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Observation and discussion with the Plant Operations Director between 2 pm and 5:30 pm on 12/6/2011 revealed that certain requirements stipulated in NFPA 72 were not met.

Connections to the light and power service shall be on a dedicated branch circuit(s). The circuit(s) and service shall be mechanically protected. Circuit disconnecting means shall have a red marking, shall be accessible only to authorized personnel, and shall be identified as FIRE ALARM CIRCUIT CONTROL. The location of the circuit disconnecting means shall be permanently identified at the fire alarm control unit [Re: NFPA 72, National Fire Alarm Code, 1999: ? 1-5.2.5.2.]

Findings: This requirement was discussed with the staff during the survey, and it was noted that the required markings were not present on the Fire Alarm Control Panel or on the breaker in the panelboard.

Observation and discussion with the Plant Operations Director between 2 pm and 5:30 pm on 12/6/2011 revealed that certain requirements stipulated in NFPA 99 were not met.

The facility must have a Level I Medical Gas and Vacuum system as specified in NFPA 99, Chapter 4, 1999.

Findings: This requirement was discussed with the staff during the survey, and it was noted that the facility had no medical air system. The facility shall either install a compliant med air system, or explain in detail why this system is not needed.

Observation and discussion with the Plant Operations Director between 2 pm and 5:30 pm on 12/6/2011 revealed that certain requirements stipulated in NFPA 99 were not met.

The LIM circuit shall be tested at intervals of not more than 1 month by actuating the LIM test switch [see 3-3.2.2.3(f).] For a LIM circuit with self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months. Actuation of the test switch shall activate both visual and audible alarm indicators [Re: NFPA 99, Health Care Facilities, 1999: ?3-3.3.4.2(b).]

Findings: This requirement was discussed with the staff during the survey, and these records were not available for review.

Observation and discussion with the Plant Operations Director between 2 pm and 5:30 pm on 12/6/2011 revealed that certain requirements stipulated in NFPA 70 and 99 were not met.

a. Battery Maintenance

Storage batteries used in connection with essential electrical systems shall be inspected at intervals of not more than seven days and shall be maintained in full compliance with manufacturer ' s specifications [Re: NFPA 99, Health Care Facilities, 1999: ?3-4.4.1.3.]

Findings: This requirement was discussed with the staff during the survey, and these records were not available for review.

b. GenSet Light & Receptacle

No function other than those listed in (a) through (f) shall be connected to the life safety branch. The life safety branch of the emergency system shall supply power for the following lighting, receptacles, and equipment: ... ...(e) Generator Set Location. Task illumination battery charger for emergency battery-powered lighting unit(s) and selected receptacles at the generator set location [Re: NFPA 70, National Electrical Code, 1999: ?517-32(e).]

Findings: These amenities were not installed as required.

Observation and discussion with the Plant Operations Director between 2 pm and 5:30 pm on 12/6/2011 revealed that certain requirements stipulated in NFPA 70 and 99 were not met.

a. Separation of Branches

The Type I EES shall be divided into the critical branch, life safety branch and the equipment system in accordance with NFPA 99 [Re: NFPA 99, Health Care Facilities, 1999: ?3.4.2.2.2. and 3.4.2.2.3.]

Findings: It could not be determined if this facility has a Type I EES. The facility shall develop a one-line diagram and determine the relationship between the ATS(s) and the electrical panelboards. The panelboards shall be labeled properly. During the survey, one panelboard was labeled " critical emergency " but the individual circuit breakers did not conform to a specific branch.

b. Functional Allocation

The various functions powered by the Type I EES must be powered by the appropriate branch of the system [Re: NFPA 99, Health Care Facilities, 1999: ?3.4.2.2.2. and 3.4.2.2.3.]

Findings: After the panelboards are identified and labeled properly, the functions shall be moved to the proper power source.


c. 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: The circuit directories in the panelboards were outdated and reflected a configuration that was not code compliant. After the functional allocation is corrected, the directories shall be updated to be accurate and meaningful.

d. Critical Powered Receptacles

The critical branch of the emergency system shall supply power for task illumination, fixed equipment, selected receptacles, and special power circuits serving the following areas and functions related to patient care: .... 3. Patient care areas - task illumination and selected receptacles in the following: ...
b. Medication preparation areas; c. Pharmacy dispensing areas ....8. Task illumination, selected receptacles, and power circuits for the following: .....(i) Postoperative recovery rooms ... [Re: NFPA 70, National Electrical Code, 1999: ?517-33(a).]

Findings: It could not be determined which branch powered the med refrigerator. The facility shall affirm that this requirement is met.

e. Mechanical Protection

The wiring of the emergency system of a hospital shall be mechanically protected by installation in nonflexible metal raceways, or shall be wired with Type MI cable. Where installed as branch circuit conductors serving patient care areas, the installation shall comply with the requirements of Section 517-13 [Re: NFPA 70, National Electrical Code, 1999: 517-30[c](3).]

Findings: At least one conduit powered by a panelboard labeled " 95CB-Critical Emergency " was a flex conduit which is not allowed. The facility shall affirm that this requirement is met.

f. Receptacles to be Labeled

Emergency system receptacles (in critical care areas) shall be identified and shall also indicate the panelboard and circuit number supplying them [Re: NFPA 70, National Electrical Code, 1999: 517-19(a).]

Findings: The red receptacles in the OR did not have this required labeling affixed to the cover plate.

