HospitalInspections.org

The facility failed to maintain the corridor walls per code. Findings include:
During the survey, the following is an example of what was observed:

The Registration Office has a window with openings above half the height of the corridor wall. This room did not have a smoke detector in it.


2000 NFAP 101, 19.3.6.5 Openings. In other than smoke compartments containing patient bedrooms, miscellaneous openings such as mail slots, pharmacy pass-through windows, laboratory pass-through windows, and cashier pass-through windows shall be permitted to be installed in vision panels or doors without special protection, provided that the aggregate area of openings per room does not exceed 20 in.2 (130 cm2), and the openings are installed at or below half the distance from the floor to the room ceiling.
Exception: For rooms protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.2, the aggregate area of openings per room shall not exceed 80 in.2 (520 cm2).


.

The facility failed to maintain the corridor openings per code. Findings include:
During the survey, the following are examples of what was observed:

1. The E.R./OR Suite corridor double doors were not:

a. Positive latching
b. Smoke resistive

2. The Laboratory Main Door (corridor) was not positive latching
3. The Registration Office corridor door was being held open by a wedge
4. The Enviromental Services corridor door had a toe stop
5. The Kitchen corridor dutch door was not positive latching top and bottom

6. The Dietary Dishwash Room corridor double doors:

a. Had toe stops
b. Were not smoke resistive




2000 NFPA 101, 19.3.6.3.1 Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 13/4-in. (4.4-cm) thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke. Compliance with NFPA 80, Standard for Fire Doors and Fire Windows, shall not be required. Clearance between the bottom of the door and the floor covering not exceeding 1 in. (2.5 cm) shall be permitted for corridor doors.
2000 NFPA 101, 19.3.6.3.2 Doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door. Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.2.
2000 NFPA 101, 19.3.6.3.3 Hold-open devices that release when the door is pushed or pulled shall be permitted.
2007 CMS - 2786R There is no impediment to the closing of the corridor doors.





.

The facility failed to maintain the corridor openings per code. Findings include:
During the survey, the following is an example of what was observed:

The corridor door for room 201 was observed with four holes at the door knob.



2000 NFPA 101, 19.3.6.3.1 Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 13/4-in. (4.4-cm) thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke. Compliance with NFPA 80, Standard for Fire Doors and Fire Windows, shall not be required. Clearance between the bottom of the door and the floor covering not exceeding 1 in. (2.5 cm) shall be permitted for corridor doors.
.

The facility failed to maintain exit signs. Findings include:
During the survey, the following is an example of what was observed:

The Exit Sign for the Exit by Environmental Services Office was obstructed by loose hanging ceiling tile.



7.10.1.4 Exit access shall be marked by signs.



.

The facility failed to maintain the smoke barrier to restrict the passage of smoke. Findings include: During the survey, the following is an example of what was observed:

The doors in the smoke barrier failed to latch/close tight so as to restrict the passage of smoke by Patient Room 206.




NFPA 101, 19.3.7.6., 8.3.4 Doors in smoke barriers to be self-closing. Doors in smoke barriers shall close the opening in the wall leaving only a minimum clearance to allow door(s) to function properly.

The facility failed to maintain separation of hazardous areas. Findings include During the survey, the following is an example of what was observed:


The South Boiler Room had a penetration around a sleeve in the wall which had been sealed with a foam material.




NFPA 101, 19.3.2.1 Hazardous areas shall be safeguarded by a fire barrier of a one-hour fire resistance rating or provided with an automatic sprinkler system.

The facility failed to maintain the hazardous areas per code. Findings include:
During the survey, the following are examples of what was observed:

1. The following storage rooms were over fifty sq. ft. and contained combustibles without a self-closing door:

a. The Central Sterile Room
b. The "Old Recovery Room"

2. The Dietary Pantry door had a self-closing device, but the door was held open by a toe stop.



2000 NFPA 101, 19.3.2.1 Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing.

.

The facility failed to provide readily accessible exits at all times. Findings include: During the survey, the following is an example of what was observed:

The Exit, across from the Environmental Services Office, was blocked at the exit discharge by a linen cart.




NFPA 101, 7.1.10.1 Means of egress shall be continuously maintained free of all obstructions or impediments for full instant use in case of fire or other emergencies.


.

The facility failed to maintain the fire barrier per code. Findings include,
During the survey, the following is an example of what was observed:

The fire barrier at room 206 had several unsealed penetrations, the wall was covered in insulation.



2000 NFPA 101, 8.2.3.2.4.2 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through fire barriers shall be protected as follows:
(1) The space between the penetrating item and the fire barrier shall meet one of the following conditions: a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier. b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the fire barrier, the sleeve shall be solidly set in the fire barrier, and the space between the item and the sleeve shall meet one of the following conditions: a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier. b. It shall be protected by an approved device that is designed for the specific purpose.
(3) * Insulation and coverings for pipes and ducts shall not pass through the fire barrier unless one of the following conditions is met: a. The material shall be capable of maintaining the fire resistance of the fire barrier. b. The material shall be protected by an approved device that is designed for the specific purpose.
(4) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions: a. It shall be made on either side of the fire barrier.b. It shall be made by an approved device that is designed for the specific purpose.
.

The facility failed to maintain the fire barrier per code. Findings include:
During the survey, the following are examples of what was observed:

1. The fire barrier at the Ultrasound Room had an unsealed penetration of a water line.
2. The fire barrier by room 201 had an unsealed penetration of a black and a yellow wire.



2000 NFPA 101, 8.2.3.2.4.2 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through fire barriers shall be protected as follows: (1) The space between the penetrating item and the fire barrier shall meet one of the following conditions: a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier. b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the fire barrier, the sleeve shall be solidly set in the fire barrier, and the space between the item and the sleeve shall meet one of the following conditions: a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier. b. It shall be protected by an approved device that is designed for the specific purpose.
(3) * Insulation and coverings for pipes and ducts shall not pass through the fire barrier unless one of the following conditions is met: a. The material shall be capable of maintaining the fire resistance of the fire barrier. b. The material shall be protected by an approved device that is designed for the specific purpose.
(4) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions: a. It shall be made on either side of the fire barrier. b. It shall be made by an approved device that is designed for the specific purpose.



.

The facility failed to provide continuous lighting for means of egress. Findings include: During the survey, the following is an example of what was observed:


The Exit for Hall 200 was observed to have a single bulb in a double bulb fixture at the Exit Discharge.




