HospitalInspections.org

Based on observation and facility staff interview, facility staff failed to provide a two-hour fire rating between hallways that separate the hospital from the outpatient clinic and medical business offices on the South Wing. This compromises the fire-resistance rating and would allow the passage of smoke, fumes and products of combustion to the hospital corridors in the event of a fire. This deficient practice as the potential to effect all patients, staff and visitors in the building. This facility had a capacity of 25. The facility census was 5.

1. Observation on 11/29/18, at approximately 3:40 P.M., during the facility tour, showed the door and assembly between the South Wing and the East Wing corridor intersection did not latch and did not have a rated frame.

Observation of the unlicensed South Wing showed the corridor contained medical business offices and an outpatient clinic.

During an interview on 11/29/2018 at approximately 5:48 P.M., the Maintenance Director said he/she did not know the two hour occupancy separation requirements. Additionally, he/she said he/she became the Maintenance Director on 08/15/2018 and had no knowledge of the prior building operations.

19.1.3.4 Contiguous Non-Health Care Occupancies.

19.1.3.4.1* Ambulatory care facilities, medical clinics, and
similar facilities that are contiguous to health care occupancies,
but are primarily intended to provide outpatient services,
shall be permitted to be classified as business occupancies or
ambulatory health care facilities, provided that the facilities
are separated from the health care occupancy by not less than
2-hour fire resistance-rated construction, and the facility is
not intended to provide services simultaneously for four or
more inpatients who are litterborne.

19.1.3.5 Where separated occupancies provisions are used in
accordance with either 19.1.3.3 or 19.1.3.4, the most stringent
construction type shall be provided throughout the building,
unless a 2-hour separation is provided in accordance with
8.2.1.3, in which case the construction type shall be determined
as follows:
(1) The construction type and supporting construction of the
health care occupancy shall be based on the story on
which it is located in the building in accordance with the
provisions of 19.1.6 and Table 19.1.6.1.
(2) The construction type of the areas of the building enclosing
the other occupancies shall be based on the applicable
occupancy chapters of this Code.

Based on observation, record review and facility staff interview, facility staff failed to ensure powered doors are equipped with hold-open devices actuated by a local smoke detector and a self-closing device. This has the potential to affect all residents, visitors and staff in the event of a fire by not limiting the passage of smoke and fire through the building structure. The census was 5 with a capacity of 25.

Observation on 11/29/2018, during the facility tour, showed the following corridor and cross corridor doors equipped with powered door opening devices not connected to the fire alarm system and were equipped with a hold open lock feature which held the doors open until the switch was engaged manually to release the doors:

- 2 sets of double powered doors on the designated exit corridor in the emergency department,

-Radiology corridor door on the designated exit corridor,

-Surgery corridor door on the designated exit corridor,

-1st floor outpatient waiting room door on the main entrance/exit corridor,

-Outpatient procedure doors #158 double door set on the designated exit corridor.

Record review of the facility's fire alarm inspection dated 6/20-21/2018 did not show connection tests with the fire alarm system.

Additional observation did not show a connection between the powered door sets and the fire alarm control panel.

During an interview on 11/29/2018 at 6:39 P.M., the Maintenance Director said he/she believed the fire alarm inspection company tested the powered doors with the fire alarm system per code requirements. Additionally, he/she said he/she became the Maintenance Director on 08/15/2018 and had no knowledge of the prior building operations.

NFPA 101, 2012 edition, section 19.2.2.2.7 states:

"19.2.2.2.7* Any door in an exit passageway, stairway enclosure,
horizontal exit, smoke barrier, or hazardous area enclosure
shall be permitted to be held open only by an automatic release
device that complies with 7.2.1.8.2. The automatic sprinkler
system, if provided, and the fire alarm system, and the
systems required by 7.2.1.8.2, shall be arranged to initiate the
closing action of all such doors throughout the smoke compartment
or throughout the entire facility."

Based on observation, staff interview, and record review, the facility staff failed to provide continuously maintained exit ways free of all obstructions or impediments continuous to a public way such as a parking lot. This deficient practice affects one exit discharge area. This deficient practice has the potential to affect all patients, staff and visitors in the facility. Failure to ensure exterior exit ways comply with LSC requirements could delay evacuation out of the building in the event of a fire or other emergency. The census was 5 with a capacity of 25.


1. Observation on 11/29/18, during the facility tour, showed the designated cafeteria exit discharge areas led to a grass covered yard that required residents, staff, and visitors to traverse grass to reach the parking lot.

Record review of the facility layout showed the exit discharge area from the cafeteria designated for use.

During an interview on 11/29/2018, the Maintenance Director said he/she did not know a sidewalk to the parking lot was not provided until discovered 11/29/2018. Additionally, he/she said he/she became the Maintenance Director on 08/15/2018 and had no knowledge of the prior building operations.

The National Fire Protection Association 101, Life Safety Code 2012 Edition, section 7.7 states:


7.7 Discharge from Exits.

7.7.1* Exit Termination. Exits shall terminate directly, at a
public way or at an exterior exit discharge, unless otherwise
provided in 7.7.1.2 through 7.7.1.4.

Based on observation and facility staff interview, facility staff failed to provide emergency lighting not controlled by light switches. This deficient practice has the potential to affect all patients, staff and visitors within the facility. Failure to provide emergency lighting could prevent proper illumination of required areas in the event of power loss. The census was 5 with a capacity of 25.

1. Observations on 11/29/18, during the Life Safety Code (LCS) tour, showed the following light fixtures in the facility controlled by light switches:

-Pharmacy compounding room,

-Outpatient medication room,

-Medication -prep area on East Wing,

-Emergency Department medication room,

-Operating room #1.

During an interview on 11/29/2018 at 7:02 P.M., the Maintenance Director said he/she has not reviewed the building for task illumination. Additionally, he/she said he/she became the Maintenance Director on 08/15/2018 and had no knowledge of the prior building operations.

