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Observation and discussion with the Director of Plant Operations between 8:30 am and 4:30 pm on 5/25/2010 revealed that certain requirements stipulated in NFPA 72 were not met.

Monthly Tests

Fire alarm systems shall be tested monthly [Re: NFPA 72, National Fire Alarm Code, 1999: ?7-3.2, Testing.] See Table 7-3.2, Item #3.

Findings: The staff could not produce a log showing when these tests were conducted.

Observation and discussion with the Director of Plant Operations between 8:30 am and 4:30 pm on 5/25/2010 revealed that certain requirements stipulated in NFPA 99 and the Department of State Health Services [DSHS] Hospital Licensing Rules [HLR] were not met.

Gas Outlets

Nonflammable medical gas and clinical vacuum installations shall be designed, installed and certified in accordance with the requirements of NFPA 99, ?5.1 for Level I systems and the requirements of this clause [Re: 25 TAC HLR, 2007: ?133.162(d)(4)(A)(iii).] The facility is required to have outlets in a 1-1-1 configuration where these numbers correspond to O-V-MA [see Table 6, Figure 25 TAC ?133.169(f).]

Findings: The facility did not have medical air operational in the exam room.

Observation and discussion with the Director of Plant Operations between 8:30 am and 4:30 pm, on 5/25/2010 revealed that certain requirements enforced by NFPA 99 and the DSHS HLR were not met.

a. DSHS Form

The facility must provide certification from the local Fire Marshal stating that the facility is worthy of a state license. This requirement is usually the completion of a specific form provided to the facility in the relicensing package every two years. The facility is required to produce this form during a LSC survey.

Findings: The staff could not produce this certification from the local Fire Marshal.

b. Letter of Preference

The facility is required to produce letters of preference for the provision of water and fuel in the event of a disaster or emergency [Re: NFPA 99, Health Care Facilities, 2002: ? 12.3.3.2.]

Findings: This staff could not provide a letter of preference for water.

c. Disaster Drills

Each facility shall conduct disaster drills at last semiannually [Re: NFPA 99, Health Care Facilities, 2002: ? 12.3.3.9.] The DSHS requires the reports for these rehearsals be maintained for at least three years [Re: 25 TAC HLR, 2007: ? 133.142(c)(3).]

Findings: The staff could not produce the reports for the past three years.


d. Line Isolation Monitors

The Line Isolation Monitor circuit shall be tested at intervals of not more than 1 month. The test switch shall activate both the visual and audible alarm indicator [Re: NFPA 99, Health Care Facilities, 2002: ? 4-3.3.3.2.2.]

Findings: This staff stated that this was not performed and a log indicating that the tests were conducted could not be produced.

Observation and discussion with the Director of Plant Operations between 8:30 am and 4:30 pm, on 5/25/2010 revealed that certain requirements enforced by NFPA 99 and NFPA 110 were not met.

a. Weekly Inspections

Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly ....[Re: NFPA 110, Standard for Emergency and Standby Power Systems, 1999: ? 6-4.1.]

Findings: The staff stated that this was not performed routinely as required and a log indicating that this maintenance was performed was not available


b. Battery Maintenance

Batteries for on-site generators shall be maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems [Re: NFPA 99, Health Care Facilities, 2002: ? 4.4 1.1.5.] Storage batteries ... shall be inspected at intervals of not more than 7 days .... [Re: NFPA 110, Standard for Emergency and Standby Power Systems, 1999: ? 6-3.6.]

Findings: The staff stated that this was not performed routinely as required and a log indicating that this maintenance was performed was not available.

Observation and discussion with the Director of Plant Operations between 8:30 am and 4:30 pm on 5/25/2010 revealed that certain requirements stipulated in NFPA 70 and the DSHS HLR were not met.


a. Functional Allocation

Specific requirements exist identifying the functions as they must be allocated to the critical branch [NFPA 70, National Electrical Code, 2002, ?517.33], life safety branch [NFPA 70, National Electrical Code, 2002, ?517.32], and the equipment system [NFPA 70, National Electrical Code, 2002, ?517.34].

Findings: During the survey, all panelboards could not be identified with respect to the branch to which it belonged, eg Panelbaord EL3 was thought to be a critical panelboard but it could not be confirmed. The facility shall ensure that every component is identified regarding the branch to which it belongs.

b. Equipment Labels

All boxes and enclosures (including transfer switches, transformers, distribution panels, and panelboards) for emergency circuits shall be permanently marked so they will be readily identified as a component of an emergency circuit or system [Re: NFPA 70, National Electrical Code, 2002: 700.9(A).] The above listed components shall be labeled with the words " LIFE SAFETY " , " CRITICAL " AND " EQUIPMENT " to be readily identifiable as part of the Essential Electrical System.

Findings: During the survey, it could not be determined which power source was connected to the various panelboards, etc. Once the requirement above has been satisfied, each component must be labeled pursuant to this requirement. The ATSs were also not labeled properly.

c. Update Circuit Directories

All circuits and circuit modifications shall be legibly identified as to purpose or use on a circuit directory located on the face or inside of the panel door in the case of a panelboard, and at each switch on a switchboard [Re: NFPA 70, National Electrical Code, 2002: ? 408.4.]

Findings: All circuit directories must be updated to be meaningful following the fulfillment of the requirements above.

d. flex conduit

Flex conduit is not allowed on emergency circuits [Re: NFPA 70, National Electrical Code, 2002: ? 517.30[C](3).]

Findings: This topic was discussed during the survey at Panelboard EL3 location; flex conduit was installed. The facility shall mitigate this deficiency once the branch designation is determined.

e. Critical Loads

The functions intended to be powered by the critical branch are enumerated [Re: NFPA 70, National Electrical Code, 2002: ? 517.33[A].]

Findings: Pumps were powered by the critical branch. These are permitted under certain situations [Re: NFPA 70, National Electrical Code, 2002: ? 517.33[A](9).]. However, the preferred power source is the equipment branch. The facility shall recircuit them to the equipment branch or describe why they should remain on the critical branch.

f. GenSet Life Safety Features

A battery powered light where the battery is charged by the life safety branch and a receptacle powered by the life safety branch is required [Re: NFPA 70, National Electrical Code, 2002: ? 517.32[E].]

Findings: This topic was discussed during the survey and these amenities were not provided.