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The facility failed to maintain the building construction type per code. Findings include:

During the survey, the facility was observed with a partial sprinkler system and a non conforming construction type for a facility with partial sprinkler system. (Separation is not maintained between the construction types.)
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2000 NFPA 101, 19.1.6.2 Health care occupancies shall be limited to the types of building construction shown in Table 19.1.6.2. (See 8.2.1.)

Table 19.1.6.2 Construction Type Limitations
Construction Stories
Type
1 2 3 4 or
More
I(443) X X X X
I(332) X X X X
II(222) X X X X
II(111) X X* X* NP
II(000) X* X* NP NP
III(211) X* X* NP NP
III(200) X* NP NP NP
IV(2HH) X* X* NP NP
V(111) X* X* NP NP
V(000) X* NP NP NP
X: Permitted type of construction.
NP: Not permitted.
*Building requires automatic sprinkler protection. (See 19.3.5.1.)
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The facility failed to maintain the Line Isolation Power System per code. Findings include:

During the survey, the following are examples of what was observed:
1. Per interview the facility was not performing monthly testing on the Line Isolation Monitor
2. Per observation OR 1 and OR 2 did not have audible alarms for the Line Isolation Monitor

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1999 NFPA 99, 3-3.2.2.3 Line Isolation Monitor. (a) * In addition to the usual control and protective devices, each isolated power system shall be provided with an approved continually operating line isolation monitor that indicates possible leakage or fault currents from either isolated conductor to ground. (b) The monitor shall be designed such that a green signal lamp, conspicuously visible to persons in the anesthetizing location, remains lighted when the system is adequately isolated from ground; and an adjacent red signal lamp and an audible warning signal (remote if desired) shall be energized when the total hazard current (consisting of possible resistive and capacitive leakage currents) from either isolated conductor to ground reaches a threshold value of 5.0 mA under normal line voltage conditions. The line isolation monitor shall not alarm for a fault hazard current of less than 3.7 mA. (c) The line isolation monitor shall have sufficient internal impedance such that, when properly connected to the isolated system, the maximum internal current that will flow through the line isolation monitor, when any point of the isolated system is grounded, shall be 1 mA. Exception:* The line isolation monitor is permitted to be of the low-impedance type such that the current through the line isolation monitor, when any point of the isolated system is grounded, will not exceed twice the alarm threshold value for a period not exceeding 5 msec. (d) * An ammeter connected to indicate the total hazard current of the system (contribution of the fault hazard current plus monitor hazard current) shall be mounted in a plainly visible place on the line isolation monitor with the " alarm on " (total hazard current = 5.0 mA) zone at approximately the center of the scale. It is desirable to locate the ammeter such that it is conspicuously visible to persons in the anesthetizing location. (e) Means shall be provided for shutting off the audible alarm while leaving the red warning lamp activated. When the fault is corrected and the green signal lamp is reactivated, the audible alarm silencing circuit shall reset automatically, or an audible or distinctive visual signal shall indicate that the audible alarm is silenced. (f) A reliable test switch shall be mounted on the line isolation monitor to test its capability to operate (i.e., cause the alarms to operate and the meter to indicate in the " alarm on " zone). This switch shall transfer the grounding connection of the line isolation monitor from the reference grounding point to a test impedance arrangement connected across the isolated line; the test impedance(s) shall be of the appropriate magnitude to produce a meter reading corresponding to the rated total hazard current at the nominal line voltage, or to a lesser alarm hazard current if the line isolation monitor is so rated. The operation of this switch shall break the grounding connection of the line isolation monitor to the reference grounding point before transferring this grounding connector to the test impedance(s), so that making this test will not add to the hazard of a system in actual use, nor will the test include the effect of the line to ground stray impedance of the system. The test switch shall be of a self-restoring type. (g) The line isolation monitor shall not generate energy of sufficient amplitude and/or frequency, as measured by a physiological monitor with a gain of at least 104 with a source impedance of 1000 ohms connected to the balanced differential input of the monitor, to create interference or artifact on human physiological signals. The output voltage from the amplifier shall not exceed 30 mV when the gain is 104. The 1000 ohms impedance shall be connected to the ends of typical unshielded electrode leads (which are a normal part of the cable assembly furnished with physiological monitors). A 60-Hz notch filter shall be used to reduce ambient interference (as is typical in physiological monitor design).
1999 NFPA 99, 3-3.3.4.2 Line Isolation Monitor Tests. The proper functioning of each line isolation monitor (LIM) circuit shall be ensured by the following: (a) The LIM circuit shall be tested after installation, and prior to being placed in service, by successively grounding each line of the energized distribution system through a resistor of 200 V ohms, where V = measured line voltage. The visual and audible alarms [see 3-3.2.2.3(b)] shall be activated. (b) 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 automated 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. (c) After any repair or renovation to an electrical distribution system and at intervals of not more than 6 months, the LIM circuit shall be tested in accordance with paragraph (a) above and only when the circuit is not otherwise in use. For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months.
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The facility failed to provide a Type 1 Essential Electrical System (EES) per code. Findings include:

