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Based on observation and staff interview during the course of the survey, it was determined that the facility failed to maintain the two-hour fire rated separation to the clinic occupancy in accordance with Life Safety Code Section 18.1.2.1. This deficient practice could affect all patients, staff and visitors within smoke compartment #2 should smoke and heat be transferred from a fire in the adjacent clinic (business occupancy). This was evidenced by the following:

A) Fire rated doors were not maintained to positively latch into the door frame, as required. One of two 1? hour rated corridor door leafs (central area near nurse ' s station) would not positively latch into the door frame when tested. The Maintenance Director confirmed the non-latching door during a tour of the facility.

B) Wall penetration fire stop systems were not maintained, as required. The two hour fire rated occupancy separation wall to the clinic (business occupancy) was observed to have a low voltage cable bundle penetration with the fire caulk pulled out. The unsealed cable bundle was located above the corridor doors in the area of the main nurse ' s station.

Life Safety Code Section 18.1.2.1 requires, in part, that sections of health care facilities that are classified as other occupancies be separated by two hour rated construction. Section 8.2.3.2.1 requires that fire doors be of a design that has been tested to meet the conditions of acceptance of NFPA 252, Standard Methods of Fire Tests of Door Assemblies, and that doors be installed in accordance with NFPA 80 Standard for Fire Doors and Fire Windows. Section 8-2.3.2.4 requires, in part, that penetrations and miscellaneous openings in fire barrier walls be filled with a material capable of maintaining the fire resistance rating of the barrier.

Based on observation and staff interview during the survey, it was determined that the facility failed to install corridor doors in accordance with Life Safety Code Section 18.3.6.3. This deficient practice could affect all patients, staff and visitors within smoke compartment #1 and #2 should the egress corridor become untenable due to smoke and heat transfer via the deficient doors separating rooms from the egress corridor. This was evidenced by the following:

A) Corridor doors were not arranged to be closed with a push or a pull, as required. The former OB suite corridor doors (2 sets) were equipped with power operators that prevented the doors from being closed with a push or pull when in the open position.

B) Corridor doors were not arranged to automatically latch, as required. Trauma Rooms #1 , #2 and the ED storage closet were all equipped with double doors. The fixed door leafs were equipped with a manual latching bolt. If the latch bolt was not engaged, the double doors would not positively latch.

C) Corridor doors were not equipped with positive latching hardware, as required. The O/R Imaging suite double corridor doors (east side of suite) were not equipped with positive latching hardware.

The Maintenance Director acknowledged the door arrangements during a tour of the facility.

Life Safety Code Section 18.3.6.3.2: Doors shall be provided with positive latching hardware. Roller latches shall be prohibited. Section 18.3.6.3.3 permits hold-open devices that release when the door is pushed or pulled.

Based on observation, record review and staff interview during the survey, it was determined that the facility failed to maintain emergency lighting systems in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code and the referenced NFPA 110. This deficient practice could affect all patients and staff should emergency lighting and power systems fail to operate as designed. This was evidenced by the following:

A) Records were not available to document the monthly and annual testing of the battery powered emergency lighting units, as required.

B) The emergency generator was not equipped with a remote manual stop, outside of the generator enclosure, as required. The Director of Facility Management confirmed that a remote manual stop was not provided for the emergency generator.

Life Safety Code Section 7.9.3, Periodic Testing of Emergency Lighting Equipment: A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1? hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.
NFPA 110 Section 3-5.5.6: All Level 1 and Level 2 installations shall have a remote manual stop station of a type similar to a break-glass station, located outside the room housing the prime mover, where so installed, or located elsewhere on the premises where the prime mover is located outside of the building.

Based on record review during the survey, it was determined that the facility failed to conduct fire drills in accordance with Life Safety Code Sections 18.7 and 4.7. This deficient practice could affect all patients when staff are not drilled in the emergency actions required during the unusual conditions that can occur in an actual emergency. This was evidenced by the following:

Fire drills were not conducted to test the response of personnel in implementing the facility fire emergency plan and were not conducted quarterly on each shift, as required. The following fire drill records were reviewed during the survey:
08-21-13: pm shift-walk around in OB area, Q&A with staff
12-12-12: Safety meeting-fire drill-had a review during the safety fair in September.
09-25-12: Safety meeting-fire drill-did a walk through table top fire drill with all employees.

