HospitalInspections.org

Based on observation and interview, the facility failed to maintain the 2 hour rated fire wall, which separated the Hospital from the Metal Maintenance Building. This deficient practice would allow fire, gasses and smoke to migrate between the two separate occupancies that would require evacuation. The facility census was 12 patients.

Findings are:
Observations on 6-27-16 at 11:07 am revealed, the 1 ½ hour rated doors separating the Hospital and Metal Maintenance Building failed to close and latch.

During an interview on 6-27-16 at 11:07 am, Maintenance Staff A confirmed the findings

NFPA Standard:
Health care occupancies in buildings housing other occupancies shall be completely separated from them by construction having a fire resistance rating of not less than 2 hours as provided for additions in 18/19.1.1.4. 2000 NFPA 101, 18/19.1.2.3

Based on observation and interview, the facility failed to ensure that smoke separation doors were capable of resisting the passage of smoke. The deficient practice would allow smoke and gasses to spread into other smoke compartments. The facility census was 12 patients.

Findings are:
Observations on 6-22-16 between 11:00 am and 1:35 pm revealed:
1. The smoke doors between ER and Pharmacy, equipped with self-closing devices, failed to close and latch within the door frame.
2. The west smoke door next to Intake at Behavioral Health, equipped with self-closing device, failed to close and latch within the door frame.
3. The smoke doors leading into Metal Maintenance Building, equipped with self-closing device, failed to close and latch within the door frame.

During an interview on 6-22-16 between 10:00 am and 1:35 pm, Maintenance Staff A confirmed the findings

NFPA Standard:
Doors in smoke barriers shall comply with 8.3.4 and shall be self-closing or automatic-closing in accordance with 18.2.2.2.6. NFPA 101, 18.3.7.6*

Based on interview and observation the facility failed to provide smoke resistant enclosures for hazard areas. This deficient practice would allow smoke, fire and gasses to spread outside the hazardous area in case of a fire. The facility census was 12 patients.

Findings are:
Observations on 6-22-16 between 10:15 am and 10:45 am revealed:
1. The OR storage room was over 100 square feet and was not equipped with a self-closing device on the door.
2. The gap between the OR storage room doors was greater than 1/8 inch.
3. The Oxygen storage room located in the Medication room contained two 12 inch by 12 inch louvers in the door.

During an interview on 6-22-16 between 10:15 am and 10:45 am, Maintenance A confirmed the findings.

NFPA Standard:
Hazardous areas are separated by construction providing at least a one-hour fire resistance rating, or are protected by an automatic sprinkler system. Severe hazardous areas require both sprinklers and separation. Doors have at least a 3/4 hour fire protection rating. Vision panels are not used. 12-3.2.1 Hazardous areas are protected in accordance with 8.4. The areas are enclosed with a one hour fire-rated barrier, with a ¾ hour fire-rated door, without windows (in accordance with 8.4). Doors are self-closing or automatic closing in accordance with 7.2.1.8. 18.3.2.1

Based on observation and interview, the facility allowed the use of more than one locking device or latching device on a door within a means of egress. The facility provided signage containing instructions for operation of a delayed egress door on a door that was not equipped with a delayed egress function. These deficient practices would prohibit or delay egress during an emergency. The facility census was 13 patients.

Findings are:
Observation on 6-22-16 at 10:46 am and 11:38 am revealed:
1. 2 of 2 sliding egress doors in Behavioral Health were equipped with thumb locks.
2. The exit door in the Sun Room provided delayed egress signage and no magnetic lock was installed.

During an interview on 6-22-16 at 10:46 am and 11:38 am, Maintenance A confirmed all the findings.

NFPA Standard:
A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 in. (86 cm), and not more than 48 in. (122 cm), above the finished floor. Doors shall be operable with not more than one releasing operation.
Exception No. 1*: Egress doors from individual living units and guest rooms of residential occupancies shall be permitted to be provided with devices that require not more than one additional releasing operation, provided that such device is operable from the inside without the use of a key or tool and is mounted at a height not exceeding 48 in. (122 cm) above the finished floor. Existing security devices shall be permitted to have two additional releasing operations. Existing security devices other than automatic latching devices shall not be located more than 60 in. (152 cm) above the finished floor. Automatic latching devices shall not be located more than 48 in. (122 cm) above the finished floor.
Exception No. 2: The minimum mounting height for the releasing mechanism shall not be applicable to existing installations. 2000 NFPA 101, 7.2.1.5.4*

Based on observation and staff interview, the facility failed to provide 8 feet of clear width for exit corridors. This condition had the potential of slowing evacuation due to the width of the corridor. The facility census was 12 patients.

Findings are:
Observation on 6-22-16 at 12:05 pm revealed, the corridor behind the Acute care nurse station failed to provide the required 8 foot minimum corridor width, and measured 69 inches wide.

During an interview on 6-22-16 at 12:05 pm, Maintenance Staff A confirmed the corridor failed to be 8 feet wide.

NFPA Standard:
Aisles, corridors, and ramps required for exit access in a hospital or nursing home shall be not less than 8 ft (2.4 m) in clear and unobstructed width. Where ramps are used as exits, see 18.2.2.6.

Based on observation and interview, the facility failed to provide sliding egress doors that provided the required clear width when pushed open. This deficient practice would delay egress and cause confusion. The facility census was 12 patients.

Findings are:
Observations on 6-22-16 between 11:00 am and 1:35 pm revealed,
1. Sliding glass egress doors in the OR failed to provide 41 ½ " of clear opening when pushed open.
2. 2 of 2 sliding glass egress doors in the ER failed to provide 41 ½ " of clear opening when pushed open.
3. 2 of 2 sliding glass egress doors in the Lobby failed to provide 41 ½ " of clear opening when pushed open.
4. 2 of 2 sliding glass egress doors in the Behavioral Health failed to provide 41 ½ " of clear opening when pushed open.

During an interview on 6-22-16 between 11:00 am and 1:35 pm, Maintenance Staff A confirmed the findings.

NFPA Standard:
Exit access doors and exit doors used by health care occupants are of the swinging type and are at least 41.5 inches wide. In ICFs/MR, doors are at least 32 inches wide. Doors in exit stairway enclosures are no less than 32 inches wide. 2000 NFPA 101, 18.2.3.5

Based on observation and interview, the facility failed to provide exit signs to indicate the continuous path of egress. The deficient practice would not direct occupants to all exits during an emergency. This deficient practice affected all patients, staff, and visitors. The facility census was 12 patients

Findings are:
Observations on 6-22-16 at 1:21 pm. revealed the facility failed to provide an exit sign above the smoke doors next to the Dining Room.

During an interview on 6-22-16 at 1:21 pm, Maintenance Staff A confirmed the lack of exit signage.

NFPA Standard:
Exit and directional signs are displayed with continuous illumination also served by the emergency lighting system in accordance with section 7.10. 2000 NFPA 101, 18.2.10.1

Based on documentation review and interview, the facility failed to hold fire drills at random times under varied conditions. The deficient practice did not challenge staff to respond to fire emergencies that might occur during various activities at different times of the day. The deficient practice affected all occupant of the facility. The facility census was 12 patients.

