HospitalInspections.org

Based on random observation during the survey walk-through, document review, and staff interview, the facility is not in compliance with a series of Life Safety and other code requirements that are not documented under other K-Tags.

Findings include:

A. Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.

Based on random observation during the survey walk-through and staff interview, the facility's electrical system is not divided into the critical branch, life safety branch, and the equipment system as required by NFPA 99.

Findings include:

A. The facility's Essential Electrical System was observed to not constitute a Type I EES System, as required by NFPA 99 1999 12-3.3.2., because the system is not subdivided into Life Safety, Critical, and Equipment Branches as required by NFPA 99 1999 3-4.2.2.; also refer to NFPA 70 1999 517-32. During an interview held in the Board Room on the morning of December 16, 2009, the provider's Facility Manager confirmed this finding.