NFPA 101, 19.2.8 and 7.8.1.2 Illumination of means of egress shall be continuous.




.

During the survey, the following is an example of what was observed:

Documentation was not provided for the monthly 30 seconds, or 1.5 annual test of the battery powered light located in the Generator Set Control Room.


NFPA 101, 7.9.3 A documented monthly test of battery-powered emergency lighting for at least 30 seconds, and an annual test for a duration of 1-1/2 hours, with equipment being fully operational for the duration of the test.

During the survey, the following is an example of what was observed:

Documentation was not provided for the monthly 30 seconds, or 1.5 annual test of the battery powered light, located in the Generator Set Control Room.


NFPA 101, 7.9.3 A documented monthly test of battery-powered emergency lighting for at least 30 seconds, and an annual test for a duration of 1-1/2 hours, with equipment being fully operational for the duration of the test.

The facility failed to provide an evacuation plan per code. Findings include:
During the survey, the following is an example of what was observed:

The written fire evacuation plan did not include the wording "evacuate from the effected smoke compartment to an uneffected smoke compartment".



2000 NFPA 101, 19.7.2.2 A written health care occupancy fire safety plan shall provide for the following:
(1) Use of alarms
(2) Transmission of alarm to fire department
(3) Response to alarms
(4) Isolation of fire
(5) Evacuation of immediate area
(6) Evacuation of smoke compartment
(7) Preparation of floors and building for evacuation
(8) Extinguishment of fire




.

The facility failed to provide an evacuation plan per code. Findings include:
During the survey, the following is an example of what was observed:

The written fire evacuation plan did not include the wording "evacuate from the effected smoke compartment to an uneffected smoke compartment".



2000 NFPA 101, 19.7.2.2 A written health care occupancy fire safety plan shall provide for the following:
(1) Use of alarms
(2) Transmission of alarm to fire department
(3) Response to alarms
(4) Isolation of fire
(5) Evacuation of immediate area
(6) Evacuation of smoke compartment
(7) Preparation of floors and building for evacuation
(8) Extinguishment of fire


.

The facility failed to conduct the fire drills per code. Findings include:
During the survey, the following are examples of what was observed:

1. No Second Shift drill for the first quarter of this year.
2. The facility is not getting all employees to sign to indicate they participated.



2000 NFPA 101, 19.7.1.2 Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building.
.

The facility failed to conduct the fire drills per code. Findings include:
During the survey, the following are examples of what was observed:

1. No Second Shift drill for the first quarter of this year.
2. The facility is not getting all employees to sign, indicating that they participated.



2000 NFPA 101, 19.7.1.2 Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms. Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building.


.

The facility failed to maintain a fire alarm system with approved component devices. Findings Include: During the survey, the following is an example of what was observed:

The magnetic hold-open devices on smoke doors, after releasing automatically upon activation of the fire alarm, reactivated when the fire alarm system was put in the silence mode, throughout the facility. Alabama requirements permit reactivation of these devices only after the resetting of the fire alarm panel.



NFPA 101, 9.6.1.4 The fire alarm system to be installed, tested, and maintained in accordance with the requirements of NFPA 70 and NFPA 72.


.

The facility failed to maintain a fire alarm system with approved component devices. Findings Include: During the survey, the following is an example of what was observed:

The magnetic hold-open devices on smoke doors, after releasing automatically upon activation of the fire alarm, reactivated when the fire alarm system was put in the silence mode, throughout the facility. Alabama requirements permit reactivation of these devices only after the resetting of the fire alarm panel.


NFPA 101, 9.6.1.4 The fire alarm system to be installed, tested, and maintained in accordance with the requirements of NFPA 70 and NFPA 72.




.

The facility failed to perform sensitivity testing of the smoke detectors. Findings include: During the survey, the following is an example of what was observed:


Documentation provided by the facility, during the survey, did not indicate sensitivity testing of the smoke detectors. Detector sensitivity shall be checked within one year after installation and every alternate year thereafter per NFPA 72, 7-3.2.1. (Up to 5 years permitted under certain circumstances. See 7-3.2.1).

The facility failed to perform sensitivity testing of the smoke detectors. Findings include: During the survey, the following is an example of what was observed:


Documentation provided by the facility, during the survey, did not indicate sensitivity testing of the smoke detectors. Detector sensitivity shall be checked within one year after installation and every alternate year thereafter per 72, 7-3.2.1. (Up to 5 years permitted under certain circumstances. See 7-3.2.1).

Sprinkler coverage was observed, during the survey, not adequately provided. Findings include: During the survey, the following are examples of what was observed:


A. Corrosion build up on a sprinkler in OR Room # 1.

1999 NFPA 25, 2-2.1.1 and 2-4.1.2 Sprinklers that are painted, corroded or damaged shall be replaced with new listed sprinklers of the same characteristics, including orifice size, thermal response, and water distribution.





B. Escutcheon plate was missing on four sprinkers in OR Room # 1.

2000 NFPA 13, 3-2.7.2 Escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly.

During the survey, the following are examples of what was observed:

A. Based upon observation, the facility failed to provide enough spare sprinklers; this surveyor observed three sprinklers in the cabinet.

NFPA 25 1998 Edition 2-4.1.4 A supply of at least six spare sprinklers shall be stored in a cabinet on the premises for replacement purposes. The stock of spare sprinklers shall be proportionately representative of the types and temperature ratings of the system sprinklers. A minimum of two sprinklers of each type and temperature rating installed shall be provided. The cabinet shall be so located that it will not be exposed to moisture, dust, corrosion, or a temperature exceeding 100 degrees.




B. The cabinet for the spare sprinklers was not provided with a wrench.

NFPA 13 3-2.9.2 A special sprinkler wrench shall also be provided and kept
in the cabinet to be used in the removal and installation of sprinklers.

The facility failed to provide metal self-closing containers for disposing of cigarette butts and ashes from ashtrays. Findings include:
During the survey, the following is an example of what was observed:

1) Ashtrays of noncombustible material or metal containers with self-closing cover devices were not provided in the designated smoking area located at Westend of 300 Hall.

2) An excessive amount of smoking materials was observed discarded on the ground at the Exit Discharge for Hall 300, and at the designated smoking area.



NFPA 101, 19.7.4 Ashtrays of noncombustible material and safe design, and metal self-closing containers for disposing of cigarette butts and ashes from ashtrays, shall be provided.

