HospitalInspections.org

Based on observation and facility staff interview, the facility staff failed to provide continuously maintained exit ways free of all obstructions or impediments continuous to a public way such as a parking lot. This deficient practice affects one exit discharge areas. This deficient practice has the potential to affect all patients, staff and visitors in the facility. Failure to ensure exterior exit ways comply with LSC requirements could delay evacuation out of the building in the event of a fire or other emergency. The facility census was one.


1. Observation on 12/09/19, during the facility tour, showed the cafeteria/medical records designated exit hallway exit discharge landing led to a grass covered yard that required residents, staff, and visitors to traverse approximately 75 feet of grass to reach the street.

During an interview on 12/10/19 at 1:42 P.M., the Director of Facilities said the building was constructed between 1970-1972 without a sidewalk.

The National Fire Protection Association 101, Life Safety Code 2012 Edition, section 7.7 states:

7.7 Discharge from Exits.

7.7.1* Exit Termination. Exits shall terminate directly, at a
public way or at an exterior exit discharge, unless otherwise
provided in 7.7.1.2 through 7.7.1.4.

Based on observation and facility staff interview, facility staff failed to provide emergency lighting not controlled by light switches inside medication rooms, post operative recovery room and the pharmacy. This deficient practice has the potential to affect all patients within the nursing unit served by the medication room. Failure to provide emergency lighting could prevent proper illumination of required areas in the event of power loss. The facility census was one.

1. Observations on 12/9-10/2019, during the Life Safety Code (LCS) tour, showed the following rooms equipped with switch controlled lights:

-2 of 2 medication rooms,
-surgery recovery,
-pharmacy.


During an interview upon the observations, the Director of Facilities confirmed the findings.



NFPA 99, 2012 edition, section 6.4.2.2.4.2 states:

"6.4.2.2.4.2 The critical branch shall supply power for task illumination,
fixed equipment, select receptacles, and select power
circuits serving the following areas and functions related to patient
care:
(1) Critical care areas that utilize anesthetizing gases, task illumination,
select receptacles, and fixed equipment
(2) Isolated power systems in special environments
(3) Task illumination and select receptacles in the following:
(a) Patient care rooms, including infant nurseries, selected
acute nursing areas, psychiatric bed areas (omit receptacles),
and ward treatment rooms
(b) Medication preparation areas
(c) Pharmacy dispensing areas
(d) Nurses ' stations (unless adequately lighted by corridor
luminaires)
(4) Additional specialized patient care task illumination and
receptacles, where needed
(5) Nurse call systems
(6) Blood, bone, and tissue banks
(7)*Telephone equipment rooms and closets
(8) Task illumination, select receptacles, and select power circuits
for the following areas:
(a) General care beds with at least one duplex receptacle
per patient bedroom, and task illumination as required
by the governing body of the health care facility
(b) Angiographic labs
(c) Cardiac catheterization labs
(d) Coronary care units
(e) Hemodialysis rooms or areas
(f) Emergency room treatment areas (select)
(g) Human physiology labs
(h) Intensive care units
(i) Postoperative recovery rooms (select)
(9) Additional task illumination, receptacles, and select power
circuits needed for effective facility operation, including
single-phase fractional horsepower motors, which are permitted
to be connected to the critical branch"

Based on record review and facility staff interview, facility staff did not ensure required equipment were installed in anesthesia areas per code requirements. This deficient practice has the potential to affect the health and welfare of any patient undergoing surgery in that operating room. The facility census was 1.

Record review of the 2018 Annual Medical Gas and Medical Vacuum Inspection dated October 29th, 2018 (2019 was unavailable), showed the following deficiencies within the operating room's surgery suite:

-Operating rooms #A & #B:
"Review the FGI guidelines for minimum outlets and inlets for surgery & operating",
"There are NO WAGD inlets in these rooms",
"OR #B also missing hose drops",
"Medical vacuum zone valve only 1/2 inch and under sized per (NFPA 99 code which requires 3/4 inch minimum",
"No area alarm panel for OR-surgery".

During an interview on 12/10/2019 at 1:12 P.M., the Director of Facilities said he/she did not know the gas and vacuum system inspection and testing requirements.

Refer to NFPA 99, 2012 edition chapter 5 for additional requirements.

Based on observation, record review and facility staff interview, facility staff failed to ensure cooking facilities are separated from the corridor. Three of three corridor doors to the kitchen did not contain positive latching mechanisms. Failure to ensure the kitchen was separated from the corridor increases the risk of delaying exiting from the building by not controlling the passage of smoke and products of combustion from the designated exit corridor in the event of a fire. Facility staff failed to ensure the six month interval range hood inspections were conducted. These deficient practices have the potential to affect all patients, staff and visitors. The facility census was 1.

Observation on 12/9-10/2019, during the building tour, showed three corridor to kitchen doors did not positively latch. Observation showed the kitchen contained a gas fired stove, cook top and deep fryer.

Record review on 12/09/2019, of the facility supplied range hood inspections, showed the last inspection dated 3/11/2019. Record review did not show the required September 2019 inspection.