NFPA 99, 2012 edition, section 6.4.2.2.4.2 states:

"6.4.2.2.4.2 The critical branch shall supply power for task illumination,
fixed equipment, select receptacles, and select power
circuits serving the following areas and functions related to patient
care:
(1) Critical care areas that utilize anesthetizing gases, task illumination,
select receptacles, and fixed equipment
(2) Isolated power systems in special environments
(3) Task illumination and select receptacles in the following:
(a) Patient care rooms, including infant nurseries, selected
acute nursing areas, psychiatric bed areas (omit receptacles),
and ward treatment rooms
(b) Medication preparation areas
(c) Pharmacy dispensing areas
(d) Nurses ' stations (unless adequately lighted by corridor
luminaires)
(4) Additional specialized patient care task illumination and
receptacles, where needed
(5) Nurse call systems
(6) Blood, bone, and tissue banks
(7)*Telephone equipment rooms and closets
(8) Task illumination, select receptacles, and select power circuits
for the following areas:
(a) General care beds with at least one duplex receptacle
per patient bedroom, and task illumination as required
by the governing body of the health care facility
(b) Angiographic labs
(c) Cardiac catheterization labs
(d) Coronary care units
(e) Hemodialysis rooms or areas
(f) Emergency room treatment areas (select)
(g) Human physiology labs
(h) Intensive care units
(i) Postoperative recovery rooms (select)
(9) Additional task illumination, receptacles, and select power
circuits needed for effective facility operation, including
single-phase fractional horsepower motors, which are permitted
to be connected to the critical branch"

Based on observation and facility staff interview, the facility staff failed to provide a 1-hour rated separation between a hazardous area (areas that pose a degree of hazard greater than normal to the general occupancy of the building such as areas used for storage or use of combustibles or flammables, toxic, noxious, or corrosive materials, or heat producing appliances) and designated exit corridors in the facility per NFPA (National Fire Protection Association) requirements. Failure to provide compliant hazardous area doors equipped with a self closing devices and latching devices puts all patients, staff and visitors at risk of injury or death from a fire by not containing the fire and smoke within the hazardous area. The facility census was 5 with a capacity of 25.

1. Observation on 11/29/2018, during the facility tour, showed the central purchasing storage room containing a large quantity of combustible materials. The room measured approximately 468 square feet. The room contained three dutch doors providing access to the room. Observation showed the corridor dutch door without a rating, had replaced hinges and did not have a self closing device. Observation showed the door was remounted in the frame in the opposite direction of original installation to reverse the door swing. Observation showed the door skin was drilled for the relocated hinges.

2. The second dutch door lead from the central purchasing storage room into central sterile. Observation showed the door did not have a rating.

3. The third dutch door lead from the central purchasing storage room into central sub-sterile. Observation showed the door did not have a rating.

4. The laundry corridor door did not contain a latching device or self closing device. Observation showed the dryers were gas fired.

5. The kitchen corridor door did not contain a latching device or self closing device. Observation showed the kitchen contained a deep fryer.

6. The kitchen door on the convalescent access corridor door did not contain a latching device or self closing device. Observation showed the door was 3 hour rated and missing a hinge.


During an interview on 11/29/2018 at 6:59 P.M., the Maintenance Director said he/she did not know a prior door inspection was not done. He/she said he/she discovered the door inspection was not done on 11/28/2018. Additionally, he/she said he/she became the Maintenance Director on 08/15/2018 and had no knowledge of the prior building operations.

Please refer to NFPA 101, 2012 edition, Section 19.3.6.3.13 for additional information regarding the use of dutch doors in hazardous areas.

19.3.2.1.1 An automatic extinguishing system, where used in
hazardous areas, shall be permitted to be in accordance with
19.3.5.9.

19.3.2.1.2* Where the sprinkler option of 19.3.2.1 is used, the
areas shall be separated from other spaces by smoke partitions
in accordance with Section 8.4.

19.3.2.1.3 The doors shall be self-closing or automatic-closing.

19.3.2.1.5 Hazardous areas shall include, but shall not be restricted
to, the following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 ft2 (9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Rooms with soiled linen in volume exceeding 64 gal (242 L)
(6) Rooms with collected trash in volume exceeding 64 gal
(242 L)
(7) Rooms or spaces larger than 50 ft2 (4.6 m2), including
repair shops, used for storage of combustible supplies and
equipment in quantities deemed hazardous by the authority
having jurisdiction

Based on observation and facility staff interview, the facility failed to ensure that one of one fire alarm systems was installed per NFPA 72, National Fire Alarm and Signaling Code, 2010 edition. The deficient practice has the potential to effect all facility patients, staff and visitors. The deficient practice could delay fire and emergency personnel response in the event of a fire. The census was 5 with a capacity of 25.

1. Observation on 11/28/18, during the facility tour, showed two of two designated exit stairwells did not have smoke detector coverage.

During an interview on 11/29/18 at 6:39 P.M., the Director of Facilities Management stated he believed the fire alarm installation/inspection company installed the fire alarm per code requirements.

During an interview on 11/29/2018 at 6:39 P.M., the Maintenance Director said he/she believed the fire alarm inspection company installed the fire alarm system per code requirements. Additionally, he/she said he/she became the Maintenance Director on 08/15/2018 and had no knowledge of the prior building operations.


National Fire Protection Association 101, 2012 edition, section 19.3.4.1 states:

"19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6."

Refer to NFPA 72, National Fire Alarm and Signaling Code, 2010 edition, sections 17.6.3 Location and Spacing and 17.6.3.3.1 Spacing for additional information.

Based on record review and facility staff interview, facility staff did not ensure all devices connected to the fire alarm system were inspected and tested per NFPA 72, National Fire Alarm and Signaling Code, 2010 edition. The census was 5 with a capacity of 25.

Record review of the annual fire alarm inspection dated 12/07-08/2017 did not show connection function tests for the following devices:

-Range hood in the cafeteria;
-Magnetic hold open devices;
-Powered doors on exit corridors and cross corridor doors;
-Six fire alarm annunciator panels (silence & reset functions work on each panel)

During an interview on 11/29/18 at 6:39 P.M., the Director of Facilities Management stated he believed the fire alarm inspection company inspected the fire alarm per code requirements. Additionally, he/she said he/she became the Maintenance Director on 08/15/2018 and had no knowledge of the prior building operations.


Refer to NFPA 72, National Fire Alarm and Signaling Code, 2010 edition, Table 14.3.1, Table 14.4.2.2, Table 14.4.5, sections 14.4.5, 14.4.5.3.1 through section 14.4.5.4 for additional testing information.

Based on observation and facility staff interview, facility staff failed to ensure areas open to the corridor contain smoke detection
per NFPA 72, National Fire Alarm and Signaling Code, 2010 edition. This deficient practice has the potential to effect all facility patients, staff and visitors. This deficient practice could delay fire and emergency personnel response in the event of a fire. The facility census was 8.