Findings are:
Fire drill documentation review on 6-27-16 at 11:20 pm revealed:
1. The first shift fire drills were conducted at 2:53pm, 2:59pm, 2:39pm, 2:53pm.
2. The second shift fire drills were conducted at 3:20pm, 4:35pm, 3:10pm and 3:06pm, 3:23pm.
3. The third shift fire drills were conducted at 1:27am, 1:34am, 6:10am, 5:45am and 5:55am.
4. 13 of 17 fire drills were conducted at the end of the month or within a few days of the end of the month.

During an interview on 6-27-16 at 11:20 am, Maintenance Staff A confirmed all the findings.

NFPA Standard:
Requires drills be conducted at least quarterly on each shift under varied conditions to simulate the unusual conditions occurring in case of fire. The fire alarm shall be transmitted during drills although a coded announcement may be used between 9:00 p.m. and 6:00 a.m. The fire alarm shall be transmitted the day before or the day after the coded drill. 2000 NFPA 101, 19.7.1.2

The proper protection of patients shall require the prompt and effective response of health care personnel. The basic response required of staff shall include the removal of all occupants directly involved with the fire emergency, transmission of an appropriate fire alarm signal to warn other building occupants and summon staff, confinement of the effects of the fire by closing doors to isolate the fire area, and the relocation of patients as detailed in the health care occupancy's fire safety plan. 2000 NFPA 101, 19.7.2.1

Based on observation and interview the facility failed to assure that only one distinct signal could be heard during the activation of the fire alarm system. This deficient practice would cause confusion during the activation of the fire alarm. The facility census was 12 patients.

Findings are:
Observations during a fire alarm activation on 6-27-16 at 10:10 am revealed that two separate and distinct alert sounds could be heard when the fire alarm system was activated. The newly installed notification devices did not match the sound of the older, existing bells.

During an interview on 6-27-16 at 10:10 am, Maintenance Staff A confirmed the findings.

Regulation:
Fire alarm audible alarm devices must produce a single notification sound. Where a system contains a combination of signals such as horns, bells and/or chimes, confusion over the intent of the signal can occur. State Fire Marshal- Formal Interpretation, 01-02

Based on documentation review and interview, the facility did not provide and maintain complete documentation for the annual testing of the fire alarm system. The deficient practice did not ensure proper operation and prompt repair of the fire alarm system and affected all occupants. The facility census was 12 patients.

Findings are:
Record review on 6-27-16 at 12:10 pm, revealed the facility's report of annual testing dated 4-29-16 did not document all of the required testing and information for the fire alarm system. The documents provided did not list all devices, circuits, and the type, quantity, method of testing and the results of testing obtained. Information on all of the supervisory devices connected, tested and the results of testing were not documented.

During an interview on 6-27-16 at 12:10 pm, Maintenance Staff A confirmed the findings.

NFPA Standard:
A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction. 2000 NFPA 101, 9.6.1.4

NFPA Standard:
A permanent record of all inspections, testing, and maintenance shall be provided that includes the following information regarding tests and all the applicable information requested in Figure 7-5.2.2, including: Date, Test frequency, Name of property, Address, Name of person performing inspection, maintenance, tests, or combination thereof, and affiliation, business address, and telephone number, Name, address, and representative of approving agency, Designation of the detector(s) tested, for example, " Tests performed in accordance with Section _. " , Functional test of detectors, Functional test of required sequence of operations, Check of all smoke detectors, Loop resistance for all fixed-temperature, line-type heat detectors, Other tests as required by equipment manufacturers, Other tests as required by the authority having jurisdiction, Signatures of tester and approved authority representative, Disposition of problems identified during test (for example, owner notified, problem corrected/successfully retested, device abandoned in place). 1999 NFPA 72, 7-5.2.2

NFPA Standard:
Fire alarm systems and other systems and equipment that are associated with fire alarm systems and accessory equipment shall be tested according to Table 7-2.2. 1999 NFPA 72, 7-2.2

NFPA Standard:
A permanent record of all inspections, testing, and maintenance shall be maintained that includes periodic tests and applicable information, per 1999 NFPA 72, 7-5.2.2 and figure 7-5.2.2; A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70. 2000 NFPA 101, 9.6.1.4

Based on documentation review and interview, the facilities failed to have the sprinkler system inspected quarterly by personnel who had developed competence through training and experience. This deficient practice could affect the operation of the sprinkler system and would affect all occupants. The facility census was 12 patients.

Findings are:
Documentation review on 6-27-16 at 11:15 am revealed, the facility had the sprinkler contractor conduct yearly inspections. The fire alarm company conducted inspections twice a year. The fourth quarter inspection of the sprinkler system was conducted by the facility.

During an interview on 6-27-16 at 11:15 am, Maintenance Staff A confirmed the findings.

NFPA Standard:
The responsibility for properly maintaining a water-based fire protection system shall be that of the owner(s) of the property. By means of periodic inspections, tests, and maintenance, the equipment shall be shown to be in good operating condition, or any defects or impairments shall be revealed.
Inspection, testing, and maintenance shall be implemented in accordance with procedures meeting or exceeding those established in this document and in accordance with the manufacturer ' s instructions. These tasks shall be performed by personnel who have developed competence through training and experience. 1998 NFPA 25, 1-4.2

Requires sprinkler systems to be continuously maintained in proper operating condition and an inspection every quarter of a calendar year. 1998 NFPA 25, 2-2 and 2000 NFPA 101, 4.6.12.1

Based on observation and interview, the facility failed to maintain the path to the fire extinguisher in the kitchen free of obstructions. This deficient practice would delay the extinguishment of a fire and could allow it to spread. The facility census was 12 patients.

Findings are:
Observations on 6-22-16 at 12:28 pm revealed, a rolling cart stored in front of the Class K fire extinguisher in the kitchen.

During an interview on 6-22-16 at 12:28 pm, Kitchen Staff A confirmed the cart and stated that it is normally stored there.

NFPA Standard:
Fire extinguishers shall be conspicuously located where they will be readily accessible and immediately available in the event of fire. Preferably they shall be located along normal paths of travel, including exits from areas. 1998 NFPA 10, 1-6.3

Based on observation and interview, the facility failed to ensure that empty oxygen cylinders were separated from full oxygen cylinders to prevent confusion when choosing tanks in an emergency. The facility census was 12 patients.

Findings are:
Observation on 6-22-16 at 11:03 am revealed, the Oxygen Storage room contained empty oxygen cylinders and full cylinders were not physically separated or identified as full or empty.

During an interview on 6-22-16 at 11:03 am, Maintenance Staff A confirmed the lack of separation.

NFPA Standard:
If stored within the same enclosure, empty cylinders shall be segregated from full cylinders. Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed hurriedly. 1999 NFPA 99, 4.3.5.2.2

Based on documentation review and interview, the facility failed to maintain required humidity levels in the operating room throughout the year. This condition increases the potential to allow a spark to occur during a procedure and cause a fire or burn.

Findings are:
Documentation review on 6-27-16 at 11:48 am, of OR humidity levels revealed Operating Room failed to have humidity levels of at least 35 percent in the months provided during 2016.

During an interview on 6-27-16 at 11:48 am Maintenance Staff A confirmed the findings. Administration Staff A was also informed of the Survey and Certification letter 13-25 from Centers for Medicare and Medicaid Services.

