HospitalInspections.org

Observation and discussion with the Chief Nursing Officer and the Maintenance Supervisor between 9 am and 1 pm, on 3/25/2010 revealed that certain requirements stipulated in NFPA 101 were not met.

Interior finish for corridors and exitways, including exposed interior surfaces of buildings such as fixed or movable walls, partitions, columns, and ceilings has a flame spread rating of Class A or Class B. [NFPA 101, Life Safety Code, 2003: ? 19.3.3.1, ? 19.3.3.2.]

Findings: This requirement was discussed and it was determined that the required documentation is not retained by the staff.

Observation and discussion with the Chief Nursing Officer and the Maintenance Supervisor between 9 am and 1 pm, on 3/25/2010 revealed that certain requirements stipulated in NFPA 101 were not met.

Interior finish for rooms and spaces not used for corridors or exitways, including exposed interior surfaces of buildings such as fixed or movable walls, partitions, columns, and ceilings has a flame spread rating of Class A or Class B. (In fully-sprinklered buildings, flame spread rating of Class A, Class B, or Class C may be continued in use within rooms separated in accordance with 19.3.6 from the access corridors.) [NFPA 101, Life Safety Code, 2003: ? 19.3.3.1, ? 19.3.3.2.]

Findings: This requirement was discussed and it was determined that the required documentation is not retained by the staff.

Observation and discussion with the Chief Nursing Officer and the Maintenance Supervisor between 9 am and 1 pm, on 3/25/2010 revealed that certain requirements stipulated in NFPA 101 were not met.

a. Smoke Passage Resisted

Corridor walls are constructed to resist smoke passage [Re: NFPA 101, Life Safety Code, 2003: ? 19.3.6.1.]

Findings: At the smoke partition above the double egress doors outside the lab waiting room, required caulking was not installed, thereby jeopardizing the integrity of the corridor. The facility shall affirm that all penetrations have been caulked properly.

b. Roller Latches

Roller latches are prohibited by CMS regulations in all health care facilities [Re: NFPA 101, Life Safety Code, 2003: ? 19.3.6.3.]

Findings: Doors were observed in the med surg suite that used roller latches. These are not allowed. The facility shall submit a plan for replacement of all roller latches.

Observation and discussion with the Chief Nursing Officer and the Maintenance Supervisor between 9 am and 1 pm, on 3/25/2010 revealed that certain requirements stipulated in NFPA 13 were not met.

A supply of spare sprinklers [never fewer than six] shall be maintained on the premises so that any sprinklers that have operated or been damaged in any way can be promptly replaced. These sprinklers shall correspond to the types and temperature ratings of the sprinklers in the property. The sprinklers shall be kept in a cabinet located where the temperature to which they are subjected will at no time exceed 100 degrees F [Re: NFPA 13, Installation of Sprinkler Systems, 1999: 3-2.9.1.]

Findings: This requirement was discussed and it was not apparent that the proper supply of spare sprinkler heads were available for use. The facility shall affirm that the proper type and number of sprinkler heads are available for use.

Observation and discussion with the Chief Nursing Officer and the Maintenance Supervisor between 9 am and 1 pm, on 3/25/2010 revealed that certain regulations enforced by the Department were not met.

a. Filtration Level

All central air handling systems serving patient care areas, including nursing unit corridors, shall be equipped with filters having efficiencies equal to, or greater than, those specified in Table 4 of ? 133.169(d) of this title. ..... [Re: 25 TAC, HLR, 2007: ? 135.162(d)(4)(D)(ii).]

Findings: During the survey, it could not be determined if the air supplied to the procedure room where the CT Scan unit is located [which is considered part of the hospital] satisfies the requirement for multiple filters and the requirement for the 90% filtration level. The facility shall verify that these requirements are met.

b. Draft Gauges

A manometer or draft gauge shall be installed across each filter bed having a required efficiency of 75% or more, including laboratory hoods requiring high efficiency particulate air [HEPA] filters [Re: 25 TAC HLR, 2007: ? 133.162(d)(4)[D](ii)(V).]

Findings: The facility shall verify that these gauges are installed in the air supply for the CT Scan location.

c. Toilet Room Exhaust

All rooms and areas in the hospital listed in Table 3 of ?133.169[c] of this title shall have provision for positive ventilation. Fans serving exhaust systems shall be located at the discharge end and shall be conveniently accessible for service. ..... [Re: 25 TAC HLR, 2007: ? 133.162(d)(4)[D](i).]