Observations on 11/29/2018, during the facility tour, showed the following areas open to the designated exit corridors requiring smoke detectors:

-East hall nurse's station measuring approximately 17 feet by 24 feet area
-East hall medication prep area measuring approximately 16 feet by 8 feet area

During an interview on 11/29/2018 at 6:39 P.M., the Maintenance Director said he/she believed the fire alarm inspection company installed the fire alarm system per code requirements. Additionally, he/she said he/she became the Maintenance Director on 08/15/2018 and had no knowledge of the prior building operations.

19.3.4.1 General. Health care occupancies shall be provided
with a fire alarm system in accordance with Section 9.6.

Refer to NFPA 72, National Fire Alarm and Signaling Code, 2010 edition, sections 17.6.3 Location and Spacing and 17.6.3.3.1 Spacing for additional information.

Based on record review and facility staff interview, facility staff failed to inspect three wet sprinkler systems and one pre action sprinkler system per NFPA 25, Standard for the Inspection, Testing, and maintenance of Water-Based Fire Protection Systems, 2011 edition. Failure to test and maintain the sprinkler system could affect the sprinkler system's performance in the event of a fire. This deficient practice has the potential to affect all patients, staff and visitors. This facility had a capacity of 25. The facility census was 5.


1) Record review on 11/28/2018 did not show the following inspections:

- monthly inspections/testing (Table 13.1.1.2)

-five year check valve interior inspections (Table 13.1.1.2)

During an interview on 11/29/2018 at 6:49 P.M., the Maintenance Director said he/she believed the sprinkler system inspection company inspected the sprinkler systems per code requirements. Additionally, he/she said he/she became the Maintenance Director on 08/15/2018 and had no knowledge of the prior building operations.


Refer to NFPA 25, Standard for the Inspection, Testing, and maintenance of Water-Based Fire Protection Systems, 2011 edition, Chapters 5, 13, and 14 for additional information.

13.4.2 Check Valves.
13.4.2.1 Inspection. Valves shall be inspected internally every
5 years to verify that all components operate correctly, move
freely, and are in good condition.

13.3.2 Inspection.
13.3.2.1 All valves shall be inspected weekly.
13.3.2.1.1 Valves secured with locks or supervised in accordance
with applicable NFPAstandards shall be permitted to be
inspected monthly.
13.3.2.1.2 After any alterations or repairs, an inspection shall
be made by the property owner or designated representative
to ensure that the system is in service and all valves are in the
normal position and properly sealed, locked, or electrically
supervised.
13.3.2.2* The valve inspection shall verify that the valves are in
the following condition:
(1) In the normal open or closed position
(2)*Sealed, locked, or supervised
(3) Accessible
(4) Provided with correct wrenches
(5) Free from external leaks
(6) Provided with applicable identification
13.4 System Valves.
13.4.1 Inspection of Alarm Valves. Alarm valves shall be inspected
as described in 13.4.1.1 and 13.4.1.2.

13.4.1.1* Alarm valves and system riser check valves shall be
externally inspected monthly and shall verify the following:
(1) The gauges indicate normal supply water pressure is being
maintained.
(2) The valve is free of physical damage.
(3) All valves are in the appropriate open or closed position.
(4) The retarding chamber or alarm drains are not leaking.

Based on observation and facility staff interview, facility staff failed to ensure corridor doors were solid, resisted the passage of smoke and were positive latching. These deficient practices have the potential to affect all patients, staff and visitors. Failure to ensure corridor doors are solid, resist the passage of smoke and positive latch has the potential to prevent or delay evacuation out of the building in the event of a fire or other emergency by allowing smoke, fumes and the products of fire from entering the exit corridors in the event of a fire. This facility had a capacity of 25. The facility census was 5.


Observation on 11/29/2018, during the building tour, showed the following doors did not latch, were not solid and did not resist the passage of smoke:

-Education room door had holes in the door
-Room #245 had a hole surrounding the door lock
-Roller latch on Radiology designated exit corridor door
-Roller latch on Tech work room designated exit corridor door

During an interview on 11/29/2018 at 6:59 P.M., the Maintenance Director said he/she did not know a prior door inspection was not done until discovered 11/28/2018. Additionally, he/she said he/she became the Maintenance Director on 08/15/2018 and had no knowledge of the prior building operations.


Roller latches are prohibited by CMS regulation.

Based on observation and facility staff interview, facility staff failed to ensure transfer grills were not installed in corridors. One room had a transfer grill installed in the corridor door. This deficient practice has the potential to affect all patients, staff and visitors. Failure to ensure transfer grills were not installed in corridors has the potential to prevent or delay evacuation out of the building in the event of a fire or other emergency by allowing smoke, fumes and the products of fire from entering the exit corridors in the event of a fire. This facility had a capacity of 25. The facility census was 5.

Observation on 11/29/2018, during the building tour, showed a 17 inch by 21 inch cut hole with transfer grill in the phone utility room class B corridor door. Observation showed the door opening on a designated exit corridor.

During an interview on 11/29/2018 at 6:59 P.M., the Maintenance Director said he/she did not know a prior door inspection was not done until discovered 11/28/2018. Additionally, he/she said he/she became the Maintenance Director on 08/15/2018 and had no knowledge of the prior building operations.


NFPA 101, 2012 edition, Section 19.3.6.4 states:

"19.3.6.4 Transfer Grilles.
19.3.6.4.1 Transfer grilles, regardless of whether they are
protected by fusible link-operated dampers, shall not be used
in corridor walls or doors."

Based on observation, facility staff failed to ensure two rooms in the facility laundry was adequately vented and kept under a relative negative pressure. This deficient practice has the potential to effect all residents, staff and visitors. Failure to provide adequate ventilation could increase the concentration of smoke, products of combustion and noxious fumes. This facility had a capacity of 25. The facility census was 5.

Observation on 11/29/18 at 1:36 P.M., showed the soiled area of the laundry room and the biohazard storage room behind the laundry room did not have functioning exhaust ventilation.

During an interview on 11/29/2018 at 6:42 P.M., the Maintenance Director said he/she did not know the laundry soiled area and biohazard room did not have venting until discovered 11/29/2018. Additionally, he/she said he/she became the Maintenance Director on 08/15/2018 and had no knowledge of the prior building operations.

Based on facility staff interview and record review, facility staff failed to inspect, test and maintain the fire egress doors in accordance with the 2010 Editions of NFPA 80 (Standard for Fire Doors and Other Opening Protectives) and NFPA 105 (Standard for Fire Doors and Other Opening Protectives). Facility staff failed to conduct an annual inspection of the non rated doors in the building. This facility had a capacity of 25. The facility census was 5.