NFPA Standard:
The mechanical ventilation system supplying anesthetizing locations shall have the capability of controlling the relative humidity at a level of 35 percent or greater. Advantages claimed for humidity include avoidance of hypothermia in patients, especially during long operative procedures; the fact that floating particulate matter increases in conditions of low relative humidity; and the fact that the incidence of wound infections can be minimized following procedures performed in those operating rooms in which the relative humidity is maintained at the level of 50 to 55 percent. 1999 NFPA 99, 5-4.1.1

The mechanical ventilation system supplying anesthetizing locations shall have the capability of controlling the relative humidity at a level of 35 percent or greater

Based on observation and interview the facility failed to maintain a gas burner on the kitchen stove in operational condition. This deficient practice had the potential to allow a build up of gas which could cause a flash fire when the burner was manually lighted. The facility census was 12 patients.

Findings are:
Observations on 6-22-16 at 12:35 pm revealed, the rear right burner on the gas stove failed to ignite when tested.

During an interview on 6-22-16 at 12:35 pm, Maintenance Staff A confirmed the burner was not operational when tested.


NFPA Standard:
Gas utilization equipment supplied with a means for automatic ignition shall be checked for proper operation. If necessary, proper adjustments shall be made. NFPA 54, 1999 Edition, Chapter 8.4.

Definition: Automatic ignition. Ignition of gas at the burner(s) when the gas controlling device is turned on, including re-ignition if the flames on the burner(s) have been extinguished by means other than by the closing of the gas controlling device.

Based on observation, interview and documentation review, the facility failed to maintain the Type I essential electrical system of the facility by having loads intermixed between the Life Safety Branch, the Critical Branch, and the Equipment System. This deficient practice had the potential to affect all occupants of the facility by affecting the egress lighting and emergency systems of the facility. The facility census was 12 patients.

Findings are:
Observations on 6-22-16 between 1:40 pm and 3:30 pm revealed:
1. Panel box ELL3 which was determined to be a Life Safety branch contained non-life safety items on circuits 7, 8, 15 and 17.
2. Panel box ECLL which was determined to be a Critical branch contained Life Safety items on circuit 17.
3. Panel box ECL2 which was determined to be a Critical branch contained Equipment items on circuits 44, 46 and 48.
4. Panel box ELL2 which was determined to be a Life Safety branch contained non-life safety items on circuits 1, 3,5,15. Other circuits shall be verified as egress requirements.
5. LPR panel box was determined to be fed from ECL3 which was determined to be a Critical branch and contained Life Safety items.

During an interview on 6-22-16 between 1:40 pm and 3:30 pm, Maintenance Staff A confirmed the findings.