Findings: The exhaust fan in the toilet room in the CT Scan procedure location appeared to be an exhaust fan similar to those used for residential purposes. The facility shall affirm the fan associated with this exhaust is located at the end of the run as required.

d. Toilet Room Ventilation

..... The ventilation rates shown in Table 3 of ? 133.169[c] of this title shall be used only as minimum requirements since they do not preclude the use of higher rates that may be appropriate [Re: 25 TAC HLR, 2007: ? 133.162(d)(4)[D](i).] This table requires a negative pressure in toilet rooms with a minimum number of air changes of 10 per hour, and that the exhaust be directed to the outside of the facility.

Findings: The toilet room [identified above] exhaust fan was switched with the toilet room overhead light. This mode of operation is not allowed. The department requires that this fan operate continuously so the required parameters can be met.

Observation and discussion with the Chief Nursing Officer and the Maintenance Supervisor between 9 am and 1 pm, on 3/25/2010 revealed that certain requirements stipulated in NFPA 10 were not met.

a. Class K Extinguisher

Fire Extinguishers provided for the protection of cooking appliances that use combustible cooking media [vegetable or animal oils and fats] shall be listed and labeled for Class K fires. Class K fire extinguishers manufactured after 1 Jan 2002 shall not be equipped with " extended wand-type " discharge devices [Re: NFPA 10, Standard for Portable Fire Extinguishers, 2002; ? 4.3.2]

Findings: This requirement was discussed with the staff and the area was checked. A Class K fire extinguisher was observed in the corner of the dietary suite, on the floor. The facility shall ensure that the proper Class K extinguisher is mounted as required for ease of use in an emergency.

b. Placard

A placard shall be conspicuously placed near the extinguisher [Class K Fire Extinguishers for Cooking Oil Fires] that states that the fire protection system shall be activated prior to using the fire extinguisher [Re: NFPA 10, Standard for Portable Fire Extinguishers, 2002; ? 4.3.2.2]

Findings: This requirement was discussed with the staff and the area was checked. The required placard was not installed as required.

Observation and discussion with the Chief Nursing Officer and the Maintenance Supervisor between 9 am and 1 pm, on 3/25/2010 revealed that certain requirements enforced by the Department of State Health Services [DSHS] were not met.

a. Use of PVC

Soil Stacks, drains, vents, waste lines, and leaders installed above ground within buildings shall be drain-waste-vent (DWV) weight or heavier and shall be: copper pipe, copper tube, cast iron pipe, or galvanized iron pipe [Re: 25 TAC HLR, 2007: ? 133.162(d)(4)(viii)(A).]

Findings: This requirement does not allow the use of PVC, which is flammable and emits noxious odors. This requirement was discussed after observing a PVC installation in the Dietary Suite. This PVC should be replaced.


b. Nurse Call System

The nurse call shall be in accordance with ?133 162(d)(5)(L) and Table 7 of ?133.169(g) of this title [Re: 25 TAC HLR, 2007: 133.163(l)(5)(B).]

Findings: The DSHS regulations require nurse call stations to be installed in imaging procedure areas. Table 7 as referenced above requires:

(i) Nurses Regular Calling System: Imaging Suite Holding, Prep and Recovery Areas; (ii) Emergency Calling System: Imaging Suite Patient Dressing Rooms; and (iii) Staff Emergency Assistance Calling System [Code Blue]:
Imaging Procedure Room. [Note - the Nurse Call system must be UL1069 compliant and have two way voice capability for Code Blue.]

These amenities were not installed in the CT Scan procedure area. The facility shall ensure that these are installed as required. The patient toilet room in the CT Scan area shall also be checked for compliance.

Observation and discussion with the Chief Nursing Officer and the Maintenance Supervisor between 9 am and 1 pm, on 3/25/2010 revealed that certain requirements stipulated by NFPA 99 and NFPA 110 were not met. [Note: there are two engine-generator set units to be tested/exercised.]

a. Monthly Full Load Tests

The emergency generator shall be exercised under full load for 30 minutes 12 times per year with testing intervals not shorter than 20 days or longer than 40 days [Re: NFPA 99, Health Care Facilities, 1999, ?3-4.4.1.1(b)(1) and NFPA 110, Emergency Standby Power Systems, 1999, ? 8.4.1.1.]

Findings:

A log was not available showing that this required maintenance was performed.

b. Transfer Switches Exercised

The transfer switches shall be exercised monthly [Re: NFPA 110, Emergency Standby Power Systems, 1999, ? 8.4.5.]

