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Based on observation and interview the hospital did not ensure that vertical openings between floors were sealed or enclosed as required.

Findings include:

1. On the afternoon of 12/2/10 during an inspection of Stair F at roof discharge the door to a small room was noted open. Interview with SP #40, Associate Executive Director of Facilities Management revealed that this room encloses the vent pipe that runs the length of the building through the roof to the exterior. The door could not be locked and closed as it lacked a lock set, in addition, the door was not provided with a self closer.

2. On the afternoon of 12/2/10 unsealed penetrations were noted in the ceiling of the basement storage rooms containing plumbing, electrical, and carpentry supplies.

Based on observation and interview not all doors required to close upon activation of the fire alarm system were designed to do so.

Finding:

On the morning of 12/3/10 two fire rated doors, in the street level exit passageway from Stair F, were noted held open and not designed to release upon activation of the fire alarm system. These include:
a. The door to CT preparation room 1144 held open with a door stop.
b. The pair of automatic doors to the emergency department (ED) on a switch. With the switch in the " on " position the pair of doors would not release upon activation of the FA system. This was confirmed in interview with SP #40.
c. The gate to the boiler room roof, located in this exit passageway, was unlocked.



21204


On the afternoon of 11/29/10, the exit door of the pediatric Emergency Department (ED) next to the triage area, was noted to held open by a trash can. This findings was confirmed with the facility staff who accompanied the state surveyor during that time.

Based on observation and staff interview, access exits was not marked by approved, readily visible signs in all cases where the exit or way to reach exit is not readily apparent to occupants.

Findings included:
1- On 12/2/2010 at approximately 11:30 AM, during a tour of the radiology department on the 5 th floor, the waiting area of the radiology department was observed not to have illuminated exit signs. That area had paper exit signs that were not illuminated and would not be readily visible in the event of smoke condition.

2- On 12/3/2010 during a tour of the CT scan trailer next to the emergency department, the followings were identified:

a- No illuminated exit signs were provided in the exit passageway of the CT scan trailer.
b- No illuminated exit signs were provided in the CT scan trailer to direct the patient and staff to the exit door in the event of fire or smoke condition.

The above findings were confirmed with the SP # 41, Patient Safety Office: Associate Director.

Based on on observation the facility did not ensure that all required smoke barrier walls in the hospital were maintained as required.

Findings:

1. On the afternoon of 11/30/10 during a tour of the 15 th floor ICU and CCU improperly sealed service equipment penetrations were noted above the dropped ceiling in the smoke barrier. Fire stop material was not installed in accordance with the manufacturer's UL requirements. The firestop material was noted applied on top of cement material on the wall rather than in the annular space around the pipe. Firestop material from two different manufacturers (one red in color and one black) was noted used on some penetrations.

2. On the afternoon of 12/2/10 during a tour of the medical surgical unit on the 11 th floor improperly sealed conduit penetrations were noted above the dropped ceiling of the smoke barrier door located between rooms 117 and 118. The firestop material was noted applied on top of cement material on the wall rather than in the annular space around the pipe as required by the manufacturer of the product. .

Based on observations, interviews and record review, the hospital did not ensure that hazardous areas are protected as required.

Findings include:

1. On the afternoon of 12/1/10 the doors to general store rooms C 125, C 126 and C 131, in the hospital's cellar, were noted held open with door stops compromising the one hour separation required.

2. On the afternoon of 12/1/10 during inspection of the laundry chute discharge room the laundry chute discharge door was noted held open with an S hook and not with a fusible link that would melt, in the event of fire, releasing the door. A manufacturer's cut sheet for the device being used to hold the door open was requested but not provided.

3. On the afternoon of 12/1/10 the one hour rated construction around the laundry chute discharge room was noted compromised. Specific reference is made to unsealed penetrations in the sheetrock wall.

4. On the morning of 12/2/10 the sprinkler system in the paint shop was compromised as four sprinkler heads were blocked by cardboard boxes. A hole was noted in the door of one of ten flammable storage cabinets dues to a missing door handle.

5. On the afternoon of 12/2/10 storage and repair shops for plumbing, electrical carpentry and sheetmetal were noted incompletely sprinklered. Floor plans show that these rooms had recently been converted from staff locker rooms. A new sprinkler system was noted partially installed along side the existing sprinkler system. According to SP #42 steam supervisor, work on the new sprinkler system was abruptly terminated approximately two months ago and is not tied into the fire alarm system. Paint was noted on several sprinkler heads of the existing system. Doors to this storage area were noted held open with a door wedge.