NFPA Standard:
NFPA 70, 1999ed.
517.30 Essential Electrical Systems for Hospitals.
(A) Applicability. The requirements of Part III, 517.30 through 517.35, shall apply to hospitals where an essential electrical system is required.
(B) General.
(1) Separate Systems. Essential electrical systems for hospitals shall be comprised of two separate systems capable of supplying a limited amount of lighting and power service, which is considered essential for life safety and effective hospital operation during the time the normal electrical service is interrupted for any reason. These two systems shall be the emergency system and the equipment system.
(2) Emergency Systems. The emergency system shall be limited to circuits essential to life safety and critical patient care. These are designated the life safety branch and the critical branch.
(3) Equipment System. The equipment system shall supply major electrical equipment necessary for patient care and basic hospital operation.
(4) Transfer Switches. The number of transfer switches to be used shall be based on reliability, design, and load considerations. Each branch of the emergency system and each equipment system shall have one or more transfer switches. One transfer switch shall be permitted to serve one or more branches or systems in a facility with a maximum demand on the essential electrical system of 150 kVA.
(5) Other Loads. Loads served by the generating equipment not specifically named in Article 517 shall be served by their own transfer switches such that these loads:
(1) Shall not be transferred if the transfer will overload the generating equipment.
(2) Shall be automatically shed upon generating equipment overloading.
(6) Contiguous Facilities. Hospital power sources and alternate power sources shall be permitted to serve the essential electrical systems of contiguous or same site facilities. [NFPA 99, 3.4.2.2.1, 12.3.3.2]
(C) Wiring Requirements.
(1) Separation from Other Circuits. The life safety branch and critical branch of the emergency system shall be kept entirely independent of all other wiring and equipment and shall not enter the same raceways, boxes, or cabinets with each other or other wiring.
Wiring of the life safety branch and the critical branch shall be permitted to occupy the same raceways, boxes, or cabinets of other circuits not part of the branch where such wiring is as follows:
(1) In transfer equipment enclosures, or
(2) In exit or emergency luminaires (lighting fixtures) supplied from two sources, or
(3) In a common junction box attached to exit or emergency luminaires (lighting fixtures) supplied from two sources, or
(4) For two or more emergency circuits supplied from the same branch
The wiring of the equipment system shall be permitted to occupy the same raceways, boxes, or cabinets of other circuits that are not part of the emergency system.
(2) Isolated Power Systems. Where isolated power systems are installed in any of the areas in 517.33(A)(1) and (A)(2), each system shall be supplied by an individual circuit serving no other load.
(3) Mechanical Protection of the Emergency System. The wiring of the emergency system of a hospital shall be mechanically protected by installation in nonflexible metal raceways, or shall be wired with Type MI cable.
Exception No. 1: Flexible power cords of appliances, or other utilization equipment, connected to the emergency system shall not be required to be enclosed in raceways.
Exception No. 2: Secondary circuits of transformer-powered communications or signaling systems shall not be required to be enclosed in raceways unless otherwise specified by Chapters 7 or 8.
Exception No. 3: Schedule 80 rigid nonmetallic conduit shall be permitted if the branch circuits do not serve patient care areas and it is not prohibited elsewhere in this Code.
Exception No. 4: Where encased in not less than 50 mm (2 in.) of concrete, Schedule 40 rigid nonmetallic conduit or electrical nonmetallic tubing shall be permitted if the branch circuits do not serve patient care areas.
Exception No. 5: Flexible metal raceways and cable assemblies shall be permitted to be used in listed prefabricated medical headwalls, listed office furnishings, or where necessary for flexible connection to equipment.
(D) Capacity of Systems. The essential electrical system shall have adequate capacity to meet the demand for the operation of all functions and equipment to be served by each system and branch.
Feeders shall be sized in accordance with Articles 215 and 220. The generator set(s) shall have sufficient capacity and proper rating to meet the demand produced by the load of the essential electrical system(s) at any given time.
Demand calculations for sizing of the generator set(s) shall be based on the following:
(1) Prudent demand factors and historical data, or
(2) Connected load, or
(3) Feeder calculation procedures described in Article 220, or
(4) Any combination of the above
The sizing requirements in 700.5 and 701.6 shall not apply to hospital generator set(s).
(E) Receptacle Identification. The cover plates for the electrical receptacles or the electrical receptacles themselves supplied from the emergency system shall have a distinctive color or marking so as to be readily identifiable. [NFPA 99, 3.4.2.2.4(b)2]
517.31 Emergency System.
Those functions of patient care depending on lighting or appliances that are connected to the emergency system shall be divided into two mandatory branches: the life safety branch and the critical branch, described in 517.32 and 517.33. The branches of the emergency system shall be installed and connected to the alternate power source so that all functions specified herein for the emergency system shall be automatically restored to operation within 10 seconds after interruption of the normal source. [NFPA 99, 3.4.2.2.2(a), 3.5.2.2.2]
517.32 Life Safety Branch.
No function other than those listed in 517.32(A) through (G) shall be connected to the life safety branch. The life safety branch of the emergency system shall supply power for the following lighting, receptacles, and equipment.
(A) Illumination of Means of Egress. Illumination of means of egress, such as lighting required for corridors, passageways, stairways, and landings at exit doors, and all necessary ways of approach to exits. Switching arrangements to transfer patient corridor lighting in hospitals from general illumination circuits to night illumination circuits shall be permitted, provided only one of two circuits can be selected and both circuits cannot be extinguished at the same time.
(B) Exit Signs. Exit signs and exit directional signs.
(C) Alarm and Alerting Systems. Alarm and alerting systems including the following:
(1) Fire alarms
(2) Alarms required for systems used for the piping of nonflammable medical gases
(D) Communications Systems. Hospital communications systems, where used for issuing instructions during emergency conditions.
(E) Generator Set Location. Task illumination battery charger for emergency battery-powered lighting unit(s) and selected receptacles at the generator set location.
(F) Elevators. Elevator cab lighting, control, communications, and signal systems.
(G) Automatic Doors. Automatically operated doors used for building egress. [NFPA 99, 3.4.2.2.2(b)]
517.33 Critical Branch.
(A) Task Illumination and Selected Receptacles. The critical branch of the emergency system shall supply power for task illumination, fixed equipment, selected receptacles, and special power circuits serving the following areas and functions related to patient care:
(1) Critical care areas that utilize anesthetizing gases - task illumination, selected receptacles, and fixed equipment
(2) The isolated power systems in special environments
(3) Patient care areas - task illumination and selected receptacles in the following:
a. Infant nurseries
b. Medication preparation areas
c. Pharmacy dispensing areas
d. Selected acute nursing areas
e. Psychiatric bed areas (omit receptacles)
f. Ward treatment rooms
g. Nurses ' stations (unless adequately lighted by corridor luminaires)
(4) Additional specialized patient care task illumination and receptacles, where needed
(5) Nurse call systems
(6) Blood, bone, and tissue banks
(7) Telephone equipment rooms and closets
(8) Task illumination, selected receptacles, and selected power circuits for the following:
a. General care beds (at least one duplex receptacle per patient bedroom)
b. Angiographic labs
c. Cardiac catheterization labs
d. Coronary care units
e. Hemodialysis rooms or areas
f. Emergency room treatment areas (selected)
g. Human physiology labs
h. Intensive care units
i. Postoperative recovery rooms (selected)
(9) Additional task illumination, receptacles, and selected power circuits needed for effective hospital operation. Single-phase fractional horsepower motors shall be permitted to be connected to the critical branch. [NFPA 99, 3.4.2.2.2(c)]
(B) Subdivision of the Critical Branch. It shall be permitted to subdivide the critical branch into two or more branches.
517.34 Equipment System Connection to Alternate Power Source.
The equipment system shall be installed and connected to the alternate power source such that the equipment described in 517.34(A) is automatically restored to operation at appropriate time-lag intervals following the energizing of the emergency system. Its arrangement shall also provide for the subsequent connection of equipment described in 517.34(B). [NFPA 99, 3.4.2.2.3(b)]
Exception: For essential electrical systems under 150 kVA, deletion of the time-lag intervals feature for delayed automatic connection to the equipment system shall be permitted.
(A) Equipment for Delayed Automatic Connection. The following equipment shall be arranged for delayed automatic connection to the alternate power source.
(1) Central suction systems serving medical and surgical functions, including controls. Such suction systems shall be permitted on the critical branch.
(2) Sump pumps and other equipment required to operate for the safety of major apparatus, including associated control systems and alarms.
(3) Compressed air systems serving medical and surgical functions, including controls. Such air systems shall be permitted on the critical branch.
(4) Smoke control and stair pressurization systems, or both.
(5) Kitchen hood supply or exhaust systems, or both, if required to operate during a fire in or under the hood. [NFPA 99, 3.4.2.2.3(d)]
Exception: Sequential delayed automatic connection to the alternate power source to prevent overloading the generator shall be permitted where engineering studies indicate it is necessary.
(B) Equipment for Delayed Automatic or Manual Connection. The following equipment shall be arranged for either delayed automatic or manual connection to the alternate power source:
(1) Heating equipment to provide heating for operating, delivery, labor, recovery, intensive care, coronary care, nurseries, infection/isolation rooms, emergency treatment spaces, and general patient rooms and pressure maintenance (jockey or make-up) pump(s) for water-based fire protection systems.
Exception: Heating of general patient rooms and infection/isolation rooms during disruption of the normal source shall not be required under any of the following conditions:
(a) The outside design temperature is higher than -6.7°C (20°F).
(b) The outside design temperature is lower than -6.7°C (20°F), and where a selected room(s) is provided for the needs of all confined patients, only such room(s) need be heated.
(c) The facility is served by a dual source of normal power.
(2) An elevator(s) selected to provide service to patient, surgical, obstetrical, and ground floors during interruption of normal power. In instances where interruption of normal power would result in other elevators stopping between floors, throw-over facilities shall be provided to allow the temporary operation of any elevator for the release of patients or other persons who may be confined between floors.
(3) Supply, return, and exhaust ventilating systems for airborne infectious/isolation rooms, protective environment rooms, exhaust fans for laboratory fume hoods, nuclear medicine areas where radioactive material is used, ethylene oxide evacuation and anesthesia evacuation. Where delayed automatic connection is not appropriate, such ventilation systems shall be permitted to be placed on the critical branch. [NFPA 99, 3.4.2.2.3(e)(4)]
(4) Hyperbaric facilities.
(5) Hypobaric facilities.
(6) Automatically operated doors.
(7) Minimal electrically heated autoclaving equipment shall be permitted to be arranged for either automatic or manual connection to the alternate source.
(8) Controls for equipment listed in 517.34.
(9) Other selected equipment shall be permitted to be served by the equipment system. [NFPA 99, 3.4.2.2.3(e)]

Based on record review and interview, the facility failed to conduct retention tests on receptacles throughout the facility. This deficient practice had the potential to affect how equipment operates which could result in an electrical fire. The facility census was 12 patients.

Findings are:
Documentation review on 6-27-16 at 11:48 am revealed, that no retention testing had been conducted on receptacles throughout the facility.

During an interview on 6-27-16 at 11:48 am, Maintenance Staff A confirmed the findings and stated that they were unaware of the requirements.

NFPA Standard:
Receptacle Testing in Patient Care Areas
a) The physical integrity of each receptacle shall be confirmed by visual inspection.
b) The continuity of the grounding circuit in each electrical receptacle shall be verified.
c) Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.
d) The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz). 1999 NFPA 99, 3-3.3.3

Testing Interval for Receptacles in Patient Care Areas
1. Testing shall be performed after initial installation, replacement, or servicing of the device.
2. Additional testing shall be performed at intervals defined by documented performance data.
Exception: Receptacles not listed as hospital-grade shall be tested at intervals not exceeding 12 months.1999 NFPA 99, 3-3.4.2.3

A record shall be maintained of the tests required by this chapter and associated repairs or modification. At a minimum, this record shall contain the date, the rooms or areas tested, and an indication of which items have met or have failed to meet the performance requirements of this chapter. 1999 NFPA 99, 3-3.4.3.1

Based on observation and interview, the facility failed to maintain the 2 hour rated fire wall, which separated the Hospital from the Metal Maintenance Building. This deficient practice would allow fire, gasses and smoke to migrate between the two separate occupancies that would require evacuation. The facility census was 12 patients.

