HospitalInspections.org

Based on random observation during the survey walk-through, not all exit access corridors are separated from use areas in accordance with 19.3.6.1.

Findings include:

A. The First Floor Imaging Department Patient Holding Bays were observed to constitute patient treatment areas which are not separated from exit access corridors as required by 19.3.6.1.

B. The (sprinklered) Fourth Floor North Waiting Room, which was observed to be open to the corridor and to not be visible from a constantly attended station, was observed to lack a smoke detector required by Exception 2. [subpart (b)] to 19.3.6.1.

Based on random observation during the survey walk-through, not all doors in exit access corridors are in compliance with 19.3.6.3.

Findings include:

A. Doors in exit access corridors were observed that are not positive latching as required by 19.3.6.3.2. Locations observed include (all First Floor):

1. Pair of corridor doors from Corridor serving Central Sterile Department to Loading Dock.

2. Surgery Department Sterile Core, pair of horizontal sliding corridor doors.
3. Pair of corridor doors at south side of Emergency Department.

Based on random observation during the survey walk-through, not all laboratories are protected in accordance with NFPA 99.

Findings include:

A. The First Floor Laboratory, which was observed to not be covered by an automatic sprinkler system, was observed to not comply with 19.3.2.1(8) and NFPA 99 1999 10.3-1.1. because it is not provided with an enclosure which carries a fire resistance rating of at least 1 hour.



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B. During the walk-through of the Laboratory area, goose neck faucets were observed to have eye wash fixtures attached without provisions to protect the eyes from injurious water pressure in accordance with NFPA 99 1999 10-6.

Based on random observation during the survey walk-through, not all exit stair shafts are constructed or maintained as fire resistive assemblies in accordance with 19.3.1.1.

Findings include:

A. A door was observed from the Lower Level Boiler Room, a room not normally occupied, to Exit Stair 4 as prohibited by 7.1.3.2.1(b).

Based on random observation during the survey walk-through and staff interview, not all exit accesses are arranged so that exits are readily accessible at all times in accordance with 19.2.1.

Findings include:

A. During an interview held at the site on the morning of June 22, 2010, the provider's Corporate Administrative Director of Facilities stated that a series of locking devices in the Second Floor Mother/baby Unit [when activated by the infant abduction (HUGS) system] release only upon activation of the building fire alarm system; the locking assemblies thus do not comply with 19.2.2.2.4. Locations at which these locking mechanisms have been identified as being installed include:
1. Door to Exit Stair 5 (located at the north end of the Nursing Wing).

2. Door to Convenience Stair adjacent to Elevator serving the Helipad.

3. Pair of doors at the northeast corner of the Well Baby Nursery.

4. Pair of doors at the southwest corner of the Well Baby Nursery.

5. Door to Exit Stair 4 (located south of the Well Baby Nursery).

6. Pair of doors in the designated 2 hour fire barrier between the Nursing Wing and the West Wing.

B. Dead end corridors of excessive length were observed, as prohibited by 19.2.5.10. Locations observed include:

1. First Floor Corridor, from the Exit Passageway serving Exit Stair 4 to the pair of doors to the Cafeteria.

2. Lower Level Corridor, from the west end of gthe Equipment Room to the pair of doors to the Professional Office Building.

C. The Second Floor Nursing Wing Elevator Lobby serving the Same Day Surgery Elevator was observed to not be provide with access to an exit stair as required by 7.4.1.6.

D. The north egress path for the Kitchen was observed to pass through a hazardous area (the Loading ock) as prohibited by 7.5.2.1.

E. The Lower Level ramp located between Exit Stairs 3 and 6 was observed to lack handrails, on both sides of the ramp, required by 7.2.2.4.2.

Based on random observation during the survey walk-through, not all exit accesses are arranged so that exits are readily accessible at all times in accordance with 39.2.1.

Findings include:

A. The exterior egress path from the north exit door was observed to not be complete to a public way, as required by 7.7.1., because there is no stable walking surface provided between the exterior stoop and the parking lot sidewalk.

Based on random observation during the survey walk-through, not all of the facilities exits are provided with exterior illumination in accordance with NFPA 101 2000.

Findings include:

A. The exit at the old main entrance/rehab area was not provided with a light fixture to illuminate the exit way in accordance with 7.8.1.1.