The facility failed to provide metal self-closing containers for disposing of cigarette butts and ashes from ashtrays. Findings include:
During the survey, the following is an example of what was observed:

1) Ashtrays of noncombustible material, or metal containers with self-closing cover devices were not provided in the designated smoking area, located at Westend of 300 Hall.

2) An excessive amount of smoking materials was observed discarded on the ground at the Exit Discharge for Hall 300, and on the ground at the designated smoking area.



NFPA 101, 19.7.4 Ashtrays of noncombustible material and safe design, and metal self-closing containers for disposing of cigarette butts and ashes from ashtrays, shall be provided.

The facility failed to maintain the HVAC per code. Findings include:
During the survey, the following are examples of what was observed:

1. The HVAC duct penetrating the two hour fire barrier at room 206 - the damper or an access panel was not obsaerved.

2. The facility failed to provide documentation of inspecting/testing the dampers every six years.



1999 NFPA 90A, 2-3.4.1 A service opening shall be provided in air ducts adjacent to each fire damper, smoke damper, and smoke detector. The opening shall be large enough to permit maintenance and resetting of the device.
1999 NFPA 90A, 3-3.1.1* Approved fire dampers shall be provided where air ducts penetrate or terminate at openings in walls or partitions required to have a fire resistance rating of 2 hours or more.
Exception*: Fire dampers shall not be required where other openings through the wall are not required to be protected.

1999 NFPA 90A, 3-4.7 At least every 4 years, fusible links (where applicable) shall be removed; all dampers shall be operated to verify that they fully close; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary.


.

The facility failed to maintain the HVAC per code. Findings include:
During the survey, the following are examples of what was observed:

1. The two HVAC ducts penetrating the two hour fire barrier at the Ultrasound Room - could not find dampers or access panels.
2. The facility failed to provide documentation of inspecting/testing the dampers every four/six years.


1999 NFPA 90A, 2-3.4.1 A service opening shall be provided in air ducts adjacent to each fire damper, smoke damper, and smoke detector. The opening shall be large enough to permit maintenance and resetting of the device.
1999 NFPA 90A, 3-3.1.1* Approved fire dampers shall be provided where air ducts penetrate or terminate at openings in walls or partitions required to have a fire resistance rating of 2 hours or more.
Exception*: Fire dampers shall not be required where other openings through the wall are not required to be protected.

1999 NFPA 90A, 3-4.7 At least every 4 years, fusible links (where applicable) shall be removed; all dampers shall be operated to verify that they fully close; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary.

.

1) The facility failed to adequately perform testing and inspection of the dietary hood extinguishment system. Findings include:
During the survey, the following are examples of what was observed:


A. Documentation provided by the facility, during the survey, indicated the inspection of the dietary hood extinguishment system was overdue. Documentation indicated the last inspection of the dietary hood extinguishment system was 7/29/2010.

NFPA 17, 9-3 and 1998 NFPA 17a, 5-3 Require inspection and servicing at least every six months by properly trained and qualified persons.


B. Documentation was not provided for hydrostatic test of the wet chemical extinguishment cylinder.

1998 NFPA 17a, 5-5, Requirements cylinder be tested every twelve year.


27382


2) The facility failed to maintain the cooking facilities per code. Findings include:
During the survey, the following is an example of what was observed:

The "K" extinguisher in the Kitchen did not have a sign indicating it was secondary to the automatic fire suppression system.

1998 NFPA 96, 7-2.1.1 A placard identifying the use of the extinguisher as a secondary backup means to the automatic fire suppression system shall be conspicuously placed near each portable fire extinguisher in the cooking area.



.

The facility failed to prohibit portable space heating devices. Findings include:
During the survey, the following are examples of what was observed:

The following rooms were observed with portable space heating devices:

a. The Doctors' Lounge
b. The Pharmacy

2000 NFPA 101, 19.7.8 Portable space-heating devices shall be prohibited in all health care occupancies.

.

The facility failed to provide a readily accessible means of egress pathway at all times. Findings include:
During the survey, the following is an example of what was observed:

The exit egeress corridor by the Kitchen was observed with food carts, linen cart, and a floor cleaning machine stored in the corridor. This surveyor observed this at approximately 3:15pm, items were still in corridor at 4:45pm.


NFPA 101, 7.1.10.1 Means of egress shall be continuously maintained free of all obstructions or impediments for full instant use in case of fire or other emergencies.

CMS Transmittal #99-94. Corridors must be maintained free of all furniture and other items. Items are considered stored in the corridor if they are not both used and moved at least once every half hour.

The facility failed to provide flame resistance documentation on the curtains/draperies per code. Findings include: During the survey, the following is an example of what was observed:

The facility failed to provide flame resistance documentation on the curtains/draperies throughout the facility.


2000 NFPA 101, 10.3.1 Where required by the applicable provisions of this Code, draperies, curtains, and other similar loosely hanging furnishings and decorations shall be flame resistant as demonstrated by testing in accordance with NFPA 701, Standard Methods of Fire Tests for Flame Propagation of Textiles and Films.
.

The facility failed to maintain the Anesthetizing Locations per code. Findings include:
During the survey, the following are examples of what was observed:

OR 1 - use general anesthesia and/or electrical life support - the following was observed:

a. No smoke venting system
b. No battery back-up light

1999 NFPA 99, 5-4.1.2 Supply and exhaust systems for windowless anesthetizing locations shall be arranged to automatically vent smoke and products of combustion.
1999 NFPA 99, 5-4.1.3 Ventilating systems for anesthetizing locations shall be provided that automatically (a) prevent recirculation of smoke originating within the surgical suite and (b) prevent the circulation of smoke entering the system intake, without in either case interfering with the exhaust function of the system.
1999 NFPA 99, 5-4.1.4 The electric supply to the ventilating system shall be served by the equipment system of the essential electrical system specified in Chapter 3, "Electrical Systems."
1999 NFPA 99, 5-6.1.1 Ventilating and humidifying equipment for anesthetizing locations shall be kept in operable condition and be continually operating during surgical procedures (see A-5-4.1).
1999 NFPA 99, 3-3.2.1.2 All Patient Care Areas. 5. Wiring in Anesthetizing Locations. e. Battery-Powered Emergency Lighting Units. One or more battery-powered emergency lighting units shall be provided in accordance with NFPA 70, National Electrical Code, Section 700-12(e).

During the survey, the following is an example of what was observed:


The generator was observed not to have met the requirements to transfer from
normal to emergency power within 10 seconds. The Facility Maintenance Staff was observed to have made one attempt with the following time noted to transfer from normal to emergency power. The times were observed to be 30 seconds.



