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The facility failed to provide a building construction type per code. Findings include:

During the survey, the following is an example of what was observed:
Unprotected wood structural members were observed above the lay-in ceiling at the roof deck at the four hour fire wall separating the 1981 addition from the 2004 addition.

____________________

2000 NFPA 101, 19.1.6.2 Health care occupancies shall be limited to the types of building construction shown in Table 19.1.6.2. (See 8.2.1.)
Table 19.1.6.2 Construction Type Limitations
Construction Stories
Type
1 2 3 4 or
More
I(443) X X X X
I(332) X X X X
II(222) X X X X
II(111) X X* X* NP
II(000) X* X* NP NP
III(211) X* X* NP NP
III(200) X* NP NP NP
IV(2HH) X* X* NP NP
V(111) X* X* NP NP
V(000) X* NP NP NP
X: Permitted type of construction.
NP: Not permitted.
*Building requires automatic sprinkler protection. (See 19.3.5.1.)


2000 NFPA 101, 8.2.1 Buildings or structures occupied or used in accordance with the individual occupancy chapters (Chapters 12 through 42) shall meet the minimum construction requirements of those chapters. NFPA 220, Standard on Types of Building Construction, shall be used to determine the requirements for the construction classification. Where the building or facility includes additions or connected structures of different construction types, the rating and classification of the structure shall be based on either of the following:
(1) Separate buildings if a 2-hour or greater vertically-aligned fire barrier wall in accordance with NFPA 221, Standard for Fire Walls and Fire Barrier Walls, exists between the portions of the building
Exception: The requirement of 8.2.1(1) shall not apply to previously approved separations between buildings.
(2) The least fire-resistive type of construction of the connected portions, if no such separation is provided
.

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The facility failed to maintain the corridor openings per code. Findings include:

During the survey, the following are examples of what was observed:
1. Room 139 corridor door was not positive latching
2. Break Room corridor door had a self-closing device on it, but was being held open by a wedge
_______________
2000 NFPA 101, 18.3.6.3.2 Doors shall be provided with positive latching hardware. Roller latches shall be prohibited.

2007 CMS - 2786R There is no impediment to the closing of the corridor doors.

.

The facility failed to maintain separation of hazardous areas. Findings include: During the survey, the following is an example of what was observed:

1. Imaging Mechanical Room had unsealed penetrations around a water line, and at the end of two sleeve's.


27382


2. Storage Room by the D.O.N.'s Office was not positive latching by the self-closing device.

_______________

2000 NFPA 101, 19.3.2.1 Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing.

2000 NFPA 101, 19.3.6.3.2 Doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door. Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.2.
.

.
The facility failed to maintain the hazardous areas per code. Findings include:

During the survey, the following are examples of what was observed:
The following doors had a self-closing devices that were not closing the door all the way to make it positive latch:
1. Soiled Utility
2. Clean Utility
_____________________
2000 NFPA 101, 8.4.1.3 Doors in barriers required to have a fire resistance rating shall have a 3/4-hour fire protection rating and shall be self-closing or automatic-closing in accordance with 7.2.1.8.
2000 NFPA 101, 7.2.1.8.1 A door normally required to be kept closed shall not be secured in the open position at any time and shall be self-closing or automatic-closing in accordance with 7.2.1.8.2.
.

The facility failed to maintain the exit access per code. Findings include:

During the survey, the following are examples of what was observed:
1. The Electrical Room corridor door in the Imaging Wing, when fully opened projected more than 7" into the corridor.
2. The following rooms had a double keyed dead bolt lock on the door:
a. Utilization Review Office
b. Front Office Break Room corridor door

_____________

2000 NFPA 101, 7.2.1.4.4 During its swing, any door in a means of egress shall leave not less than one-half of the required width of an aisle, corridor, passageway, or landing unobstructed and shall not project more than 7 in. (17.8 cm) into the required width of an aisle, corridor, passageway, or landing, when fully open. Doors shall not open directly onto a stair without a landing. The landing shall have a width not less than the width of the door. (See 7.2.1.3.)
2000 NFPA 101, 7.1.9 Any device or alarm installed to restrict the improper use of a means of egress shall be designed and installed so that it cannot, even in case of failure, impede or prevent emergency use of such means of egress unless otherwise provided in 7.2.1.6 and Chapters 18, 19, 22, and 23.
.

