurse ' s stations. Pull stations are located in the path of egress. Electronic or written records of tests shall be available. A reliable second source of power must be provided. Fire alarm systems shall be in accordance with NFPA72, and records of maintenance kept readily available. There shall be annunciation of the fire alarm system to an approved central station. 19.3.4, 9.6

The inspector observed, while accompanied by the Human Resource Director during the hours of the inspection from 1:00 pm to 4:15 pm on 4/27/2016 that there were the following issues. In the main electrical room, there were numerous penetrations that were not properly sealed with a firestop sealant.

''Penetrations for cables, cable trays, conduits, pipes, tubes, combustion vents and exhaust vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a fire barrier shall be protected by a firestop system or device.'' - NFPA 101, 2003, 8.3.5.1.

The inspector observed, while accompanied by the Human Resource Director during the hours of the inspection from 1:00 pm to 4:15 pm on 4/27/2016 that there were the following issues. The medical gas tanks in the medical gas storage area were not individually secured.

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

The inspector observed, while accompanied by the Human Resource Director during the hours of the inspection from 1:00 pm to 4:15 pm on 4/27/2016 that there were the following issues. The electrical room located near the Acute Care area was incorrectly being used to store open buckets of water and one gallon containers of ice-melt chemicals.

''Clear Spaces. Working space required by this section shall not be used for storage. When normally enclosed live parts are exposed for inspection or servicing, the working space, if in a passageway or general open space, shall be suitably guarded.'' - NFPA 70, 2002, 110.26(B)

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

The inspector observed, while accompanied by the Human Resource Director during the hours of the inspection from 1:00 pm to 4:15 pm on 4/27/2016 that there were the following issues. The inspector was not able to verify that all required generator testing was being completed due to unavailability of complete testing logs.

Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.
Exception: If the generator set is used for standby power or for peak load shaving, such use shall be recorded and shall be permitted to be substituted for scheduled operations and testing of the generator set, provided the appropriate data are recorded.
6-4.2*
Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
The date and time of day for required testing shall be decided by the owner, based on facility operations.
6-4.2.1
Equivalent loads used for testing shall be automatically replaced with the emergency loads in case of failure of the primary source.
6-4.2.2
Diesel-powered EPS installations that do not meet the requirements of 6-4.2 shall be exercised monthly with the available EPSS load and exercised annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of 2 continuous hours. (Categorical Waiver for this see below)
6-4.3
Load tests of generator sets shall include complete cold starts.
6-4.4
Time delays shall be set as follows:
(a) Time delay on start: 1 second minimum
Exception: Gas turbine cycle: 0.5 second minimum.
(b) Time delay on transfer to emergency: no minimum required
(c) Time delay on restoration to normal: 5 minutes minimum (see A-4-2.4.7)
(d) Time delay on shutdown: 5 minutes minimum
6-4.5
Level 1 and Level 2 transfer switches shall be operated monthly. The monthly test of a transfer switch shall consist of electrically operating the transfer switch from the standard position to the alternate position and then a return to the standard position.
6-4.6*
EPSS circuit breakers for Level 1 system usage, including main and feed breakers between the EPS and the transfer switch load terminals, shall be exercised annually with the EPS in the off position.
Exception: Medium- and high-voltage circuit breakers for Level 1 system usage shall be exercised every 6 months and tested under simulated overload conditions every 2 years.
6-4.7
The routine maintenance and operational testing program shall be overseen by a properly instructed individual

'' 3. Emergency Generators and Standby Power Systems
Section 9.1.3 of the 2000 LSC requires emergency generators and standby power systems to be installed, tested, and maintained in accordance with 1999 NFPA 110, Standard for Emergency and Standby Power Systems. Section 6-4.2.2 of the 1999 NFPA 110 requires diesel-powered generators that do not meet the monthly testing requirements under section 6-4.2 to be run annually with various loads for a total of two (2) continuous hours. Shorter generator run times will reduce undue cost burden and negative environmental impacts. In the 2010 NFPA 110, the NFPA began to allow for total test duration of one hour and 30 minutes (1-1/2 continuous hours). Accordingly, we are permitting a waiver to allow for a reduction in the annual diesel-powered generator exercising requirement from two (2) continuous hours to one hour and 30 minutes (1-1/2 continuous hours), but only if the provider/supplier is in compliance with all other applicable 1999 NFPA 110 operational inspection and testing provisions, as well as with section 8.4.2.3 of the 2010 NFPA 110. '' - S&C: 13-58-LSC

The inspector observed, while accompanied by the Human Resource Director during the hours of the inspection from 1:00 pm to 4:15 pm on 4/27/2016 that there were the following issues. In the main electrical room, there were numerous penetrations that were not properly sealed with a firestop sealant. The rated walls above the double doors failed to have the sprinkler penetrations and data line penetrations sealed by firestop systems.

''Penetrations for cables, cable trays, conduits, pipes, tubes, combustion vents and exhaust vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a fire barrier shall be protected by a firestop system or device.'' - NFPA 101, 2003, 8.3.5.1.