During the survey, per documentation provided by the facility, generator #1 was installed in 2006 - the EES was not divided into the three separate branches.
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1999 NFPA 99, 3-4.2.2.2 Emergency System. (a) General. Those functions of patient care depending on lighting or appliances that are permitted to be connected to the emergency system are divided into two mandatory branches, described in 3-4.2.2.2(b) and (c). +All ac-powered support and accessory equipment necessary to the operation of the EPS shall be supplied from the load side of the automatic transfer switch(es), or the output terminals of the EPS, ahead of the main EPS overcurrent protection, as necessary, to ensure continuity of the EPSS operation and performance. (NFPA 110: 5-12.5) (b) Life Safety Branch. The life safety branch of the emergency system shall supply power for the following lighting, receptacles, and equipment: 1. Illumination of means of egress as required in NFPA 101,? Life Safety Code? 2. Exit signs and exit direction signs required in NFPA 101, Life Safety Code 3. Alarm and alerting systems including the following: a. Fire alarms b. Alarms required for systems used for the piping of nonflammable medical gases as specified in Chapter 4, "Gas and Vacuum Systems" 4. * Hospital communication systems, where used for issuing instruction during emergency conditions 5. Task illumination, battery charger for emergency battery-powered lighting unit(s), and selected receptacles at the generator set location 6. Elevator cab lighting, control, communication, and signal systems 7. Automatically operated doors used for building egress. No function other than those listed above in items 1 through 7 shall be connected to the life safety branch. Exception: The auxiliary functions of fire alarm combination systems complying with NAPA 72, National Fire Alarm Code, shall be permitted to be connected to the life safety branch. (c) * Critical Branch. The critical branch of the emergency system shall supply power for task illumination, fixed equipment, selected receptacles, and selected power circuits serving the following areas and functions related to patient care. It shall be permitted to subdivide the critical branch into two or more branches. 1. Critical care areas that utilize anesthetizing gases, task illumination, selected receptacles, and fixed equipment 2. The isolated power systems in special environments 3. Patient care areas - task illumination and selected receptacles in the following: a. Infant nurseries b. Medication preparation areas c. Pharmacy dispensing areas d. Selected acute nursing areas e. Psychiatric bed areas (omit receptacles) f. Ward treatment rooms g. Nurses' stations (unless adequately lighted by corridor luminaires) 4. Additional specialized patient care task illumination and receptacles, where needed 5. Nurse call systems 6. Blood, bone, and tissue banks 7. * Telephone equipment rooms and closets 8. Task illumination, selected receptacles, and selected power circuits for the following: a. General care beds (at least one duplex receptacle per patient bedroom) b. Angiographic labs c. Cardiac catheterization labs d. Coronary care units e. Hemodialysis rooms or areas f. Emergency Room treatment areas (selected) g. Human Physiology Labs h. Intensive Care Units i. Postoperative Recovery Rooms (selected) 9. Additional task illumination, receptacles, and selected power circuits needed for effective facility operation. Single-phase fractional horsepower motors shall be permitted to be connected to the critical branch.