NFPA 101, 7.9.2.3, and 1999 NFPA 99, 3-4.1.1.8, 3-5.3.1 and 3-6.3.1.2 Emergency generator shall start/crank and transfer from normal to emergency power within ten seconds.



.

During the survey, the following is an example of what was observed:

The generator was observed not meeting the requirements to transfer from
normal to emergency power within 10 seconds. The Facility Maintenance Staff was observed to have made one attempt with the following time noted to transfer from normal to emergency power. The times were observed to be 30 seconds.



NFPA 101, 7.9.2.3, and 1999 NFPA 99, 3-4.1.1.8, 3-5.3.1 and 3-6.3.1.2 Emergency generator shall start/crank and transfer from normal to emergency power within ten seconds.

During the survey, the following is an example of what was observed:

The Remote Annunciator indicated low fuel level warning. Based on interview with Maintenance, the problem had been addressed. The company, who provides service for the generator, had been notified and this was to be corrected. Also, annunciator failed to indicate generator under load when Maintanance conducted the transfer of generator from normal power to under load.


NFPA 99, 3-4. 1.1.15, A remote annunciator storage battery powered shall be provided to operate outside of the Generating Room in a location readily observed by operating personnel at a regular work station.
Remote annunicator alarm condition shall indicate the following:
1. Low lubricating oil pressure
2. Low water temperature (below those required in 3-4.1.1.9)
3. Excessive water temperature
4. Low fuel - when the main fuel storage tank contains less than a 3-hour operating supply
5. Over crank (failed to start)
6. Over speed
Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established. At the time of the survey, it was observed that the Generator Alarm Annunciator was not provided in a continuously monitored constantly attended location for generator.

1999 NFPA 99, 3-4.1.1.15 A remote annunciator, storage battery powered, shall be provided to operate outside of the Generating Room in a location readily observed by operating personnel at a regular work station (see NFPA 70, National Electrical Code, Section 700-12.)
The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows:
(a) Individual visual signals shall indicate the following:
1. When the emergency or auxiliary power source is operating to supply power to load
2. When the battery charger is malfunctioning
(b) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall be provided at a monitored location within the facility. This derangement signal shall activate when any of the conditions listed in 3-4.1.1.15(a) and (b) occur, but need not display these conditions individually. [110: 3-5.5.2]

During the survey, the following is an examples of what was observed:

The Remote Annunciator indicated low fuel level warning. Based on interview with Maintenance, the problem had been addressed. The company which provides service for the generator had been notified, and it would be corrected. Also, annunciator failed to indicate generator under load when Maintanance conducted the transfer of generator from normal power to under load.


NFPA 99, 3-4. 1.1.15, A remote annunciator storage battery powered shall be provided to operate outside of the Generating Room in a location readily observed by operating personnel at a regular work station. Remote annunicator alarm condition shall indicate the following:
1. Low lubricating oil pressure
2. Low water temperature (below those required in 3-4.1.1.9)
3. Excessive water temperature
4. Low fuel - when the main fuel storage tank contains less than a 3-hour operating supply
5. Over crank (failed to start)
6. Over speed

Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established. At the time of the survey, it was observed that the Generator Alarm Annunciator was not provided in a continuously monitored constantly attended location for generator.

1999 NFPA 99, 3-4.1.1.15 A remote annunciator, storage battery powered, shall be provided to operate outside of the Generating room in a location readily observed by operating personnel at a regular work station (see NFPA 70, National Electrical Code, Section 700-12.)

The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows:
(a) Individual visual signals shall indicate the following:
1. When the emergency or auxiliary power source is operating to supply power to load
2. When the battery charger is malfunctioning
(b) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall be provided at a monitored location within the facility. This derangement signal shall activate when any of the conditions in 3-4.1.1.15(a) and (b) occur, but need not display these conditions individually. [110: 3-5.5.2]

1) The facility failed to provide receptacles for appliances. Findings include:
During the survey, the following is an example of what was observed:

A junction box was missing the cover above the ceiling in the Janitor Closet Hall 200


1999 NFPA 70, 370-25 and 410-12. Each box in completed installations to have a cover, face plate, or fixture canopy.




2) The facility failed to provide clearance to the electrical control panels. Findings include:

South Boiler Room had boxes stored in front of electrical panels, aprroximately one foot between boxes and panels.


1999 NFPA 70, Table 110-26(a) A minimum clearance of 3 feet shall be maintained in front of electrical panels and equipment operating at less than 600 volts.

A) The facility failed to provide receptacles for appliances. Findings include:
During the survey, the following are examples of what was observed:


1. A junction box was missing the cover in back of the dryer in Laundry.

2. Surge protector was plugged into a surge protector in OR Rooms One, and Two.

1999 NFPA 70, 370-25 and 410-12. Each box in completed installations to have a cover, face plate, or fixture canopy.

NFPA 101 Life Safety Code (Sec. 19-5.1) Utilities shall comply with NFPA 101 (Sec. 9-1.) Electrical shall comply with the NFPA 70 National Electrical Code.


27382


B) The facility failed to maintain the electrical system per code. Findings include:
During the survey, the following are examples of what was observed:

3. The OR 1 Storage Room had a refrigerator plugged into an orange extension cord.
4. The Ultrasound Room had a multi outlet adapter being used.
5. The shower in the Doctors' Lounge had a junction box on the outside not covered.
6. Information Technology Room had

a. An air conditioner plugged into an extension cord
b. A server plugged into an extension cord

7. Medical Records Room had

a. A copier plugged into an extension cord
b. (3) multi outlet extension cords being used




1999 NFPA 70, 370-28. Pull and Junction Boxes
Boxes and conduit bodies used as pull or junction boxes shall comply with (a) through (d).
(c) Covers. All pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use. Where metal covers are used, they shall comply with the grounding requirements of Section 250-110. An extension from the cover of an exposed box shall comply with Section 370-22, Exception.

1999 NFPA 70, 400-7 and 400-8, and HCFA Transmittal Notice 22-99 The 1984 edition of the National Electric Code restricts the use of extension cords to temporary short term uses. It is the policy of HCFA to prohibit non-circuit breaker protected extension cords in health care. The limited use of circuit breaker protected power strips is acceptable, provided the current is limited to 15 amps or less, and no major appliances such as air conditioners, refrigerators, or heating units are connected to the power strip.