Findings are:
Observations on 6-27-16 at 11:07 am revealed, the 1 ½ hour rated doors separating the Hospital and Metal Maintenance Building failed to close and latch.

During an interview on 6-27-16 at 11:07 am, Maintenance Staff A confirmed the findings

NFPA Standard:
Health care occupancies in buildings housing other occupancies shall be completely separated from them by construction having a fire resistance rating of not less than 2 hours as provided for additions in 18/19.1.1.4. 2000 NFPA 101, 18/19.1.2.3

Based on observation and interview, the facility failed to ensure that smoke separation doors were capable of resisting the passage of smoke. The deficient practice would allow smoke and gasses to spread into other smoke compartments. The facility census was 12 patients.

Findings are:
Observations on 6-22-16 between 11:00 am and 1:35 pm revealed:
1. The smoke doors between ER and Pharmacy, equipped with self-closing devices, failed to close and latch within the door frame.
2. The west smoke door next to Intake at Behavioral Health, equipped with self-closing device, failed to close and latch within the door frame.
3. The smoke doors leading into Metal Maintenance Building, equipped with self-closing device, failed to close and latch within the door frame.

During an interview on 6-22-16 between 10:00 am and 1:35 pm, Maintenance Staff A confirmed the findings

NFPA Standard:
Doors in smoke barriers shall comply with 8.3.4 and shall be self-closing or automatic-closing in accordance with 18.2.2.2.6. NFPA 101, 18.3.7.6*

Based on interview and observation the facility failed to provide smoke resistant enclosures for hazard areas. This deficient practice would allow smoke, fire and gasses to spread outside the hazardous area in case of a fire. The facility census was 12 patients.

Findings are:
Observations on 6-22-16 between 10:15 am and 10:45 am revealed:
1. The OR storage room was over 100 square feet and was not equipped with a self-closing device on the door.
2. The gap between the OR storage room doors was greater than 1/8 inch.
3. The Oxygen storage room located in the Medication room contained two 12 inch by 12 inch louvers in the door.

During an interview on 6-22-16 between 10:15 am and 10:45 am, Maintenance A confirmed the findings.

NFPA Standard:
Hazardous areas are separated by construction providing at least a one-hour fire resistance rating, or are protected by an automatic sprinkler system. Severe hazardous areas require both sprinklers and separation. Doors have at least a 3/4 hour fire protection rating. Vision panels are not used. 12-3.2.1 Hazardous areas are protected in accordance with 8.4. The areas are enclosed with a one hour fire-rated barrier, with a ¾ hour fire-rated door, without windows (in accordance with 8.4). Doors are self-closing or automatic closing in accordance with 7.2.1.8. 18.3.2.1

Based on observation and interview, the facility allowed the use of more than one locking device or latching device on a door within a means of egress. The facility provided signage containing instructions for operation of a delayed egress door on a door that was not equipped with a delayed egress function. These deficient practices would prohibit or delay egress during an emergency. The facility census was 13 patients.

Findings are:
Observation on 6-22-16 at 10:46 am and 11:38 am revealed:
1. 2 of 2 sliding egress doors in Behavioral Health were equipped with thumb locks.
2. The exit door in the Sun Room provided delayed egress signage and no magnetic lock was installed.

During an interview on 6-22-16 at 10:46 am and 11:38 am, Maintenance A confirmed all the findings.

NFPA Standard:
A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 in. (86 cm), and not more than 48 in. (122 cm), above the finished floor. Doors shall be operable with not more than one releasing operation.
Exception No. 1*: Egress doors from individual living units and guest rooms of residential occupancies shall be permitted to be provided with devices that require not more than one additional releasing operation, provided that such device is operable from the inside without the use of a key or tool and is mounted at a height not exceeding 48 in. (122 cm) above the finished floor. Existing security devices shall be permitted to have two additional releasing operations. Existing security devices other than automatic latching devices shall not be located more than 60 in. (152 cm) above the finished floor. Automatic latching devices shall not be located more than 48 in. (122 cm) above the finished floor.
Exception No. 2: The minimum mounting height for the releasing mechanism shall not be applicable to existing installations. 2000 NFPA 101, 7.2.1.5.4*

Based on observation and staff interview, the facility failed to provide 8 feet of clear width for exit corridors. This condition had the potential of slowing evacuation due to the width of the corridor. The facility census was 12 patients.

Findings are:
Observation on 6-22-16 at 12:05 pm revealed, the corridor behind the Acute care nurse station failed to provide the required 8 foot minimum corridor width, and measured 69 inches wide.

During an interview on 6-22-16 at 12:05 pm, Maintenance Staff A confirmed the corridor failed to be 8 feet wide.

NFPA Standard:
Aisles, corridors, and ramps required for exit access in a hospital or nursing home shall be not less than 8 ft (2.4 m) in clear and unobstructed width. Where ramps are used as exits, see 18.2.2.6.

Based on observation and interview, the facility failed to provide sliding egress doors that provided the required clear width when pushed open. This deficient practice would delay egress and cause confusion. The facility census was 12 patients.

Findings are:
Observations on 6-22-16 between 11:00 am and 1:35 pm revealed,
1. Sliding glass egress doors in the OR failed to provide 41 ½ " of clear opening when pushed open.
2. 2 of 2 sliding glass egress doors in the ER failed to provide 41 ½ " of clear opening when pushed open.
3. 2 of 2 sliding glass egress doors in the Lobby failed to provide 41 ½ " of clear opening when pushed open.
4. 2 of 2 sliding glass egress doors in the Behavioral Health failed to provide 41 ½ " of clear opening when pushed open.

During an interview on 6-22-16 between 11:00 am and 1:35 pm, Maintenance Staff A confirmed the findings.

NFPA Standard:
Exit access doors and exit doors used by health care occupants are of the swinging type and are at least 41.5 inches wide. In ICFs/MR, doors are at least 32 inches wide. Doors in exit stairway enclosures are no less than 32 inches wide. 2000 NFPA 101, 18.2.3.5

Based on observation and interview, the facility failed to provide exit signs to indicate the continuous path of egress. The deficient practice would not direct occupants to all exits during an emergency. This deficient practice affected all patients, staff, and visitors. The facility census was 12 patients

Findings are:
Observations on 6-22-16 at 1:21 pm. revealed the facility failed to provide an exit sign above the smoke doors next to the Dining Room.

During an interview on 6-22-16 at 1:21 pm, Maintenance Staff A confirmed the lack of exit signage.

NFPA Standard:
Exit and directional signs are displayed with continuous illumination also served by the emergency lighting system in accordance with section 7.10. 2000 NFPA 101, 18.2.10.1

Based on documentation review and interview, the facility failed to hold fire drills at random times under varied conditions. The deficient practice did not challenge staff to respond to fire emergencies that might occur during various activities at different times of the day. The deficient practice affected all occupant of the facility. The facility census was 12 patients.