Life Safety Code, Section 18.7.1.2 requires that fire drills in health care occupancies include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills shall be conducted quarterly on each shift to familiarize 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 pm and 6:00 am, a coded announcement shall be permitted to be used instead of audible alarms. Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building. Section 4.7.3 requires that the responsibility for planning and conduct of drills be assigned only to competent persons qualified to exercise leadership. Section 4.7.5 requires that drills be held at unexpected times and under varying conditions to simulate the unusual conditions that can occur in an actual emergency.
Life Safety Code Annex A.18.7.1.2 (explanatory material) explains that the purpose of a fire drill is to test and evaluate the efficiency, knowledge and response of personnel in implementing the facility fire emergency plan. Its purpose is not to disturb or excite residents or patients. Drills should consider the ability to move patients or residents to an adjacent smoke compartment. Relocation can be practiced using simulated patients or empty wheelchairs. Annex A.18.7.2.1 offers additional recommendations that can be adapted as appropriate to individual facilities.

Based on observation and record review during the survey, it was determined that the facility failed to install and maintain the fire alarm system in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code, and NFPA 72, National Fire Alarm Code. This deficient practice could affect all patients, staff and visitors should the fire alarm system fail to function as designed and fail to notify staff in all areas of the building. This was evidenced by the following:

A) Fire alarm system secondary power supply sealed lead-acid batteries were not load voltage tested semiannually, as required. The Maintenance Director confirmed that the fire alarm system was subject to annual inspections only.
NFPA 72, Section 7.3.2 subsection 6d requires that sealed lead-acid type fire alarm system batteries be subject to a load voltage test semiannually.

B) Fire alarm notification appliances were not installed in all areas, as required. The O/R (critical care area) was not equipped with a visual notification appliance
Life Safety Code Section 18.7.2.1 requires, in part, that within health care occupancies, the proper protection of patients shall require the prompt and effective response of health care personnel. Section 18.3.4.3.1 requires that occupant notification be accomplished automatically. Exception #1: In lieu of audible alarm signals, visible alarm-indicating appliances shall be permitted to be used in critical care areas.

C) Smoke detector sensitivity testing was not documented, as required. The 03-15-13 fire alarm system inspection report noted 120 smoke detectors were sensitivity tested. A sensitivity test report that listed the test results on each detector was not part of the records on premises.

Based on observation and record review, it was determined that the facility failed to maintain the automatic fire sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 25. This deficient practice could affect all patients, staff and visitors should the automatic sprinkler system fail to operate in a timely and effective manner due to non-code compliant maintenance. This was evidenced by the following:

A) The sprinkler system tamper switches were not tested semi-annually as required. Records on premises documented the testing of sprinkler system valve tamper switches on 03-15-13.
NFPA 25 Section 9-3.4.3 requires that valve supervisory switches be tested semi-annually in accordance with manufacturer's instructions.

B) Sprinkler system pressure gauges were not replaced or calibrated every 5 years, as required. The sprinkler pressure gauges, installed at the main system riser, were dated 2006 and 2007. There were no records available that documented calibration testing.
NFPA 25 Section 9-2.8.2: Gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge. Gauges not accurate to within 3 percent of the full scale shall be recalibrated or replaced.

C) Sprinkler system spray patterns were not maintained free of obstructions to water spray distribution, as required. Patient rooms 9 and 11 were both observed to have a pendant sprinkler head obstructed by a ceiling reveal that was approximately 4 inches lower than the main ceiling.
NFPA 25, Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems, Section 2-2.1.2: Unacceptable obstructions to spray patterns shall be corrected.

D) Anti-freeze solutions were not tested and documented annually, as required. The sprinkler system inspection report, dated 03-15-13 did not document testing of the anti-freeze solution. NFPA 25 Section 2-3.4 (Antifreeze Systems) requires that the freezing point of solutions in antifreeze be tested annually by measuring the specific gravity with a hydrometer or refractometer and adjusting the solutions if necessary.

Based on observation, staff interview and record review during the course of the survey, it was determined that the facility failed to install and maintain the piped medical gas system in accordance with National Fire Protection Association Standard 99, Health Care Facilities. This deficient practice could affect all patients should the medical gas system malfunction or not be readily shut down in an emergency. This was evidenced by the following:

A) Zone valves were not accurately labeled, as required. The patient wing zone valves were labeled with construction plan room numbers and not the current facility patient room numbers.
NFPA 99 Section 4-3.5.4.2: The shutoff valves described in 4-3.1.2.3, 4-3.1.2.3(m), and 4-3.1.2.3(n) shall be labeled to reflect the rooms that are controlled by such valves.