The facility failed to maintain the corridor walls per code. Findings include:
During the survey, the following is an example of what was observed:

The Registration Office has a window with openings above half the height of the corridor wall. This room did not have a smoke detector in it.


2000 NFAP 101, 19.3.6.5 Openings. In other than smoke compartments containing patient bedrooms, miscellaneous openings such as mail slots, pharmacy pass-through windows, laboratory pass-through windows, and cashier pass-through windows shall be permitted to be installed in vision panels or doors without special protection, provided that the aggregate area of openings per room does not exceed 20 in.2 (130 cm2), and the openings are installed at or below half the distance from the floor to the room ceiling.
Exception: For rooms protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.2, the aggregate area of openings per room shall not exceed 80 in.2 (520 cm2).


.

The facility failed to maintain the corridor openings per code. Findings include:
During the survey, the following are examples of what was observed:

1. The E.R./OR Suite corridor double doors were not:

a. Positive latching
b. Smoke resistive

2. The Laboratory Main Door (corridor) was not positive latching
3. The Registration Office corridor door was being held open by a wedge
4. The Enviromental Services corridor door had a toe stop
5. The Kitchen corridor dutch door was not positive latching top and bottom

6. The Dietary Dishwash Room corridor double doors:

a. Had toe stops
b. Were not smoke resistive




2000 NFPA 101, 19.3.6.3.1 Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 13/4-in. (4.4-cm) thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke. Compliance with NFPA 80, Standard for Fire Doors and Fire Windows, shall not be required. Clearance between the bottom of the door and the floor covering not exceeding 1 in. (2.5 cm) shall be permitted for corridor doors.
2000 NFPA 101, 19.3.6.3.2 Doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door. Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.2.
2000 NFPA 101, 19.3.6.3.3 Hold-open devices that release when the door is pushed or pulled shall be permitted.
2007 CMS - 2786R There is no impediment to the closing of the corridor doors.





.

The facility failed to maintain the corridor openings per code. Findings include:
During the survey, the following is an example of what was observed:

The corridor door for room 201 was observed with four holes at the door knob.



2000 NFPA 101, 19.3.6.3.1 Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 13/4-in. (4.4-cm) thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke. Compliance with NFPA 80, Standard for Fire Doors and Fire Windows, shall not be required. Clearance between the bottom of the door and the floor covering not exceeding 1 in. (2.5 cm) shall be permitted for corridor doors.
.

The facility failed to maintain exit signs. Findings include:
During the survey, the following is an example of what was observed:

The Exit Sign for the Exit by Environmental Services Office was obstructed by loose hanging ceiling tile.



7.10.1.4 Exit access shall be marked by signs.



.

The facility failed to maintain the smoke barrier to restrict the passage of smoke. Findings include: During the survey, the following is an example of what was observed:

The doors in the smoke barrier failed to latch/close tight so as to restrict the passage of smoke by Patient Room 206.




NFPA 101, 19.3.7.6., 8.3.4 Doors in smoke barriers to be self-closing. Doors in smoke barriers shall close the opening in the wall leaving only a minimum clearance to allow door(s) to function properly.

The facility failed to maintain separation of hazardous areas. Findings include During the survey, the following is an example of what was observed:


The South Boiler Room had a penetration around a sleeve in the wall which had been sealed with a foam material.




NFPA 101, 19.3.2.1 Hazardous areas shall be safeguarded by a fire barrier of a one-hour fire resistance rating or provided with an automatic sprinkler system.

The facility failed to maintain the hazardous areas per code. Findings include:
During the survey, the following are examples of what was observed:

1. The following storage rooms were over fifty sq. ft. and contained combustibles without a self-closing door:

a. The Central Sterile Room
b. The "Old Recovery Room"

2. The Dietary Pantry door had a self-closing device, but the door was held open by a toe stop.



2000 NFPA 101, 19.3.2.1 Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing.

.

The facility failed to provide readily accessible exits at all times. Findings include: During the survey, the following is an example of what was observed:

The Exit, across from the Environmental Services Office, was blocked at the exit discharge by a linen cart.




NFPA 101, 7.1.10.1 Means of egress shall be continuously maintained free of all obstructions or impediments for full instant use in case of fire or other emergencies.


.

The facility failed to maintain the fire barrier per code. Findings include,
During the survey, the following is an example of what was observed:

The fire barrier at room 206 had several unsealed penetrations, the wall was covered in insulation.



2000 NFPA 101, 8.2.3.2.4.2 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through fire barriers shall be protected as follows:
(1) The space between the penetrating item and the fire barrier shall meet one of the following conditions: a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier. b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the fire barrier, the sleeve shall be solidly set in the fire barrier, and the space between the item and the sleeve shall meet one of the following conditions: a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier. b. It shall be protected by an approved device that is designed for the specific purpose.
(3) * Insulation and coverings for pipes and ducts shall not pass through the fire barrier unless one of the following conditions is met: a. The material shall be capable of maintaining the fire resistance of the fire barrier. b. The material shall be protected by an approved device that is designed for the specific purpose.
(4) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions: a. It shall be made on either side of the fire barrier.b. It shall be made by an approved device that is designed for the specific purpose.
.

The facility failed to maintain the fire barrier per code. Findings include:
During the survey, the following are examples of what was observed:

1. The fire barrier at the Ultrasound Room had an unsealed penetration of a water line.
2. The fire barrier by room 201 had an unsealed penetration of a black and a yellow wire.



2000 NFPA 101, 8.2.3.2.4.2 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through fire barriers shall be protected as follows: (1) The space between the penetrating item and the fire barrier shall meet one of the following conditions: a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier. b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the fire barrier, the sleeve shall be solidly set in the fire barrier, and the space between the item and the sleeve shall meet one of the following conditions: a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier. b. It shall be protected by an approved device that is designed for the specific purpose.
(3) * Insulation and coverings for pipes and ducts shall not pass through the fire barrier unless one of the following conditions is met: a. The material shall be capable of maintaining the fire resistance of the fire barrier. b. The material shall be protected by an approved device that is designed for the specific purpose.
(4) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions: a. It shall be made on either side of the fire barrier. b. It shall be made by an approved device that is designed for the specific purpose.



.

The facility failed to provide continuous lighting for means of egress. Findings include: During the survey, the following is an example of what was observed:


The Exit for Hall 200 was observed to have a single bulb in a double bulb fixture at the Exit Discharge.