The facility failed to maintain/provide a fire alarm system per code. Findings include:

During the survey, the following are examples of what was observed:
1. "Kitchen Smoke Compartment":
a. Did not have a visual device
b. The audible device did not work upon:
i. Activation of the fire alarm system in the Imaging Wing
ii. Activation of the fire alarm system in the East Wing (building 0202)
2. "Laboratory Smoke Compartment" did not have an audible/visual device

___________________

2000 NFPA 101, 9.6.1.4 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.
1999 NFPA 72, 4-4.3.1
Visible notification appliances used in the public mode shall be located and shall be of a type, size, intensity, and number so that the operating effect of the appliance is seen by the intended viewers regardless of the viewer ' s orientation.

2000 NFPA 101, 9.6.3.2 Notification shall be provided by audible and visible signals in accordance with 9.6.3.3 through 9.6.3.12.
.

The facility failed to perform sensitivity testing of the smoke detectors. Findings include: During the survey, the following is an example of what was observed:


Documentation provided by the facility during the survey did not indicate sensitivity testing of the smoke detectors. Detector sensitivity shall be checked with one year after installation and every alternate year thereafter per 72, 7-3.2.1. (Up to 5 years permitted under certain circumstances. See 7-3.2.1).

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The facility failed to perform sensitivity testing of the smoke detectors. Findings include: During the survey, the following is an example of what was observed:


Documentation provided by the facility during the survey did not indicate sensitivity testing of the smoke detectors. Detector sensitivity shall be checked with one year after installation and every alternate year thereafter per 72, 7-3.2.1. (Up to 5 years permitted under certain circumstances. See 7-3.2.1).
.

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Sprinkler coverage was observed during the survey not adequately provided. Findings include: During the survey, the following are examples of what was observed:

1. Escutcheon plate loose on a sprinkler in the walk in cooler.

2. Ceiling tile missing in the Biohazard Room by the Administrator Office.

----------------------------------
2000 NFPA 13, 3-2.7.2 Escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly.

NFPA 13 5-6., Sprinklers shall be arranged to be in compliance.
.

The facility failed to perform the required maintenance of the facility sprinkler system. Findings include: During the survey, the following are examples of what was observed:


1. Identification sign for fire department connections was not provided.

2. Documentation of the calibration test for the sprinkler system gauges was not provided.


27382


3. D.O.N.'s Storage Closet next to the Lab. Manager's Office had binders piled up around the sidewall sprinkler head.

___________________
NFPA 101,2000 Edition, 9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this code shall be inspected, tested, and maintained in accordance with NFPA 25, Standards for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

NFPA 25, 1998 Edition, 9-7.1 Fire department connections shall be inspected quarterly. The inspection shall verify the following:
(a) The fire department connections are visible and accessible.
(b) Couplings or swivels are not damaged and rotate smoothly.
(c) Plugs or caps are in place and undamaged.
(d) Gaskets are in place and in good conition.
(e) Identification signs are in place.
(f) The check valve is not leaking.
(g) The automatic drain valve is in place and operating properly.

NFPA 25, Table 2-1 Summary of Sprinkler System Inspection, Testing, and Maintenance

1999 NFPA 13, 5-5.6 The clearance between the deflector and the top of storage shall be 18 in. (457 mm) or greater.
.

The facility failed to perform the required maintenance of the facility sprinkler system. Findings include: During the survey, the following are examples of what was observed:


1. Cap missing on the fire department connection located at the pit.

2. Documentation of the calibration test for the sprinkler system gauges was not provided.



NFPA 101,2000 Edition, 9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this code shall be inspected, tested, and maintained in accordance with NFPA 25, Standards for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

NFPA 25, 1998 Edition, 9-7.1 Fire department connections shall be inspected quarterly. The inspection shall verify the following:
(a) The fire department connections are visible and accessible.
(b) Couplings or swivels are not damaged and rotate smoothly.
(c) Plugs or caps are in place and undamaged.
(d) Gaskets are in place and in good conition.
(e) Identification signs are in place.
(f) The check valve is not leaking.
(g) The automatic drain valve is in place and operating properly.

NFPA 25, Table 2-1 Summary of Sprinkler System Inspection, Testing, and Maintenance

NFPA 25, 9-2.8.2: Gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge. Gauges not accurate to within 3 percent of the full scale shall be recalibrated or replaced.

NFPA 25, 9-2.8.1: Gauges shall be inspected monthly to verify that they are in good condition and that normal pressure is being maintained. Exception: When other sections of this standard have different frequency requirements for specific gauges.