B) There were no records available to document the periodic testing of the medical gas alarm system, as required. The Maintenance Director confirmed that the medical gas system had not been inspected or tested since the initial acceptance in 2008.

NFPA 99 Section 4-3.5.2.3(g) requires that a periodic testing procedure for nonflammable medical gas and related alarm systems be implemented. Section 4-3.5.2.3(i) requires that periodic retesting of audible and visual alarm indicators shall be performed to determine that they are functioning properly and records of the test shall be maintained until the next test.

C) There were no records available to document the required periodic tests for detecting leaks in the vacuum system, as required. NFPA 99 Section 4-3.5.6.1
(a) The facility shall establish routine preventive maintenance programs applicable to both the vacuum piping system and to the secondary equipment attached to vacuum station inlets to ensure the continued good performance of the entire vacuum system.
(b) Leakage Tests: " The facility shall perform periodic tests for detecting leaks in the system in accordance with Section 4-3.4.2.2.

Based on record review and staff interview during the course of the survey, it was determined that the facility failed to test anesthetizing location electrical systems in accordance with National Fire Protection Association Standard 99, Health Care Facilities. This deficient practice could affect patients and staff within the O/R should the ground-fault monitoring system not function as designed. This was evidenced by the following:

The line isolation monitor system, installed in Operating Room #1, was not tested in accordance with NFPA 99 Section 3-3.3.4.2, as required.
The Maintenance Director reported that a regular testing program for the line isolation monitors was not in place and that the only testing had occurred when the units were installed in 2008.

NFPA 99 Section 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.

Based on record review, observation and staff interview during the survey, it was determined that the facility failed to maintain emergency power systems in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code and the referenced NFPA 110, Standard for Emergency and Standby Power Systems. This deficient practice could affect all patients, staff and visitors should the essential electrical system not function as designed due to lack of maintenance and testing. This was evidenced by the following:

A) Automatic transfer switches were not exercised monthly, as required. The Maintenance Director reported that all three transfer switches were exercised during a weekly load test initiated via an automatic time clock. The time clock exercise was witness on September 5, 2013 at approximately 12:50 pm during the survey. The time clock started the generator for a 15 minute exercise but none of the 3 automatic transfer switches transferred the electrical load to the generator.
NFPA 110 Section 6-4.5: Level 1 and Level 2 transfer switches shall be operated monthly. The monthly test of a transfer switch shall consist of electrically operating the transfer switch from the standard position to the alternate position and then a return to the standard position.

B) The emergency generator was not exercised under load for a minimum of 30 minutes per month, as required. The Maintenance Director reported that all three transfer switches were exercised during a weekly load test initiated via an automatic time clock. The time clock exercise was witness on September 5, 2013 during the survey at approximately 12:50 pm. The time clock started the generator for a 15 minute exercise but none of the 3 automatic transfer switches transferred the electrical load to the generator.
NFPA 110 Section 6-4.2: Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer

C) The diesel powered emergency generator was not being load tested monthly at a minimum of 30% of nameplate rating, and was not exercised annually with supplemental loads, as required. Records on premises documented generator testing with supplemental loads for a period of 2 hours on May 29, 2013. The Maintenance Director reported that the diesel generator had only been tested with supplemental loads (load bank test) twice since the facility opened in 2008.
NFPA 110 Section 6-4.2: Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
Section 6-4.2.2: Diesel-powered EPS installations that do not meet the requirements of 6-4.2 shall be exercised monthly with the available EPSS load and exercised annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of 2 continuous hours.

D) The diesel generator was not visually inspected weekly, as required.
The Maintenance Director reported that the generator was visually inspected, approximately once per month, but records were not maintained that documented the visual inspections.
NFPA 99 Section 3-4.4.1.1 requires, in part, that generators serving emergency and equipment systems be in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6. NFPA 110 Section 6-4.1 requires Level 1 and Level 2 Emergency Power Supply Systems (EPSS) including all appurtenant components, be inspected weekly and exercised under load at least monthly.
NFPA 110 Section 6-3.4 requires, in part, that a written record of the EPSS inspections, tests, exercising, operation, and repairs shall be maintained on the premises.

Based on observation and staff interview during the survey, it was determined that the facility failed to install alcohol based hand rub dispensers in accordance with Life Safety Code Section 18.3.2.7 (as amended by NFPA Technical Interim Amendment TIA 00-1 (101). This deficient practice could affect all patients, staff and visitors in smoke compartment #2 should the flammable liquid ignite due to the proximity to an ignition source. This was evidenced by the following:

Alcohol Based Hand Rub dispensers were not installed with adequate separation from an ignition source, as required. A wall mounted dispenser was observed to be installed directly above a duplex light switch in the laboratory. The Maintenance Director acknowledged the dispenser location during a tour of the facility.