Findings:

A log was not available showing that this required maintenance was performed.

c. Circuit Breakers

Main and feeder circuit breakers shall be inspected annually and a program for periodically exercising the components shall be established according to manufacturer ' s recommendations [Re: NFPA 99, Health Care Facilities, 2002: ? 4.4.4.1.2.1.]

Findings: This requirement was discussed with the staff and it was determined that this requirement was not met. A log must be maintained for review.

d. Testing of Generator

If the monthly generator tests identified in (a) above are not performed, the generator must be tested for 2 continuous hours at 30% level of EPS nameplate KW rating annually [Re: NFPA 110, Emergency Standby Power Systems, 1999, ? 8-4.2.]. The generator must be tested under full load for 4 continuous hours every 3-4 years [Re: NFPA 110, Emergency Standby Power Systems, 1999, ? 8.4.8.]

Findings: This requirement was discussed with the staff and it was determined that this requirement was not met. A log must be maintained for review.

Observation and discussion with the Chief Nursing Officer and the Maintenance Supervisor between 9 am and 1 pm, on 3/25/2010 revealed that certain requirements stipulated by NFPA 70, NFPA 99 and NFPA 110 were not met. This topic is relevant to the required Type I Essential Electrical System in DSHS regulations.

a. Type I Essential Electrical System

A Type I essential electrical system shall be provided in each hospital in accordance with requirements of NFPA 99, Health Care Facilities, 2002 edition, NFPA 101, Life Safety Code, 2003 edition, and NFPA 110, Standard for Emergency and Standby Power Systems, 2002 edition [Re: 25 TAC, HLR, 2007: ?133.162(d)(5)(M).]

Findings: During the survey, it could not be determined if the electrical system in place was code compliant. Since the last LSC survey, a new 900 KW generator has been installed, evidently without DSHS oversight. It appeared that panelboards, previously classified as normal panelboards, are now powered by the new generator as though they are emergency panelboards. Therefore, receptacles installed in the ED exam rooms and labeled as normal receptacles, are now functioning as emergency receptacles powered by the new generator.

In response to this survey, the facility shall submit a one-line diagram depicting the interconnection of the electrical components required to constitute the Type I Essential Electrical System, stamped by a Registered Professional Engineer in the State of Texas, in the electrical discipline.

b. Emergency System Receptacles

Each patient bed location shall be supplied by at least two branch circuits, one or more from the emergency system and one or more from the normal system. At least one branch circuit from the emergency system shall supply an outlet(s) only at that bed location. All branch circuits from the normal system shall be from a single panelboard. Emergency system receptacles shall be identified and shall also indicate the panelboard and circuit supplying them [Re: NFPA 70, National Electrical Code, 2002; ??517.19(A).]

Findings: Receptacles previously connected to the normal power source, and still identified as normal receptacles, were observed in the exam rooms in the ED. All receptacles now connected to the new generator shall be marked [color] as required by NFPA 99, Health Care Facilities, 2002: 4.4.2.2.4.2(B), and labeled with circuit and panelboard numbers as required by NFPA 70, National Electrical Code, 2002: 517.19[A]. It should be noted that in critical areas [including emergency departments], an emergency branch circuit can provide power to only one patient location.

c. 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, functions specifically designated for different systems and branches were intermingled on panelboards, etc. Once the power sources are identified as required above, the facility shall ensure that all functions are allocated appropriately to the correct power sources.

d. Equipment 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, National Electrical Code, 2002: 700.9(A).] ' The above listed components shall be labeled with the words " LIFE SAFETY " , " CRITICAL " AND " EQUIPMENT " to be readily identifiable as part of the Essential Electrical System.

Findings: During the survey, it could not be determined which power source was connected to the various panelboards, etc. Each component must be labeled pursuant to this requirement, and the relevant generator shall be specified.

e. Update Circuit Directories

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 meaningful following the fulfillment of the requirements above.

f. Panelboard Bonding

The equipment grounding terminal buses of the normal and essential branch-circuit panelboards serving the same individual patient vicinity shall be bonded together with an insulated continuous copper conductor not smaller than 10 AWG. Where more than two panels serve the same location, this conductor shall be continuous from panel to panel, but shall be permitted to be broken in order to terminate on the ground bus in each panel [Re: NFPA 70, National Electrical Code, 2002: ? 517.14.] General reminder.

Findings: This topic was discussed during the survey, and it was not possible to determine that this feature was implemented properly. This feature shall be included in the one line diagram to be submitted.