6. The door to the toilet room, in close proximity to the entrance to the trades storage room, was held open and a 20 gallon trash container was noted overflowing with toilet tissue.

7. On the afternoon of 12/2/10 unsealed penetrations around waste and electrical pipes were noted in the fire barrier separating plumbing storage from nuclear medicine.

8. On the afternoon of 12/2/10 approximately 15 to 20 cardboard boxes containing HVAC filters were noted inappropriately stored in the non-rated mechanical /equipment room C 101.

9. On the morning of 12/3/10 the doors to the storage room, in the vicinity of the medical gas manifold room, were noted held open and lacked self closing devices. Review of the Interim Life Safety Measures (ILSM) revealed that installation of the door was started on 4/28/10 but has not yet been completed.

Based on observation, floor plan review and interview exit components did not provide adequate protection against fire or smoke. exit from Stairs A and D was not arranged to provide a continuous protected path to a public way.

Findings:

1. On the morning of 12/3/10 inspection of the exit passageway from Stairs A and D at the level of discharge revealed that the exit passageway was not arranged to provide a continuous protected path to a public way. The exit passageway did not did not provide the same level of protection as did the stairwells A and D. The floor plan showed a 30 minute separation around the lobby rather than the 2 hour separation required and the lobby is not sprinklered. This was confirmed in interview with SP #40, Associate Executive Director of Facilities Management.

2. On the morning of 12/3/10 the four (4) auditorium room doors were noted not designed to limit the passage of smoke. The gap between the meeting edges of the doors was greater than the 1/8 " allowed.

Based on observation the hospital did not ensure that stairways were provided with adequate stair identification signs.

Findings:

1. On the afternoon of 12/2/10 no stair identification sign was available at the 18 th floor landing of Stair F.

2. On the morning of 12/3/10 the stair identification sign at Stair E discharge incorrectly identified the terminus of the stair as the 7 th floor rather than the 18 th floor.

Based on observation exits are not readily available at all times. Exit doors shall not require more than one releasing action.

Finding:

On the afternoon of 12/2/10 exit to the roof at Stairs E and F was noted to require two motions rather than one. An employee swipe card is required in addition to use of the door handle

NFPA 19.2.2.2 / 7.2.1.5.4

Based on observation the hospital did not ensure that illumination of the means of egress was adequately illuminated.

Finding:

On the afternoon of 12/2/10 the lighting in stair F at roof level consisted of a single bulb. In addition, the bulb was hanging from the wall and the electrical wires were exposed. There was no indication that this this bulb was tied into the emergency generator so that it could provide illumination in the event of power failure.

Based on observation and interview the hospital did not ensure that procedure areas are provided with back up battery lighting.

Finding:

On the morning of 11/29/10 the hospital's operating rooms were not provided with battery powered emergency lighting to ensure task illumination during the possible 10 second switch over time from normal power to emergency power in the event of power failure or failure of the generator. Concurrent interview with SP #40 confirmed that battery powered lighting was not provided.

NFPA 99 1999 3-3.2.1.2(5)(e)

Based on record review the hospital did not ensure that staff members are familiar with all procedures.

Finding:

Although there is a written plan for Operating Room (OR) fires there was no documentation that an in-service was provide to OR staff or that any site specific OR drills were conducted. This documentation was requested but not provided.

NFPA 99 1999 12-4.1.2.10

Based on observation and interview the hospital did not ensure that the required fire alarm system was maintained in accordance with the requirements of NFPA 72.

Findings:

1. Review of fire alarm records on 12/30/10 revealed that it did not include the name of the testing company, name of the monitoring entity, type of transmission, panel manufacturer, quantity of alarm initiating devices and appliances, supervisory signals, type of battery, testing of battery, and all required systems tests, etc.

2. On the morning of 12/2/10 during an inspection of the cellar electrical storage room a combination horn/strobe was noted hanging from overhead conduit with a piece of sheetrock attached to it. According to SP # 43, Supervisor for Electricians, the horn/strobe had been attached to a wall that had been removed and that a request to have the notification device relocated had been made approximately two months ago.

