HospitalInspections.org

Based on observation the facility failed to provide acceptable documentation of any of the interior finishes.

The inspector observed while accompanied by the Director of Maintenance and the Clinical Services Director during the hours of the inspection from 9:30 am to 12:30 pm that there was not any documentation on the interior finishes. Some of the finishes were so old that documentation could not be found. However, there was carpet that may have documentation available.

Based on observation the facility failed to provide a complete fire alarm system.

The inspector observed while accompanied by the Director of Maintenance and the Clinical Services Director during the hours of the inspection from 9:30 am to 12:30 pm that the FACP was not properly cross referenced to the panel and breaker supplying its power.

" The circuit breaker at the electrical panel board for the fire alarm shall have a red marking, shall be accessible only to authorized personnel, and shall be identified as "FIRE ALARM CIRCUIT CONTROL" " - NFPA 72, 2002: 4.4.1.4.2.2.

" The location of the circuit disconnecting means shall be permanently identified at the fire alarm control unit. " - NFPA 72, 2002: 4.4.1.4.2.3.

In addition: there were not fire alarm pulls located at the following exits: 1) the main entry, 2) the exit to the clinic, 3) the emergency entrance, and 4) the CT trailer.

Based on observation the facility failed to provide an acceptable medical gas installation.

The inspector observed while accompanied by the Director of Maintenance and the Clinical Services Director during the hours of the inspection from 9:30 am to 12:30 pm that there were dead leaves around the oxygen storage in the medical gas enclosure. This is in violation of the following code: " Storage locations for oxygen and nitrous oxide shall be kept free of flammable materials. " - NFPA 99, 1999, 4-3.1.1.2(a)5.

In addition, the oxygen tanks were very loosely chained to the fence such that they could be tipped over. The tanks should be individually secured in a snug manner to prevent from falling over. See the following code requirement. " Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over. " - NFPA 99, 1999: 4-3.1.1.1.

Based on observation the facility failed to provide an acceptable number of alarms for the emergency generator.

The inspector observed while accompanied by the Director of Maintenance and the Clinical Services Director during the hours of the inspection from 9:30 am to 12:30 pm that there was only one alarm for the emergency generator and it was located at the nurse station. There should be a second where the maintenance personnel are located. See the following. " A remote annunciator, storage battery-powered, shall be provided to operate outside the generating room in a location readily observed by operating personnel at a regular work station (see NFPA 70, National Electrical Code, Section 700.12). " - NFPA 99, 2002: 4.4.1.1.18. " Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. " - NFPA 99, 2002: 4.4.1.1.18.


Based on observation the facility failed to provide an acceptable enclosure for the gas water heaters.

The inspector observed while accompanied by the Director of Maintenance and the Clinical Services Director during the hours of the inspection from 9:30 am to 12:30 pm that there was a gas water heater in the basement that was in a space with an excessive amount of paper trash. This in violation of the following code: " Any heating device other than a central heating plant shall be designed and installed so that combustible material will not be ignited by the device or its appurtenances. " - NFPA 101, 2000:19.5.2.2. The trash in the basement is an unnecessary hazard and must be removed.

In addition, the exterior gas water heater room had leaves accumulating in the room. This is an unnecessary hazard and must be removed.


Based on observation the facility failed to provide an acceptable emergency generator location.

The inspector observed while accompanied by the Director of Maintenance and the Clinical Services Director during the hours of the inspection from 9:30 am to 12:30 pm that there was not an electrical receptacle for use at the emergency generator location. The emergency generator location shall have " task illumination, battery charger for emergency battery powered lighting unit(s), and selected receptacles at the generator set location " - NFPA 99, 1999: 3-4.2.2.2.(b)5.


Based on observation the facility failed to provide an acceptable interval of disaster drills and that the disaster plan was not well developed.

The inspector observed while accompanied by the Director of Maintenance and the Clinical Services Director during the hours of the inspection from 9:30 am to 12:30 pm that there was an insufficient number of disaster drills. NFPA 99, 11-5.3.9 and hospital regulations requires one or more specific responses of the emergency preparedness plan at least semi-annually. At least one semi-annual drill shall rehearse mass casualty response for health care facilities with emergency services, disaster receiving stations, or both. This means that a second drill does not need to be a mass casualty drill, but can be a less involved exercise.

