HospitalInspections.org

Based on observation, review of fire drills and interviews with staff, the facility failed to orient and train staff in fire safety procedures. The facility also failed to provide orientation and training to hospital personnel responsible for overseeing and conducting fire drills. The facility failed to provide qualified leadership to oversee the Life Safety Program. 19.7.1.2

Findings:

1. On 01/15/13, staff members F and U (in separate interviews) were asked to demonstrate the established routine in case fire or smoke was detected. Both F and U staff members could not give a detailed method or explanation. Staff F and U were familiar with the RACE method (Rescue,Alarm, Confine, Extinguish) and explained that they were aware, but had not been in-serviced.

2. In an interview on 01/15/13, Staff V explained to the surveyors that he had not been oriented and trained to oversee the Fire Safety training. Staff V was not aware of policies and procedures related to Fire Safety. Staff V was not able to provide construction documents related to the Fire Safety System. Staff V was not aware of all of the requirements necessary for the system to be green tagged.

3. On 001/15/13, Staff K was asked if there had been specific training regarding fire safety in the operating room. Staff K told surveyors she was unaware of any training that had occurred.

4. These findings were verified with administration at the time of the exit conference on 01/23/13.

Based on observation, review of the annual inspections, and interviews, the facility failed to provide a fire alarm system maintained in accordance with NFPA 70 National Electrical Code and NFPA 72. The facility failed to provide an approved maintenance and testing program complying with applicable requirements of NFPA 70 and 72. 9.6.1.4

Findings include:

#1 On 1/15/13 and 1/23/13 The facility could not provide an as-built or copy of the fire alarm drawings.

#2 The facility could not provide documentation a preventive maintenance program was in place on fixed and moveable systems and equipment including the fire system. There was no staff oriented and trained to identify locations of components in the fire system. The facility was not able to correct known problems with the system due to lack of system maintenance knowledge.

#3 Annual inspections documentation failed to document combination fire and smoke dampers and Smoke Evacuation System for Operating Rooms on annual test documentation.

#4 The fire system was yellow tagged for the last two years. The first yellow tag was in 11-19-2011 and second 11-15-2012. The facility contracted with a vendor to repair system on 11-30-2012. On 12-18-2012 the system was repaired, however the facility failed to provide documentation that reflects a reacceptance test in accordance with NFPA 72, 7-1.6.2. so that a Green Tag could be applied. In an interview Staff V told surveyors he was unaware of the need for the documentation .

Based on observation, interviews, and review of daily logs the facility failed to maintain heating, ventilation, and air conditioning that comply with the provisions of section 9.2 and are installed in accordance with the manufacturer's specifications. 19.5.2.1, 9.2, NFPA 90A, 19.5.2.2

According to the daily logs kept by Staff V, the exhaust system for Isolation Room 7 was not functioning as of September 20, 2012 The exhaust system was not functioning on 1/15/2013 (the first day of the physical plant inspection). On 1/18/2013, the surveyor returned to see if repairs had been made to the exhaust fan-they had not. In an interview, Staff V told surveyors he did not know where the breaker was. Surveyors requested blueprints and determined where the breaker panel was housed. Staff V was instructed on reading the blue prints. Upon inspection the breakers were not tripped. On 1/21/13 Staff V telephoned and explained that the fan was functioning. He stated that the facility hired an electrician and they went on the roof and found a reset button that was tripped on the motor. Staff V explained that he had never been in-serviced on the fan operation. Staff V also stated he did not know where the manual was for that piece of equipment. Staff V was asked why the repair took so long- Staff Member V stated "I have been so busy with both hospitals".


On 1-1-2013 the hospital freeze stat tripped that allowed HVAC equipment to malfunction. The monitoring equipment indicated that the fan tripped at 0530 on 1-1-2013, however staff did not call in the complaint or notify the plant manager until 1045 that same day. The problem was fixed at 1415 1-1-2013. Staff V told surveyors at the time of the incident there was not a process in place for notfication.
According to documents received at the department (after the incident) and on-site, a process has been put in place to notify Plant Manager, IT Director, CEO, CFO, and COO. The process will inform staff the minute the unit shuts down instead of receiving calls from staff and cut the response time down.