NFPA 101, 19.2.8 and 7.8.1.2 Illumination of means of egress shall be continuous.




.

During the survey, the following is an example of what was observed:

Documentation was not provided for the monthly 30 seconds, or 1.5 annual test of the battery powered light located in the Generator Set Control Room.


NFPA 101, 7.9.3 A documented monthly test of battery-powered emergency lighting for at least 30 seconds, and an annual test for a duration of 1-1/2 hours, with equipment being fully operational for the duration of the test.

During the survey, the following is an example of what was observed:

Documentation was not provided for the monthly 30 seconds, or 1.5 annual test of the battery powered light, located in the Generator Set Control Room.


NFPA 101, 7.9.3 A documented monthly test of battery-powered emergency lighting for at least 30 seconds, and an annual test for a duration of 1-1/2 hours, with equipment being fully operational for the duration of the test.

The facility failed to provide an evacuation plan per code. Findings include:
During the survey, the following is an example of what was observed:

The written fire evacuation plan did not include the wording "evacuate from the effected smoke compartment to an uneffected smoke compartment".



2000 NFPA 101, 19.7.2.2 A written health care occupancy fire safety plan shall provide for the following:
(1) Use of alarms
(2) Transmission of alarm to fire department
(3) Response to alarms
(4) Isolation of fire
(5) Evacuation of immediate area
(6) Evacuation of smoke compartment
(7) Preparation of floors and building for evacuation
(8) Extinguishment of fire




.

The facility failed to provide an evacuation plan per code. Findings include:
During the survey, the following is an example of what was observed:

The written fire evacuation plan did not include the wording "evacuate from the effected smoke compartment to an uneffected smoke compartment".



2000 NFPA 101, 19.7.2.2 A written health care occupancy fire safety plan shall provide for the following:
(1) Use of alarms
(2) Transmission of alarm to fire department
(3) Response to alarms
(4) Isolation of fire
(5) Evacuation of immediate area
(6) Evacuation of smoke compartment
(7) Preparation of floors and building for evacuation
(8) Extinguishment of fire


.

The facility failed to conduct the fire drills per code. Findings include:
During the survey, the following are examples of what was observed:

1. No Second Shift drill for the first quarter of this year.
2. The facility is not getting all employees to sign to indicate they participated.



2000 NFPA 101, 19.7.1.2 Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building.
.

The facility failed to conduct the fire drills per code. Findings include:
During the survey, the following are examples of what was observed:

1. No Second Shift drill for the first quarter of this year.
2. The facility is not getting all employees to sign, indicating that they participated.



2000 NFPA 101, 19.7.1.2 Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms. Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building.


.

The facility failed to maintain a fire alarm system with approved component devices. Findings Include: During the survey, the following is an example of what was observed:

The magnetic hold-open devices on smoke doors, after releasing automatically upon activation of the fire alarm, reactivated when the fire alarm system was put in the silence mode, throughout the facility. Alabama requirements permit reactivation of these devices only after the resetting of the fire alarm panel.



NFPA 101, 9.6.1.4 The fire alarm system to be installed, tested, and maintained in accordance with the requirements of NFPA 70 and NFPA 72.


.

The facility failed to maintain a fire alarm system with approved component devices. Findings Include: During the survey, the following is an example of what was observed:

The magnetic hold-open devices on smoke doors, after releasing automatically upon activation of the fire alarm, reactivated when the fire alarm system was put in the silence mode, throughout the facility. Alabama requirements permit reactivation of these devices only after the resetting of the fire alarm panel.


NFPA 101, 9.6.1.4 The fire alarm system to be installed, tested, and maintained in accordance with the requirements of NFPA 70 and NFPA 72.




.

The facility failed to perform sensitivity testing of the smoke detectors. Findings include: During the survey, the following is an example of what was observed:


Documentation provided by the facility, during the survey, did not indicate sensitivity testing of the smoke detectors. Detector sensitivity shall be checked within one year after installation and every alternate year thereafter per NFPA 72, 7-3.2.1. (Up to 5 years permitted under certain circumstances. See 7-3.2.1).

The facility failed to perform sensitivity testing of the smoke detectors. Findings include: During the survey, the following is an example of what was observed:


Documentation provided by the facility, during the survey, did not indicate sensitivity testing of the smoke detectors. Detector sensitivity shall be checked within one year after installation and every alternate year thereafter per 72, 7-3.2.1. (Up to 5 years permitted under certain circumstances. See 7-3.2.1).

Sprinkler coverage was observed, during the survey, not adequately provided. Findings include: During the survey, the following are examples of what was observed:


A. Corrosion build up on a sprinkler in OR Room # 1.

1999 NFPA 25, 2-2.1.1 and 2-4.1.2 Sprinklers that are painted, corroded or damaged shall be replaced with new listed sprinklers of the same characteristics, including orifice size, thermal response, and water distribution.





B. Escutcheon plate was missing on four sprinkers in OR Room # 1.

2000 NFPA 13, 3-2.7.2 Escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly.

During the survey, the following are examples of what was observed:

A. Based upon observation, the facility failed to provide enough spare sprinklers; this surveyor observed three sprinklers in the cabinet.

NFPA 25 1998 Edition 2-4.1.4 A supply of at least six spare sprinklers shall be stored in a cabinet on the premises for replacement purposes. The stock of spare sprinklers shall be proportionately representative of the types and temperature ratings of the system sprinklers. A minimum of two sprinklers of each type and temperature rating installed shall be provided. The cabinet shall be so located that it will not be exposed to moisture, dust, corrosion, or a temperature exceeding 100 degrees.




B. The cabinet for the spare sprinklers was not provided with a wrench.

NFPA 13 3-2.9.2 A special sprinkler wrench shall also be provided and kept
in the cabinet to be used in the removal and installation of sprinklers.

The facility failed to provide metal self-closing containers for disposing of cigarette butts and ashes from ashtrays. Findings include:
During the survey, the following is an example of what was observed:

1) Ashtrays of noncombustible material or metal containers with self-closing cover devices were not provided in the designated smoking area located at Westend of 300 Hall.

2) An excessive amount of smoking materials was observed discarded on the ground at the Exit Discharge for Hall 300, and at the designated smoking area.



NFPA 101, 19.7.4 Ashtrays of noncombustible material and safe design, and metal self-closing containers for disposing of cigarette butts and ashes from ashtrays, shall be provided.