Based on staff interview, not all emergency lighting is maintained in accordance with 7.9.

Findings include:

A. During an interview conducted in the building on the afternoon of June 22, 2010, the provider's Corporate Manager of Facilities stated that battery-powered emergency lights are not tested for a period of 1-1/2 hours at least once each year as required by 7.9.3.

Based on random observation during the survey walk-through, not all of the facilities battery powered lights are tested and maintained in accordance with NFPA 101 2000.

Findings include:

A. During the documentation review process it was discovered monthly testing for 30 seconds was not documented for the lights in the generator and equipment rooms in accordance with 7.9.3.

Based on random observation during the survey walk-through, exit signs did not illuminate a continuous path of egress in all cases in accordance with 19.2.10.1. and 7.10.

Findings include:

A. An egress path was observed, in the First Floor Corridor serving the Central Sterile Department toward the west (through a designated 2 hour fire barrier), which is not identified by an exit sign as required by 7.10.1.1.

Based on staff interview, exit signs are not installed and maintained in accordance with 7.10.

Findings include:

During an interview conducted in the building on the afternoon of June 22, 2010, the provider's Corporate Manager of Facilities stated that battery-powered exit lights are not tested for a period of 1-1/2 hours at least once each year as required by 7.9.3.

Based on document review, fire drills are not held at varying times and varying conditions in accordance with 19.7.1.2.

Findings include:

A. Based on document review, fire drills are not conducted at varying times as required by 19.7.1.2. During the calendar year 2009, fire drills for the following quarters/shifts were conducted at the similar times listed:

1. Second Shift:

a. March 18, 2009: 4:00 PM.

b. May 19, 2009: 3:45 PM.

c. July 22, 2009: 3:45 PM.

d. November 18, 2009: 3:45 PM.

2. Third Shift:
a. February 24, 2009: 6:30 AM.

b. June 25, 2009: 6:30 AM.

c. September 22, 2009: 6:30 AM.

d. December 17, 2009: 6:30 AM.

Based on random observation during the survey walk-through, not all portions of the building fire alarm system are installed in accordance with 19.3.4.

Findings include:

A. Manual fire alarm pull stations were observed which are more than 4'-6" above the floor, as prohibited by NFPA 72 1999 2-8.1. Locations observed include (all Nursing Wing):

1. Fourth Floor.

2. Third Floor.

B. A smoke detector was observed, in a First Floor Emergency Department construction area, which is more than 12" below the ceiling as prohibited by NFPA 72 1999 2-3.4.3.1. because the ceiling has been removed from the area for the construction to occur.

Based on random observation during the survey walk-through, not all portions of the facility's automatic sprinkler system are installed and maintained in accordance with NFPA 13 1999.

Findings include:

A. Ceiling tiles were observed to be missing from the Third Floor Nursing Wing Telephone/Data Closet (immediately south of the Same Day Surgery Elevator), which compromises sprinkler coverage as prohibited by NFPA 13 1999 5-6.4.1.1.

B. A sprinkler head was observed, in a First Floor Emergency Department construction area, which is more than 12" below the ceiling as prohibited by NFPA 13 1999 5-6.4.1.1. because the ceiling has been removed from the area for the construction to occur.



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C. The lower level equipment room # 9 was observed to not have sprinklers installed under 3 ducts more than 4' wide in accordance with 5-5.5.3.1.

D. During the walk-through of Equipment Room # 8 a sprinkler head was observed with a shield that was not listed for sprinkler system use in accordance with 3-2.8.

Based on the document review process, not all sprinkler flow tests are in accordance with NFPA 72 1999.

Findings include:

A. During the document review process records for testing flow switches were observed to have no alarm activation time documented to show compliance with 2-6.2 for initiating the alarm within 90 seconds.

Based on random observation during the survey walk-through, not all portions of the facilities Heating, Ventilating and A ir Conditioning System are installed in accordance with NFPA 90A 1999.

Findings include:

A. During the survey, access panels were observed throughout the facility with no labels identifying the fire safety device within in accordance with 2-3.4.2.

Based on random observation during the survey walk-through, not all portions of the facilities commercial cooking fire extinguishment systems are in accordance with NFPA 96 1998.

Findings include:

A. During the survey walk-through of the Dietary Department 2 exhaust hoods for cooking equipment were observed remote from each other with only one class K fire extinguisher provided, thus not in accordance with 7-10.1.