3. On the afternoon of 12/2/10 it was noted that no manual fire alarm pull was available at roof exit from Stairs E and F.

Based on record reviews and interview during the survey the facility did not ensure that all fire protection systems were maintained, inspected, and tested in accordance with the requirements found in NFPA 25, Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems.

Findings:

1. On 11/30/10 review of automatic fire sprinkler maintenance records revealed that there were no records that the sprinkler system water storage tank was inspected and maintained.
NFPA 25 Table 9.1

2. On 11/30/10 review of automatic fire sprinkler maintenance records revealed that there was no documentation available to determine that the O S & Y valve was tested to ensure that it was operated annually through its full range.
NFPA 25 Table 12.1

2. No documentation was available to show that five (5) year inspection tests for gauges and five (5) year internal inspections for obstructions on the sprinkler piping, alarm valves and associated trim and check valves were conducted. The documentation was requested but not provided.
NFPA 25 table 5.1

4. On the morning of 12/2/10 inspection of the sprinkler box in the engineering/mechanical room revealed that it did not contain at least two (2) of each type of sprinkler head used in the hospital. Specific reference is made to the lack of the quick response heads.

Based on observations the hospital did not ensure that all means of egress were continuously maintained to provide full instant use in the event of emergency.

Findings are:

1. On the morning of 12/29/10 a pallet containing anesthesia supplies was noted stored in the hallway outside the anesthesia work room hampering egress in the event of emergency. OR staff indicated that the placement of the supplies in that area was only temporary. The pallet and supplies were noted still stored outside the anesthesia room on the afternoon of the same day.

2. On the afternoon of 12/1/10 one of two exits from the generator room was noted obstructed by a work platform. In addition, the footing of the scaffolding created a possible tripping hazard.

3. On the afternoon of 12/2/10 access to exit Stair A from the plumbing storage area was noted hampered by a cabinet, a motor on the floor and by a trash container.

4. On the morning of 12/3/10 the fire door at the level of exit discharge from Stair F was found to be sticking and very difficult to open without > than 15 lbf. to release the latch.

5. On the morning of 12/3/10 the concrete sidewalk at the discharge from Stair "F" was broken and uneven creating a tripping hazard.

Based on observation and interview the hospital did not ensure that that trash collection receptacles greater than 32 gallon in capacity were located in room protected as a hazardous area.

Findings:

1. On the morning of 11/29/10 two (2) unsupervised 55 gallon medical waste containers were noted stored in the corridor outside the soiled utility room in the OR suite.

2. On the morning of 11/29/10 four (4) unsupervised 90 gallon trash receptacles referred to as "gondolas" by staff were noted stored in the corridor ,adjacent to the service elevators, on the OR floor.
Interview with SP # 44, Housekeeper, revealed that the gondolas are stored in this area until filled and then brought down to the loading dock.

Based on observation and record review the medical gas storage room was not maintained as required.

Finding:

On the morning of 12/3/10 the medical gas tanks in the manifold room were noted covered with a thick layer of dust. Review of the Infection Control Risk Assessment (ICRA) revealed that construction of a new wall and double doors has been ongoing since 4/28/10 in the adjacent storage room.

Based on document review and interview generators are not inspected weekly.

Finding:

Review of generator records on 11/30/10 revealed that monthly generator tests are conducted but weekly inspections are not. This was confirmed in concurrent interview with SP #45, Interim Dir. of Facilities Management.

Based on observations and record review, the facility provides general anesthesia, has NFPA 99 - 1999 defined "Critical Care Areas" (i.e., Operating Rooms where NFPA 99 defined "invasive procedures" are performed and patients are connected to line operated patient care-related electrical appliances.) and the Essential Electrical System (EES) is not a Type 1 EES in full compliance with NFPA 99 and NFPA 70.

Finding includes:

The wiring for items required to be served by the Equipment System was not independent from wiring for items required to be served by the Emergency System and the wiring for items required to be served by the Emergency System-Critical Branch was not separate from the wiring for items required to be served by the Emergency System - Life Safety Branch. Verified in interview with SP #40 and SP #15, Dir. of Maintenance) these staff members indicated that the hospital is currently in the process of installing a new generator and providing a Type l ESS.