In addition, the emergency preparedness plan was not complete. Refer to NFPA 99, 1999, Chapter 11 for a list of the items to be addressed in the emergency plan. The plan shall be the responsibility of the emergency preparedness committee and shall be evaluated and revised as directed by senior management.


Based on observation the facility failed to provide a history of records for grounding test of electrical receptacles per NFPA 99: 3-3.3.3. in patient care areas.

The inspector observed while accompanied by the Director of Maintenance and the Clinical Services Director during the hours of the inspection from 9:30 am to 12:30 pm that there were no records of receptacle testing in patient care areas.

NFPA 99, 1999, 3-3.4.2.3(a) states that testing of electrical receptacles shall be performed after initial installation, replacement or servicing of a device, and that additional testing shall be performed at intervals defined by documented performance data. If the facility has documented performance data for the electrical receptacles in all patient care areas then the schedule defined by this data will be acceptable. In the absence of the data the following schedule shall be maintained by the facility. Receptacle testing shall be performed in all general care areas every 12 months and in critical care areas every 6 months. (NFPA 99, 1984).

NFFA 99, 1999, 3-3.3.3 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).


Based on observation the facility failed to provide a letter from a vendor for emergency fuel and water indicating that they have a preferred customer status.

The inspector observed while accompanied by the Director of Maintenance and the Clinical Services Director during the hours of the inspection from 9:30 am to 12:30 pm that there were no records of preferred customer status for water and fuel. This should also be integrated into the emergency preparedness plan for other utilities and supplies, i.e. medical gas, pharmaceuticals, medical supplies, food, and linen.

Based on observation the facility failed to provide an acceptable medical gas alarm system.

The inspector observed while accompanied by the Director of Maintenance and the Clinical Services Director during the hours of the inspection from 9:30 am to 12:30 pm that there was not a medical gas alarm in two locations. There was only an alarm at the nurse station.

Based on observation the facility failed to provide acceptable documentation of any of the interior finishes.

The inspector observed while accompanied by the Director of Maintenance and the Clinical Services Director during the hours of the inspection from 9:30 am to 12:30 pm that there was not any documentation on the interior finishes. Some of the finishes were so old that documentation could not be found. However, there was carpet that may have documentation available.

Based on observation the facility failed to provide a complete fire alarm system.

The inspector observed while accompanied by the Director of Maintenance and the Clinical Services Director during the hours of the inspection from 9:30 am to 12:30 pm that the FACP was not properly cross referenced to the panel and breaker supplying its power.

" The circuit breaker at the electrical panel board for the fire alarm shall have a red marking, shall be accessible only to authorized personnel, and shall be identified as "FIRE ALARM CIRCUIT CONTROL" " - NFPA 72, 2002: 4.4.1.4.2.2.

" The location of the circuit disconnecting means shall be permanently identified at the fire alarm control unit. " - NFPA 72, 2002: 4.4.1.4.2.3.

In addition: there were not fire alarm pulls located at the following exits: 1) the main entry, 2) the exit to the clinic, 3) the emergency entrance, and 4) the CT trailer.

Based on observation the facility failed to provide an acceptable medical gas installation.

The inspector observed while accompanied by the Director of Maintenance and the Clinical Services Director during the hours of the inspection from 9:30 am to 12:30 pm that there were dead leaves around the oxygen storage in the medical gas enclosure. This is in violation of the following code: " Storage locations for oxygen and nitrous oxide shall be kept free of flammable materials. " - NFPA 99, 1999, 4-3.1.1.2(a)5.

In addition, the oxygen tanks were very loosely chained to the fence such that they could be tipped over. The tanks should be individually secured in a snug manner to prevent from falling over. See the following code requirement. " Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over. " - NFPA 99, 1999: 4-3.1.1.1.

Based on observation the facility failed to provide an acceptable number of alarms for the emergency generator.