1. Review of the facility's inspection, testing and maintenance records did not show documentation of an annual inspection of the non rated doors in the building.

2. Review of the contracted door inspection company fire door inspection dated 12/13/2017 showed 44 of 77 fire doors listed on the report were found noncompliant.

Observation during the facility tour 11/28-29/2018 showed none of the deficient doors were repaired or replaced.

3. Observation during the facility tour 11/28-29/2018 showed the following doors deficient in addition to the doors listed on the report:

A. Central purchasing storage room measured approximately 468 square feet. The room contained three dutch doors providing access to the room. Observation showed the corridor dutch door had replaced hinges and did not have a self closing device. Observation showed the door was remounted in the frame in the opposite direction of original installation to reverse the door swing. Observation showed the door skin was drilled for the relocated hinges. Observation showed the door did not have a latching device on both the upper and lower door leaves or a rabbet, astragal or bevel.

B. The second dutch door lead from the central purchasing storage room into central sterile. Observation showed the door did not have a latching device on both the upper and lower door leaves or a rabbet, astragal or bevel.

C. The third dutch door lead from the central purchasing storage room into central sub-sterile. Observation showed the door did not have a latching device on both the upper and lower door leaves or a rabbet, astragal or bevel.

D. The laundry corridor door did not contain a latching device or self closing device. .

E. The kitchen corridor door did not contain a latching device or self closing device.

F. The kitchen door on the convalescent access corridor door did not contain a latching device or self closing device. Observation showed the door was 3 hour rated and missing a hinge.

G. Education room door had holes in the door

H. Room #245 had a hole surrounding the door lock

I. Roller latch on Radiology designated exit corridor door

J. Roller latch on Tech work room designated exit corridor door

K. 17 inch by 21 inch cut hole with transfer grill in the phone utility room class B corridor door.

L. Observation showed the following corridor and cross corridor doors equipped with powered door opening devices not connected to the fire alarm system and were equipped with a hold open lock feature which held the doors open until the switch was engaged manually to release the doors:

- 2 sets of double powered doors on the designated exit corridor in the emergency department,

-Radiology corridor door on the designated exit corridor,

-Surgery corridor door on the designated exit corridor,

-1st floor outpatient waiting room door on the main entrance/exit corridor,

-Outpatient procedure doors #158 double door set on the designated exit corridor.

During an interview on 11/29/2018 at 6:59 P.M., the Maintenance Director said he/she did not know a prior door inspection was not done until discovered 11/28/2018. Additionally, he/she said he/she became the Maintenance Director on 08/15/2018 and had no knowledge of the prior building operations.


NFPA 101, 2012 Edition states:

19.2.2.2.1 Doors complying with 7.2.1 shall be permitted.

7.2.1.15 Inspection of Door Openings.

7.2.1.15.1* Where required by Chapters 11 through 43, the
following door assemblies shall be inspected and tested not
less than annually in accordance with 7.2.1.15.2 through
7.2.1.15.8:
(1) Door leaves equipped with panic hardware or fire exit
hardware in accordance with 7.2.1.7
(2) Door assemblies in exit enclosures
(3) Electrically controlled egress doors
(4) Door assemblies with special locking arrangements subject
to 7.2.1.6

7.2.1.15.2 Fire-rated door assemblies shall be inspected and
tested in accordance with NFPA 80, Standard for Fire Doors and
Other Opening Protectives. Smoke door assemblies shall be inspected
and tested in accordance with NFPA 105, Standard for
Smoke Door Assemblies and Other Opening Protectives.

7.2.1.15.3 The inspection and testing interval for fire-rated
and nonrated door assemblies shall be permitted to exceed 12
months under a written performance-based program in accordance
with 5.2.2 of NFPA 80, Standard for Fire Doors and Other
Opening Protectives.

7.2.1.15.4 A written record of the inspections and testing
shall be signed and kept for inspection by the authority having
jurisdiction.

7.2.1.15.5 Functional testing of door assemblies shall be performed
by individuals who can demonstrate knowledge and
understanding of the operating components of the type of
door being subjected to testing.

7.2.1.15.6 Door assemblies shall be visually inspected from
both sides of the opening to assess the overall condition of the
assembly.

7.2.1.15.7 As a minimum, the following items shall be verified:
(1) Floor space on both sides of the openings is clear of obstructions,
and door leaves open fully and close freely.
(2) Forces required to set door leaves in motion and move to
the fully open position do not exceed the requirements
in 7.2.1.4.5.
(3) Latching and locking devices comply with 7.2.1.5.
(4) Releasing hardware devices are installed in accordance
with 7.2.1.5.10.1.
(5) Door leaves of paired openings are installed in accordance
with 7.2.1.5.11.
(6) Door closers are adjusted properly to control the closing
speed of door leaves in accordance with accessibility requirements.
(7) Projection of door leaves into the path of egress does not
exceed the encroachment permitted by 7.2.1.4.3.
(8) Powered door openings operate in accordance with
7.2.1.9.
(9) Signage required by 7.2.1.4.1(3), 7.2.1.5.5, 7.2.1.6, and
7.2.1.9 is intact and legible.
(10) Door openings with special locking arrangements function
in accordance with 7.2.1.6
(11) Security devices that impede egress are not installed on
openings, as required by 7.2.1.5.12.

19.3.6.3.13 Dutch doors shall be permitted where they conform
to 19.3.6.3 and meet all of the following criteria:
(1) Both the upper leaf and lower leaf are equipped with a
latching device.
(2) The meeting edges of the upper and lower leaves are
equipped with an astragal, a rabbet, or a bevel.
(3) Where protecting openings in enclosures around hazardous
areas, the doors comply with NFPA80, Standard for Fire
Doors and Other Opening Protectives.

Based on record review and facility staff interview, the facility staff failed to provide completed fundamental risk assessments and formally documented risk assessment procedures for all building systems categories are determined by a performed by qualified personnel. Failure to have the building systems risk assessments completed puts patients at risk for a potential negative outcome if category one systems (Category 1 system in which a failure of such equipment or system is likely to cause major injury or death of patients or caregivers) fail with no plan on how to respond if the system fails. This facility had a capacity of 25. The facility census was 5.


1. Review of the facility documents for fire safety, building system tests, and policies did not show how the categorical risk assessment scores for the building systems were determined.

2. During an interview on 11/29/2018, the Maintenance Director said he/she did not know how the hospital determined the categorical risk assessment scores. Additionally, he/she said he/she became the Maintenance Director on 08/15/2018 and had no knowledge of the prior building operations.

