HospitalInspections.org
Bringing transparency to federal inspections
ST JOSEPH'S HOSPITAL
No Description Available
Tag No.: K0144
A) Based on document review for all of 2012 and based on interview of the Director of Plant Operations, the surveyor finds that the emergency power system is not tested and documented in accordance with NFPA 110-1999:
1) Weekly visual inspection of the emergency generator is not documented. The provide documents weekly testing and inspection of the generator batteries and conducts a daily visual inspection of the generator. However, the documentation lacks specifics for a weekly visual inspection in accordance with NFPA 110 and the generator manufacturer's requirements. Only the date and the initials of the person conducting the daily visual are actually documented.
2) The emergency generator has been tested monthly for the past 12 months. The documentation indicates that each test was conducted under load for a least 35 minutes. The Director of Plant Operations indicates that the generator has a 5 minute cool down cycle; however, this is not documented on each load test. The documents also identify the output of from an hourly run meter for the generator which includes a typical reading down to tenths of an hour. The time recorded for the hourly run meter conflicts with the total run times being record. Based on interview, the surveyor finds that there is no run meter for the generator and the log for this item is a long time carry over from previous personnel.
The monthly load test does not identify the start time for the test, the time that load is removed from the generator and the time that the generator shuts down (after the cool down cycle). In other words, the provider does record the total time under load and then identify the time for the cool down cycle.
LIFE SAFETY CODE STANDARD
Tag No.: K0144
A) Based on document review for all of 2012 and based on interview of the Director of Plant Operations, the surveyor finds that the emergency power system is not tested and documented in accordance with NFPA 110-1999:
1) Weekly visual inspection of the emergency generator is not documented. The provide documents weekly testing and inspection of the generator batteries and conducts a daily visual inspection of the generator. However, the documentation lacks specifics for a weekly visual inspection in accordance with NFPA 110 and the generator manufacturer's requirements. Only the date and the initials of the person conducting the daily visual are actually documented.
2) The emergency generator has been tested monthly for the past 12 months. The documentation indicates that each test was conducted under load for a least 35 minutes. The Director of Plant Operations indicates that the generator has a 5 minute cool down cycle; however, this is not documented on each load test. The documents also identify the output of from an hourly run meter for the generator which includes a typical reading down to tenths of an hour. The time recorded for the hourly run meter conflicts with the total run times being record. Based on interview, the surveyor finds that there is no run meter for the generator and the log for this item is a long time carry over from previous personnel.
The monthly load test does not identify the start time for the test, the time that load is removed from the generator and the time that the generator shuts down (after the cool down cycle). In other words, the provider does record the total time under load and then identify the time for the cool down cycle.