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The inspector observed, while accompanied by The CEO, CFO, COO, director of the medical staff services, director of the facilities, Quality analyst and maintenance personnel, during the hours of the inspection from 01:20 PM to 05:30 PM on 02/11/2019 that there were the following issues. They were the following issues.

A) There were doors were not released from the magnetic hold open device upon activate the fire alarm system .



B) Some of the smoke barrier cross corridor doors was not fully closed upon the fire alarm activation.

The inspector observed, while accompanied by The CEO, CFO, COO, director of the medical staff services, director of the facilities, Quality analyst and maintenance personnel, during the hours of the inspection from 01:20 PM to 05:30 PM on 02/11/2019 that there were the following issues. They were the following issues.

(A) The boilers' certificates were not available.

The inspector observed, while accompanied by The CEO, CFO, COO, director of the medical staff services, director of the facilities, Quality analyst and maintenance personnel, during the hours of the inspection from 01:20 PM to 05:30 PM on 02/11/2019 that there were the following issues. They were the following issues.


(A) There was a missing battery powered lighting unit at the generator set location and the automatic transfer switch location.



(B) The electrical directory was not updated in accordance to the new or modified receptacles.



(C) There was not a bonding wire provided between the normal and essential branch-circuits panelboards. This does not comply with NFPA 70, 2002: 517-14. - Panelboard bonding requires the equipment grounding terminal buses of the normal and essential branch-circuits panelboards serving the same individual patient vicinity be bonded together with an insulated continuous copper conductor not smaller than # 10 AWG.



(D) The nurse call system was powered from the life safety branch and not from the critical branch. This does not comply with NFPA 70, 517.33



(E) Receptacles were not tested or logged for the isolation monitor inside the OR. Electrical Systems -Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. The facility shall establish a testing interval and maintain testing records.



(F) The labels provided for the electrical panels and the essential transfer switches were not readily identifiable to identify life safety, critical and equipment branch. This is not in accordance with NFPA 70.

The inspector observed, while accompanied by The CEO, CFO, COO, director of the medical staff services, director of the facilities, Quality analyst and maintenance personnel. during the hours of the inspection from 01:20 PM to 05:30 PM on 02/11/2019 that there were the following issues. They were the following issues.


(A) There was no isolation between the galvanized conduits and the copper medical air gas pipes.



(B) The med gas cylinders either full or empty stored in the open was not protected. This is not in accordance with NFPA 99.



(C) The distance between the parked vehicle and the bulk storage tank was less than 10'-0". This does not comply with NFPA 50.