The National Fire Protection Association 99 Health Care Facilities Code, 2012 edition, Chapter 4 states:

"Chapter 4 Fundamentals

4.1* Building System Categories. Building systems in health
care facilities shall be designed to meet system Category 1
through Category 4 requirements as detailed in this code.

4.1.1* Category 1. Facility systems in which failure of such equipment
or system is likely to cause major injury or death of patients
or caregivers shall be designed to meet system Category 1 requirements
as defined in this code.

4.1.2* Category 2. Facility systems in which failure of such equipment
is likely to cause minor injury to patients or caregivers shall
be designed to meet system Category 2 requirements as defined
in this code.

4.1.3 Category 3. Facility systems in which failure of such equipment
is not likely to cause injury to patients or caregivers, but can
cause patient discomfort, shall be designed to meet system Category
3 requirements as defined in this code.

4.1.4 Category 4. Facility systems in which failure of such equipment
would have no impact on patient care shall be designed to
meet system Category 4 requirements as defined in this code.

4.2* Risk Assessment. Categories shall be determined by following
and documenting a defined risk assessment procedure.

4.3 Application. The Category definitions in Chapter 4 shall
apply to Chapters 5 through 11."

A.4.2 Risk assessment should follow procedures such as those
outlined in ISO/IEC 31010, Risk Management-Risk Assessment
Techniques, NFPA 551, Guide for the Evaluation of Fire Risk Assessments,
Guide for the Evaluation of Fire Risk Assessments, SEMI S10-
0307E, Safety Guideline for Risk Assessment and Risk Evaluation
Process, or other formal process. The results of the assessment
procedure should be documented and records retained.

Based on facility staff interview and record review, the facility staff failed to develop a maintenance program for the medical gas, vacuum or support gas system based on a risk assessment within the facility. Facility staff failed to ensure a qualified person inspected and maintained the medical gas, vacuum, WAGD, and medical support gas systems. This facility had a capacity of 25. The facility census was 5.

1. Review of the facility maintenance program documentation did not show the facility had a program in place which includes an inventory of all source systems, control valves, alarms, manufactured assemblies, outlets, and an inspection and maintenance schedule for this system.

2. Review of the facility maintenance program documentation did not show the facility had a qualified person inspecting/maintaining the medical gas, vacuum, WAGD, and medical support gas systems.

3. Record review did not show the maintenance program inspection procedures were not determined by risk assessments.


During an interview on 12/11/2018 at approximately 9:20 A.M., the Maintenance Director said the inspection records, inspector's qualifications and maintenance program risk assessments were not available. Additionally, he/she said he/she became the Maintenance Director on 08/15/2018 and had no prior knowledge of the building operations.


5.1.14.2 Maintenance of Medical Gas, Vacuum, WAGD, and
Medical Support Gas Systems.

5.1.14.2.1* General. Health care facilities with installed medical
gas, vacuum,WAGD, or medical support gas systems, or combinations
thereof, shall develop and document periodic maintenance
programs for these systems and their subcomponents as appropriate
to the equipment installed.

5.1.14.2.2 Maintenance Programs.

5.1.14.2.2.1 Inventories. Inventories of medical gas, vacuum,
WAGD, and medical support gas systems shall include at least
all source subsystems, control valves, alarms, manufactured assemblies
containing patient gases, and outlets.

5.1.14.2.2.2* Inspection Schedules. Scheduled inspections for
equipment and procedures shall be established through the
risk assessment of the facility and developed with consideration
of the original equipment manufacturer recommendations
and other recommendations as required by the authority
having jurisdiction.

5.1.14.2.2.3 Inspection Procedures. The facility shall be permitted
to use any inspection procedure(s) or testing methods
established through its own risk assessment.

5.1.14.2.2.4 Maintenance Schedules. Scheduled maintenance
for equipment and procedures shall be established through
the risk assessment of the facility and developed with consideration
of the original equipment manufacturer recommendations
and other recommendations as required by the authority
having jurisdiction.

5.1.14.2.2.5 Qualifications. Persons maintaining these systems
shall be qualified to perform these operations.Appropriate qualification
shall be demonstrated by any of the following:
(1) Training and certification through the health care facility
by which such persons are employed to work with specific
equipment as installed in that facility
(2) Credentialing to the requirements of ASSE 6040, Professional
Qualification Standard for Medical Gas Maintenance Personnel
(3) Credentialing to the requirements of ASSE 6030, Professional
Qualification Standard for Medical Gas Systems Verifiers

A.5.1.14.2.2.2 In addition to the minimum inspection and
testing in 5.1.14, facilities should consider annually inspecting
equipment and procedures and correcting any deficiencies.

Based on record review and facility staff interview, the facility staff failed to maintain records of inspections and testing of their piped in oxygen systems in accordance with National Fire Protection Association (NFPA) 99, 2012 edition. This facility had a capacity of 25. The facility census was 5.

1. Review of the facility's maintenance program documentation did not show complete inspections or testing of the piped-in oxygen system.

During an interview on 12/11/2018 at approximately 9:20 A.M., the Maintenance Director said the inspection records were not available. Additionally, he/she said he/she became the Maintenance Director on 08/15/2018 and had no prior knowledge of the building operations.


5.1.14.2.3 Inspection and Testing Operations.

5.1.14.2.3.1 General. The elements in 5.1.14.2.2.2 through
5.1.15 shall be inspected or tested as part of the maintenance
program as follows:

(1)*Medical air source, as follows:
(a) Room temperature
(b) Shaft seal condition
(c) Filter condition
(d) Presence of hydrocarbons
(e) Room ventilation
(f) Water quality, if so equipped
(g) Intake location
(h) Carbon monoxide monitor calibration
(i) Air purity
(j) Dew point
(2)*Medical vacuum source - exhaust location
(3) WAGD source - exhaust location
(4)*Instrument air source - filter condition
(5)*Manifold sources (including systems complying with
5.1.3.5.10, 5.1.3.5.11, 5.1.3.5.12, and 5.1.3.5.13), as follows:
(a) Ventilation
(b) Enclosure labeling
(6) Bulk cryogenic liquid source inspected in accordance
with NFPA 55, Compressed Gases and Cryogenic Fluids Code
(7) Final line regulation for all positive pressure systems -
delivery pressure
(8)*Valves - labeling
(9)*Alarms and warning systems-lamp and audio operation
(10) Alarms and warning systems, as follows:
(a) Master alarm signal operation
(b) Area alarm signal operation
(c) Local alarm signal operation
(11)*Station outlets/inlets, as follows:
(a) Flow
(b) Labeling
(c) Latching/delatching
(d) Leaks