On 1/15/13 there was no documentation this process and many others have not been adopted by the Safety Committee and approved by the Governing Body and fully implemented. .

On 1/23/13 Staff V, CEO, and the Chairman of the Board indicated the HVAC Equipment has many problems-heat and humidity. According to Staff V these repairs require the vendor to repair as the system has a sophisticated computerized system. The Vendor was called out on December 14 and 19th for heating issues. On 1/8/13 and 1/10/13 the vendor repaired the outside air dampers. Staff V states that the leaving air still has a problem. The leaving air moves from 59 degrees to 120 degrees intermittently. On 1/23/13 the CEO stated that he had just met with the vendors and was in the process of securing a service agreement. At the time of exit the agreement was not in place with the vendor.

Based on observation and interview with staff, the facility failed to provide a piped in medical gas system to comply with NFPA 99, and NFPA 50 . Findings include:

#1 The source valve for the supply to the hospital was not labeled in accordance with NFPA 99, 1999 edition, chapter 4-3.1.2.3, Gas Shutoff Valves.
#2 The Bulk site is required to be secure (NFPA 99, 1999 edition chapter 4-31.1.2.11 c ) , however Staff V was asked on 1-15-2013 for the key to the enclosure. He stated he did not have the key and failed to know where the key was located. On Friday 01-18-2013, Staff V was asked if he had located the key his answer was, "I have been busy with Air Problems at the other hospital and have not found time to look".
#3 There was no evidence that the Safety officer coordinated with personnel of the Hyperbaric Chambers/Equipment to ensure proper facilities policies and procedures were being followed to reduce the risk of explosion and mitigate safety issues, NFPA 19, 1999 edition, 19-3.1.3.3.
All hazards involved with the use of the hyperbaric facilities can be mitigated successfully when all areas of hazards are fully recognized 19-3.1.2 . During observation of the oxygen source valve-the source valve for the supply to the Hyperbaric Chamber Supply was not labeled, NFPA 99, Chapter 4-3.1.2.3, and the key to the supply was not available

Based on observation , review of logs, and interviews with Staff V, the facility failed to maintain anesthetizing locations that are protected in accordance with NFPA 99, Standard for Health Care Facilities with Relative humidity that is maintained equal to or greater than 35%. NFPA 99 4.3.1.2.3(n) and 5.4.1.1, 19.3.2.3. Findings include:

The OR Humidity Logs reflect humidity ranges that are less than the minimum of 30%. In December, 2012, and January, 2013, the humidity ranges were less the the minimum for 13 days in January 1, 2013 through January 23, 2013 and 7 days in December, 2012 . NFPA 99 , 1999 EDITION, chapter 5, requires that Humidifying equipment for Anesthetizing locations shall be kept in operable condition and be continually operating during surgical procedures. 5-6.1.1.
Findings: The facility failed to provide documentation that the rooms were brought up to the minimum before procedures and failed to contract with the vendor that could adjust the software that controls the HVAC equipment of the Hospital. Staff Member V explained that he did not have the expertise to work or control the system and the CEO was in the process of obtaining a contract with the vendor that could control and maintain the system. The Chairman of the board indicated that equipment has had problems since it was installed.

(A) Based on interview with Staff member K, hired for the Operating Room, this staff member was not in-serviced in the Operating Room Protocols. A fire loss prevention program shall be included for all new personnel. Staff shall be taught general safety practices in for an area specific in accordance with NFPA 99, 1999 edition, chapter 12-4.1.2.10.