The inspector observed while accompanied by the Director of Maintenance and the Clinical Services Director during the hours of the inspection from 9:30 am to 12:30 pm that there was only one alarm for the emergency generator and it was located at the nurse station. There should be a second where the maintenance personnel are located. See the following. " A remote annunciator, storage battery-powered, shall be provided to operate outside the generating room in a location readily observed by operating personnel at a regular work station (see NFPA 70, National Electrical Code, Section 700.12). " - NFPA 99, 2002: 4.4.1.1.18. " Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. " - NFPA 99, 2002: 4.4.1.1.18.


Based on observation the facility failed to provide an acceptable enclosure for the gas water heaters.

The inspector observed while accompanied by the Director of Maintenance and the Clinical Services Director during the hours of the inspection from 9:30 am to 12:30 pm that there was a gas water heater in the basement that was in a space with an excessive amount of paper trash. This in violation of the following code: " Any heating device other than a central heating plant shall be designed and installed so that combustible material will not be ignited by the device or its appurtenances. " - NFPA 101, 2000:19.5.2.2. The trash in the basement is an unnecessary hazard and must be removed.

In addition, the exterior gas water heater room had leaves accumulating in the room. This is an unnecessary hazard and must be removed.


Based on observation the facility failed to provide an acceptable emergency generator location.

The inspector observed while accompanied by the Director of Maintenance and the Clinical Services Director during the hours of the inspection from 9:30 am to 12:30 pm that there was not an electrical receptacle for use at the emergency generator location. The emergency generator location shall have " task illumination, battery charger for emergency battery powered lighting unit(s), and selected receptacles at the generator set location " - NFPA 99, 1999: 3-4.2.2.2.(b)5.


Based on observation the facility failed to provide an acceptable interval of disaster drills and that the disaster plan was not well developed.

The inspector observed while accompanied by the Director of Maintenance and the Clinical Services Director during the hours of the inspection from 9:30 am to 12:30 pm that there was an insufficient number of disaster drills. NFPA 99, 11-5.3.9 and hospital regulations requires one or more specific responses of the emergency preparedness plan at least semi-annually. At least one semi-annual drill shall rehearse mass casualty response for health care facilities with emergency services, disaster receiving stations, or both. This means that a second drill does not need to be a mass casualty drill, but can be a less involved exercise.

In addition, the emergency preparedness plan was not complete. Refer to NFPA 99, 1999, Chapter 11 for a list of the items to be addressed in the emergency plan. The plan shall be the responsibility of the emergency preparedness committee and shall be evaluated and revised as directed by senior management.


Based on observation the facility failed to provide a history of records for grounding test of electrical receptacles per NFPA 99: 3-3.3.3. in patient care areas.

The inspector observed while accompanied by the Director of Maintenance and the Clinical Services Director during the hours of the inspection from 9:30 am to 12:30 pm that there were no records of receptacle testing in patient care areas.

NFPA 99, 1999, 3-3.4.2.3(a) states that testing of electrical receptacles shall be performed after initial installation, replacement or servicing of a device, and that additional testing shall be performed at intervals defined by documented performance data. If the facility has documented performance data for the electrical receptacles in all patient care areas then the schedule defined by this data will be acceptable. In the absence of the data the following schedule shall be maintained by the facility. Receptacle testing shall be performed in all general care areas every 12 months and in critical care areas every 6 months. (NFPA 99, 1984).

NFFA 99, 1999, 3-3.3.3 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).


Based on observation the facility failed to provide a letter from a vendor for emergency fuel and water indicating that they have a preferred customer status.

The inspector observed while accompanied by the Director of Maintenance and the Clinical Services Director during the hours of the inspection from 9:30 am to 12:30 pm that there were no records of preferred customer status for water and fuel. This should also be integrated into the emergency preparedness plan for other utilities and supplies, i.e. medical gas, pharmaceuticals, medical supplies, food, and linen.

Based on observation the facility failed to provide an acceptable medical gas alarm system.

The inspector observed while accompanied by the Director of Maintenance and the Clinical Services Director during the hours of the inspection from 9:30 am to 12:30 pm that there was not a medical gas alarm in two locations. There was only an alarm at the nurse station.