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400 N EDWARDS STREET

ENTERPRISE, AL 36330

No Description Available

Tag No.: K0011

Unsealed openings/penetrations were observed in the fire walls as follows: During the survey, unsealed penetrations were observed, at the end of a sleeve, in the (2) hour wall, First Floor, by double doors, Main Lobby.


8.2.2.2* Fire compartments shall be formed with fire barriers that are continuous from outside wall to outside wall, from one fire barrier to another, or a combination thereof, including continuity through all concealed spaces, such as those found above a ceiling, including interstitial spaces. Walls used as fire barriers shall comply with Chapter 3 of NFPA 221, Standard for Fire Walls and Fire Barrier Walls. The NFPA 221 limitation on percentage width of openings shall not apply.

8.2.3.2.4.2* Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through fire barriers shall be protected as follows:
(1) The space between the penetrating item and the fire barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the fire barrier, the sleeve shall be solidly set in the fire barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) * Insulation and coverings for pipes and ducts shall not pass through the fire barrier unless one of the following conditions is met:
a. The material shall be capable of maintaining the fire resistance of the fire barrier.
b. The material shall be protected by an approved device that is designed for the specific purpose.
(4) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the fire barrier.
b. It shall be made by an approved device that is designed for the specific purpose.
.

No Description Available

Tag No.: K0018

The facility failed to provide corridor doors that would close and resist the passage of smoke. Findings include: During the survey, the door failed to latch, Monitor Equipment Room by Patient Room 324.

NFPA 101, 19.3.6.3.2 Doors in corridor walls shall be provided with suitable means to keep doors closed.
.

No Description Available

Tag No.: K0025

The facility failed to provide smoke barriers that would provide at least a half hour fire resistance rating. Findings include: During the survey, unsealed penetrations were observed, at the end of a sleeve, and around (2) sections of flex conduit in the Smoke Barrier by OR (1).

NFPA 101, 19.3.7.3 Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1/2 hour.

NFPA 101, 8.3.2 Smoke barriers required by this Code shall be continuous from an outside wall to an outside wall, from a floor to a floor, or from a smoke barrier to a smoke barrier or a combination thereof. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces.
.

No Description Available

Tag No.: K0029

1) The facility failed to provide separation of hazardous areas. Findings include: During the survey, the Dietary Combustible Storage Room, over 50 sq. feet, was observed not to have a self-closing device on the door.


27382


2) The facility failed to maintain a hazardous area per code. Findings include:
During the survey, on the second floor the Soiled Utility Room across from room 233, the self-closing device was observed not having enough force to close the door so that it positive latched.

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.

.

No Description Available

Tag No.: K0038

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

During the survey, on the second floor, the Back Hall/Service Corridor, a paper shredder was observed blocking the exit access.

2000 NFPA 101, 7.1.10.1 Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.
.

No Description Available

Tag No.: K0051

Facility failed to maintain the Digital Alarm Communicator Transmitter in the fire alarm system. Findings include: During the survey, the following was observed:

1. When the Auto Dialer was tested for phone line 1, failure of a visual was not indicated at the protected premise within the allotted four (4) minute time frame.

2. When the Auto Dialer was tested for phone line 2, failure of a visual was not indicated at the protected premise within the allotted four (4) minute time frame.

3. When the Auto Dialer was tested for Communication Failure, failure was not indicated at the protected premise within the allotted fifteen (15) minute time frame (5 minimum to 10 maximum attempts for signal transmission).

1999 NFPA 72, Section 1-5.4.6, 5-5.3.2.1.5, and 5-5.3.2.1.6.2. Phone line and communication failure shall be indicated at the facility.
.

No Description Available

Tag No.: K0052

The facility failed to maintain the fire alarm system in proper working order. Findings include: During the survey, while testing the fire alarm, a horn/strobe was not observed in the Housekeeping Office/Supply located on the first floor. The fire alarm was not audible in this area during the testing of the fire alarm system.

2000 NFPA 101, 9.6.3.1 Occupant notification shall provide signal notification to alert occupants of fire or other emergency as required by other sections of this Code.

2000 NFPA 101. 9.6.3.8 Audible alarm notification appliances shall be of such a character and so distributed as to be effectively heard above the aveage ambient sound level occurring under normal conditions of occupancy.
.

No Description Available

Tag No.: K0061

Upon review of the documentation, during the survey, Simplex-Grinnell noted on their inspection report dated 10/18/2010, that the flow switch, fourth floor stairwell failed to send an alarm.

2000 NFPA 101,9.6.2.7 The sprinkler system shall automatically initiate the fire alarm when there is water flow.

NFPA 101, 9.7.5, and 1999 NFPA 25, 2-2 and Table 2-1.