(B) Based on review of equipment, interview with staff, the facility failed to implement a Bio Medical Program that is in accordance with NFPA 99, 1999 edition, chapter 7-6.1 through 7-6.5.1
#1 It is the responsibility of the Governing Body of Medical and Surgical Instrumentation and Monitoring Devices as well as all electrical appliances used for the care and entertainment of patients, purchased or otherwise acquired for the use by the facility to meet the safety criteria 9-2.1 and Manufactures Requirements. The facility failed to establish Testing Intervals 7-6.2.1.2.
#2 The Anesthetizing Machines located in the Operating Room were checked in June, however in accordance with the sticker the machines were required to be retested in December. The inspection conducted in June was by a vendor who repaired the machines, however, the facility failed to provide documentation in accordance with 7-6.3.1.2 and failed to keep logs 7-6.3.1.3. The machines were kept in service. Machines were required to be retested in December.
#3 The facility failed to provide qualification and training for personnel concerned with the application and maintenance including physicians, nurses, nurse aides, engineers, technicians. The hospital also failed to be cognizant of the risks associated with use and failed to provide appropriate programs for continuing education. 7-6.5.1. Personnel involved with energy driven devices failed to receive training in Fire Suppression 7-6.5.2.

(C) Based on observation and interview with Staff V the facility failed to provide training for staff to maintain Continuity of Essential System in accordance with NFPA 99 1999 edition chapter 11-5.3.2. Findings include:
(1) The boiler and water heaters are installed with Natural Gas supply and backed up with a propane stored in tanks outside in an enclosure. Staff V could not demonstrate the method used to change from Natural Gas to Propane. Staff V stated that monitoring of the propane back up (verifying that propane tanks are full) has never been part of established routine. The enclosure to propane tanks was not secured and gauge to Pressure Reducing Valve on the supply line inside the enclosure was fogged over. The gauge could not be read. The enclosure was unsecured on 1/15,/2013 , 1/18/13, and 1/23/13. One of the four tanks were empty. I asked Staff V about the empty tank and he was unaware of the condition or its role in emergency condition.

Based on review of documents, observation, and staff interviews the facility failed to establish emergency procedures to contain and control spills throughout the facility.

Findings:

1. On 1/15/13 surveyors requested environmental policies and procedures. None were provided.
2. Although the lab director provided policies and procedures for spills within the laboratory, there was no policy, procedure and process implemented throughout the facility which guided staff on processes to contain chemical spills occurring outside of the laboratory. There were no procedures for areas likely to have spills from preserving agents such as formalin or disinfecting agents used for scope cleaning such as gluteraldehyde.
3. There was no documentation of training in controlling chemical spills in any of the personnel files reviewed during the survey.
4. Staff V, the Safety Officer could not provide documentation of inservicing regarding chemical spills.

Based on review of documents, interviews with staff, and review of meeting minutes the facility failed to have a comprehensive analysis of laboratory incidents included in Quality Assurance Performance Improvement (QAPI) to improve reduce risks and improve patient and personnel safety.

1. There was no documentation in any monthly meeting minutes (2012) which included any incident reports.
2. Staff V told surveyors there was no Safety Committee. Staff V told surveyors he was the Safety Officer.
3. There was no documentation lab incidents were reviewed in any current committees.

Based on observation, record review and staff interview, it was determined the hospital failed to comply with 2012 NFPA 99 Code for Healthcare Facilities, Chapter 14: Hyperbaric Facilities. Findings:

1. On 1/15/13 during a tour of the hospital, surveyors observed a hyperbaric program within the licensed space. When asked, the Director of Plant Operations stated he had no knowledge of who was designated as the on-site hyperbaric safety director. (14.3.1.3.2)

2. There was no evidence the hyperbaric safety director participated with the hospital leadership to develop procedures for operation and maintenance of the hyperbaric facility within the hospital. (14.3.1.3.2.1)

3. On 01/18/13, the surveyors asked for hyperbaric department safety policies and procedures. No policies were provided by the Director of Plant Operations. (14.3.1.3.2.2)