The facility failed to provide metal self-closing containers for disposing of cigarette butts and ashes from ashtrays. Findings include: During the survey, the following is an example of what was observed:


Metal containers/noncombustible ashtrays were not provided for the designated smoking area, located in the courtyard adjacent to the East Wing Rear Entrance.


NFPA 101, 19.7.4 Ashtrays of noncombustible material and safe design, and metal self-closing containers for disposing of cigarette butts and ashes from ashtrays, shall be provided.

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The facility failed to maintain the dietary hood. Findings include: During the survey, the following is an example of what was observed:

Loose/missing caulk in the seams of the dietary hood.
----------------------------------
NFPA 96, 2-1.2 Internal hood joints, seams, filter support frames, and appendages attached inside the hood need not be welded but shall be sealed or otherwise made grease tight.
.

.
The facility failed to provide proper storage of oxygen cylinders. Findings include: During the survey, the following are examples of what was observed:

1. Four unsecured oxygen cylinders.

2. Signage not provided for empty/full cylinders.

-----------------------------------
1999 NFPA 99, 8-3.1.11.2(g) Cylinders shall be secured from mechanical shock.

CGA G-4, 4.1.10, and 1999 NFPA 99, 4-3.5.2.2(b)2 and 4-5.5.2.2(b)2 Full and empty cylinders shall be stored separately, with appropriate signage.
.

.
During the survey, the facility was not able to provide documentation for the annual service of the fire hydrant.

NFPA 25, 4-4.3, Hydrants 4-4.3.1, Hydrants shall be lubricated annually to ensure that all stems, caps, plugs, and threads are in proper operating condition.
.

The facility failed to maintain the emergency generator per code. Findings include:

During the survey, the following is an example of what was observed:
The emergency generator remote annunciator did not indicate "engine running" when the generator was tested

___________________

1999 NFPA 99, 3-4.1.1.15 A remote annunciator, storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station (see NFPA 70, National Electrical Code, Section 700-12.)
The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows:
(a) Individual visual signals shall indicate the following:
1. When the emergency or auxiliary power source is operating to supply power to load
2. When the battery charger is malfunctioning
(b) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following:
1. Low lubricating oil pressure
2. Low water temperature (below those required in 3-4.1.1.9)
3. Excessive water temperature
4. Low fuel - when the main fuel storage tank contains less than a 3-hour operating supply
5. Overcrank (failed to start)
6. Overspeed
Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions in 3-4.1.1.15(a) and (b) occur, but need not display these conditions individually. [110: 3-5.5.2]

The facility failed to provide receptacles for appliances. Findings include: During the survey, the following is an example of what was observed:


The AP File Room had a junction box that was missing the cover.

1999 NFPA 70, 370-25 and 410-12. Each box in completed installations to have a cover, face plate, or fixture canopy.

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A) The facility failed to provide receptacles for appliances. Findings include: During the survey, the following is an example of what was observed:


The AC wall unit in the Laboratory was plugged into an overcurrent protection device.

Appliances, such as air conditioners and refrigerators, shall plug directly into a receptacle. 1999 NFPA 70, 400-7 and 400-8, and HCFA Transmittal Notice 22-99.


27382


B) The facility failed to maintain the electrical system per code. Findings include:

During the survey, the following are examples of what was observed:
1. Front Lobby above the ceiling had two surge protectors piggy backed
2. Corridor in front of the Kitchen above the ceiling had an electrical junction box missing a cover plate
3. Break Room/Blood Storage Room:
a. Surge protector plugged into an extension cord
b. Microwave plugged into the above mentioned surge protector
c. Two more surge protectors with refrigerators and a freezer plugged into them
4. Insurance Billing Office had a surge protector plugged into an extension cord

________________

1999 NFPA 70, 400-7 (b) Attachment Plugs. Where used as permitted in subsections (a)(3), (a)(6), and (a)(8), each flexible cord shall be equipped with an attachment plug and shall be energized from a receptacle outlet.

1999 NFPA 70, 400-7 and 400-8, and HCFA Transmittal Notice 22-99 The 1984 edition of the National Electric Code restricts the use of extension cords to temporary short term uses. It is the policy of HCFA to prohibit non-circuit breaker protected extension cords in health care. The limited use of circuit breaker protected power strips is acceptable, provided the current is limited to 15 amps or less, and no major appliances such as air conditioners, refrigerators, or heating units are connected to the power strip.