No Description Available

Tag No.: K0062

a ) The facility failed to provide a sprinkler system which meets code requirements. Findings include: During the survey, the cabinets (2), located in the riser room, were not equipped with the appropriate amount of spare sprinklers.

NFPA 25, 1998 2-4.1.4 A supply of at least six spare sprinklers shall be stored in a cabinet on the premises for replacement purposes. The stock of spare sprinklers shall be proportionally representative of the types and temperature ratings of the system sprinklers. A minimum of two sprinklers of each type and temperature rating installed shall be provided. The cabinet shall be so located that it will not be exposed to moisture, dust, corrosion, or a temperature exceeding 100 dgress F.


27382


b) The facility failed to maintain the automatic sprinkler system per code. Findings include:
During the survey, the following was observed on the Second Floor:
1. Labor and Delivery Computer/Communications Room labeled as "Clean Utility" was missing ceiling tiles.
2. MRI/Surgery/PACU Communications Room had a hole in the ceiling tile.

1999 NFPA 13, 5-8.4.2 Deflectors of sprinklers shall be aligned parallel to ceilings or roofs.
.

No Description Available

Tag No.: K0067

The facility failed to maintain the HVAC per code. Findings include:
During the survey, the following was observed:

First Floor -
1. The Lab had an HVAC duct penetrating the smoke barrier without access in the duct to the damper.
2. The Mamogram Consultation Room
a. Had a round metal duct ending above the ceiling that did not have a damper.
b. Had a 10" - 12" round metal duct without a damper or access panel.

Third Floor
3. Two smoke dampers at room 323 did not close upon the activation of the fire alarm.

1999 NFPA 90A, 2-3.4.1 A service opening shall be provided in air ducts adjacent to each fire damper, smoke damper, and smoke detector. The opening shall be large enough to permit maintenance and resetting of the device.

1999 NFPA 90A, 3-3.5.1 Smoke dampers shall be installed at or adjacent to the point where air ducts pass through required smoke barriers, but in no case shall a smoke damper be installed more than 2 ft (0.6 m) from the barrier or after the first air duct inlet or outlet, whichever is closer to the smoke barrier.
.

No Description Available

Tag No.: K0078

The facility failed to provide a smoke ventilating system for the windowless O.R.s per code. Findings include:

Based on an interview with the maintenance director, during the survey, the four windowless O.R.s did not have a smoke ventilating system.

1999 NFPA 99, 5-4.1.2 Supply and exhaust systems for windowless anesthetizing locations shall be arranged to automatically vent smoke and products of combustion.
1999 NFPA 99, 5-4.1.3 Ventilating systems for anesthetizing locations shall be provided that automatically (a) prevent recirculation of smoke originating within the surgical suite and (b) prevent the circulation of smoke entering the system intake, without in either case interfering with the exhaust function of the system.
1999 NFPA 99, 5-4.1.4 The electric supply to the ventilating system shall be served by the equipment system of the essential electrical system specified in Chapter 3, "Electrical Systems."
1999 NFPA 99, 5-6.1.1 Ventilating and humidifying equipment for anesthetizing locations shall be kept in operable condition and be continually operating during surgical procedures (see A-5-4.1).
.

No Description Available

Tag No.: K0104

The facility failed to maintain the smoke barriers per code. Findings include:

During the survey, the following was observed:

Second Floor -
1. The smoke barrier in room 203 was not sealed at the bathroom wall.
2. The smoke barrier in the bathroom in room 203 had an unsealed pipe penetration.

First Floor -
The smoke barrier in the Clean Room/Auto Clave Room had unsealed penetrations of:
1. A flex conduit
2. A yellow wire
3. Missing sheetrock around the HVAC duct

2000 NFPA 101, 8.3.6.1 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.
.

No Description Available

Tag No.: K0146

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

During the survey, the remote annunciator for generator #2 was observed not to show that the generator was supplying power. The panel did not indicate "generator power" 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-.5.2]

.

No Description Available

Tag No.: K0147

a) During the survey, the following was observed:

1. The cover was missing on three junction boxes in the Pent House near the air compessor.

2. The cover was missing on a junction box above the ceiling third floor by Patient Room 301.
*** This was corrected during the survey.***

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


27382


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

During the survey, the following was observed:

First Floor -
1. Reading Room - had a refrigerator plugged into a surge protector.
2. Radiology Front Desk Area - had three surge protectors piggy backed off each other.
3. Pharmacy Breakroom/Fluid Supply Room - had a refrigerator plugged into a surge protector.

Second Floor -
4. Day Surgery/I.C.U. Manager's Office in the bathroom a refrigerator plugged into a surge protector.

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

2000 NFPA 101, 9.1.2 Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

LIFE SAFETY CODE STANDARD

Tag No.: K0011

Unsealed openings/penetrations were observed in the fire walls as follows: During the survey, unsealed penetrations were observed, at the end of a sleeve, in the (2) hour wall, First Floor, by double doors, Main Lobby.