NFPA 99 - 1999: Ch 3, NFPA 70: Article 517, Article 700

Based on observation and interview the hospital did not ensure that vertical openings between floors were sealed or enclosed as required.

Findings include:

1. On the afternoon of 12/2/10 during an inspection of Stair F at roof discharge the door to a small room was noted open. Interview with SP #40, Associate Executive Director of Facilities Management revealed that this room encloses the vent pipe that runs the length of the building through the roof to the exterior. The door could not be locked and closed as it lacked a lock set, in addition, the door was not provided with a self closer.

2. On the afternoon of 12/2/10 unsealed penetrations were noted in the ceiling of the basement storage rooms containing plumbing, electrical, and carpentry supplies.

Based on observation and interview not all doors required to close upon activation of the fire alarm system were designed to do so.

Finding:

On the morning of 12/3/10 two fire rated doors, in the street level exit passageway from Stair F, were noted held open and not designed to release upon activation of the fire alarm system. These include:
a. The door to CT preparation room 1144 held open with a door stop.
b. The pair of automatic doors to the emergency department (ED) on a switch. With the switch in the " on " position the pair of doors would not release upon activation of the FA system. This was confirmed in interview with SP #40.
c. The gate to the boiler room roof, located in this exit passageway, was unlocked.



21204


On the afternoon of 11/29/10, the exit door of the pediatric Emergency Department (ED) next to the triage area, was noted to held open by a trash can. This findings was confirmed with the facility staff who accompanied the state surveyor during that time.

Based on observation and staff interview, access exits was not marked by approved, readily visible signs in all cases where the exit or way to reach exit is not readily apparent to occupants.

Findings included:
1- On 12/2/2010 at approximately 11:30 AM, during a tour of the radiology department on the 5 th floor, the waiting area of the radiology department was observed not to have illuminated exit signs. That area had paper exit signs that were not illuminated and would not be readily visible in the event of smoke condition.

2- On 12/3/2010 during a tour of the CT scan trailer next to the emergency department, the followings were identified:

a- No illuminated exit signs were provided in the exit passageway of the CT scan trailer.
b- No illuminated exit signs were provided in the CT scan trailer to direct the patient and staff to the exit door in the event of fire or smoke condition.

The above findings were confirmed with the SP # 41, Patient Safety Office: Associate Director.

Based on on observation the facility did not ensure that all required smoke barrier walls in the hospital were maintained as required.

Findings:

1. On the afternoon of 11/30/10 during a tour of the 15 th floor ICU and CCU improperly sealed service equipment penetrations were noted above the dropped ceiling in the smoke barrier. Fire stop material was not installed in accordance with the manufacturer's UL requirements. The firestop material was noted applied on top of cement material on the wall rather than in the annular space around the pipe. Firestop material from two different manufacturers (one red in color and one black) was noted used on some penetrations.

2. On the afternoon of 12/2/10 during a tour of the medical surgical unit on the 11 th floor improperly sealed conduit penetrations were noted above the dropped ceiling of the smoke barrier door located between rooms 117 and 118. The firestop material was noted applied on top of cement material on the wall rather than in the annular space around the pipe as required by the manufacturer of the product. .

Based on observations, interviews and record review, the hospital did not ensure that hazardous areas are protected as required.

Findings include:

1. On the afternoon of 12/1/10 the doors to general store rooms C 125, C 126 and C 131, in the hospital's cellar, were noted held open with door stops compromising the one hour separation required.

2. On the afternoon of 12/1/10 during inspection of the laundry chute discharge room the laundry chute discharge door was noted held open with an S hook and not with a fusible link that would melt, in the event of fire, releasing the door. A manufacturer's cut sheet for the device being used to hold the door open was requested but not provided.

3. On the afternoon of 12/1/10 the one hour rated construction around the laundry chute discharge room was noted compromised. Specific reference is made to unsealed penetrations in the sheetrock wall.

4. On the morning of 12/2/10 the sprinkler system in the paint shop was compromised as four sprinkler heads were blocked by cardboard boxes. A hole was noted in the door of one of ten flammable storage cabinets dues to a missing door handle.

5. On the afternoon of 12/2/10 storage and repair shops for plumbing, electrical carpentry and sheetmetal were noted incompletely sprinklered. Floor plans show that these rooms had recently been converted from staff locker rooms. A new sprinkler system was noted partially installed along side the existing sprinkler system. According to SP #42 steam supervisor, work on the new sprinkler system was abruptly terminated approximately two months ago and is not tied into the fire alarm system. Paint was noted on several sprinkler heads of the existing system. Doors to this storage area were noted held open with a door wedge.