Observation and discussion with the Chief Nursing Officer and the Maintenance Supervisor between 9 am and 1 pm, on 3/25/2010 revealed that certain requirements stipulated in NFPA 101 were not met.

Interior finish for corridors and exitways, including exposed interior surfaces of buildings such as fixed or movable walls, partitions, columns, and ceilings has a flame spread rating of Class A or Class B. [NFPA 101, Life Safety Code, 2003: ? 19.3.3.1, ? 19.3.3.2.]

Findings: This requirement was discussed and it was determined that the required documentation is not retained by the staff.

Observation and discussion with the Chief Nursing Officer and the Maintenance Supervisor between 9 am and 1 pm, on 3/25/2010 revealed that certain requirements stipulated in NFPA 101 were not met.

Interior finish for rooms and spaces not used for corridors or exitways, including exposed interior surfaces of buildings such as fixed or movable walls, partitions, columns, and ceilings has a flame spread rating of Class A or Class B. (In fully-sprinklered buildings, flame spread rating of Class A, Class B, or Class C may be continued in use within rooms separated in accordance with 19.3.6 from the access corridors.) [NFPA 101, Life Safety Code, 2003: ? 19.3.3.1, ? 19.3.3.2.]

Findings: This requirement was discussed and it was determined that the required documentation is not retained by the staff.

Observation and discussion with the Chief Nursing Officer and the Maintenance Supervisor between 9 am and 1 pm, on 3/25/2010 revealed that certain requirements stipulated in NFPA 101 were not met.

a. Smoke Passage Resisted

Corridor walls are constructed to resist smoke passage [Re: NFPA 101, Life Safety Code, 2003: ? 19.3.6.1.]

Findings: At the smoke partition above the double egress doors outside the lab waiting room, required caulking was not installed, thereby jeopardizing the integrity of the corridor. The facility shall affirm that all penetrations have been caulked properly.

b. Roller Latches

Roller latches are prohibited by CMS regulations in all health care facilities [Re: NFPA 101, Life Safety Code, 2003: ? 19.3.6.3.]

Findings: Doors were observed in the med surg suite that used roller latches. These are not allowed. The facility shall submit a plan for replacement of all roller latches.

Observation and discussion with the Chief Nursing Officer and the Maintenance Supervisor between 9 am and 1 pm, on 3/25/2010 revealed that certain requirements stipulated in NFPA 13 were not met.

A supply of spare sprinklers [never fewer than six] shall be maintained on the premises so that any sprinklers that have operated or been damaged in any way can be promptly replaced. These sprinklers shall correspond to the types and temperature ratings of the sprinklers in the property. The sprinklers shall be kept in a cabinet located where the temperature to which they are subjected will at no time exceed 100 degrees F [Re: NFPA 13, Installation of Sprinkler Systems, 1999: 3-2.9.1.]

Findings: This requirement was discussed and it was not apparent that the proper supply of spare sprinkler heads were available for use. The facility shall affirm that the proper type and number of sprinkler heads are available for use.

Observation and discussion with the Chief Nursing Officer and the Maintenance Supervisor between 9 am and 1 pm, on 3/25/2010 revealed that certain regulations enforced by the Department were not met.

a. Filtration Level

All central air handling systems serving patient care areas, including nursing unit corridors, shall be equipped with filters having efficiencies equal to, or greater than, those specified in Table 4 of ? 133.169(d) of this title. ..... [Re: 25 TAC, HLR, 2007: ? 135.162(d)(4)(D)(ii).]

Findings: During the survey, it could not be determined if the air supplied to the procedure room where the CT Scan unit is located [which is considered part of the hospital] satisfies the requirement for multiple filters and the requirement for the 90% filtration level. The facility shall verify that these requirements are met.

b. Draft Gauges

A manometer or draft gauge shall be installed across each filter bed having a required efficiency of 75% or more, including laboratory hoods requiring high efficiency particulate air [HEPA] filters [Re: 25 TAC HLR, 2007: ? 133.162(d)(4)[D](ii)(V).]

Findings: The facility shall verify that these gauges are installed in the air supply for the CT Scan location.

c. Toilet Room Exhaust

All rooms and areas in the hospital listed in Table 3 of ?133.169[c] of this title shall have provision for positive ventilation. Fans serving exhaust systems shall be located at the discharge end and shall be conveniently accessible for service. ..... [Re: 25 TAC HLR, 2007: ? 133.162(d)(4)[D](i).]