The inspector observed, while accompanied by the Human Resource Director during the hours of the inspection from 1:00 pm to 4:15 pm on 4/27/2016 that there were the following issues. Fire alarm pull stations was missing at main entrance to hospital. These fire alarm pull stations should be within five feet of the exits.

A fire alarm system with approved component, devices or equipment installed according to NFPA 72, National Fire Alarm Code to provide effective warning of fire in any part of the building. Activation of the complete fire alarm system shall be by manual fire alarm initiation, automatic detection or extinguishing system operation. Pull stations in patient sleeping areas, may be omitted provided that manual pull stations are within 200 ft of nurse ' s stations. Pull stations are located in the path of egress. Electronic or written records of tests shall be available. A reliable second source of power must be provided. Fire alarm systems shall be in accordance with NFPA72, and records of maintenance kept readily available. There shall be annunciation of the fire alarm system to an approved central station. 19.3.4, 9.6

The inspector observed, while accompanied by the Human Resource Director during the hours of the inspection from 1:00 pm to 4:15 pm on 4/27/2016 that there were the following issues. In the main electrical room, there were numerous penetrations that were not properly sealed with a firestop sealant.

''Penetrations for cables, cable trays, conduits, pipes, tubes, combustion vents and exhaust vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a fire barrier shall be protected by a firestop system or device.'' - NFPA 101, 2003, 8.3.5.1.

The inspector observed, while accompanied by the Human Resource Director during the hours of the inspection from 1:00 pm to 4:15 pm on 4/27/2016 that there were the following issues. The medical gas tanks in the medical gas storage area were not individually secured.

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

The inspector observed, while accompanied by the Human Resource Director during the hours of the inspection from 1:00 pm to 4:15 pm on 4/27/2016 that there were the following issues. The electrical room located near the Acute Care area was incorrectly being used to store open buckets of water and one gallon containers of ice-melt chemicals.

''Clear Spaces. Working space required by this section shall not be used for storage. When normally enclosed live parts are exposed for inspection or servicing, the working space, if in a passageway or general open space, shall be suitably guarded.'' - NFPA 70, 2002, 110.26(B)

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

The inspector observed, while accompanied by the Human Resource Director during the hours of the inspection from 1:00 pm to 4:15 pm on 4/27/2016 that there were the following issues. The inspector was not able to verify that all required generator testing was being completed due to unavailability of complete testing logs.

Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.
Exception: If the generator set is used for standby power or for peak load shaving, such use shall be recorded and shall be permitted to be substituted for scheduled operations and testing of the generator set, provided the appropriate data are recorded.
6-4.2*
Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
The date and time of day for required testing shall be decided by the owner, based on facility operations.
6-4.2.1
Equivalent loads used for testing shall be automatically replaced with the emergency loads in case of failure of the primary source.
6-4.2.2
Diesel-powered EPS installations that do not meet the requirements of 6-4.2 shall be exercised monthly with the available EPSS load and exercised annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of 2 continuous hours. (Categorical Waiver for this see below)
6-4.3
Load tests of generator sets shall include complete cold starts.
6-4.4
Time delays shall be set as follows:
(a) Time delay on start: 1 second minimum
Exception: Gas turbine cycle: 0.5 second minimum.
(b) Time delay on transfer to emergency: no minimum required
(c) Time delay on restoration to normal: 5 minutes minimum (see A-4-2.4.7)
(d) Time delay on shutdown: 5 minutes minimum
6-4.5
Level 1 and Level 2 transfer switches shall be operated monthly. The monthly test of a transfer switch shall consist of electrically operating the transfer switch from the standard position to the alternate position and then a return to the standard position.
6-4.6*
EPSS circuit breakers for Level 1 system usage, including main and feed breakers between the EPS and the transfer switch load terminals, shall be exercised annually with the EPS in the off position.
Exception: Medium- and high-voltage circuit breakers for Level 1 system usage shall be exercised every 6 months and tested under simulated overload conditions every 2 years.
6-4.7
The routine maintenance and operational testing program shall be overseen by a properly instructed individual

'' 3. Emergency Generators and Standby Power Systems
Section 9.1.3 of the 2000 LSC requires emergency generators and standby power systems to be installed, tested, and maintained in accordance with 1999 NFPA 110, Standard for Emergency and Standby Power Systems. Section 6-4.2.2 of the 1999 NFPA 110 requires diesel-powered generators that do not meet the monthly testing requirements under section 6-4.2 to be run annually with various loads for a total of two (2) continuous hours. Shorter generator run times will reduce undue cost burden and negative environmental impacts. In the 2010 NFPA 110, the NFPA began to allow for total test duration of one hour and 30 minutes (1-1/2 continuous hours). Accordingly, we are permitting a waiver to allow for a reduction in the annual diesel-powered generator exercising requirement from two (2) continuous hours to one hour and 30 minutes (1-1/2 continuous hours), but only if the provider/supplier is in compliance with all other applicable 1999 NFPA 110 operational inspection and testing provisions, as well as with section 8.4.2.3 of the 2010 NFPA 110. '' - S&C: 13-58-LSC