6. The door to the toilet room, in close proximity to the entrance to the trades storage room, was held open and a 20 gallon trash container was noted overflowing with toilet tissue.

7. On the afternoon of 12/2/10 unsealed penetrations around waste and electrical pipes were noted in the fire barrier separating plumbing storage from nuclear medicine.

8. On the afternoon of 12/2/10 approximately 15 to 20 cardboard boxes containing HVAC filters were noted inappropriately stored in the non-rated mechanical /equipment room C 101.

9. On the morning of 12/3/10 the doors to the storage room, in the vicinity of the medical gas manifold room, were noted held open and lacked self closing devices. Review of the Interim Life Safety Measures (ILSM) revealed that installation of the door was started on 4/28/10 but has not yet been completed.

Based on observation, floor plan review and interview exit components did not provide adequate protection against fire or smoke. exit from Stairs A and D was not arranged to provide a continuous protected path to a public way.

Findings:

1. On the morning of 12/3/10 inspection of the exit passageway from Stairs A and D at the level of discharge revealed that the exit passageway was not arranged to provide a continuous protected path to a public way. The exit passageway did not did not provide the same level of protection as did the stairwells A and D. The floor plan showed a 30 minute separation around the lobby rather than the 2 hour separation required and the lobby is not sprinklered. This was confirmed in interview with SP #40, Associate Executive Director of Facilities Management.

2. On the morning of 12/3/10 the four (4) auditorium room doors were noted not designed to limit the passage of smoke. The gap between the meeting edges of the doors was greater than the 1/8 " allowed.

Based on observation the hospital did not ensure that stairways were provided with adequate stair identification signs.

Findings:

1. On the afternoon of 12/2/10 no stair identification sign was available at the 18 th floor landing of Stair F.

2. On the morning of 12/3/10 the stair identification sign at Stair E discharge incorrectly identified the terminus of the stair as the 7 th floor rather than the 18 th floor.

Based on observation exits are not readily available at all times. Exit doors shall not require more than one releasing action.

Finding:

On the afternoon of 12/2/10 exit to the roof at Stairs E and F was noted to require two motions rather than one. An employee swipe card is required in addition to use of the door handle

NFPA 19.2.2.2 / 7.2.1.5.4

Based on observation the hospital did not ensure that illumination of the means of egress was adequately illuminated.

Finding:

On the afternoon of 12/2/10 the lighting in stair F at roof level consisted of a single bulb. In addition, the bulb was hanging from the wall and the electrical wires were exposed. There was no indication that this this bulb was tied into the emergency generator so that it could provide illumination in the event of power failure.

Based on observation and interview the hospital did not ensure that procedure areas are provided with back up battery lighting.

Finding:

On the morning of 11/29/10 the hospital's operating rooms were not provided with battery powered emergency lighting to ensure task illumination during the possible 10 second switch over time from normal power to emergency power in the event of power failure or failure of the generator. Concurrent interview with SP #40 confirmed that battery powered lighting was not provided.

NFPA 99 1999 3-3.2.1.2(5)(e)

Based on record review the hospital did not ensure that staff members are familiar with all procedures.

Finding:

Although there is a written plan for Operating Room (OR) fires there was no documentation that an in-service was provide to OR staff or that any site specific OR drills were conducted. This documentation was requested but not provided.

NFPA 99 1999 12-4.1.2.10

Based on observation and interview the hospital did not ensure that the required fire alarm system was maintained in accordance with the requirements of NFPA 72.

Findings:

1. Review of fire alarm records on 12/30/10 revealed that it did not include the name of the testing company, name of the monitoring entity, type of transmission, panel manufacturer, quantity of alarm initiating devices and appliances, supervisory signals, type of battery, testing of battery, and all required systems tests, etc.

2. On the morning of 12/2/10 during an inspection of the cellar electrical storage room a combination horn/strobe was noted hanging from overhead conduit with a piece of sheetrock attached to it. According to SP # 43, Supervisor for Electricians, the horn/strobe had been attached to a wall that had been removed and that a request to have the notification device relocated had been made approximately two months ago.