Findings: The exhaust fan in the toilet room in the CT Scan procedure location appeared to be an exhaust fan similar to those used for residential purposes. The facility shall affirm the fan associated with this exhaust is located at the end of the run as required.

d. Toilet Room Ventilation

..... The ventilation rates shown in Table 3 of ? 133.169[c] of this title shall be used only as minimum requirements since they do not preclude the use of higher rates that may be appropriate [Re: 25 TAC HLR, 2007: ? 133.162(d)(4)[D](i).] This table requires a negative pressure in toilet rooms with a minimum number of air changes of 10 per hour, and that the exhaust be directed to the outside of the facility.

Findings: The toilet room [identified above] exhaust fan was switched with the toilet room overhead light. This mode of operation is not allowed. The department requires that this fan operate continuously so the required parameters can be met.

Observation and discussion with the Chief Nursing Officer and the Maintenance Supervisor between 9 am and 1 pm, on 3/25/2010 revealed that certain requirements stipulated in NFPA 10 were not met.

a. Class K Extinguisher

Fire Extinguishers provided for the protection of cooking appliances that use combustible cooking media [vegetable or animal oils and fats] shall be listed and labeled for Class K fires. Class K fire extinguishers manufactured after 1 Jan 2002 shall not be equipped with " extended wand-type " discharge devices [Re: NFPA 10, Standard for Portable Fire Extinguishers, 2002; ? 4.3.2]

Findings: This requirement was discussed with the staff and the area was checked. A Class K fire extinguisher was observed in the corner of the dietary suite, on the floor. The facility shall ensure that the proper Class K extinguisher is mounted as required for ease of use in an emergency.

b. Placard

A placard shall be conspicuously placed near the extinguisher [Class K Fire Extinguishers for Cooking Oil Fires] that states that the fire protection system shall be activated prior to using the fire extinguisher [Re: NFPA 10, Standard for Portable Fire Extinguishers, 2002; ? 4.3.2.2]

Findings: This requirement was discussed with the staff and the area was checked. The required placard was not installed as required.

Observation and discussion with the Chief Nursing Officer and the Maintenance Supervisor between 9 am and 1 pm, on 3/25/2010 revealed that certain requirements enforced by the Department of State Health Services [DSHS] were not met.

a. Use of PVC

Soil Stacks, drains, vents, waste lines, and leaders installed above ground within buildings shall be drain-waste-vent (DWV) weight or heavier and shall be: copper pipe, copper tube, cast iron pipe, or galvanized iron pipe [Re: 25 TAC HLR, 2007: ? 133.162(d)(4)(viii)(A).]

Findings: This requirement does not allow the use of PVC, which is flammable and emits noxious odors. This requirement was discussed after observing a PVC installation in the Dietary Suite. This PVC should be replaced.


b. Nurse Call System

The nurse call shall be in accordance with ?133 162(d)(5)(L) and Table 7 of ?133.169(g) of this title [Re: 25 TAC HLR, 2007: 133.163(l)(5)(B).]

Findings: The DSHS regulations require nurse call stations to be installed in imaging procedure areas. Table 7 as referenced above requires:

(i) Nurses Regular Calling System: Imaging Suite Holding, Prep and Recovery Areas; (ii) Emergency Calling System: Imaging Suite Patient Dressing Rooms; and (iii) Staff Emergency Assistance Calling System [Code Blue]:
Imaging Procedure Room. [Note - the Nurse Call system must be UL1069 compliant and have two way voice capability for Code Blue.]

These amenities were not installed in the CT Scan procedure area. The facility shall ensure that these are installed as required. The patient toilet room in the CT Scan area shall also be checked for compliance.

Observation and discussion with the Chief Nursing Officer and the Maintenance Supervisor between 9 am and 1 pm, on 3/25/2010 revealed that certain requirements stipulated by NFPA 99 and NFPA 110 were not met. [Note: there are two engine-generator set units to be tested/exercised.]

a. Monthly Full Load Tests

The emergency generator shall be exercised under full load for 30 minutes 12 times per year with testing intervals not shorter than 20 days or longer than 40 days [Re: NFPA 99, Health Care Facilities, 1999, ?3-4.4.1.1(b)(1) and NFPA 110, Emergency Standby Power Systems, 1999, ? 8.4.1.1.]

Findings:

A log was not available showing that this required maintenance was performed.

b. Transfer Switches Exercised

The transfer switches shall be exercised monthly [Re: NFPA 110, Emergency Standby Power Systems, 1999, ? 8.4.5.]