Based on random observation during the survey walk-through, not all linen or refuse chutes are constructed and maintained as fire resistive assemblies.

Findings include:

A. Linen chute service rooms were observed which are not constructed as 2 hour fire rated assemblies (which matches the fire rating for the linen chute) as required by 8.2.5.4(1) and NFPA 82 1996 3-2.3., because enclosure walls appear to consist of metal studs with 1 layer of drywall each side and the doors to the rooms carry a fire resistance rating of only 3/4 hour. Locations observed include (all Nursing Wing):

1. Fourth Floor Linen Chute Room, located between Patient Sleeping Rooms 405 and 406.

2. Third Floor Soiled Utility Room (across from Patient Sleeping Room 371), which serves as a linen chute service room.

3. Second Floor Linen Chute Service Room.

Based on random observation during the survey walk-through, not all egress paths are maintained free of obstructions or impediments to full instant use in the case of fire or other emergency in accordance with 19.2.3.3.

Findings include:

A. Carts and equipment were observed in exit access corridors that obstruct egress as prohibited by 19.2.3.3. and 7.1.10.2.1. Locations and items observed include:

1. Fourth Floor:

a. Nursing Wing: 4 work stations on wheels, across from Patient Sleeping Room 419.

b. Phase I Wing, work stations on wheels placed in Alcoves serving Patient Sleeping Rooms.
2. Third Floor:

a. ICU Corridor, scale.

b. Phase I Wing, work stations on wheels placed in Alcoves serving Patient Sleeping Rooms.
3. Second Floor Phase I Wing:

a. Work stations on wheels placed in Alcoves serving Patient Sleeping Rooms.

b. Bassinets in Corridor across from Patient Sleeping Room 238.

4. First Floor:

a. Surgical Department:

1) Carts, gurneys, and equipment in:

a) North East-West Corridor.

b) North-South Corridor.

c) South East-West Corridor.

2) C-Arm adjacent to Anesthesia Office.

b. Carts and equipment in Exit Passageway immediately east of Surgical Department.

c. Gurneys and equipment in Corridor serving Endoscopy Unit.
d. Boxes and pallets in Corridor west of Central Sterile Processing Department.

e. Racks for food trays and garbage cans, Corridor from Kitchen south door.

Based on random observation during the survey walk-through, not all piped-in medical gas systems are installed and maintained in accordance with NFPA 99.

Findings include:

A. Manual medical gas shutoff (zone) valves were observed that are located in the same room as the station outlets they serve, as prohibited by NFPA 99 1999 4.3.1.2.3(d). Locations observed include (all First Floor):

1. Same Day Surgery Recovery Room.

2. Imaging Department Patient Holding Bays.



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B. Medical gas source valves were observed in various locations with no identification tags identifying them as source valves with the areas they served in accordance with 4-3.1.2.14 (b). Areas include:

1. The Vacuum Pumps.

2. The Medical Air system.

3. The gas Manifold Room.

Based on random observation and staff interview during the survey walk-through, not all portions of the facilities Type 1 EES are installed in accordance with NFPA 99 1999.

Findings include:

A. During the walk-through of the Maintenance Shop an interview was held with the Manager of Facilities Engineering and the Maintenance IV Technician and it was confirmed a remote monitoring panel for the 3 Emergency Generators was not provided for the engineering space in accordance with 3-4.1.1.15.

Based on random observation during the survey walk-through, document review, and staff interview, the facility is not in compliance with a series of Life Safety and other code requirements that are not documented under other K-Tags.

Findings include:

A. Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.

Based on random observation during the survey walk-through, not all portions of the facilities Emergency Electrical System are installed in accordance with NFPA 70 1999.

Findings include:

A. During the walk-through of the Emergency Department emergency power outlets were observed without labeling to identify the panel and circuit serving them in accordance with 517-19.

Based on random observation during the survey walk-through and staff interview, not all portions of the building electrical system are installed in accordance with NFPA 70 1999.

Findings include:

A. The Second Floor Phase I Wing Post-Partum Rooms (identified, during an interview held at the site on the morning of June 22, 2010, by Unit staff as being included in the provider's rooming-in program) were observed to lack a minimum of 4 electrical receptacles, as required by NFPA 70 1999 517-18(b), at bassinet locations.

