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The facility did not ensure that the facilities air conditioning and ventilation equipment was in accordance with NFPA 90A: Standard for the Installation of Air Conditioning and Ventilation Systems as required by the referenced LSC.

On 11/03/11 at 10:00 AM, The surveyor was not provided with documentation by the Engineering and Facility Administration staff that the smoke dampers and of fire dampers identified as needing repair and or access panels had been repaired and/or access panels cut in to maintain compliance that smoke dampers were tested annually and that the mechanical fire dampers were maintained as required in NFPA 90A 3-4.7

The facility did not ensure that Means of egress are continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. No furnishings, decorations, or other objects obstruct exits, access to, egress from, or visibility of exits. 7.1.10

On 11/01/11 thru 11/03/11 at 09:30 AM and at other times throughout the survey, the surveyors along with Engineering and Facility Administration staff observed the following;
a. Computer workstations on wheels were being stored and charged in the corridors throughout the facility and the facility staff was observed to be sitting in chairs at the computer workstations on wheels processing records in the corridor.

b. The Verdi 3 W egress corridor had a work station complete with desks and file cabinets adjacent to the exit door.

The facility did not ensure that piped in medical gas systems are in compliance with NFPA 99, 4.1, 4.1.1, NFPA 70.

On 11/03/11 at 11:00 AM, the surveyor was not provided with documentation by the Engineering staff that the facility was completing repairs identified as needed during the periodic testing, and maintenance of the Oxygen Medical Gas, Medical Air Compress Air and Vacuum System as required by NFPA 99 i.e. deficiencies identified on the annual inspection report had not been completed and or tracked on the facility electronic work order system.

1. The facility did not ensure that electrical power was provided to facility patient care and equipment in compliance with NFPA 70 " National Electrical Code " and NFPA 99 " Health Care Facilities "

On 11/01/11 thru 11/03/11 at 09:30 AM and at other times throughout the survey, the surveyors along with Engineering and Facility Administration staff observed that the facility was utilizing extension cords and multiple plug surge suppressor extension cords throughout the facility as a permanent primary source of power for electrically powered equipment not in compliance with the requirements of NFPA 70 " National Electrical Code " and NFPA 99 " Health Care Facilities " regarding the use of temporary power.

2. The facility did not ensure that all employees are periodically instructed as to their duties during a fire emergency as
required by NFPA 101 " Life Safety Code " 19.7.1 and annually as required in NFPA 99 " Health Care Facilities " 11-5.3.8.
On 11/03/11 at 2:30 PM, the surveyors were not provided with documentation that all employees received annual, fire safety education that was site specific, non-generic or otherwise reflected/supported the facilities ' written plan of protection for all persons in the event of a fire.

3. The facility did not ensure that patient care electrical devices in-patient areas were being inspected as required in NFPA 99 " Health Care Facility ' s " .

a. On 11/02/11 at 9:00 AM and at other times throughout the day, the surveyor while accompanied by the Engineering and Facility Administration staff, observed that all of the electric, patient beds throughout the Operating Room Suites and all of the exam tables throughout the Cyber Knife Department/area lacked valid, current & non-expired preventive maintenance stickers and the facility failed to provide documentation that all patient care electrical devices are inspected as required in NFPA 99, Section 7-5.1.3, 7-5.2.2.1 and 7-6.2.1.2 and as part of the facility ' s preventive maintenance program; i.e. Maintenance Operations Manager shared work order that indicated electric, patient beds not inspected for at least 2 (two) years;

b. On 11/02/11 at 9:00 AM and at other times throughout the day, the surveyor while accompanied by the Engineering and Facility Administration staff, observed that all of the Perfusion devices (two) the Transfusion device (1) staged and ready for use in the Operating Rooms # 11 & 12 clean, equipment rooms and all of the electric, operating tables in each of the operating suites that was toured lacked valid, current & non-expired preventive maintenance stickers as required as part of the facility ' s preventive maintenance program; i.e. Perfusion devices due for PM in 07/11 and Transfusion device due in 07/11;

4. The facility did not ensure that electrical receptacle outlets in patient areas were maintained as required in NFPA 99 " Health Care Facilities " Section 3-3.3.3 and 3-3.4.2.3, and as part of the facilities preventive maintenance program..

On 11/03/11 at 11:30 AM, the surveyor was not provided with documentation by the Engineering and Facility Administration staff that electrical receptacle outlets identified as failing retention force/tension testing had been replaced as required in NFPA 99, i.e. No labor and or supplies were logged and/or tracked on the facility electronic work order system that these failures had been corrected and this testing had been utilized to extend the testing interval of the hospital grade outlets as allowed in NFPA 99

The facility did not ensure that fume hoods were in accordance with NFPA 99 " Health Care Facilities " and the facilities preventive maintenance program.
On 11/03/11 at 09:30 AM, the surveyor was not provided with documentation by the Engineering and Facility Administration staff to indicate that the facilities fume hoods are inspected as required in NFPA 99, and as part of the facilities preventive maintenance program i.e. the hoods certification expired on 10/2011.