4. Upon review of the governing body by-laws and annual meeting minutes, there was no documentation the hospital governing body was responsible to ensure the care and safety of patients and staff in the hyperbaric facility. (14.3.1.3.3)

5. Upon review of the medical staff by-laws and annual meeting minutes, there was no documentation the medical staff adopted and enforced rules and regulations related to the use of the hyperbaric facility. (14.3.1.3.4)

6. There was no documentation provided by the hospital that indicated the hyperbaric safety director participated with the medical staff and the governing body for the development of regulations related to the hyperbaric facility. (14.3.1.3.4.1)

7. There was no documentation the safety director included the hyperbaric chamber as a part of the routine electrical, monitoring, life-support, protection, and ventilation maintenance program. (14.3.1.3.5)

8. On 01/18/13, the Director of Plant Operations stated he was not familiar with the rules and regulations for hyperbaric facilities (14.3.1.4). He stated he did not have a key to access the main gas (oxygen) shut off valves to the hospital or to the oxygen shut off to the hyperbaric chamber. When questioned by the surveyors, he had no knowledge or training related to the general safety requirements for hyperbaric facilities. (14.3.1.5)

Based on observation, interviews with staff and review of the Generator Load Test Record, the facility failed to inspect the Generator weekly and exercise under load for 30 minutes every month in accordance with NFPA 99. 3.4.4.1. and NFPA 110 Findings include:

#1. On January 15, 2013, in an interview with Staff V, this surveyor asked why the entire log was not completed. Staff V stated, "No one has provided me with the in-service to know where the readings come from." Staff V was asked where the numbers came from. Staff V told this surveyor, "The readings are just written in." Staff V further explained that he had written in what was started at the top of the log sheet by someone else. On 01/23/13, surveyors reviewed the log with Staff V. The findings above were again confirmed. NFPA 110, CHAPTER 6-4.7 requires that routine maintenance and operational testing program shall be overseen by a properly instructed individual.

#2. On 01/15, 01/18/13, and 01/23/13, surveyors observed the Automatic Transfer Switch for the generator required a key to switch from automatic to manual operation. The keys to the switches were not available. Staff V told surveyors he had been too busy with the other co-managed facility to find the keys. 6-2.3. Special Tools and testing devices shall be available.

#3. On 01/15/13 and 01/23/13, surveyors were told Transfer Switch testing had not been established. A maintenance program for testing of the automatic transfer switch shall be established. 6-3.5

#4. On 01/15/13 surveyors requested all operating manuals for special systems. No manuals were provided.

Based on observation, review of fire drills and interviews with staff, the facility failed to orient and train staff in fire safety procedures. The facility also failed to provide orientation and training to hospital personnel responsible for overseeing and conducting fire drills. The facility failed to provide qualified leadership to oversee the Life Safety Program. 19.7.1.2

Findings:

1. On 01/15/13, staff members F and U (in separate interviews) were asked to demonstrate the established routine in case fire or smoke was detected. Both F and U staff members could not give a detailed method or explanation. Staff F and U were familiar with the RACE method (Rescue,Alarm, Confine, Extinguish) and explained that they were aware, but had not been in-serviced.

2. In an interview on 01/15/13, Staff V explained to the surveyors that he had not been oriented and trained to oversee the Fire Safety training. Staff V was not aware of policies and procedures related to Fire Safety. Staff V was not able to provide construction documents related to the Fire Safety System. Staff V was not aware of all of the requirements necessary for the system to be green tagged.

3. On 001/15/13, Staff K was asked if there had been specific training regarding fire safety in the operating room. Staff K told surveyors she was unaware of any training that had occurred.