3. On the afternoon of 12/2/10 it was noted that no manual fire alarm pull was available at roof exit from Stairs E and F.

Based on record reviews and interview during the survey the facility did not ensure that all fire protection systems were maintained, inspected, and tested in accordance with the requirements found in NFPA 25, Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems.

Findings:

1. On 11/30/10 review of automatic fire sprinkler maintenance records revealed that there were no records that the sprinkler system water storage tank was inspected and maintained.
NFPA 25 Table 9.1

2. On 11/30/10 review of automatic fire sprinkler maintenance records revealed that there was no documentation available to determine that the O S & Y valve was tested to ensure that it was operated annually through its full range.
NFPA 25 Table 12.1

2. No documentation was available to show that five (5) year inspection tests for gauges and five (5) year internal inspections for obstructions on the sprinkler piping, alarm valves and associated trim and check valves were conducted. The documentation was requested but not provided.
NFPA 25 table 5.1

4. On the morning of 12/2/10 inspection of the sprinkler box in the engineering/mechanical room revealed that it did not contain at least two (2) of each type of sprinkler head used in the hospital. Specific reference is made to the lack of the quick response heads.

Based on observations the hospital did not ensure that all means of egress were continuously maintained to provide full instant use in the event of emergency.

Findings are:

1. On the morning of 12/29/10 a pallet containing anesthesia supplies was noted stored in the hallway outside the anesthesia work room hampering egress in the event of emergency. OR staff indicated that the placement of the supplies in that area was only temporary. The pallet and supplies were noted still stored outside the anesthesia room on the afternoon of the same day.

2. On the afternoon of 12/1/10 one of two exits from the generator room was noted obstructed by a work platform. In addition, the footing of the scaffolding created a possible tripping hazard.

3. On the afternoon of 12/2/10 access to exit Stair A from the plumbing storage area was noted hampered by a cabinet, a motor on the floor and by a trash container.

4. On the morning of 12/3/10 the fire door at the level of exit discharge from Stair F was found to be sticking and very difficult to open without > than 15 lbf. to release the latch.

5. On the morning of 12/3/10 the concrete sidewalk at the discharge from Stair "F" was broken and uneven creating a tripping hazard.

Based on observation and interview the hospital did not ensure that that trash collection receptacles greater than 32 gallon in capacity were located in room protected as a hazardous area.

Findings:

1. On the morning of 11/29/10 two (2) unsupervised 55 gallon medical waste containers were noted stored in the corridor outside the soiled utility room in the OR suite.

2. On the morning of 11/29/10 four (4) unsupervised 90 gallon trash receptacles referred to as "gondolas" by staff were noted stored in the corridor ,adjacent to the service elevators, on the OR floor.
Interview with SP # 44, Housekeeper, revealed that the gondolas are stored in this area until filled and then brought down to the loading dock.

Based on observation and record review the medical gas storage room was not maintained as required.

Finding:

On the morning of 12/3/10 the medical gas tanks in the manifold room were noted covered with a thick layer of dust. Review of the Infection Control Risk Assessment (ICRA) revealed that construction of a new wall and double doors has been ongoing since 4/28/10 in the adjacent storage room.

Based on document review and interview generators are not inspected weekly.

Finding:

Review of generator records on 11/30/10 revealed that monthly generator tests are conducted but weekly inspections are not. This was confirmed in concurrent interview with SP #45, Interim Dir. of Facilities Management.

Based on observations and record review, the facility provides general anesthesia, has NFPA 99 - 1999 defined "Critical Care Areas" (i.e., Operating Rooms where NFPA 99 defined "invasive procedures" are performed and patients are connected to line operated patient care-related electrical appliances.) and the Essential Electrical System (EES) is not a Type 1 EES in full compliance with NFPA 99 and NFPA 70.

Finding includes:

The wiring for items required to be served by the Equipment System was not independent from wiring for items required to be served by the Emergency System and the wiring for items required to be served by the Emergency System-Critical Branch was not separate from the wiring for items required to be served by the Emergency System - Life Safety Branch. Verified in interview with SP #40 and SP #15, Dir. of Maintenance) these staff members indicated that the hospital is currently in the process of installing a new generator and providing a Type l ESS.

NFPA 99 - 1999: Ch 3, NFPA 70: Article 517, Article 700