The facility failed to provide a building construction type per code. Findings include:

During the survey, the following is an example of what was observed:
Unprotected wood structural members were observed above the lay-in ceiling at the roof deck at the four hour fire wall separating the 1981 addition from the 2004 addition.

____________________

2000 NFPA 101, 19.1.6.2 Health care occupancies shall be limited to the types of building construction shown in Table 19.1.6.2. (See 8.2.1.)
Table 19.1.6.2 Construction Type Limitations
Construction Stories
Type
1 2 3 4 or
More
I(443) X X X X
I(332) X X X X
II(222) X X X X
II(111) X X* X* NP
II(000) X* X* NP NP
III(211) X* X* NP NP
III(200) X* NP NP NP
IV(2HH) X* X* NP NP
V(111) X* X* NP NP
V(000) X* NP NP NP
X: Permitted type of construction.
NP: Not permitted.
*Building requires automatic sprinkler protection. (See 19.3.5.1.)


2000 NFPA 101, 8.2.1 Buildings or structures occupied or used in accordance with the individual occupancy chapters (Chapters 12 through 42) shall meet the minimum construction requirements of those chapters. NFPA 220, Standard on Types of Building Construction, shall be used to determine the requirements for the construction classification. Where the building or facility includes additions or connected structures of different construction types, the rating and classification of the structure shall be based on either of the following:
(1) Separate buildings if a 2-hour or greater vertically-aligned fire barrier wall in accordance with NFPA 221, Standard for Fire Walls and Fire Barrier Walls, exists between the portions of the building
Exception: The requirement of 8.2.1(1) shall not apply to previously approved separations between buildings.
(2) The least fire-resistive type of construction of the connected portions, if no such separation is provided
.

.
The facility failed to maintain the corridor openings per code. Findings include:

During the survey, the following are examples of what was observed:
1. Room 139 corridor door was not positive latching
2. Break Room corridor door had a self-closing device on it, but was being held open by a wedge
_______________
2000 NFPA 101, 18.3.6.3.2 Doors shall be provided with positive latching hardware. Roller latches shall be prohibited.

2007 CMS - 2786R There is no impediment to the closing of the corridor doors.

.

The facility failed to maintain separation of hazardous areas. Findings include: During the survey, the following is an example of what was observed:

1. Imaging Mechanical Room had unsealed penetrations around a water line, and at the end of two sleeve's.


27382


2. Storage Room by the D.O.N.'s Office was not positive latching by the self-closing device.

_______________

2000 NFPA 101, 19.3.2.1 Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing.

2000 NFPA 101, 19.3.6.3.2 Doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door. Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.2.
.

.
The facility failed to maintain the hazardous areas per code. Findings include:

During the survey, the following are examples of what was observed:
The following doors had a self-closing devices that were not closing the door all the way to make it positive latch:
1. Soiled Utility
2. Clean Utility
_____________________
2000 NFPA 101, 8.4.1.3 Doors in barriers required to have a fire resistance rating shall have a 3/4-hour fire protection rating and shall be self-closing or automatic-closing in accordance with 7.2.1.8.
2000 NFPA 101, 7.2.1.8.1 A door normally required to be kept closed shall not be secured in the open position at any time and shall be self-closing or automatic-closing in accordance with 7.2.1.8.2.
.

The facility failed to maintain the exit access per code. Findings include:

During the survey, the following are examples of what was observed:
1. The Electrical Room corridor door in the Imaging Wing, when fully opened projected more than 7" into the corridor.
2. The following rooms had a double keyed dead bolt lock on the door:
a. Utilization Review Office
b. Front Office Break Room corridor door

_____________

2000 NFPA 101, 7.2.1.4.4 During its swing, any door in a means of egress shall leave not less than one-half of the required width of an aisle, corridor, passageway, or landing unobstructed and shall not project more than 7 in. (17.8 cm) into the required width of an aisle, corridor, passageway, or landing, when fully open. Doors shall not open directly onto a stair without a landing. The landing shall have a width not less than the width of the door. (See 7.2.1.3.)
2000 NFPA 101, 7.1.9 Any device or alarm installed to restrict the improper use of a means of egress shall be designed and installed so that it cannot, even in case of failure, impede or prevent emergency use of such means of egress unless otherwise provided in 7.2.1.6 and Chapters 18, 19, 22, and 23.
.

