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Tag No.: K0077

Observation and discussion with the Vice President for Operations, the Coordinator for Clinical Processes Management, and the Director of the Physical Plant between 8:30 am and 12:30 pm on 8/31/2011 revealed that certain requirements stipulated in NFPA 99 were not met.

Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over [Re: NFPA 99, Health Care Facilities, 1999: ? 4-3.1.1.1.]

Findings: The medical gas cylinders were observed and they were not individually constrained as required.

No Description Available

Tag No.: K0130

Observation and discussion with the Vice President for Operations, the Coordinator for Clinical Processes Management, and the Director of the Physical Plant between 8:30 am and 12:30 pm on 8/31/2011 revealed that certain requirements stipulated in NFPA 99 were not met.

The LIM circuit shall be tested at intervals of not more than 1 month by actuating the LIM test switch [see 3-3.2.2.3(f)]. For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed far intervals of not more than 12 months. Actuation of the test switch shall activate both visual and audible alarm indicators [Re: NFPA 99, Health Care Facilities, 1999: ? 3-3.3.4.2(b).]

Findings: The staff indicated these tests are not performed and logs of the tests were not available for review.