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Based on observations during the survey walk of the facility on the morning and afternoon of 11/05/2013, with the Maintenance Supervisor, the facility failed to provide adequate signage. "NO SMOKING " signs shall be posted with the international symbol for no smoking at Emergency Department ' s entrance doors since their written smoking policy stated no smoking at this facility. Signage was provided at all other doors.

Based on observations during the survey walk of the facility on the morning and afternoon of 11/05/2013, with the Maintenance Supervisor, the facility failed to provide adequate signage. "NO SMOKING " signs shall be posted with the international symbol for no smoking at Emergency Department ' s entrance doors since their written smoking policy stated no smoking at this facility. Signage was provided at all other doors.

Based on review of records during the survey of facility on the afternoon of 11/05/2013, with the Administrator, Maintenance Director and Maintenance Supervisor, the facility failed to provide documentation of grounding system records. The electrical grounding of duplex outlets in general patient care areas shall be tested annually and critical care areas tested semi-annually. The facility must initiate a file to retain these records.
Receptacle testing in patient care areas shall be tested as follows:
Physical integrity of each receptacle. (visual)
Continuity of the grounding of each receptacle. (test)
Correct polarity of hot and neutral connections in each receptacle. (test)
The retention force of the grounding blade shall be not less than 4 oz. (test)



Based on observations during the survey walk of the facility on the morning and afternoon of 11/05/2013, with the Maintenance Supervisor, the facility failed to provide, at newest emergency generator set location, a light fixture which illuminates the generator that is energized by battery power. The battery in turn must be charged by an electrical connection to a life safety branch panelboard.

Based on observations during the survey walk of the facility on the morning and afternoon of 11/05/2013, with the Maintenance Supervisor, the facility failed to maintain the fire alarm system. Escutcheon plates used with a recessed or flush-type sprinkler head were not part of a listed assembly at emergency ' s department ' s clean utility.

Based on observations during the survey walk of the facility on the morning and afternoon of 11/05/2013, with the Maintenance Supervisor, the facility failed to assure that the essential electrical system was in full compliance. All electrical panels (both normal and emergency) were identified with the same color labels.
Electrical room ' s emergency electrical panels were not clearly identified as components of essential electrical system. All electrical power and lighting panels on the EES shall be clearly identified with color coded labels (preferable red) on each panel, identifying them as " Emergency-Life Safety " , Emergency-Critical Branch " and/or " Emergency-Equipment Branch " .




Based on observations during the survey walk of the facility on the morning and afternoon of 11/05/2013, with the Maintenance Supervisor, the facility failed to assure that the essential electrical system was in full compliance. Sprinkler Controller and exterior signage were supplied with power from the life safety branch of the essential electrical system. If they are not part of a system listed below, the circuits will need to be moved to another panel.
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 or ASC) 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 ... 7. Automatically opened doors used for building egress. No functions other than those listed above in items 1 through 7 shall be connected to the life safety branch.