Findings are:
Fire drill documentation review on 6-27-16 at 11:20 pm revealed:
1. The first shift fire drills were conducted at 2:53pm, 2:59pm, 2:39pm, 2:53pm.
2. The second shift fire drills were conducted at 3:20pm, 4:35pm, 3:10pm and 3:06pm, 3:23pm.
3. The third shift fire drills were conducted at 1:27am, 1:34am, 6:10am, 5:45am and 5:55am.
4. 13 of 17 fire drills were conducted at the end of the month or within a few days of the end of the month.

During an interview on 6-27-16 at 11:20 am, Maintenance Staff A confirmed all the findings.

NFPA Standard:
Requires drills be conducted at least quarterly on each shift under varied conditions to simulate the unusual conditions occurring in case of fire. The fire alarm shall be transmitted during drills although a coded announcement may be used between 9:00 p.m. and 6:00 a.m. The fire alarm shall be transmitted the day before or the day after the coded drill. 2000 NFPA 101, 19.7.1.2

The proper protection of patients shall require the prompt and effective response of health care personnel. The basic response required of staff shall include the removal of all occupants directly involved with the fire emergency, transmission of an appropriate fire alarm signal to warn other building occupants and summon staff, confinement of the effects of the fire by closing doors to isolate the fire area, and the relocation of patients as detailed in the health care occupancy's fire safety plan. 2000 NFPA 101, 19.7.2.1

Based on observation and interview the facility failed to assure that only one distinct signal could be heard during the activation of the fire alarm system. This deficient practice would cause confusion during the activation of the fire alarm. The facility census was 12 patients.

Findings are:
Observations during a fire alarm activation on 6-27-16 at 10:10 am revealed that two separate and distinct alert sounds could be heard when the fire alarm system was activated. The newly installed notification devices did not match the sound of the older, existing bells.

During an interview on 6-27-16 at 10:10 am, Maintenance Staff A confirmed the findings.

Regulation:
Fire alarm audible alarm devices must produce a single notification sound. Where a system contains a combination of signals such as horns, bells and/or chimes, confusion over the intent of the signal can occur. State Fire Marshal- Formal Interpretation, 01-02

Based on documentation review and interview, the facility did not provide and maintain complete documentation for the annual testing of the fire alarm system. The deficient practice did not ensure proper operation and prompt repair of the fire alarm system and affected all occupants. The facility census was 12 patients.

Findings are:
Record review on 6-27-16 at 12:10 pm, revealed the facility's report of annual testing dated 4-29-16 did not document all of the required testing and information for the fire alarm system. The documents provided did not list all devices, circuits, and the type, quantity, method of testing and the results of testing obtained. Information on all of the supervisory devices connected, tested and the results of testing were not documented.

During an interview on 6-27-16 at 12:10 pm, Maintenance Staff A confirmed the findings.

NFPA Standard:
A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction. 2000 NFPA 101, 9.6.1.4

NFPA Standard:
A permanent record of all inspections, testing, and maintenance shall be provided that includes the following information regarding tests and all the applicable information requested in Figure 7-5.2.2, including: Date, Test frequency, Name of property, Address, Name of person performing inspection, maintenance, tests, or combination thereof, and affiliation, business address, and telephone number, Name, address, and representative of approving agency, Designation of the detector(s) tested, for example, " Tests performed in accordance with Section _. " , Functional test of detectors, Functional test of required sequence of operations, Check of all smoke detectors, Loop resistance for all fixed-temperature, line-type heat detectors, Other tests as required by equipment manufacturers, Other tests as required by the authority having jurisdiction, Signatures of tester and approved authority representative, Disposition of problems identified during test (for example, owner notified, problem corrected/successfully retested, device abandoned in place). 1999 NFPA 72, 7-5.2.2

NFPA Standard:
Fire alarm systems and other systems and equipment that are associated with fire alarm systems and accessory equipment shall be tested according to Table 7-2.2. 1999 NFPA 72, 7-2.2

NFPA Standard:
A permanent record of all inspections, testing, and maintenance shall be maintained that includes periodic tests and applicable information, per 1999 NFPA 72, 7-5.2.2 and figure 7-5.2.2; A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70. 2000 NFPA 101, 9.6.1.4

Based on documentation review and interview, the facilities failed to have the sprinkler system inspected quarterly by personnel who had developed competence through training and experience. This deficient practice could affect the operation of the sprinkler system and would affect all occupants. The facility census was 12 patients.

Findings are:
Documentation review on 6-27-16 at 11:15 am revealed, the facility had the sprinkler contractor conduct yearly inspections. The fire alarm company conducted inspections twice a year. The fourth quarter inspection of the sprinkler system was conducted by the facility.

During an interview on 6-27-16 at 11:15 am, Maintenance Staff A confirmed the findings.

NFPA Standard:
The responsibility for properly maintaining a water-based fire protection system shall be that of the owner(s) of the property. By means of periodic inspections, tests, and maintenance, the equipment shall be shown to be in good operating condition, or any defects or impairments shall be revealed.
Inspection, testing, and maintenance shall be implemented in accordance with procedures meeting or exceeding those established in this document and in accordance with the manufacturer ' s instructions. These tasks shall be performed by personnel who have developed competence through training and experience. 1998 NFPA 25, 1-4.2

Requires sprinkler systems to be continuously maintained in proper operating condition and an inspection every quarter of a calendar year. 1998 NFPA 25, 2-2 and 2000 NFPA 101, 4.6.12.1

Based on observation and interview, the facility failed to maintain the path to the fire extinguisher in the kitchen free of obstructions. This deficient practice would delay the extinguishment of a fire and could allow it to spread. The facility census was 12 patients.

Findings are:
Observations on 6-22-16 at 12:28 pm revealed, a rolling cart stored in front of the Class K fire extinguisher in the kitchen.

During an interview on 6-22-16 at 12:28 pm, Kitchen Staff A confirmed the cart and stated that it is normally stored there.

NFPA Standard:
Fire extinguishers shall be conspicuously located where they will be readily accessible and immediately available in the event of fire. Preferably they shall be located along normal paths of travel, including exits from areas. 1998 NFPA 10, 1-6.3

Based on observation and interview, the facility failed to ensure that empty oxygen cylinders were separated from full oxygen cylinders to prevent confusion when choosing tanks in an emergency. The facility census was 12 patients.

Findings are:
Observation on 6-22-16 at 11:03 am revealed, the Oxygen Storage room contained empty oxygen cylinders and full cylinders were not physically separated or identified as full or empty.

During an interview on 6-22-16 at 11:03 am, Maintenance Staff A confirmed the lack of separation.

NFPA Standard:
If stored within the same enclosure, empty cylinders shall be segregated from full cylinders. Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed hurriedly. 1999 NFPA 99, 4.3.5.2.2

Based on documentation review and interview, the facility failed to maintain required humidity levels in the operating room throughout the year. This condition increases the potential to allow a spark to occur during a procedure and cause a fire or burn.

Findings are:
Documentation review on 6-27-16 at 11:48 am, of OR humidity levels revealed Operating Room failed to have humidity levels of at least 35 percent in the months provided during 2016.

During an interview on 6-27-16 at 11:48 am Maintenance Staff A confirmed the findings. Administration Staff A was also informed of the Survey and Certification letter 13-25 from Centers for Medicare and Medicaid Services.