Life Safety Code Section 18.3.2.7 states, in part, that alcohol based hand rub dispensers shall not be installed over or adjacent to an ignition source.

Based on observation and staff interview during the course of the survey, it was determined that the facility failed to maintain the two-hour fire rated separation to the clinic occupancy in accordance with Life Safety Code Section 18.1.2.1. This deficient practice could affect all patients, staff and visitors within smoke compartment #2 should smoke and heat be transferred from a fire in the adjacent clinic (business occupancy). This was evidenced by the following:

A) Fire rated doors were not maintained to positively latch into the door frame, as required. One of two 1? hour rated corridor door leafs (central area near nurse ' s station) would not positively latch into the door frame when tested. The Maintenance Director confirmed the non-latching door during a tour of the facility.

B) Wall penetration fire stop systems were not maintained, as required. The two hour fire rated occupancy separation wall to the clinic (business occupancy) was observed to have a low voltage cable bundle penetration with the fire caulk pulled out. The unsealed cable bundle was located above the corridor doors in the area of the main nurse ' s station.

Life Safety Code Section 18.1.2.1 requires, in part, that sections of health care facilities that are classified as other occupancies be separated by two hour rated construction. Section 8.2.3.2.1 requires that fire doors be of a design that has been tested to meet the conditions of acceptance of NFPA 252, Standard Methods of Fire Tests of Door Assemblies, and that doors be installed in accordance with NFPA 80 Standard for Fire Doors and Fire Windows. Section 8-2.3.2.4 requires, in part, that penetrations and miscellaneous openings in fire barrier walls be filled with a material capable of maintaining the fire resistance rating of the barrier.

Based on observation and staff interview during the survey, it was determined that the facility failed to install corridor doors in accordance with Life Safety Code Section 18.3.6.3. This deficient practice could affect all patients, staff and visitors within smoke compartment #1 and #2 should the egress corridor become untenable due to smoke and heat transfer via the deficient doors separating rooms from the egress corridor. This was evidenced by the following:

A) Corridor doors were not arranged to be closed with a push or a pull, as required. The former OB suite corridor doors (2 sets) were equipped with power operators that prevented the doors from being closed with a push or pull when in the open position.

B) Corridor doors were not arranged to automatically latch, as required. Trauma Rooms #1 , #2 and the ED storage closet were all equipped with double doors. The fixed door leafs were equipped with a manual latching bolt. If the latch bolt was not engaged, the double doors would not positively latch.

C) Corridor doors were not equipped with positive latching hardware, as required. The O/R Imaging suite double corridor doors (east side of suite) were not equipped with positive latching hardware.

The Maintenance Director acknowledged the door arrangements during a tour of the facility.

Life Safety Code Section 18.3.6.3.2: Doors shall be provided with positive latching hardware. Roller latches shall be prohibited. Section 18.3.6.3.3 permits hold-open devices that release when the door is pushed or pulled.

Based on observation, record review and staff interview during the survey, it was determined that the facility failed to maintain emergency lighting systems in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code and the referenced NFPA 110. This deficient practice could affect all patients and staff should emergency lighting and power systems fail to operate as designed. This was evidenced by the following:

A) Records were not available to document the monthly and annual testing of the battery powered emergency lighting units, as required.

B) The emergency generator was not equipped with a remote manual stop, outside of the generator enclosure, as required. The Director of Facility Management confirmed that a remote manual stop was not provided for the emergency generator.

Life Safety Code Section 7.9.3, Periodic Testing of Emergency Lighting Equipment: A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1? hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.
NFPA 110 Section 3-5.5.6: All Level 1 and Level 2 installations shall have a remote manual stop station of a type similar to a break-glass station, located outside the room housing the prime mover, where so installed, or located elsewhere on the premises where the prime mover is located outside of the building.

Based on record review during the survey, it was determined that the facility failed to conduct fire drills in accordance with Life Safety Code Sections 18.7 and 4.7. This deficient practice could affect all patients when staff are not drilled in the emergency actions required during the unusual conditions that can occur in an actual emergency. This was evidenced by the following:

Fire drills were not conducted to test the response of personnel in implementing the facility fire emergency plan and were not conducted quarterly on each shift, as required. The following fire drill records were reviewed during the survey:
08-21-13: pm shift-walk around in OB area, Q&A with staff
12-12-12: Safety meeting-fire drill-had a review during the safety fair in September.
09-25-12: Safety meeting-fire drill-did a walk through table top fire drill with all employees.