Based on random observation during the survey walk-through, not all exit access corridors are separated from use areas in accordance with 19.3.6.1.

Findings include:

A. The First Floor Imaging Department Patient Holding Bays were observed to constitute patient treatment areas which are not separated from exit access corridors as required by 19.3.6.1.

B. The (sprinklered) Fourth Floor North Waiting Room, which was observed to be open to the corridor and to not be visible from a constantly attended station, was observed to lack a smoke detector required by Exception 2. [subpart (b)] to 19.3.6.1.

Based on random observation during the survey walk-through, not all doors in exit access corridors are in compliance with 19.3.6.3.

Findings include:

A. Doors in exit access corridors were observed that are not positive latching as required by 19.3.6.3.2. Locations observed include (all First Floor):

1. Pair of corridor doors from Corridor serving Central Sterile Department to Loading Dock.

2. Surgery Department Sterile Core, pair of horizontal sliding corridor doors.
3. Pair of corridor doors at south side of Emergency Department.

Based on random observation during the survey walk-through, not all laboratories are protected in accordance with NFPA 99.

Findings include:

A. The First Floor Laboratory, which was observed to not be covered by an automatic sprinkler system, was observed to not comply with 19.3.2.1(8) and NFPA 99 1999 10.3-1.1. because it is not provided with an enclosure which carries a fire resistance rating of at least 1 hour.



26665


B. During the walk-through of the Laboratory area, goose neck faucets were observed to have eye wash fixtures attached without provisions to protect the eyes from injurious water pressure in accordance with NFPA 99 1999 10-6.

Based on random observation during the survey walk-through, not all exit stair shafts are constructed or maintained as fire resistive assemblies in accordance with 19.3.1.1.

Findings include:

A. A door was observed from the Lower Level Boiler Room, a room not normally occupied, to Exit Stair 4 as prohibited by 7.1.3.2.1(b).

Based on random observation during the survey walk-through and staff interview, not all exit accesses are arranged so that exits are readily accessible at all times in accordance with 19.2.1.

Findings include:

A. During an interview held at the site on the morning of June 22, 2010, the provider's Corporate Administrative Director of Facilities stated that a series of locking devices in the Second Floor Mother/baby Unit [when activated by the infant abduction (HUGS) system] release only upon activation of the building fire alarm system; the locking assemblies thus do not comply with 19.2.2.2.4. Locations at which these locking mechanisms have been identified as being installed include:
1. Door to Exit Stair 5 (located at the north end of the Nursing Wing).

2. Door to Convenience Stair adjacent to Elevator serving the Helipad.

3. Pair of doors at the northeast corner of the Well Baby Nursery.

4. Pair of doors at the southwest corner of the Well Baby Nursery.

5. Door to Exit Stair 4 (located south of the Well Baby Nursery).

6. Pair of doors in the designated 2 hour fire barrier between the Nursing Wing and the West Wing.

B. Dead end corridors of excessive length were observed, as prohibited by 19.2.5.10. Locations observed include:

1. First Floor Corridor, from the Exit Passageway serving Exit Stair 4 to the pair of doors to the Cafeteria.

2. Lower Level Corridor, from the west end of gthe Equipment Room to the pair of doors to the Professional Office Building.

C. The Second Floor Nursing Wing Elevator Lobby serving the Same Day Surgery Elevator was observed to not be provide with access to an exit stair as required by 7.4.1.6.

D. The north egress path for the Kitchen was observed to pass through a hazardous area (the Loading ock) as prohibited by 7.5.2.1.

E. The Lower Level ramp located between Exit Stairs 3 and 6 was observed to lack handrails, on both sides of the ramp, required by 7.2.2.4.2.

Based on random observation during the survey walk-through, not all exit accesses are arranged so that exits are readily accessible at all times in accordance with 39.2.1.

Findings include:

A. The exterior egress path from the north exit door was observed to not be complete to a public way, as required by 7.7.1., because there is no stable walking surface provided between the exterior stoop and the parking lot sidewalk.

Based on random observation during the survey walk-through, not all of the facilities exits are provided with exterior illumination in accordance with NFPA 101 2000.

Findings include:

A. The exit at the old main entrance/rehab area was not provided with a light fixture to illuminate the exit way in accordance with 7.8.1.1.