Findings:

A log was not available showing that this required maintenance was performed.

c. Circuit Breakers

Main and feeder circuit breakers shall be inspected annually and a program for periodically exercising the components shall be established according to manufacturer ' s recommendations [Re: NFPA 99, Health Care Facilities, 2002: ? 4.4.4.1.2.1.]

Findings: This requirement was discussed with the staff and it was determined that this requirement was not met. A log must be maintained for review.

d. Testing of Generator

If the monthly generator tests identified in (a) above are not performed, the generator must be tested for 2 continuous hours at 30% level of EPS nameplate KW rating annually [Re: NFPA 110, Emergency Standby Power Systems, 1999, ? 8-4.2.]. The generator must be tested under full load for 4 continuous hours every 3-4 years [Re: NFPA 110, Emergency Standby Power Systems, 1999, ? 8.4.8.]

Findings: This requirement was discussed with the staff and it was determined that this requirement was not met. A log must be maintained for review.

Observation and discussion with the Chief Nursing Officer and the Maintenance Supervisor between 9 am and 1 pm, on 3/25/2010 revealed that certain requirements stipulated by NFPA 70, NFPA 99 and NFPA 110 were not met. This topic is relevant to the required Type I Essential Electrical System in DSHS regulations.

a. Type I Essential Electrical System

A Type I essential electrical system shall be provided in each hospital in accordance with requirements of NFPA 99, Health Care Facilities, 2002 edition, NFPA 101, Life Safety Code, 2003 edition, and NFPA 110, Standard for Emergency and Standby Power Systems, 2002 edition [Re: 25 TAC, HLR, 2007: ?133.162(d)(5)(M).]

Findings: During the survey, it could not be determined if the electrical system in place was code compliant. Since the last LSC survey, a new 900 KW generator has been installed, evidently without DSHS oversight. It appeared that panelboards, previously classified as normal panelboards, are now powered by the new generator as though they are emergency panelboards. Therefore, receptacles installed in the ED exam rooms and labeled as normal receptacles, are now functioning as emergency receptacles powered by the new generator.

In response to this survey, the facility shall submit a one-line diagram depicting the interconnection of the electrical components required to constitute the Type I Essential Electrical System, stamped by a Registered Professional Engineer in the State of Texas, in the electrical discipline.

b. Emergency System Receptacles

Each patient bed location shall be supplied by at least two branch circuits, one or more from the emergency system and one or more from the normal system. At least one branch circuit from the emergency system shall supply an outlet(s) only at that bed location. All branch circuits from the normal system shall be from a single panelboard. Emergency system receptacles shall be identified and shall also indicate the panelboard and circuit supplying them [Re: NFPA 70, National Electrical Code, 2002; ??517.19(A).]

Findings: Receptacles previously connected to the normal power source, and still identified as normal receptacles, were observed in the exam rooms in the ED. All receptacles now connected to the new generator shall be marked [color] as required by NFPA 99, Health Care Facilities, 2002: 4.4.2.2.4.2(B), and labeled with circuit and panelboard numbers as required by NFPA 70, National Electrical Code, 2002: 517.19[A]. It should be noted that in critical areas [including emergency departments], an emergency branch circuit can provide power to only one patient location.

c. 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, functions specifically designated for different systems and branches were intermingled on panelboards, etc. Once the power sources are identified as required above, the facility shall ensure that all functions are allocated appropriately to the correct power sources.

d. Equipment 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, National Electrical Code, 2002: 700.9(A).] ' The above listed components shall be labeled with the words " LIFE SAFETY " , " CRITICAL " AND " EQUIPMENT " to be readily identifiable as part of the Essential Electrical System.

Findings: During the survey, it could not be determined which power source was connected to the various panelboards, etc. Each component must be labeled pursuant to this requirement, and the relevant generator shall be specified.

e. Update Circuit Directories

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 meaningful following the fulfillment of the requirements above.

f. Panelboard Bonding

The equipment grounding terminal buses of the normal and essential branch-circuit panelboards serving the same individual patient vicinity shall be bonded together with an insulated continuous copper conductor not smaller than 10 AWG. Where more than two panels serve the same location, this conductor shall be continuous from panel to panel, but shall be permitted to be broken in order to terminate on the ground bus in each panel [Re: NFPA 70, National Electrical Code, 2002: ? 517.14.] General reminder.

Findings: This topic was discussed during the survey, and it was not possible to determine that this feature was implemented properly. This feature shall be included in the one line diagram to be submitted.