4. These findings were verified with administration at the time of the exit conference on 01/23/13.

Based on observation, review of the annual inspections, and interviews, the facility failed to provide a fire alarm system maintained in accordance with NFPA 70 National Electrical Code and NFPA 72. The facility failed to provide an approved maintenance and testing program complying with applicable requirements of NFPA 70 and 72. 9.6.1.4

Findings include:

#1 On 1/15/13 and 1/23/13 The facility could not provide an as-built or copy of the fire alarm drawings.

#2 The facility could not provide documentation a preventive maintenance program was in place on fixed and moveable systems and equipment including the fire system. There was no staff oriented and trained to identify locations of components in the fire system. The facility was not able to correct known problems with the system due to lack of system maintenance knowledge.

#3 Annual inspections documentation failed to document combination fire and smoke dampers and Smoke Evacuation System for Operating Rooms on annual test documentation.

#4 The fire system was yellow tagged for the last two years. The first yellow tag was in 11-19-2011 and second 11-15-2012. The facility contracted with a vendor to repair system on 11-30-2012. On 12-18-2012 the system was repaired, however the facility failed to provide documentation that reflects a reacceptance test in accordance with NFPA 72, 7-1.6.2. so that a Green Tag could be applied. In an interview Staff V told surveyors he was unaware of the need for the documentation .

Based on observation, interviews, and review of daily logs the facility failed to maintain heating, ventilation, and air conditioning that comply with the provisions of section 9.2 and are installed in accordance with the manufacturer's specifications. 19.5.2.1, 9.2, NFPA 90A, 19.5.2.2

According to the daily logs kept by Staff V, the exhaust system for Isolation Room 7 was not functioning as of September 20, 2012 The exhaust system was not functioning on 1/15/2013 (the first day of the physical plant inspection). On 1/18/2013, the surveyor returned to see if repairs had been made to the exhaust fan-they had not. In an interview, Staff V told surveyors he did not know where the breaker was. Surveyors requested blueprints and determined where the breaker panel was housed. Staff V was instructed on reading the blue prints. Upon inspection the breakers were not tripped. On 1/21/13 Staff V telephoned and explained that the fan was functioning. He stated that the facility hired an electrician and they went on the roof and found a reset button that was tripped on the motor. Staff V explained that he had never been in-serviced on the fan operation. Staff V also stated he did not know where the manual was for that piece of equipment. Staff V was asked why the repair took so long- Staff Member V stated "I have been so busy with both hospitals".


On 1-1-2013 the hospital freeze stat tripped that allowed HVAC equipment to malfunction. The monitoring equipment indicated that the fan tripped at 0530 on 1-1-2013, however staff did not call in the complaint or notify the plant manager until 1045 that same day. The problem was fixed at 1415 1-1-2013. Staff V told surveyors at the time of the incident there was not a process in place for notfication.
According to documents received at the department (after the incident) and on-site, a process has been put in place to notify Plant Manager, IT Director, CEO, CFO, and COO. The process will inform staff the minute the unit shuts down instead of receiving calls from staff and cut the response time down.

On 1/15/13 there was no documentation this process and many others have not been adopted by the Safety Committee and approved by the Governing Body and fully implemented. .

On 1/23/13 Staff V, CEO, and the Chairman of the Board indicated the HVAC Equipment has many problems-heat and humidity. According to Staff V these repairs require the vendor to repair as the system has a sophisticated computerized system. The Vendor was called out on December 14 and 19th for heating issues. On 1/8/13 and 1/10/13 the vendor repaired the outside air dampers. Staff V states that the leaving air still has a problem. The leaving air moves from 59 degrees to 120 degrees intermittently. On 1/23/13 the CEO stated that he had just met with the vendors and was in the process of securing a service agreement. At the time of exit the agreement was not in place with the vendor.