NFPA Standard:
The mechanical ventilation system supplying anesthetizing locations shall have the capability of controlling the relative humidity at a level of 35 percent or greater. Advantages claimed for humidity include avoidance of hypothermia in patients, especially during long operative procedures; the fact that floating particulate matter increases in conditions of low relative humidity; and the fact that the incidence of wound infections can be minimized following procedures performed in those operating rooms in which the relative humidity is maintained at the level of 50 to 55 percent. 1999 NFPA 99, 5-4.1.1

The mechanical ventilation system supplying anesthetizing locations shall have the capability of controlling the relative humidity at a level of 35 percent or greater

Based on observation and interview the facility failed to maintain a gas burner on the kitchen stove in operational condition. This deficient practice had the potential to allow a build up of gas which could cause a flash fire when the burner was manually lighted. The facility census was 12 patients.

Findings are:
Observations on 6-22-16 at 12:35 pm revealed, the rear right burner on the gas stove failed to ignite when tested.

During an interview on 6-22-16 at 12:35 pm, Maintenance Staff A confirmed the burner was not operational when tested.


NFPA Standard:
Gas utilization equipment supplied with a means for automatic ignition shall be checked for proper operation. If necessary, proper adjustments shall be made. NFPA 54, 1999 Edition, Chapter 8.4.

Definition: Automatic ignition. Ignition of gas at the burner(s) when the gas controlling device is turned on, including re-ignition if the flames on the burner(s) have been extinguished by means other than by the closing of the gas controlling device.

Based on observation, interview and documentation review, the facility failed to maintain the Type I essential electrical system of the facility by having loads intermixed between the Life Safety Branch, the Critical Branch, and the Equipment System. This deficient practice had the potential to affect all occupants of the facility by affecting the egress lighting and emergency systems of the facility. The facility census was 12 patients.

Findings are:
Observations on 6-22-16 between 1:40 pm and 3:30 pm revealed:
1. Panel box ELL3 which was determined to be a Life Safety branch contained non-life safety items on circuits 7, 8, 15 and 17.
2. Panel box ECLL which was determined to be a Critical branch contained Life Safety items on circuit 17.
3. Panel box ECL2 which was determined to be a Critical branch contained Equipment items on circuits 44, 46 and 48.
4. Panel box ELL2 which was determined to be a Life Safety branch contained non-life safety items on circuits 1, 3,5,15. Other circuits shall be verified as egress requirements.
5. LPR panel box was determined to be fed from ECL3 which was determined to be a Critical branch and contained Life Safety items.

During an interview on 6-22-16 between 1:40 pm and 3:30 pm, Maintenance Staff A confirmed the findings.

