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Tag No.: K0064
Fire Extinguishers shall be inspected when initially placed in service and thereafter at approximately 30 day intervals [Re: NFPA 10: Portable Fire Extinguishers, 2002: ? 6.2.1.]
Findings: This requirement was discussed with the facility staff, and this requirement was not met. The facility shall establish a procedure that satisfies this requirement and maintain a log reflecting the action.
Tag No.: K0130
Letters of Preference
When designated by the emergency management plan to provide continuous service in a disaster or emergency, health care facilities shall establish contingency plans for the continuity of essential building systems, as applicable: (1) Electricity; (2) Water; (3) Ventilation; (4) Fire protection systems; (5) Fuel sources; (6) Medical gas and vacuum systems (if applicable); (7) Communication systems. [Re: NFPA 99, Health Care Facilities, 2002: ? 12.3.3.2.] At a minimum, letters of preference for the delivery of water and fuel in the event of an emergency shall be available for review.
Findings: After discussion with the hospital staff between 9:30 am and 3 pm, on 2/16/2010, it was determined that certain requirements essential to the state of emergency preparedness were not met. The letter of preference for potable water was not available for review.
Tag No.: K0145
Observation and discussion with the hospital staff between 9:30 am and 3 pm, on 2/16/2010 revealed that certain requirements relevant to the required Type I Essential Electrical System in DSHS regulations and NFPA 70, National Electrical Code, 2002, and NFPA 99, Health Care Facilities, 2002, were not met.
a.Receptacles Labeled
Requirements 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 [Re: NFPA 70, National Electrical Code, 2002: ? 517.41(E).] The department requires that red be used and the circuit and panelboard numbers be provided on the receptacle.
Findings: The receptacles in the " older area " of the Emergency Department were not labeled as required.
b.Generator Set Location
Requirements: The life safety branch of the emergency system shall supply power for the following lighting, receptacles, and equipment: (1) .... means of egress ...., (2) .... exit signs and direction signs ...., (3) Alarm and alerting systems ...., (4) ....communications systems ...., (5) Generator Set Location: Task illumination, battery charger for emergency battery-powered lighting unit(s), and selected receptacles at the generator set location and essential electrical system transfer switch locations, (6) Elevator cab lighting, control, communication, and signal systems, (7) Automatically operated doors used for building egress, (8) .... auxiliary functions of fire alarm .... systems .... No other function other than those listed in items (1) through (8) shall be connected to the life safety branch. [Re: NFPA 99, Health Care Facilities, 2002: ? 4.4.2.2.2.2.]
Findings: The amenities at the generator set location were installed, but dysfunctional.
c.Functional Allocation
Requirements: The life safety branch of the emergency system shall supply power for the following lighting, receptacles, and equipment: (1) .... means of egress ...., (2) .... exit signs and direction signs ...., (3) Alarm and alerting systems ...., (4) ....communications systems ...., (5) Generator Set Location: Task illumination, battery charger for emergency battery-powered lighting unit(s), and selected receptacles at the generator set location and essential electrical system transfer switch locations, (6) Elevator cab lighting, control, communication, and signal systems, (7) Automatically operated doors used for building egress, (8) .... auxiliary functions of fire alarm .... systems .... No other function other than those listed in items (1) through (8) shall be connected to the life safety branch. [Re: NFPA 99, Health Care Facilities, 2002: ? 4.4.2.2.2.2.]
Findings: Unallowable functions were powered from the Life Safety panel LLS in the northeast electrical room. The " generator battery charger " loads are not authorized for the Life Safety branch.