Life Safety Code, Section 18.7.1.2 requires that fire drills in health care occupancies include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills shall be conducted quarterly on each shift to familiarize 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 pm and 6:00 am, a coded announcement shall be permitted to be used instead of audible alarms. Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building. Section 4.7.3 requires that the responsibility for planning and conduct of drills be assigned only to competent persons qualified to exercise leadership. Section 4.7.5 requires that drills be held at unexpected times and under varying conditions to simulate the unusual conditions that can occur in an actual emergency.
Life Safety Code Annex A.18.7.1.2 (explanatory material) explains that the purpose of a fire drill is to test and evaluate the efficiency, knowledge and response of personnel in implementing the facility fire emergency plan. Its purpose is not to disturb or excite residents or patients. Drills should consider the ability to move patients or residents to an adjacent smoke compartment. Relocation can be practiced using simulated patients or empty wheelchairs. Annex A.18.7.2.1 offers additional recommendations that can be adapted as appropriate to individual facilities.

Based on observation and record review during the survey, it was determined that the facility failed to install and maintain the fire alarm system in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code, and NFPA 72, National Fire Alarm Code. This deficient practice could affect all patients, staff and visitors should the fire alarm system fail to function as designed and fail to notify staff in all areas of the building. This was evidenced by the following:

A) Fire alarm system secondary power supply sealed lead-acid batteries were not load voltage tested semiannually, as required. The Maintenance Director confirmed that the fire alarm system was subject to annual inspections only.
NFPA 72, Section 7.3.2 subsection 6d requires that sealed lead-acid type fire alarm system batteries be subject to a load voltage test semiannually.

B) Fire alarm notification appliances were not installed in all areas, as required. The O/R (critical care area) was not equipped with a visual notification appliance
Life Safety Code Section 18.7.2.1 requires, in part, that within health care occupancies, the proper protection of patients shall require the prompt and effective response of health care personnel. Section 18.3.4.3.1 requires that occupant notification be accomplished automatically. Exception #1: In lieu of audible alarm signals, visible alarm-indicating appliances shall be permitted to be used in critical care areas.

C) Smoke detector sensitivity testing was not documented, as required. The 03-15-13 fire alarm system inspection report noted 120 smoke detectors were sensitivity tested. A sensitivity test report that listed the test results on each detector was not part of the records on premises.

Based on observation and record review, it was determined that the facility failed to maintain the automatic fire sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 25. This deficient practice could affect all patients, staff and visitors should the automatic sprinkler system fail to operate in a timely and effective manner due to non-code compliant maintenance. This was evidenced by the following:

A) The sprinkler system tamper switches were not tested semi-annually as required. Records on premises documented the testing of sprinkler system valve tamper switches on 03-15-13.
NFPA 25 Section 9-3.4.3 requires that valve supervisory switches be tested semi-annually in accordance with manufacturer's instructions.

B) Sprinkler system pressure gauges were not replaced or calibrated every 5 years, as required. The sprinkler pressure gauges, installed at the main system riser, were dated 2006 and 2007. There were no records available that documented calibration testing.
NFPA 25 Section 9-2.8.2: Gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge. Gauges not accurate to within 3 percent of the full scale shall be recalibrated or replaced.

C) Sprinkler system spray patterns were not maintained free of obstructions to water spray distribution, as required. Patient rooms 9 and 11 were both observed to have a pendant sprinkler head obstructed by a ceiling reveal that was approximately 4 inches lower than the main ceiling.
NFPA 25, Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems, Section 2-2.1.2: Unacceptable obstructions to spray patterns shall be corrected.

D) Anti-freeze solutions were not tested and documented annually, as required. The sprinkler system inspection report, dated 03-15-13 did not document testing of the anti-freeze solution. NFPA 25 Section 2-3.4 (Antifreeze Systems) requires that the freezing point of solutions in antifreeze be tested annually by measuring the specific gravity with a hydrometer or refractometer and adjusting the solutions if necessary.