Based on observation and interview with staff, the facility failed to provide a piped in medical gas system to comply with NFPA 99, and NFPA 50 . Findings include:

#1 The source valve for the supply to the hospital was not labeled in accordance with NFPA 99, 1999 edition, chapter 4-3.1.2.3, Gas Shutoff Valves.
#2 The Bulk site is required to be secure (NFPA 99, 1999 edition chapter 4-31.1.2.11 c ) , however Staff V was asked on 1-15-2013 for the key to the enclosure. He stated he did not have the key and failed to know where the key was located. On Friday 01-18-2013, Staff V was asked if he had located the key his answer was, "I have been busy with Air Problems at the other hospital and have not found time to look".
#3 There was no evidence that the Safety officer coordinated with personnel of the Hyperbaric Chambers/Equipment to ensure proper facilities policies and procedures were being followed to reduce the risk of explosion and mitigate safety issues, NFPA 19, 1999 edition, 19-3.1.3.3.
All hazards involved with the use of the hyperbaric facilities can be mitigated successfully when all areas of hazards are fully recognized 19-3.1.2 . During observation of the oxygen source valve-the source valve for the supply to the Hyperbaric Chamber Supply was not labeled, NFPA 99, Chapter 4-3.1.2.3, and the key to the supply was not available

Based on observation , review of logs, and interviews with Staff V, the facility failed to maintain anesthetizing locations that are protected in accordance with NFPA 99, Standard for Health Care Facilities with Relative humidity that is maintained equal to or greater than 35%. NFPA 99 4.3.1.2.3(n) and 5.4.1.1, 19.3.2.3. Findings include:

The OR Humidity Logs reflect humidity ranges that are less than the minimum of 30%. In December, 2012, and January, 2013, the humidity ranges were less the the minimum for 13 days in January 1, 2013 through January 23, 2013 and 7 days in December, 2012 . NFPA 99 , 1999 EDITION, chapter 5, requires that Humidifying equipment for Anesthetizing locations shall be kept in operable condition and be continually operating during surgical procedures. 5-6.1.1.
Findings: The facility failed to provide documentation that the rooms were brought up to the minimum before procedures and failed to contract with the vendor that could adjust the software that controls the HVAC equipment of the Hospital. Staff Member V explained that he did not have the expertise to work or control the system and the CEO was in the process of obtaining a contract with the vendor that could control and maintain the system. The Chairman of the board indicated that equipment has had problems since it was installed.

(A) Based on interview with Staff member K, hired for the Operating Room, this staff member was not in-serviced in the Operating Room Protocols. A fire loss prevention program shall be included for all new personnel. Staff shall be taught general safety practices in for an area specific in accordance with NFPA 99, 1999 edition, chapter 12-4.1.2.10.

(B) Based on review of equipment, interview with staff, the facility failed to implement a Bio Medical Program that is in accordance with NFPA 99, 1999 edition, chapter 7-6.1 through 7-6.5.1
#1 It is the responsibility of the Governing Body of Medical and Surgical Instrumentation and Monitoring Devices as well as all electrical appliances used for the care and entertainment of patients, purchased or otherwise acquired for the use by the facility to meet the safety criteria 9-2.1 and Manufactures Requirements. The facility failed to establish Testing Intervals 7-6.2.1.2.
#2 The Anesthetizing Machines located in the Operating Room were checked in June, however in accordance with the sticker the machines were required to be retested in December. The inspection conducted in June was by a vendor who repaired the machines, however, the facility failed to provide documentation in accordance with 7-6.3.1.2 and failed to keep logs 7-6.3.1.3. The machines were kept in service. Machines were required to be retested in December.
#3 The facility failed to provide qualification and training for personnel concerned with the application and maintenance including physicians, nurses, nurse aides, engineers, technicians. The hospital also failed to be cognizant of the risks associated with use and failed to provide appropriate programs for continuing education. 7-6.5.1. Personnel involved with energy driven devices failed to receive training in Fire Suppression 7-6.5.2.