8.2.2.2* Fire compartments shall be formed with fire barriers that are continuous from outside wall to outside wall, from one fire barrier to another, or a combination thereof, including continuity through all concealed spaces, such as those found above a ceiling, including interstitial spaces. Walls used as fire barriers shall comply with Chapter 3 of NFPA 221, Standard for Fire Walls and Fire Barrier Walls. The NFPA 221 limitation on percentage width of openings shall not apply.

8.2.3.2.4.2* Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through fire barriers shall be protected as follows:
(1) The space between the penetrating item and the fire barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the fire barrier, the sleeve shall be solidly set in the fire barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) * Insulation and coverings for pipes and ducts shall not pass through the fire barrier unless one of the following conditions is met:
a. The material shall be capable of maintaining the fire resistance of the fire barrier.
b. The material shall be protected by an approved device that is designed for the specific purpose.
(4) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the fire barrier.
b. It shall be made by an approved device that is designed for the specific purpose.
.

LIFE SAFETY CODE STANDARD

Tag No.: K0018

The facility failed to provide corridor doors that would close and resist the passage of smoke. Findings include: During the survey, the door failed to latch, Monitor Equipment Room by Patient Room 324.

NFPA 101, 19.3.6.3.2 Doors in corridor walls shall be provided with suitable means to keep doors closed.
.

LIFE SAFETY CODE STANDARD

Tag No.: K0025

The facility failed to provide smoke barriers that would provide at least a half hour fire resistance rating. Findings include: During the survey, unsealed penetrations were observed, at the end of a sleeve, and around (2) sections of flex conduit in the Smoke Barrier by OR (1).

NFPA 101, 19.3.7.3 Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1/2 hour.

NFPA 101, 8.3.2 Smoke barriers required by this Code shall be continuous from an outside wall to an outside wall, from a floor to a floor, or from a smoke barrier to a smoke barrier or a combination thereof. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces.
.

LIFE SAFETY CODE STANDARD

Tag No.: K0029

1) The facility failed to provide separation of hazardous areas. Findings include: During the survey, the Dietary Combustible Storage Room, over 50 sq. feet, was observed not to have a self-closing device on the door.


27382


2) The facility failed to maintain a hazardous area per code. Findings include:
During the survey, on the second floor the Soiled Utility Room across from room 233, the self-closing device was observed not having enough force to close the door so that it positive latched.

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.

.

LIFE SAFETY CODE STANDARD

Tag No.: K0038

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

During the survey, on the second floor, the Back Hall/Service Corridor, a paper shredder was observed blocking the exit access.

2000 NFPA 101, 7.1.10.1 Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.
.

LIFE SAFETY CODE STANDARD

Tag No.: K0051

Facility failed to maintain the Digital Alarm Communicator Transmitter in the fire alarm system. Findings include: During the survey, the following was observed:

1. When the Auto Dialer was tested for phone line 1, failure of a visual was not indicated at the protected premise within the allotted four (4) minute time frame.

2. When the Auto Dialer was tested for phone line 2, failure of a visual was not indicated at the protected premise within the allotted four (4) minute time frame.

3. When the Auto Dialer was tested for Communication Failure, failure was not indicated at the protected premise within the allotted fifteen (15) minute time frame (5 minimum to 10 maximum attempts for signal transmission).

1999 NFPA 72, Section 1-5.4.6, 5-5.3.2.1.5, and 5-5.3.2.1.6.2. Phone line and communication failure shall be indicated at the facility.
.

LIFE SAFETY CODE STANDARD

Tag No.: K0052

The facility failed to maintain the fire alarm system in proper working order. Findings include: During the survey, while testing the fire alarm, a horn/strobe was not observed in the Housekeeping Office/Supply located on the first floor. The fire alarm was not audible in this area during the testing of the fire alarm system.

2000 NFPA 101, 9.6.3.1 Occupant notification shall provide signal notification to alert occupants of fire or other emergency as required by other sections of this Code.

2000 NFPA 101. 9.6.3.8 Audible alarm notification appliances shall be of such a character and so distributed as to be effectively heard above the aveage ambient sound level occurring under normal conditions of occupancy.
.

LIFE SAFETY CODE STANDARD

Tag No.: K0061

Upon review of the documentation, during the survey, Simplex-Grinnell noted on their inspection report dated 10/18/2010, that the flow switch, fourth floor stairwell failed to send an alarm.

2000 NFPA 101,9.6.2.7 The sprinkler system shall automatically initiate the fire alarm when there is water flow.

NFPA 101, 9.7.5, and 1999 NFPA 25, 2-2 and Table 2-1.