The facility failed to provide metal self-closing containers for disposing of cigarette butts and ashes from ashtrays. Findings include:
During the survey, the following is an example of what was observed:

1) Ashtrays of noncombustible material, or metal containers with self-closing cover devices were not provided in the designated smoking area, located at Westend of 300 Hall.

2) An excessive amount of smoking materials was observed discarded on the ground at the Exit Discharge for Hall 300, and on the ground at the designated smoking area.



NFPA 101, 19.7.4 Ashtrays of noncombustible material and safe design, and metal self-closing containers for disposing of cigarette butts and ashes from ashtrays, shall be provided.

The facility failed to maintain the HVAC per code. Findings include:
During the survey, the following are examples of what was observed:

1. The HVAC duct penetrating the two hour fire barrier at room 206 - the damper or an access panel was not obsaerved.

2. The facility failed to provide documentation of inspecting/testing the dampers every six years.



1999 NFPA 90A, 2-3.4.1 A service opening shall be provided in air ducts adjacent to each fire damper, smoke damper, and smoke detector. The opening shall be large enough to permit maintenance and resetting of the device.
1999 NFPA 90A, 3-3.1.1* Approved fire dampers shall be provided where air ducts penetrate or terminate at openings in walls or partitions required to have a fire resistance rating of 2 hours or more.
Exception*: Fire dampers shall not be required where other openings through the wall are not required to be protected.

1999 NFPA 90A, 3-4.7 At least every 4 years, fusible links (where applicable) shall be removed; all dampers shall be operated to verify that they fully close; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary.


.

The facility failed to maintain the HVAC per code. Findings include:
During the survey, the following are examples of what was observed:

1. The two HVAC ducts penetrating the two hour fire barrier at the Ultrasound Room - could not find dampers or access panels.
2. The facility failed to provide documentation of inspecting/testing the dampers every four/six years.


1999 NFPA 90A, 2-3.4.1 A service opening shall be provided in air ducts adjacent to each fire damper, smoke damper, and smoke detector. The opening shall be large enough to permit maintenance and resetting of the device.
1999 NFPA 90A, 3-3.1.1* Approved fire dampers shall be provided where air ducts penetrate or terminate at openings in walls or partitions required to have a fire resistance rating of 2 hours or more.
Exception*: Fire dampers shall not be required where other openings through the wall are not required to be protected.

1999 NFPA 90A, 3-4.7 At least every 4 years, fusible links (where applicable) shall be removed; all dampers shall be operated to verify that they fully close; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary.

.

1) The facility failed to adequately perform testing and inspection of the dietary hood extinguishment system. Findings include:
During the survey, the following are examples of what was observed:


A. Documentation provided by the facility, during the survey, indicated the inspection of the dietary hood extinguishment system was overdue. Documentation indicated the last inspection of the dietary hood extinguishment system was 7/29/2010.

NFPA 17, 9-3 and 1998 NFPA 17a, 5-3 Require inspection and servicing at least every six months by properly trained and qualified persons.


B. Documentation was not provided for hydrostatic test of the wet chemical extinguishment cylinder.

1998 NFPA 17a, 5-5, Requirements cylinder be tested every twelve year.


27382


2) The facility failed to maintain the cooking facilities per code. Findings include:
During the survey, the following is an example of what was observed:

The "K" extinguisher in the Kitchen did not have a sign indicating it was secondary to the automatic fire suppression system.

1998 NFPA 96, 7-2.1.1 A placard identifying the use of the extinguisher as a secondary backup means to the automatic fire suppression system shall be conspicuously placed near each portable fire extinguisher in the cooking area.



.

The facility failed to prohibit portable space heating devices. Findings include:
During the survey, the following are examples of what was observed:

The following rooms were observed with portable space heating devices:

a. The Doctors' Lounge
b. The Pharmacy

2000 NFPA 101, 19.7.8 Portable space-heating devices shall be prohibited in all health care occupancies.

.

The facility failed to provide a readily accessible means of egress pathway at all times. Findings include:
During the survey, the following is an example of what was observed:

The exit egeress corridor by the Kitchen was observed with food carts, linen cart, and a floor cleaning machine stored in the corridor. This surveyor observed this at approximately 3:15pm, items were still in corridor at 4:45pm.


NFPA 101, 7.1.10.1 Means of egress shall be continuously maintained free of all obstructions or impediments for full instant use in case of fire or other emergencies.

CMS Transmittal #99-94. Corridors must be maintained free of all furniture and other items. Items are considered stored in the corridor if they are not both used and moved at least once every half hour.

The facility failed to provide flame resistance documentation on the curtains/draperies per code. Findings include: During the survey, the following is an example of what was observed:

The facility failed to provide flame resistance documentation on the curtains/draperies throughout the facility.


2000 NFPA 101, 10.3.1 Where required by the applicable provisions of this Code, draperies, curtains, and other similar loosely hanging furnishings and decorations shall be flame resistant as demonstrated by testing in accordance with NFPA 701, Standard Methods of Fire Tests for Flame Propagation of Textiles and Films.
.

The facility failed to maintain the Anesthetizing Locations per code. Findings include:
During the survey, the following are examples of what was observed:

OR 1 - use general anesthesia and/or electrical life support - the following was observed:

a. No smoke venting system
b. No battery back-up light

1999 NFPA 99, 5-4.1.2 Supply and exhaust systems for windowless anesthetizing locations shall be arranged to automatically vent smoke and products of combustion.
1999 NFPA 99, 5-4.1.3 Ventilating systems for anesthetizing locations shall be provided that automatically (a) prevent recirculation of smoke originating within the surgical suite and (b) prevent the circulation of smoke entering the system intake, without in either case interfering with the exhaust function of the system.
1999 NFPA 99, 5-4.1.4 The electric supply to the ventilating system shall be served by the equipment system of the essential electrical system specified in Chapter 3, "Electrical Systems."
1999 NFPA 99, 5-6.1.1 Ventilating and humidifying equipment for anesthetizing locations shall be kept in operable condition and be continually operating during surgical procedures (see A-5-4.1).
1999 NFPA 99, 3-3.2.1.2 All Patient Care Areas. 5. Wiring in Anesthetizing Locations. e. Battery-Powered Emergency Lighting Units. One or more battery-powered emergency lighting units shall be provided in accordance with NFPA 70, National Electrical Code, Section 700-12(e).

During the survey, the following is an example of what was observed:


The generator was observed not to have met the requirements to transfer from
normal to emergency power within 10 seconds. The Facility Maintenance Staff was observed to have made one attempt with the following time noted to transfer from normal to emergency power. The times were observed to be 30 seconds.