(C) Based on observation and interview with Staff V the facility failed to provide training for staff to maintain Continuity of Essential System in accordance with NFPA 99 1999 edition chapter 11-5.3.2. Findings include:
(1) The boiler and water heaters are installed with Natural Gas supply and backed up with a propane stored in tanks outside in an enclosure. Staff V could not demonstrate the method used to change from Natural Gas to Propane. Staff V stated that monitoring of the propane back up (verifying that propane tanks are full) has never been part of established routine. The enclosure to propane tanks was not secured and gauge to Pressure Reducing Valve on the supply line inside the enclosure was fogged over. The gauge could not be read. The enclosure was unsecured on 1/15,/2013 , 1/18/13, and 1/23/13. One of the four tanks were empty. I asked Staff V about the empty tank and he was unaware of the condition or its role in emergency condition.

Based on observation, record review and staff interview, it was determined the hospital failed to comply with 2012 NFPA 99 Code for Healthcare Facilities, Chapter 14: Hyperbaric Facilities. Findings:

1. On 1/15/13 during a tour of the hospital, surveyors observed a hyperbaric program within the licensed space. When asked, the Director of Plant Operations stated he had no knowledge of who was designated as the on-site hyperbaric safety director. (14.3.1.3.2)

2. There was no evidence the hyperbaric safety director participated with the hospital leadership to develop procedures for operation and maintenance of the hyperbaric facility within the hospital. (14.3.1.3.2.1)

3. On 01/18/13, the surveyors asked for hyperbaric department safety policies and procedures. No policies were provided by the Director of Plant Operations. (14.3.1.3.2.2)

4. Upon review of the governing body by-laws and annual meeting minutes, there was no documentation the hospital governing body was responsible to ensure the care and safety of patients and staff in the hyperbaric facility. (14.3.1.3.3)

5. Upon review of the medical staff by-laws and annual meeting minutes, there was no documentation the medical staff adopted and enforced rules and regulations related to the use of the hyperbaric facility. (14.3.1.3.4)

6. There was no documentation provided by the hospital that indicated the hyperbaric safety director participated with the medical staff and the governing body for the development of regulations related to the hyperbaric facility. (14.3.1.3.4.1)

7. There was no documentation the safety director included the hyperbaric chamber as a part of the routine electrical, monitoring, life-support, protection, and ventilation maintenance program. (14.3.1.3.5)

8. On 01/18/13, the Director of Plant Operations stated he was not familiar with the rules and regulations for hyperbaric facilities (14.3.1.4). He stated he did not have a key to access the main gas (oxygen) shut off valves to the hospital or to the oxygen shut off to the hyperbaric chamber. When questioned by the surveyors, he had no knowledge or training related to the general safety requirements for hyperbaric facilities. (14.3.1.5)

Based on observation, interviews with staff and review of the Generator Load Test Record, the facility failed to inspect the Generator weekly and exercise under load for 30 minutes every month in accordance with NFPA 99. 3.4.4.1. and NFPA 110 Findings include:

#1. On January 15, 2013, in an interview with Staff V, this surveyor asked why the entire log was not completed. Staff V stated, "No one has provided me with the in-service to know where the readings come from." Staff V was asked where the numbers came from. Staff V told this surveyor, "The readings are just written in." Staff V further explained that he had written in what was started at the top of the log sheet by someone else. On 01/23/13, surveyors reviewed the log with Staff V. The findings above were again confirmed. NFPA 110, CHAPTER 6-4.7 requires that routine maintenance and operational testing program shall be overseen by a properly instructed individual.

#2. On 01/15, 01/18/13, and 01/23/13, surveyors observed the Automatic Transfer Switch for the generator required a key to switch from automatic to manual operation. The keys to the switches were not available. Staff V told surveyors he had been too busy with the other co-managed facility to find the keys. 6-2.3. Special Tools and testing devices shall be available.

#3. On 01/15/13 and 01/23/13, surveyors were told Transfer Switch testing had not been established. A maintenance program for testing of the automatic transfer switch shall be established. 6-3.5

#4. On 01/15/13 surveyors requested all operating manuals for special systems. No manuals were provided.