5.1.14.2.3.2 Manufactured Assemblies Employing Flexible Connection(
s) Between the User Terminal and the Piping System.
(A) Nonstationary booms and articulating assemblies, other
than head walls utilizing flexible connectors, shall be tested for
leaks, per manufacturer ' s recommendations, every 18 months or
at a duration as determined by a risk assessment.
(B) The system pressure to nonstationary booms and articulating
arms shall be maintained at operating pressure until each
joint has been examined for leakage by effective means of leak
detection that is safe for use with oxygen.
(C) Safe working condition of the flexible assemblies shall be
confirmed.
(D) D.I.S.S. connectors internal to the boom and assemblies
shall be checked for leakage.
(E) Leaks, if any, shall be repaired (if permitted), or the components
replaced (if required), and the equipment retested prior
to placing the equipment back into service.
(F) Additional testing of nonstationary booms or articulating
arms shall be performed at intervals defined by documented performance
data.

5.1.14.2.2.2* Inspection Schedules. Scheduled inspections for
equipment and procedures shall be established through the
risk assessment of the facility and developed with consideration
of the original equipment manufacturer recommendations
and other recommendations as required by the authority
having jurisdiction.

5.1.14.2.2.3 Inspection Procedures. The facility shall be permitted
to use any inspection procedure(s) or testing methods
established through its own risk assessment.

5.1.14.2.2.4 Maintenance Schedules. Scheduled maintenance
for equipment and procedures shall be established through
the risk assessment of the facility and developed with consideration
of the original equipment manufacturer recommendations
and other recommendations as required by the authority
having jurisdiction.

5.1.14.2.2.5 Qualifications. Persons maintaining these systems
shall be qualified to perform these operations.Appropriate qualification
shall be demonstrated by any of the following:
(1) Training and certification through the health care facility
by which such persons are employed to work with specific
equipment as installed in that facility
(2) Credentialing to the requirements of ASSE 6040, Professional
Qualification Standard for Medical Gas Maintenance Personnel
(3) Credentialing to the requirements of ASSE 6030, Professional
Qualification Standard for Medical Gas Systems Verifiers

5.1.14.2.3 Inspection and Testing Operations.
5.1.14.2.3.1 General. The elements in 5.1.14.2.2.2 through
5.1.15 shall be inspected or tested as part of the maintenance
program as follows:
(1)*Medical air source, as follows:
(a) Room temperature
(b) Shaft seal condition
(c) Filter condition
(d) Presence of hydrocarbons
(e) Room ventilation
(f) Water quality, if so equipped
(g) Intake location
(h) Carbon monoxide monitor calibration
(i) Air purity
(j) Dew point

(2)*Medical vacuum source - exhaust location
(3) WAGD source - exhaust location
(4)*Instrument air source - filter condition
(5)*Manifold sources (including systems complying with
5.1.3.5.10, 5.1.3.5.11, 5.1.3.5.12, and 5.1.3.5.13), as follows:
(a) Ventilation
(b) Enclosure labeling
(6) Bulk cryogenic liquid source inspected in accordance
with NFPA 55, Compressed Gases and Cryogenic Fluids Code
(7) Final line regulation for all positive pressure systems -
delivery pressure
(8)*Valves - labeling
(9)*Alarms and warning systems-lamp and audio operation
(10) Alarms and warning systems, as follows:
(a) Master alarm signal operation
(b) Area alarm signal operation
(c) Local alarm signal operation
(11)*Station outlets/inlets, as follows:
(a) Flow
(b) Labeling
(c) Latching/delatching
(d) Leaks

5.1.14.2.3.2 Manufactured Assemblies Employing Flexible Connection(
s) Between the User Terminal and the Piping System.
(A) Nonstationary booms and articulating assemblies, other
than head walls utilizing flexible connectors, shall be tested for
leaks, per manufacturer ' s recommendations, every 18 months or
at a duration as determined by a risk assessment.
(B) The system pressure to nonstationary booms and articulating
arms shall be maintained at operating pressure until each
joint has been examined for leakage by effective means of leak
detection that is safe for use with oxygen.
(C) Safe working condition of the flexible assemblies shall be
confirmed.
(D) D.I.S.S. connectors internal to the boom and assemblies
shall be checked for leakage.
(E) Leaks, if any, shall be repaired (if permitted), or the components
replaced (if required), and the equipment retested prior
to placing the equipment back into service.
(F) Additional testing of nonstationary booms or articulating
arms shall be performed at intervals defined by documented performance
data.

5.1.14.3 Medical Gas and Vacuum Systems Information and
Warning Signs.

5.1.14.3.1 The gas content of medical gas and vacuum piping
systems shall be labeled in accordance with 5.1.11.1.

5.1.14.3.2 Labels for shutoff valves shall be in accordance with
5.1.11.2 and updated when modifications are made changing the
areas served.

5.1.14.4 Medical Gas and Vacuum Systems Maintenance and
Record Keeping. See B.5.2.

5.1.14.4.1 Permanent records of all tests required by 5.1.12.3.1
through 5.1.12.3.14 shall be maintained in the organization ' s
files.

5.1.14.4.2 The supplier of the bulk cryogenic liquid system
shall, upon request, provide documentation of vaporizer(s) sizing
criteria to the facility.

5.1.14.4.3 An annual review of bulk system capacity shall be
conducted to ensure the source system has sufficient capacity.

5.1.14.4.4 Central supply systems for nonflammable medical
gases shall conform to the following:
(1) They shall be inspected annually.
(2) They shall be maintained by a qualified representative of
the equipment owner.
(3) A record of the annual inspection shall be available for
review by the authority having jurisdiction.

5.1.14.4.5 A periodic testing procedure for nonflammable
medical gas and vacuum and related alarm systems shall be
implemented.

5.1.14.4.6 Whenever modifications are made that breach the
pipeline, any necessary installer and verification test specified
in 5.1.12 shall be conducted on the downstream portions of
the medical gas piping system.