Based on observation, staff interview and record review during the course of the survey, it was determined that the facility failed to install and maintain the piped medical gas system in accordance with National Fire Protection Association Standard 99, Health Care Facilities. This deficient practice could affect all patients should the medical gas system malfunction or not be readily shut down in an emergency. This was evidenced by the following:

A) Zone valves were not accurately labeled, as required. The patient wing zone valves were labeled with construction plan room numbers and not the current facility patient room numbers.
NFPA 99 Section 4-3.5.4.2: The shutoff valves described in 4-3.1.2.3, 4-3.1.2.3(m), and 4-3.1.2.3(n) shall be labeled to reflect the rooms that are controlled by such valves.

B) There were no records available to document the periodic testing of the medical gas alarm system, as required. The Maintenance Director confirmed that the medical gas system had not been inspected or tested since the initial acceptance in 2008.

NFPA 99 Section 4-3.5.2.3(g) requires that a periodic testing procedure for nonflammable medical gas and related alarm systems be implemented. Section 4-3.5.2.3(i) requires that periodic retesting of audible and visual alarm indicators shall be performed to determine that they are functioning properly and records of the test shall be maintained until the next test.

C) There were no records available to document the required periodic tests for detecting leaks in the vacuum system, as required. NFPA 99 Section 4-3.5.6.1
(a) The facility shall establish routine preventive maintenance programs applicable to both the vacuum piping system and to the secondary equipment attached to vacuum station inlets to ensure the continued good performance of the entire vacuum system.
(b) Leakage Tests: " The facility shall perform periodic tests for detecting leaks in the system in accordance with Section 4-3.4.2.2.

Based on record review and staff interview during the course of the survey, it was determined that the facility failed to test anesthetizing location electrical systems in accordance with National Fire Protection Association Standard 99, Health Care Facilities. This deficient practice could affect patients and staff within the O/R should the ground-fault monitoring system not function as designed. This was evidenced by the following:

The line isolation monitor system, installed in Operating Room #1, was not tested in accordance with NFPA 99 Section 3-3.3.4.2, as required.
The Maintenance Director reported that a regular testing program for the line isolation monitors was not in place and that the only testing had occurred when the units were installed in 2008.

NFPA 99 Section 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.

Based on record review, observation and staff interview during the survey, it was determined that the facility failed to maintain emergency power systems in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code and the referenced NFPA 110, Standard for Emergency and Standby Power Systems. This deficient practice could affect all patients, staff and visitors should the essential electrical system not function as designed due to lack of maintenance and testing. This was evidenced by the following:

A) Automatic transfer switches were not exercised monthly, as required. The Maintenance Director reported that all three transfer switches were exercised during a weekly load test initiated via an automatic time clock. The time clock exercise was witness on September 5, 2013 at approximately 12:50 pm during the survey. The time clock started the generator for a 15 minute exercise but none of the 3 automatic transfer switches transferred the electrical load to the generator.
NFPA 110 Section 6-4.5: Level 1 and Level 2 transfer switches shall be operated monthly. The monthly test of a transfer switch shall consist of electrically operating the transfer switch from the standard position to the alternate position and then a return to the standard position.

B) The emergency generator was not exercised under load for a minimum of 30 minutes per month, as required. The Maintenance Director reported that all three transfer switches were exercised during a weekly load test initiated via an automatic time clock. The time clock exercise was witness on September 5, 2013 during the survey at approximately 12:50 pm. The time clock started the generator for a 15 minute exercise but none of the 3 automatic transfer switches transferred the electrical load to the generator.
NFPA 110 Section 6-4.2: Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer

C) The diesel powered emergency generator was not being load tested monthly at a minimum of 30% of nameplate rating, and was not exercised annually with supplemental loads, as required. Records on premises documented generator testing with supplemental loads for a period of 2 hours on May 29, 2013. The Maintenance Director reported that the diesel generator had only been tested with supplemental loads (load bank test) twice since the facility opened in 2008.
NFPA 110 Section 6-4.2: Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
Section 6-4.2.2: Diesel-powered EPS installations that do not meet the requirements of 6-4.2 shall be exercised monthly with the available EPSS load and exercised annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of 2 continuous hours.

D) The diesel generator was not visually inspected weekly, as required.
The Maintenance Director reported that the generator was visually inspected, approximately once per month, but records were not maintained that documented the visual inspections.
NFPA 99 Section 3-4.4.1.1 requires, in part, that generators serving emergency and equipment systems be in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6. NFPA 110 Section 6-4.1 requires Level 1 and Level 2 Emergency Power Supply Systems (EPSS) including all appurtenant components, be inspected weekly and exercised under load at least monthly.
NFPA 110 Section 6-3.4 requires, in part, that a written record of the EPSS inspections, tests, exercising, operation, and repairs shall be maintained on the premises.