NFPA Standard:
NFPA 70, 1999ed.
517.30 Essential Electrical Systems for Hospitals.
(A) Applicability. The requirements of Part III, 517.30 through 517.35, shall apply to hospitals where an essential electrical system is required.
(B) General.
(1) Separate Systems. Essential electrical systems for hospitals shall be comprised of two separate systems capable of supplying a limited amount of lighting and power service, which is considered essential for life safety and effective hospital operation during the time the normal electrical service is interrupted for any reason. These two systems shall be the emergency system and the equipment system.
(2) Emergency Systems. The emergency system shall be limited to circuits essential to life safety and critical patient care. These are designated the life safety branch and the critical branch.
(3) Equipment System. The equipment system shall supply major electrical equipment necessary for patient care and basic hospital operation.
(4) Transfer Switches. The number of transfer switches to be used shall be based on reliability, design, and load considerations. Each branch of the emergency system and each equipment system shall have one or more transfer switches. One transfer switch shall be permitted to serve one or more branches or systems in a facility with a maximum demand on the essential electrical system of 150 kVA.
(5) Other Loads. Loads served by the generating equipment not specifically named in Article 517 shall be served by their own transfer switches such that these loads:
(1) Shall not be transferred if the transfer will overload the generating equipment.
(2) Shall be automatically shed upon generating equipment overloading.
(6) Contiguous Facilities. Hospital power sources and alternate power sources shall be permitted to serve the essential electrical systems of contiguous or same site facilities. [NFPA 99, 3.4.2.2.1, 12.3.3.2]
(C) Wiring Requirements.
(1) Separation from Other Circuits. The life safety branch and critical branch of the emergency system shall be kept entirely independent of all other wiring and equipment and shall not enter the same raceways, boxes, or cabinets with each other or other wiring.
Wiring of the life safety branch and the critical branch shall be permitted to occupy the same raceways, boxes, or cabinets of other circuits not part of the branch where such wiring is as follows:
(1) In transfer equipment enclosures, or
(2) In exit or emergency luminaires (lighting fixtures) supplied from two sources, or
(3) In a common junction box attached to exit or emergency luminaires (lighting fixtures) supplied from two sources, or
(4) For two or more emergency circuits supplied from the same branch
The wiring of the equipment system shall be permitted to occupy the same raceways, boxes, or cabinets of other circuits that are not part of the emergency system.
(2) Isolated Power Systems. Where isolated power systems are installed in any of the areas in 517.33(A)(1) and (A)(2), each system shall be supplied by an individual circuit serving no other load.
(3) Mechanical Protection of the Emergency System. The wiring of the emergency system of a hospital shall be mechanically protected by installation in nonflexible metal raceways, or shall be wired with Type MI cable.
Exception No. 1: Flexible power cords of appliances, or other utilization equipment, connected to the emergency system shall not be required to be enclosed in raceways.
Exception No. 2: Secondary circuits of transformer-powered communications or signaling systems shall not be required to be enclosed in raceways unless otherwise specified by Chapters 7 or 8.
Exception No. 3: Schedule 80 rigid nonmetallic conduit shall be permitted if the branch circuits do not serve patient care areas and it is not prohibited elsewhere in this Code.
Exception No. 4: Where encased in not less than 50 mm (2 in.) of concrete, Schedule 40 rigid nonmetallic conduit or electrical nonmetallic tubing shall be permitted if the branch circuits do not serve patient care areas.
Exception No. 5: Flexible metal raceways and cable assemblies shall be permitted to be used in listed prefabricated medical headwalls, listed office furnishings, or where necessary for flexible connection to equipment.
(D) Capacity of Systems. The essential electrical system shall have adequate capacity to meet the demand for the operation of all functions and equipment to be served by each system and branch.
Feeders shall be sized in accordance with Articles 215 and 220. The generator set(s) shall have sufficient capacity and proper rating to meet the demand produced by the load of the essential electrical system(s) at any given time.
Demand calculations for sizing of the generator set(s) shall be based on the following:
(1) Prudent demand factors and historical data, or
(2) Connected load, or
(3) Feeder calculation procedures described in Article 220, or
(4) Any combination of the above
The sizing requirements in 700.5 and 701.6 shall not apply to hospital generator set(s).
(E) Receptacle Identification. The cover plates for the electrical receptacles or the electrical receptacles themselves supplied from the emergency system shall have a distinctive color or marking so as to be readily identifiable. [NFPA 99, 3.4.2.2.4(b)2]
517.31 Emergency System.
Those functions of patient care depending on lighting or appliances that are connected to the emergency system shall be divided into two mandatory branches: the life safety branch and the critical branch, described in 517.32 and 517.33. The branches of the emergency system shall be installed and connected to the alternate power source so that all functions specified herein for the emergency system shall be automatically restored to operation within 10 seconds after interruption of the normal source. [NFPA 99, 3.4.2.2.2(a), 3.5.2.2.2]
517.32 Life Safety Branch.
No function other than those listed in 517.32(A) through (G) shall be connected to the life safety branch. The life safety branch of the emergency system shall supply power for the following lighting, receptacles, and equipment.
(A) Illumination of Means of Egress. Illumination of means of egress, such as lighting required for corridors, passageways, stairways, and landings at exit doors, and all necessary ways of approach to exits. Switching arrangements to transfer patient corridor lighting in hospitals from general illumination circuits to night illumination circuits shall be permitted, provided only one of two circuits can be selected and both circuits cannot be extinguished at the same time.
(B) Exit Signs. Exit signs and exit directional signs.
(C) Alarm and Alerting Systems. Alarm and alerting systems including the following:
(1) Fire alarms
(2) Alarms required for systems used for the piping of nonflammable medical gases
(D) Communications Systems. Hospital communications systems, where used for issuing instructions during emergency conditions.
(E) Generator Set Location. Task illumination battery charger for emergency battery-powered lighting unit(s) and selected receptacles at the generator set location.
(F) Elevators. Elevator cab lighting, control, communications, and signal systems.
(G) Automatic Doors. Automatically operated doors used for building egress. [NFPA 99, 3.4.2.2.2(b)]
517.33 Critical Branch.
(A) Task Illumination and Selected Receptacles. The critical branch of the emergency system shall supply power for task illumination, fixed equipment, selected receptacles, and special power circuits serving the following areas and functions related to patient care:
(1) Critical care areas that utilize anesthetizing gases - task illumination, selected receptacles, and fixed equipment
(2) The isolated power systems in special environments
(3) Patient care areas - task illumination and selected receptacles in the following:
a. Infant nurseries
b. Medication preparation areas
c. Pharmacy dispensing areas
d. Selected acute nursing areas
e. Psychiatric bed areas (omit receptacles)
f. Ward treatment rooms
g. Nurses ' stations (unless adequately lighted by corridor luminaires)
(4) Additional specialized patient care task illumination and receptacles, where needed
(5) Nurse call systems
(6) Blood, bone, and tissue banks
(7) Telephone equipment rooms and closets
(8) Task illumination, selected receptacles, and selected power circuits for the following:
a. General care beds (at least one duplex receptacle per patient bedroom)
b. Angiographic labs
c. Cardiac catheterization labs
d. Coronary care units
e. Hemodialysis rooms or areas
f. Emergency room treatment areas (selected)
g. Human physiology labs
h. Intensive care units
i. Postoperative recovery rooms (selected)
(9) Additional task illumination, receptacles, and selected power circuits needed for effective hospital operation. Single-phase fractional horsepower motors shall be permitted to be connected to the critical branch. [NFPA 99, 3.4.2.2.2(c)]
(B) Subdivision of the Critical Branch. It shall be permitted to subdivide the critical branch into two or more branches.
517.34 Equipment System Connection to Alternate Power Source.
The equipment system shall be installed and connected to the alternate power source such that the equipment described in 517.34(A) is automatically restored to operation at appropriate time-lag intervals following the energizing of the emergency system. Its arrangement shall also provide for the subsequent connection of equipment described in 517.34(B). [NFPA 99, 3.4.2.2.3(b)]
Exception: For essential electrical systems under 150 kVA, deletion of the time-lag intervals feature for delayed automatic connection to the equipment system shall be permitted.
(A) Equipment for Delayed Automatic Connection. The following equipment shall be arranged for delayed automatic connection to the alternate power source.
(1) Central suction systems serving medical and surgical functions, including controls. Such suction systems shall be permitted on the critical branch.
(2) Sump pumps and other equipment required to operate for the safety of major apparatus, including associated control systems and alarms.
(3) Compressed air systems serving medical and surgical functions, including controls. Such air systems shall be permitted on the critical branch.
(4) Smoke control and stair pressurization systems, or both.
(5) Kitchen hood supply or exhaust systems, or both, if required to operate during a fire in or under the hood. [NFPA 99, 3.4.2.2.3(d)]
Exception: Sequential delayed automatic connection to the alternate power source to prevent overloading the generator shall be permitted where engineering studies indicate it is necessary.
(B) Equipment for Delayed Automatic or Manual Connection. The following equipment shall be arranged for either delayed automatic or manual connection to the alternate power source:
(1) Heating equipment to provide heating for operating, delivery, labor, recovery, intensive care, coronary care, nurseries, infection/isolation rooms, emergency treatment spaces, and general patient rooms and pressure maintenance (jockey or make-up) pump(s) for water-based fire protection systems.
Exception: Heating of general patient rooms and infection/isolation rooms during disruption of the normal source shall not be required under any of the following conditions:
(a) The outside design temperature is higher than -6.7°C (20°F).
(b) The outside design temperature is lower than -6.7°C (20°F), and where a selected room(s) is provided for the needs of all confined patients, only such room(s) need be heated.
(c) The facility is served by a dual source of normal power.
(2) An elevator(s) selected to provide service to patient, surgical, obstetrical, and ground floors during interruption of normal power. In instances where interruption of normal power would result in other elevators stopping between floors, throw-over facilities shall be provided to allow the temporary operation of any elevator for the release of patients or other persons who may be confined between floors.
(3) Supply, return, and exhaust ventilating systems for airborne infectious/isolation rooms, protective environment rooms, exhaust fans for laboratory fume hoods, nuclear medicine areas where radioactive material is used, ethylene oxide evacuation and anesthesia evacuation. Where delayed automatic connection is not appropriate, such ventilation systems shall be permitted to be placed on the critical branch. [NFPA 99, 3.4.2.2.3(e)(4)]
(4) Hyperbaric facilities.
(5) Hypobaric facilities.
(6) Automatically operated doors.
(7) Minimal electrically heated autoclaving equipment shall be permitted to be arranged for either automatic or manual connection to the alternate source.
(8) Controls for equipment listed in 517.34.
(9) Other selected equipment shall be permitted to be served by the equipment system. [NFPA 99, 3.4.2.2.3(e)]

Based on record review and interview, the facility failed to conduct retention tests on receptacles throughout the facility. This deficient practice had the potential to affect how equipment operates which could result in an electrical fire. The facility census was 12 patients.

Findings are:
Documentation review on 6-27-16 at 11:48 am revealed, that no retention testing had been conducted on receptacles throughout the facility.

During an interview on 6-27-16 at 11:48 am, Maintenance Staff A confirmed the findings and stated that they were unaware of the requirements.

NFPA Standard:
Receptacle Testing in Patient Care Areas
a) The physical integrity of each receptacle shall be confirmed by visual inspection.
b) The continuity of the grounding circuit in each electrical receptacle shall be verified.
c) Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.
d) The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz). 1999 NFPA 99, 3-3.3.3

Testing Interval for Receptacles in Patient Care Areas
1. Testing shall be performed after initial installation, replacement, or servicing of the device.
2. Additional testing shall be performed at intervals defined by documented performance data.
Exception: Receptacles not listed as hospital-grade shall be tested at intervals not exceeding 12 months.1999 NFPA 99, 3-3.4.2.3

A record shall be maintained of the tests required by this chapter and associated repairs or modification. At a minimum, this record shall contain the date, the rooms or areas tested, and an indication of which items have met or have failed to meet the performance requirements of this chapter. 1999 NFPA 99, 3-3.4.3.1