5.1.14.4.7 Procedures, as specified, shall be established for
the following:
(1) Maintenance program for the medical air compressor
supply system in accordance with the manufacturer ' s recommendations
(2) Facility testing and calibration procedure that ensures
carbon monoxide monitors are calibrated at least annually
or more often if recommended by the manufacturer
(3) Maintenance program for both the medical-surgical
vacuum piping system and the secondary equipment attached
to medical-surgical vacuum station inlets to ensure
the continued good performance of the entire
medical-surgical vacuum system
(4) Maintenance program for the WAGD system to ensure
performance

5.1.14.4.8 Audible and visual alarm indicators shall meet the
following requirements:
(1) They shall be periodically tested to determine that they
are functioning properly.
(2) Records of the test shall be maintained until the next test
is performed.

5.1.14.4.9 Medical-surgical vacuum station inlet terminal performance,
as required in 5.1.12.3.10.4, shall be tested as follows:
(1) On a regular preventive maintenance schedule as determined
by the facility maintenance staff
(2) Based on flow of free air (Nl/min or SCFM) into a station
inlet while simultaneously checking the vacuum level
5.1.15* Category 1 Maintenance. Facilities shall have a routine
maintenance program for their piped medical gas and vacuum
systems.

A.5.1.14.2.2.2 In addition to the minimum inspection and
testing in 5.1.14, facilities should consider annually inspecting
equipment and procedures and correcting any deficiencies.

A.5.1.14.2.3.1(1) Additional inspections for medical air sources
include the following:
(1) Aftercoolers (condition, operation of automatic drains)
(2) Operating pressures (cut-in, cut-out, and control pressures)
(3) Electrical operation
(4) Receiver elements (auto drain, manual drain, sight glass,
pressure gauge)
(5) Pressure regulators (condition)
(6) Dryer (operation, outlet dew point, condition, housekeeping)
(7) Dew point calibration
(8) Housekeeping around compressors

A.5.1.14.2.3.1(2) Additional inspections for medical vacuum
sources and WAGD sources include the following:
(1) Operating vacuum (cut-in, cut-out, and control pressures)
(2) Electrical operation
(3) Receiver elements (manual drain, sight glass, vacuum
gauge)
(4) Housekeeping around pump

A.5.1.14.2.3.1(4) Additional inspections for instrument air
sources include the following:
(1) Aftercoolers (condition, operation of drains)
(2) Operating pressures (cut in, cut out, and control pressures)
(3) Electrical operation
(4) Receiver elements (auto drain, manual drain, sight glass,
pressure gauge)
(5) Pressure regulators (condition)
(6) Housekeeping around compressors

A.5.1.14.2.3.1(5) Additional inspections for manifold sources
include the following:
(1) Cylinder leads (condition)
(2) Cascade (switching from one header to another)
(3) Source valve (labeling)
(4) Relief valves (discharge location and condition)
(5) Leaks
(6) Security (door or gate locks and signage)
(7) Housekeeping around manifolds

A.5.1.14.2.3.1(8) Additional inspections for zone valves include
the following:
(1) Locations (relationship to terminals controlled)
(2) Leaks
(3) Labeling
(4) Housekeeping around alarm

A.5.1.14.2.3.1(9) Additional inspections for alarms include
the following:
(1) Dew point monitor (operation and calibration)
(2) Carbon monoxide monitor (operation and calibration)
(3) All local alarms on medical air, vacuum, WAGD, manifolds,
medical support gas sources (verify presence of required
alarms, perform electrical test, test lag alarm)
(4) Locations (visible to staff)
(5) Housekeeping around alarms

A.5.1.14.2.3.1(11) An additional inspection for station outlets/
inlets is a general condition (noninterchangeable indexing).

A.5.1.15 Medical gas and vacuum systems should be surveyed
at least annually for the items that follow and deficient items
corrected. Survey of medical air and instrument air sources
should include, but not be limited to, the following:
(1) Dew point monitor (operation and calibration)
(2) Carbon monoxide monitor (medical air only) (operation
and calibration)
(3) Aftercoolers (condition, operation of drains)
(4) Operating pressures (cut-in, cut-out, and control pressures)
(5) All local alarms (verify presence of required alarms, perform
electrical test, test lag alarm)
(6) Receiver elements (auto drain, manual drain, sight glass,
pressure gauge)
(7) Filters (condition)
(8) Pressure regulators (condition, output pressure)
(9) Source valve (labeling)
(10) Intake (location and condition)
(11) Housekeeping around compressors

Survey of the medical vacuum and the WAGD source(s)
should include, but not be limited to, the following:
(1) Operating vacuum (cut-in, cut-out, and control pressures)
(2) All local alarms (verify presence of required alarms, perform
electrical test, test lag alarm)
(3) Receiver elements (manual drain, sight glass, vacuum
gauge)
(4) Source valve (labeling)
(5) Exhaust (location and condition)
(6) Housekeeping around pump

Survey of the medical gas manifold source(s) should include,
but not be limited to, the following:
(1) Number of cylinders (damaged connectors)
(2) Cylinder leads (condition)
(3) Cascade (switching from one header to another)
(4) All local alarms (verify presence of required alarms, perform
electrical test, test all alarms)
(5) Source valve (labeling)
(6) Relief valves (discharge location and condition)
(7) Leaks
(8) Security (door or gate locks and signage)
(9) Ventilation (general operation, housekeeping)
(10) Housekeeping around manifolds

Survey of medical gas area alarms should include, but not
be limited to, the following:
(1) Locations (visible to staff)
(2) Signals (audible and visual, use test function)
(3) Activation at low pressure
(4) Housekeeping around alarm

Survey of medical gas master alarms should include, but
not be limited to, the following:
(1) Locations (visible to appropriate staff)
(2) Signals (audible and visual, use test function)
(3) Activation at low pressure
(4) Housekeeping around alarm

Survey of zone valves should include, but not be limited to,
the following:
(1) Locations (relationship to terminals controlled)
(2) Leaks
(3) Labeling
(4) Housekeeping around alarm

Survey of medical gas outlet/inlets should include, but not
be limited to, the following:
(1) Flow and function
(2) Latching/delatching
(3) Leaks
(4) General condition (noninterchangeable indexing)
The facility should retain a written or an electronic copy of
all findings and any corrections performed.

Based on observation and facility staff interview, facility staff did not ensure receptacles in wet locations were equipped with GFCI protection. Failure to protect electrical service in a wet location puts any person in the area at risk of electrical shock in the event of water coming into contact with energized electrical equipment. This facility had a capacity of 25. The facility census was 5.