The facility failed to maintain/provide a fire alarm system per code. Findings include:

During the survey, the following are examples of what was observed:
1. "Kitchen Smoke Compartment":
a. Did not have a visual device
b. The audible device did not work upon:
i. Activation of the fire alarm system in the Imaging Wing
ii. Activation of the fire alarm system in the East Wing (building 0202)
2. "Laboratory Smoke Compartment" did not have an audible/visual device

___________________

2000 NFPA 101, 9.6.1.4 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.
1999 NFPA 72, 4-4.3.1
Visible notification appliances used in the public mode shall be located and shall be of a type, size, intensity, and number so that the operating effect of the appliance is seen by the intended viewers regardless of the viewer ' s orientation.

2000 NFPA 101, 9.6.3.2 Notification shall be provided by audible and visible signals in accordance with 9.6.3.3 through 9.6.3.12.
.

The facility failed to perform sensitivity testing of the smoke detectors. Findings include: During the survey, the following is an example of what was observed:


Documentation provided by the facility during the survey did not indicate sensitivity testing of the smoke detectors. Detector sensitivity shall be checked with one year after installation and every alternate year thereafter per 72, 7-3.2.1. (Up to 5 years permitted under certain circumstances. See 7-3.2.1).

.
The facility failed to perform sensitivity testing of the smoke detectors. Findings include: During the survey, the following is an example of what was observed:


Documentation provided by the facility during the survey did not indicate sensitivity testing of the smoke detectors. Detector sensitivity shall be checked with one year after installation and every alternate year thereafter per 72, 7-3.2.1. (Up to 5 years permitted under certain circumstances. See 7-3.2.1).
.

.
Sprinkler coverage was observed during the survey not adequately provided. Findings include: During the survey, the following are examples of what was observed:

1. Escutcheon plate loose on a sprinkler in the walk in cooler.

2. Ceiling tile missing in the Biohazard Room by the Administrator Office.

----------------------------------
2000 NFPA 13, 3-2.7.2 Escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly.

NFPA 13 5-6., Sprinklers shall be arranged to be in compliance.
.

The facility failed to perform the required maintenance of the facility sprinkler system. Findings include: During the survey, the following are examples of what was observed:


1. Identification sign for fire department connections was not provided.

2. Documentation of the calibration test for the sprinkler system gauges was not provided.


27382


3. D.O.N.'s Storage Closet next to the Lab. Manager's Office had binders piled up around the sidewall sprinkler head.

___________________
NFPA 101,2000 Edition, 9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this code shall be inspected, tested, and maintained in accordance with NFPA 25, Standards for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

NFPA 25, 1998 Edition, 9-7.1 Fire department connections shall be inspected quarterly. The inspection shall verify the following:
(a) The fire department connections are visible and accessible.
(b) Couplings or swivels are not damaged and rotate smoothly.
(c) Plugs or caps are in place and undamaged.
(d) Gaskets are in place and in good conition.
(e) Identification signs are in place.
(f) The check valve is not leaking.
(g) The automatic drain valve is in place and operating properly.

NFPA 25, Table 2-1 Summary of Sprinkler System Inspection, Testing, and Maintenance

1999 NFPA 13, 5-5.6 The clearance between the deflector and the top of storage shall be 18 in. (457 mm) or greater.
.

The facility failed to perform the required maintenance of the facility sprinkler system. Findings include: During the survey, the following are examples of what was observed:


1. Cap missing on the fire department connection located at the pit.

2. Documentation of the calibration test for the sprinkler system gauges was not provided.



NFPA 101,2000 Edition, 9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this code shall be inspected, tested, and maintained in accordance with NFPA 25, Standards for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

NFPA 25, 1998 Edition, 9-7.1 Fire department connections shall be inspected quarterly. The inspection shall verify the following:
(a) The fire department connections are visible and accessible.
(b) Couplings or swivels are not damaged and rotate smoothly.
(c) Plugs or caps are in place and undamaged.
(d) Gaskets are in place and in good conition.
(e) Identification signs are in place.
(f) The check valve is not leaking.
(g) The automatic drain valve is in place and operating properly.

NFPA 25, Table 2-1 Summary of Sprinkler System Inspection, Testing, and Maintenance

NFPA 25, 9-2.8.2: Gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge. Gauges not accurate to within 3 percent of the full scale shall be recalibrated or replaced.

NFPA 25, 9-2.8.1: Gauges shall be inspected monthly to verify that they are in good condition and that normal pressure is being maintained. Exception: When other sections of this standard have different frequency requirements for specific gauges.