LIFE SAFETY CODE STANDARD

Tag No.: K0062

a ) The facility failed to provide a sprinkler system which meets code requirements. Findings include: During the survey, the cabinets (2), located in the riser room, were not equipped with the appropriate amount of spare sprinklers.

NFPA 25, 1998 2-4.1.4 A supply of at least six spare sprinklers shall be stored in a cabinet on the premises for replacement purposes. The stock of spare sprinklers shall be proportionally representative of the types and temperature ratings of the system sprinklers. A minimum of two sprinklers of each type and temperature rating installed shall be provided. The cabinet shall be so located that it will not be exposed to moisture, dust, corrosion, or a temperature exceeding 100 dgress F.


27382


b) The facility failed to maintain the automatic sprinkler system per code. Findings include:
During the survey, the following was observed on the Second Floor:
1. Labor and Delivery Computer/Communications Room labeled as "Clean Utility" was missing ceiling tiles.
2. MRI/Surgery/PACU Communications Room had a hole in the ceiling tile.

1999 NFPA 13, 5-8.4.2 Deflectors of sprinklers shall be aligned parallel to ceilings or roofs.
.

LIFE SAFETY CODE STANDARD

Tag No.: K0067

The facility failed to maintain the HVAC per code. Findings include:
During the survey, the following was observed:

First Floor -
1. The Lab had an HVAC duct penetrating the smoke barrier without access in the duct to the damper.
2. The Mamogram Consultation Room
a. Had a round metal duct ending above the ceiling that did not have a damper.
b. Had a 10" - 12" round metal duct without a damper or access panel.

Third Floor
3. Two smoke dampers at room 323 did not close upon the activation of the fire alarm.

1999 NFPA 90A, 2-3.4.1 A service opening shall be provided in air ducts adjacent to each fire damper, smoke damper, and smoke detector. The opening shall be large enough to permit maintenance and resetting of the device.

1999 NFPA 90A, 3-3.5.1 Smoke dampers shall be installed at or adjacent to the point where air ducts pass through required smoke barriers, but in no case shall a smoke damper be installed more than 2 ft (0.6 m) from the barrier or after the first air duct inlet or outlet, whichever is closer to the smoke barrier.
.

LIFE SAFETY CODE STANDARD

Tag No.: K0078

The facility failed to provide a smoke ventilating system for the windowless O.R.s per code. Findings include:

Based on an interview with the maintenance director, during the survey, the four windowless O.R.s did not have a smoke ventilating system.

1999 NFPA 99, 5-4.1.2 Supply and exhaust systems for windowless anesthetizing locations shall be arranged to automatically vent smoke and products of combustion.
1999 NFPA 99, 5-4.1.3 Ventilating systems for anesthetizing locations shall be provided that automatically (a) prevent recirculation of smoke originating within the surgical suite and (b) prevent the circulation of smoke entering the system intake, without in either case interfering with the exhaust function of the system.
1999 NFPA 99, 5-4.1.4 The electric supply to the ventilating system shall be served by the equipment system of the essential electrical system specified in Chapter 3, "Electrical Systems."
1999 NFPA 99, 5-6.1.1 Ventilating and humidifying equipment for anesthetizing locations shall be kept in operable condition and be continually operating during surgical procedures (see A-5-4.1).
.

LIFE SAFETY CODE STANDARD

Tag No.: K0104

The facility failed to maintain the smoke barriers per code. Findings include:

During the survey, the following was observed:

Second Floor -
1. The smoke barrier in room 203 was not sealed at the bathroom wall.
2. The smoke barrier in the bathroom in room 203 had an unsealed pipe penetration.

First Floor -
The smoke barrier in the Clean Room/Auto Clave Room had unsealed penetrations of:
1. A flex conduit
2. A yellow wire
3. Missing sheetrock around the HVAC duct

2000 NFPA 101, 8.3.6.1 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.
.

LIFE SAFETY CODE STANDARD

Tag No.: K0146

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

During the survey, the remote annunciator for generator #2 was observed not to show that the generator was supplying power. The panel did not indicate "generator power" 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-.5.2]

.

LIFE SAFETY CODE STANDARD

Tag No.: K0147

a) During the survey, the following was observed:

1. The cover was missing on three junction boxes in the Pent House near the air compessor.

2. The cover was missing on a junction box above the ceiling third floor by Patient Room 301.
*** This was corrected during the survey.***

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


27382


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

During the survey, the following was observed:

First Floor -
1. Reading Room - had a refrigerator plugged into a surge protector.
2. Radiology Front Desk Area - had three surge protectors piggy backed off each other.
3. Pharmacy Breakroom/Fluid Supply Room - had a refrigerator plugged into a surge protector.

Second Floor -
4. Day Surgery/I.C.U. Manager's Office in the bathroom a refrigerator plugged into a surge protector.

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

2000 NFPA 101, 9.1.2 Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.