Observation and discussion with the Plant Operations Director between 2 pm and 5:30 pm on 12/6/2011 revealed that certain requirements stipulated in NFPA 72 were not met.

Connections to the light and power service shall be on a dedicated branch circuit(s). The circuit(s) and service shall be mechanically protected. Circuit disconnecting means shall have a red marking, shall be accessible only to authorized personnel, and shall be identified as FIRE ALARM CIRCUIT CONTROL. The location of the circuit disconnecting means shall be permanently identified at the fire alarm control unit [Re: NFPA 72, National Fire Alarm Code, 1999: ? 1-5.2.5.2.]

Findings: This requirement was discussed with the staff during the survey, and it was noted that the required markings were not present on the Fire Alarm Control Panel or on the breaker in the panelboard.

Observation and discussion with the Plant Operations Director between 2 pm and 5:30 pm on 12/6/2011 revealed that certain requirements stipulated in NFPA 99 were not met.

The facility must have a Level I Medical Gas and Vacuum system as specified in NFPA 99, Chapter 4, 1999.

Findings: This requirement was discussed with the staff during the survey, and it was noted that the facility had no medical air system. The facility shall either install a compliant med air system, or explain in detail why this system is not needed.

Observation and discussion with the Plant Operations Director between 2 pm and 5:30 pm on 12/6/2011 revealed that certain requirements stipulated in NFPA 99 were not met.

The LIM circuit shall be tested at intervals of not more than 1 month by actuating the LIM test switch [see 3-3.2.2.3(f).] For a LIM circuit with self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months. Actuation of the test switch shall activate both visual and audible alarm indicators [Re: NFPA 99, Health Care Facilities, 1999: ?3-3.3.4.2(b).]

Findings: This requirement was discussed with the staff during the survey, and these records were not available for review.

Observation and discussion with the Plant Operations Director between 2 pm and 5:30 pm on 12/6/2011 revealed that certain requirements stipulated in NFPA 70 and 99 were not met.

a. Battery Maintenance

Storage batteries used in connection with essential electrical systems shall be inspected at intervals of not more than seven days and shall be maintained in full compliance with manufacturer ' s specifications [Re: NFPA 99, Health Care Facilities, 1999: ?3-4.4.1.3.]

Findings: This requirement was discussed with the staff during the survey, and these records were not available for review.

b. GenSet Light & Receptacle

No function other than those listed in (a) through (f) shall be connected to the life safety branch. The life safety branch of the emergency system shall supply power for the following lighting, receptacles, and equipment: ... ...(e) Generator Set Location. Task illumination battery charger for emergency battery-powered lighting unit(s) and selected receptacles at the generator set location [Re: NFPA 70, National Electrical Code, 1999: ?517-32(e).]

Findings: These amenities were not installed as required.

Observation and discussion with the Plant Operations Director between 2 pm and 5:30 pm on 12/6/2011 revealed that certain requirements stipulated in NFPA 70 and 99 were not met.

a. Separation of Branches

The Type I EES shall be divided into the critical branch, life safety branch and the equipment system in accordance with NFPA 99 [Re: NFPA 99, Health Care Facilities, 1999: ?3.4.2.2.2. and 3.4.2.2.3.]

Findings: It could not be determined if this facility has a Type I EES. The facility shall develop a one-line diagram and determine the relationship between the ATS(s) and the electrical panelboards. The panelboards shall be labeled properly. During the survey, one panelboard was labeled " critical emergency " but the individual circuit breakers did not conform to a specific branch.

b. Functional Allocation

The various functions powered by the Type I EES must be powered by the appropriate branch of the system [Re: NFPA 99, Health Care Facilities, 1999: ?3.4.2.2.2. and 3.4.2.2.3.]

Findings: After the panelboards are identified and labeled properly, the functions shall be moved to the proper power source.


c. 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: The circuit directories in the panelboards were outdated and reflected a configuration that was not code compliant. After the functional allocation is corrected, the directories shall be updated to be accurate and meaningful.

d. Critical Powered Receptacles

The critical branch of the emergency system shall supply power for task illumination, fixed equipment, selected receptacles, and special power circuits serving the following areas and functions related to patient care: .... 3. Patient care areas - task illumination and selected receptacles in the following: ...
b. Medication preparation areas; c. Pharmacy dispensing areas ....8. Task illumination, selected receptacles, and power circuits for the following: .....(i) Postoperative recovery rooms ... [Re: NFPA 70, National Electrical Code, 1999: ?517-33(a).]

Findings: It could not be determined which branch powered the med refrigerator. The facility shall affirm that this requirement is met.

e. Mechanical Protection

The wiring of the emergency system of a hospital shall be mechanically protected by installation in nonflexible metal raceways, or shall be wired with Type MI cable. Where installed as branch circuit conductors serving patient care areas, the installation shall comply with the requirements of Section 517-13 [Re: NFPA 70, National Electrical Code, 1999: 517-30[c](3).]

Findings: At least one conduit powered by a panelboard labeled " 95CB-Critical Emergency " was a flex conduit which is not allowed. The facility shall affirm that this requirement is met.

f. Receptacles to be Labeled

Emergency system receptacles (in critical care areas) shall be identified and shall also indicate the panelboard and circuit number supplying them [Re: NFPA 70, National Electrical Code, 1999: 517-19(a).]

Findings: The red receptacles in the OR did not have this required labeling affixed to the cover plate.