Based on staff interview, not all emergency lighting is maintained in accordance with 7.9.

Findings include:

A. During an interview conducted in the building on the afternoon of June 22, 2010, the provider's Corporate Manager of Facilities stated that battery-powered emergency lights are not tested for a period of 1-1/2 hours at least once each year as required by 7.9.3.

Based on random observation during the survey walk-through, not all of the facilities battery powered lights are tested and maintained in accordance with NFPA 101 2000.

Findings include:

A. During the documentation review process it was discovered monthly testing for 30 seconds was not documented for the lights in the generator and equipment rooms in accordance with 7.9.3.

Based on random observation during the survey walk-through, exit signs did not illuminate a continuous path of egress in all cases in accordance with 19.2.10.1. and 7.10.

Findings include:

A. An egress path was observed, in the First Floor Corridor serving the Central Sterile Department toward the west (through a designated 2 hour fire barrier), which is not identified by an exit sign as required by 7.10.1.1.

Based on staff interview, exit signs are not installed and maintained in accordance with 7.10.

Findings include:

During an interview conducted in the building on the afternoon of June 22, 2010, the provider's Corporate Manager of Facilities stated that battery-powered exit lights are not tested for a period of 1-1/2 hours at least once each year as required by 7.9.3.

Based on document review, fire drills are not held at varying times and varying conditions in accordance with 19.7.1.2.

Findings include:

A. Based on document review, fire drills are not conducted at varying times as required by 19.7.1.2. During the calendar year 2009, fire drills for the following quarters/shifts were conducted at the similar times listed:

1. Second Shift:

a. March 18, 2009: 4:00 PM.

b. May 19, 2009: 3:45 PM.

c. July 22, 2009: 3:45 PM.

d. November 18, 2009: 3:45 PM.

2. Third Shift:
a. February 24, 2009: 6:30 AM.

b. June 25, 2009: 6:30 AM.

c. September 22, 2009: 6:30 AM.

d. December 17, 2009: 6:30 AM.

Based on random observation during the survey walk-through, not all portions of the building fire alarm system are installed in accordance with 19.3.4.

Findings include:

A. Manual fire alarm pull stations were observed which are more than 4'-6" above the floor, as prohibited by NFPA 72 1999 2-8.1. Locations observed include (all Nursing Wing):

1. Fourth Floor.

2. Third Floor.

B. A smoke detector was observed, in a First Floor Emergency Department construction area, which is more than 12" below the ceiling as prohibited by NFPA 72 1999 2-3.4.3.1. because the ceiling has been removed from the area for the construction to occur.

Based on random observation during the survey walk-through, not all portions of the facility's automatic sprinkler system are installed and maintained in accordance with NFPA 13 1999.

Findings include:

A. Ceiling tiles were observed to be missing from the Third Floor Nursing Wing Telephone/Data Closet (immediately south of the Same Day Surgery Elevator), which compromises sprinkler coverage as prohibited by NFPA 13 1999 5-6.4.1.1.

B. A sprinkler head was observed, in a First Floor Emergency Department construction area, which is more than 12" below the ceiling as prohibited by NFPA 13 1999 5-6.4.1.1. because the ceiling has been removed from the area for the construction to occur.



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C. The lower level equipment room # 9 was observed to not have sprinklers installed under 3 ducts more than 4' wide in accordance with 5-5.5.3.1.

D. During the walk-through of Equipment Room # 8 a sprinkler head was observed with a shield that was not listed for sprinkler system use in accordance with 3-2.8.

Based on the document review process, not all sprinkler flow tests are in accordance with NFPA 72 1999.

Findings include:

A. During the document review process records for testing flow switches were observed to have no alarm activation time documented to show compliance with 2-6.2 for initiating the alarm within 90 seconds.

Based on random observation during the survey walk-through, not all portions of the facilities Heating, Ventilating and A ir Conditioning System are installed in accordance with NFPA 90A 1999.

Findings include:

A. During the survey, access panels were observed throughout the facility with no labels identifying the fire safety device within in accordance with 2-3.4.2.

Based on random observation during the survey walk-through, not all portions of the facilities commercial cooking fire extinguishment systems are in accordance with NFPA 96 1998.

Findings include:

A. During the survey walk-through of the Dietary Department 2 exhaust hoods for cooking equipment were observed remote from each other with only one class K fire extinguisher provided, thus not in accordance with 7-10.1.