Observations on 11/29/2018, during the facility tour, showed the following rooms did not contain GFCI protected electrical outlets in wet locations:

-Outlets above the sinks in patient rooms #224, #225, #226, #227, #228, #235, #237, #240, #242;

- East hallway IT/Janitor's closet/soiled hopper/Electrical room contained three outlets without GFCI protection, an energized electrical transformer and a soiled laundry hopper with spray nozzle connected to the domestic water supply connected to patient rooms.

During an interview on 11/29/2018 at approximately 7:14 P.M., the Maintenance Director said he/she discovered facility staff were not doing electrical inspections of receptacles on 11/29/2018. Additionally, he/she said he/she became the Maintenance Director on 08/15/2018 and had no knowledge of the prior building operations.

NFPA 99, 2012 edition, section 6.3.2.2.4.2 states: "6.3.2.2.4.2* Personnel Protection. If used, ground-fault circuit
interrupters (GFCIs) shall be listed."

Based on record review and facility staff interview, facility staff failed to conduct an annual load bank test for one of two facility emergency generators. Facility staff failed to provide an emergency stop switch away from the generator set location for one of two facility emergency generators. This facility had a capacity of 25. The facility census was 5.

1) Observation 11/29/2018, during the facility tour, showed emergency generator #2 's emergency stop switch located in the generator casing. Observation did not show another emergency stop switch for generator #2 at another location.

2) Record review on 11/28/2018, of generator #1's testing and inspection records, did not show records of annual testing with the available building electrical load at a minimum of 30% of the generator nameplate rating or load bank records.

During an interview on 11/29/2018 at 6:59 P.M., the Maintenance Director said generator #1's load bank test date was missed due to a pending repair to the generator. He/she said he/she did not know about generator #2's emergency stop switch requirement. Additionally, he/she said he/she became the Maintenance Director on 08/15/2018 and had no knowledge of the prior building operations.


NFPA 110, Standard for Emergency and Standby Power Systems, 2010 edition states:

5.6.5.6* All installations shall have a remote manual stop station
of a type to prevent inadvertent or unintentional operation located
outside the room housing the prime mover, where so installed,
or elsewhere on the premises where the prime mover is
located outside the building.

5.6.5.6.1 The remote manual stop station shall be labeled.

8.4.2* Diesel generator sets in service shall be exercised at
least once monthly, for a minimum of 30 minutes, using one
of the following methods:
(1) Loading that maintains the minimum exhaust gas temperatures
as recommended by the manufacturer
(2) Under operating temperature conditions and at not less
than 30 percent of the EPS nameplate kW rating

8.4.2.1 The date and time of day for required testing shall be
decided by the owner, based on facility operations.

8.4.2.2 Equivalent loads used for testing shall be automatically
replaced with the emergency loads in case of failure of
the primary source.

8.4.2.3 Diesel-powered EPS installations that do not meet the
requirements of 8.4.2 shall be exercised monthly with the available
EPSS load and shall be exercised annually with supplemental
loads at not less than 50 percent of the EPS nameplate kW
rating for 30 continuous minutes and at not less than 75 percent
of the EPS nameplate kWrating for 1 continuous hour for a total
test duration of not less than 1.5 continuous hours.

8.3 Maintenance and Operational Testing.

8.3.1* The EPSS shall be maintained to ensure to a reasonable
degree that the system is capable of supplying service within the
time specified for the type and for the time duration specified for
the class.

8.3.2 A routine maintenance and operational testing program
shall be initiated immediately after the EPSS has passed
acceptance tests or after completion of repairs that impact the
operational reliability of the system.

8.3.2.1 The operational test shall be initiated at an ATS and
shall include testing of each EPSS component on which maintenance
or repair has been performed, including the transfer of
each automatic and manual transfer switch to the alternate
power source, for a period of not less than 30 minutes under
operating temperature.

8.3.3 A written schedule for routine maintenance and operational
testing of the EPSS shall be established.

8.3.4 A permanent record of the EPSS inspections, tests, exercising,
operation, and repairs shall be maintained and readily
available.

8.3.4.1 The permanent record shall include the following:
(1) The date of the maintenance report
(2) Identification of the servicing personnel
(3) Notation of any unsatisfactory condition and the corrective
action taken, including parts replaced
(4) Testing of any repair for the time as recommended by the
manufacturer

8.3.5* Transfer switches shall be subjected to a maintenance and
testing program that includes all of the following operations:
(1) Checking of connections
(2) Inspection or testing for evidence of overheating and excessive
contact erosion
(3) Removal of dust and dirt
(4) Replacement of contacts when required

8.3.6 Paralleling gear shall be subject to an inspection, testing,
and maintenance program that includes all of the following
operations:
(1) Checking of connections
(2) Inspection or testing for evidence of overheating and excessive
contact erosion
(3) Removal of dust and dirt
(4) Replacement of contacts when required

8.3.7* Storage batteries, including electrolyte levels or battery
voltage, used in connection with systems shall be inspected
weekly and maintained in full compliance with manufacturer ' s
specifications.

8.3.7.1 Maintenance of lead-acid batteries shall include the
monthly testing and recording of electrolyte specific gravity. Battery
conductance testing shall be permitted in lieu of the testing
of specific gravity when applicable or warranted.

8.3.7.2 Defective batteries shall be replaced immediately
upon discovery of defects.

8.3.8 A fuel quality test shall be performed at least annually
using tests approved by ASTM standards.

8.4 Operational Inspection and Testing.

8.4.1* EPSSs, including all appurtenant components, shall be
inspected weekly and exercised under load at least monthly.

8.4.6 Transfer switches shall be operated monthly.

8.4.6.1 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.

7.2.4* Minimizing the possibility of damage resulting from interruptions
of the emergency source shall be a design consideration
for EPSS equipment.

A.7.2.4 When installing the EPSS equipment and related
auxiliaries, environmental considerations should be given,
particularly with regard to the installation of the fuel tanks
and exhaust lines, or the EPS building, or both.
To protect against disruption of power in the facility, it is recommended
that the transfer switch be located as close to the load
as possible. The following are examples of external influences:
(1) Natural conditions
(a) Storms
(b) Floods
(c) Earthquakes
(d) Tornadoes
(e) Hurricanes
(f) Lightning
(g) Ice storms
(h) Wind
(i) Fire
(2) Human-caused conditions
(a) Vandalism
(b) Sabotage
(c) Other similar occurrences
(3) Material and equipment failures
For natural conditions, EPSS design should consider the
"100-year storm" flooding level or the flooding level predicted
by the Sea, Lake, and Overland Surges from Hurricanes
(SLOSH) models for a Class 4 hurricane.