NFPA 101, 7.9.2.3, and 1999 NFPA 99, 3-4.1.1.8, 3-5.3.1 and 3-6.3.1.2 Emergency generator shall start/crank and transfer from normal to emergency power within ten seconds.



.

During the survey, the following is an example of what was observed:

The generator was observed not meeting the requirements to transfer from
normal to emergency power within 10 seconds. The Facility Maintenance Staff was observed to have made one attempt with the following time noted to transfer from normal to emergency power. The times were observed to be 30 seconds.



NFPA 101, 7.9.2.3, and 1999 NFPA 99, 3-4.1.1.8, 3-5.3.1 and 3-6.3.1.2 Emergency generator shall start/crank and transfer from normal to emergency power within ten seconds.

During the survey, the following is an example of what was observed:

The Remote Annunciator indicated low fuel level warning. Based on interview with Maintenance, the problem had been addressed. The company, who provides service for the generator, had been notified and this was to be corrected. Also, annunciator failed to indicate generator under load when Maintanance conducted the transfer of generator from normal power to under load.


NFPA 99, 3-4. 1.1.15, A remote annunciator storage battery powered shall be provided to operate outside of the Generating Room in a location readily observed by operating personnel at a regular work station.
Remote annunicator alarm condition shall indicate the following:
1. Low lubricating oil pressure
2. Low water temperature (below those required in 3-4.1.1.9)
3. Excessive water temperature
4. Low fuel - when the main fuel storage tank contains less than a 3-hour operating supply
5. Over crank (failed to start)
6. Over speed
Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established. At the time of the survey, it was observed that the Generator Alarm Annunciator was not provided in a continuously monitored constantly attended location for generator.

1999 NFPA 99, 3-4.1.1.15 A remote annunciator, storage battery powered, shall be provided to operate outside of the Generating Room in a location readily observed by operating personnel at a regular work station (see NFPA 70, National Electrical Code, Section 700-12.)
The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows:
(a) Individual visual signals shall indicate the following:
1. When the emergency or auxiliary power source is operating to supply power to load
2. When the battery charger is malfunctioning
(b) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall be provided at a monitored location within the facility. This derangement signal shall activate when any of the conditions listed in 3-4.1.1.15(a) and (b) occur, but need not display these conditions individually. [110: 3-5.5.2]

During the survey, the following is an examples of what was observed:

The Remote Annunciator indicated low fuel level warning. Based on interview with Maintenance, the problem had been addressed. The company which provides service for the generator had been notified, and it would be corrected. Also, annunciator failed to indicate generator under load when Maintanance conducted the transfer of generator from normal power to under load.


NFPA 99, 3-4. 1.1.15, A remote annunciator storage battery powered shall be provided to operate outside of the Generating Room in a location readily observed by operating personnel at a regular work station. Remote annunicator alarm condition shall indicate the following:
1. Low lubricating oil pressure
2. Low water temperature (below those required in 3-4.1.1.9)
3. Excessive water temperature
4. Low fuel - when the main fuel storage tank contains less than a 3-hour operating supply
5. Over crank (failed to start)
6. Over speed

Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established. At the time of the survey, it was observed that the Generator Alarm Annunciator was not provided in a continuously monitored constantly attended location for generator.

1999 NFPA 99, 3-4.1.1.15 A remote annunciator, storage battery powered, shall be provided to operate outside of the Generating room in a location readily observed by operating personnel at a regular work station (see NFPA 70, National Electrical Code, Section 700-12.)

The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows:
(a) Individual visual signals shall indicate the following:
1. When the emergency or auxiliary power source is operating to supply power to load
2. When the battery charger is malfunctioning
(b) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall be provided at a monitored location within the facility. This derangement signal shall activate when any of the conditions in 3-4.1.1.15(a) and (b) occur, but need not display these conditions individually. [110: 3-5.5.2]

1) The facility failed to provide receptacles for appliances. Findings include:
During the survey, the following is an example of what was observed:

A junction box was missing the cover above the ceiling in the Janitor Closet Hall 200


1999 NFPA 70, 370-25 and 410-12. Each box in completed installations to have a cover, face plate, or fixture canopy.




2) The facility failed to provide clearance to the electrical control panels. Findings include:

South Boiler Room had boxes stored in front of electrical panels, aprroximately one foot between boxes and panels.


1999 NFPA 70, Table 110-26(a) A minimum clearance of 3 feet shall be maintained in front of electrical panels and equipment operating at less than 600 volts.

A) The facility failed to provide receptacles for appliances. Findings include:
During the survey, the following are examples of what was observed:


1. A junction box was missing the cover in back of the dryer in Laundry.

2. Surge protector was plugged into a surge protector in OR Rooms One, and Two.

1999 NFPA 70, 370-25 and 410-12. Each box in completed installations to have a cover, face plate, or fixture canopy.

NFPA 101 Life Safety Code (Sec. 19-5.1) Utilities shall comply with NFPA 101 (Sec. 9-1.) Electrical shall comply with the NFPA 70 National Electrical Code.


27382


B) The facility failed to maintain the electrical system per code. Findings include:
During the survey, the following are examples of what was observed:

3. The OR 1 Storage Room had a refrigerator plugged into an orange extension cord.
4. The Ultrasound Room had a multi outlet adapter being used.
5. The shower in the Doctors' Lounge had a junction box on the outside not covered.
6. Information Technology Room had

a. An air conditioner plugged into an extension cord
b. A server plugged into an extension cord

7. Medical Records Room had

a. A copier plugged into an extension cord
b. (3) multi outlet extension cords being used




1999 NFPA 70, 370-28. Pull and Junction Boxes
Boxes and conduit bodies used as pull or junction boxes shall comply with (a) through (d).
(c) Covers. All pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use. Where metal covers are used, they shall comply with the grounding requirements of Section 250-110. An extension from the cover of an exposed box shall comply with Section 370-22, Exception.

1999 NFPA 70, 400-7 and 400-8, and HCFA Transmittal Notice 22-99 The 1984 edition of the National Electric Code restricts the use of extension cords to temporary short term uses. It is the policy of HCFA to prohibit non-circuit breaker protected extension cords in health care. The limited use of circuit breaker protected power strips is acceptable, provided the current is limited to 15 amps or less, and no major appliances such as air conditioners, refrigerators, or heating units are connected to the power strip.