The facility failed to provide metal self-closing containers for disposing of cigarette butts and ashes from ashtrays. Findings include: During the survey, the following is an example of what was observed:


Metal containers/noncombustible ashtrays were not provided for the designated smoking area, located in the courtyard adjacent to the East Wing Rear Entrance.


NFPA 101, 19.7.4 Ashtrays of noncombustible material and safe design, and metal self-closing containers for disposing of cigarette butts and ashes from ashtrays, shall be provided.

.
The facility failed to maintain the dietary hood. Findings include: During the survey, the following is an example of what was observed:

Loose/missing caulk in the seams of the dietary hood.
----------------------------------
NFPA 96, 2-1.2 Internal hood joints, seams, filter support frames, and appendages attached inside the hood need not be welded but shall be sealed or otherwise made grease tight.
.

.
The facility failed to provide proper storage of oxygen cylinders. Findings include: During the survey, the following are examples of what was observed:

1. Four unsecured oxygen cylinders.

2. Signage not provided for empty/full cylinders.

-----------------------------------
1999 NFPA 99, 8-3.1.11.2(g) Cylinders shall be secured from mechanical shock.

CGA G-4, 4.1.10, and 1999 NFPA 99, 4-3.5.2.2(b)2 and 4-5.5.2.2(b)2 Full and empty cylinders shall be stored separately, with appropriate signage.
.

.
During the survey, the facility was not able to provide documentation for the annual service of the fire hydrant.

NFPA 25, 4-4.3, Hydrants 4-4.3.1, Hydrants shall be lubricated annually to ensure that all stems, caps, plugs, and threads are in proper operating condition.
.

The facility failed to maintain the emergency generator per code. Findings include:

During the survey, the following is an example of what was observed:
The emergency generator remote annunciator did not indicate "engine running" when the generator was tested

___________________

1999 NFPA 99, 3-4.1.1.15 A remote annunciator, storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station (see NFPA 70, National Electrical Code, Section 700-12.)
The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows:
(a) Individual visual signals shall indicate the following:
1. When the emergency or auxiliary power source is operating to supply power to load
2. When the battery charger is malfunctioning
(b) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following:
1. Low lubricating oil pressure
2. Low water temperature (below those required in 3-4.1.1.9)
3. Excessive water temperature
4. Low fuel - when the main fuel storage tank contains less than a 3-hour operating supply
5. Overcrank (failed to start)
6. Overspeed
Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions in 3-4.1.1.15(a) and (b) occur, but need not display these conditions individually. [110: 3-5.5.2]

The facility failed to provide receptacles for appliances. Findings include: During the survey, the following is an example of what was observed:


The AP File Room had a junction box that was missing the cover.

1999 NFPA 70, 370-25 and 410-12. Each box in completed installations to have a cover, face plate, or fixture canopy.

.
A) The facility failed to provide receptacles for appliances. Findings include: During the survey, the following is an example of what was observed:


The AC wall unit in the Laboratory was plugged into an overcurrent protection device.

Appliances, such as air conditioners and refrigerators, shall plug directly into a receptacle. 1999 NFPA 70, 400-7 and 400-8, and HCFA Transmittal Notice 22-99.


27382


B) The facility failed to maintain the electrical system per code. Findings include:

During the survey, the following are examples of what was observed:
1. Front Lobby above the ceiling had two surge protectors piggy backed
2. Corridor in front of the Kitchen above the ceiling had an electrical junction box missing a cover plate
3. Break Room/Blood Storage Room:
a. Surge protector plugged into an extension cord
b. Microwave plugged into the above mentioned surge protector
c. Two more surge protectors with refrigerators and a freezer plugged into them
4. Insurance Billing Office had a surge protector plugged into an extension cord

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1999 NFPA 70, 400-7 (b) Attachment Plugs. Where used as permitted in subsections (a)(3), (a)(6), and (a)(8), each flexible cord shall be equipped with an attachment plug and shall be energized from a receptacle outlet.

1999 NFPA 70, 400-7 and 400-8, and HCFA Transmittal Notice 22-99 The 1984 edition of the National Electric Code restricts the use of extension cords to temporary short term uses. It is the policy of HCFA to prohibit non-circuit breaker protected extension cords in health care. The limited use of circuit breaker protected power strips is acceptable, provided the current is limited to 15 amps or less, and no major appliances such as air conditioners, refrigerators, or heating units are connected to the power strip.