Based on random observation during the survey walk-through, not all linen or refuse chutes are constructed and maintained as fire resistive assemblies.

Findings include:

A. Linen chute service rooms were observed which are not constructed as 2 hour fire rated assemblies (which matches the fire rating for the linen chute) as required by 8.2.5.4(1) and NFPA 82 1996 3-2.3., because enclosure walls appear to consist of metal studs with 1 layer of drywall each side and the doors to the rooms carry a fire resistance rating of only 3/4 hour. Locations observed include (all Nursing Wing):

1. Fourth Floor Linen Chute Room, located between Patient Sleeping Rooms 405 and 406.

2. Third Floor Soiled Utility Room (across from Patient Sleeping Room 371), which serves as a linen chute service room.

3. Second Floor Linen Chute Service Room.

Based on random observation during the survey walk-through, not all egress paths are maintained free of obstructions or impediments to full instant use in the case of fire or other emergency in accordance with 19.2.3.3.

Findings include:

A. Carts and equipment were observed in exit access corridors that obstruct egress as prohibited by 19.2.3.3. and 7.1.10.2.1. Locations and items observed include:

1. Fourth Floor:

a. Nursing Wing: 4 work stations on wheels, across from Patient Sleeping Room 419.

b. Phase I Wing, work stations on wheels placed in Alcoves serving Patient Sleeping Rooms.
2. Third Floor:

a. ICU Corridor, scale.

b. Phase I Wing, work stations on wheels placed in Alcoves serving Patient Sleeping Rooms.
3. Second Floor Phase I Wing:

a. Work stations on wheels placed in Alcoves serving Patient Sleeping Rooms.

b. Bassinets in Corridor across from Patient Sleeping Room 238.

4. First Floor:

a. Surgical Department:

1) Carts, gurneys, and equipment in:

a) North East-West Corridor.

b) North-South Corridor.

c) South East-West Corridor.

2) C-Arm adjacent to Anesthesia Office.

b. Carts and equipment in Exit Passageway immediately east of Surgical Department.

c. Gurneys and equipment in Corridor serving Endoscopy Unit.
d. Boxes and pallets in Corridor west of Central Sterile Processing Department.

e. Racks for food trays and garbage cans, Corridor from Kitchen south door.

Based on random observation during the survey walk-through, not all piped-in medical gas systems are installed and maintained in accordance with NFPA 99.

Findings include:

A. Manual medical gas shutoff (zone) valves were observed that are located in the same room as the station outlets they serve, as prohibited by NFPA 99 1999 4.3.1.2.3(d). Locations observed include (all First Floor):

1. Same Day Surgery Recovery Room.

2. Imaging Department Patient Holding Bays.



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B. Medical gas source valves were observed in various locations with no identification tags identifying them as source valves with the areas they served in accordance with 4-3.1.2.14 (b). Areas include:

1. The Vacuum Pumps.

2. The Medical Air system.

3. The gas Manifold Room.

Based on random observation and staff interview during the survey walk-through, not all portions of the facilities Type 1 EES are installed in accordance with NFPA 99 1999.

Findings include:

A. During the walk-through of the Maintenance Shop an interview was held with the Manager of Facilities Engineering and the Maintenance IV Technician and it was confirmed a remote monitoring panel for the 3 Emergency Generators was not provided for the engineering space in accordance with 3-4.1.1.15.

Based on random observation during the survey walk-through, document review, and staff interview, the facility is not in compliance with a series of Life Safety and other code requirements that are not documented under other K-Tags.

Findings include:

A. Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.

Based on random observation during the survey walk-through, not all portions of the facilities Emergency Electrical System are installed in accordance with NFPA 70 1999.

Findings include:

A. During the walk-through of the Emergency Department emergency power outlets were observed without labeling to identify the panel and circuit serving them in accordance with 517-19.

Based on random observation during the survey walk-through and staff interview, not all portions of the building electrical system are installed in accordance with NFPA 70 1999.

Findings include:

A. The Second Floor Phase I Wing Post-Partum Rooms (identified, during an interview held at the site on the morning of June 22, 2010, by Unit staff as being included in the provider's rooming-in program) were observed to lack a minimum of 4 electrical receptacles, as required by NFPA 70 1999 517-18(b), at bassinet locations.