During an interview on 12/10/2019 at 12:29 P.M., the Director of Facilities said the three doors to the kitchen was constructed 1970-1972 and never had positive latching devices installed on them. Additionally, he/she said the range hood inspection company was running behind conducting the inspections.

NFPA 101, 2012 edition, Section 19.3.2.5.5 states:

"19.3.2.5.5* Where cooking facilities are protected in accordance
with 9.2.3, the presence of the cooking equipment shall
not cause the room or space housing the equipment to be
classified as a hazardous area with respect to the requirements
of 19.3.2.1, and the room or space shall not be permitted to be
open to the corridor."

NFPA 96, 2011 edition, NFPA® 96 Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations
2011 Edition, section 11.2 Inspection, Testing, and Maintenance of Fire-Extinguishing
Systems states:

11.2.1* Maintenance of the fire-extinguishing systems and
listed exhaust hoods containing a constant or fire-activated
water system that is listed to extinguish a fire in the grease
removal devices, hood exhaust plenums, and exhaust ducts
shall be made by properly trained, qualified, and certified person(
s) acceptable to the authority having jurisdiction at least
every 6 months.

Based on record review and facility staff interview, facility staff did not ensure all devices connected to the fire alarm system were inspected and tested per NFPA 72, National Fire Alarm and Signaling Code, 2010 edition. Failure to inspect and test all devices has the potential to effect all patients, staff and visitors in the event of a fire. The facility census was one.

Record review of the annual fire alarm inspection records dated 3/11/2019 showed the following devices not tested per code requirements:

- corridor roll down window at the business office

- powered doors in the x-ray to ER designated exit corridor


During an interview on 12/10/2019 at approximately 1:44 P.M., with the Director of Facilities, he/she said he/she believed the fire alarm system inspection company inspected the fire alarm system per code requirements.

Refer to NFPA 72, National Fire Alarm and Signaling Code, 2010 edition, Table 14.3.1, Table 14.4.2.2, Table 14.4.5, sections 14.4.5, 14.4.5.3.1 through section 14.4.5.4 for additional testing information.

Refer to NFPA 72, National Fire Alarm and Signaling Code, 2010 edition, Figure 14.6.2.4 for Example of an Inspection and Testing Form.

Based on record review and facility staff interview, facility staff failed to inspect the one wet sprinkler system per NFPA 25, Standard for the Inspection, Testing, and maintenance of Water-Based Fire Protection Systems, 2011 edition. Facility staff failed to ensure sprinkler system components were inspected per code requirements. Facility staff failed to provide correct application of sprinkler heads. This deficient practice could delay activation of the sprinkler system for prompt fire suppression. These deficient practices have the potential to affect all facility patients, staff and visitors. The facility census was one.


1) Record review on 12/09/2019 did not show the five year check valve/backflow interior inspections.

During an interview on 12/10/2019 at 12:27 P.M., the Director of Facilities said he/she did not know the sprinkler inspection five year backflow code requirements.

NFPA 25, Standard for the Inspection, Testing, and maintenance of Water-Based Fire Protection Systems, 2011 edition, section 13.4.2 states:


13.4.2 Check Valves.
13.4.2.1 Inspection. Valves shall be inspected internally every
5 years to verify that all components operate correctly, move
freely, and are in good condition.


2) Observation on 12/09-10/2019, during the facility tour, of the therapy room, showed a mix of 6 quick response sprinkler heads and 2 standard response sprinkler heads in the same compartmented space.

During an interview on 12/10/2019 at 12:27 P.M., the Director of Facilities said the sprinkler heads were installed before he/she was employed at the facility.

NFPA 13, Standard For The Installation Of Sprinkler Systems, 2010 edition states:

8.3.3 Thermal Sensitivity.
8.3.3.1* Sprinklers in light hazard occupancies shall be one of
the following:
(1) Quick-response type as defined in 3.6.4.7
(2) Residential sprinklers in accordance with the requirements
of 8.4.5
(3) Standard-response sprinklers used for modifications or
additions to existing light hazard systems equipped with
standard-response sprinklers
(4) Standard-response sprinklers used where individual
standard-response sprinklers are replaced in existing light
hazard systems
8.3.3.2 Where quick-response sprinklers are installed, all
sprinklers within a compartment shall be quick-response unless
otherwise permitted in 8.3.3.3.
8.3.3.3 Where there are no listed quick-response sprinklers
in the temperature range required, standard-response sprinklers
shall be permitted to be used.
8.3.3.4 When existing light hazard systems are converted to
use quick-response or residential sprinklers, all sprinklers in a
compartmented space shall be changed.

Based on observation and facility staff interview, facility staff failed to ensure corridor doors met code requirements. This deficient practice has the potential to affect all patients, staff and visitors. The facility census was one.

1. Observation on 12/9-10/2019, during the building tour, showed a Dutch door separating the pharmacy from the designated exit corridor. The Dutch door did not have both upper and lower leaves latching devices and the door did not have a rabbet, bevel or astragal between the upper and lower leaves.

2. Observation on 12/9-10/2019, during the building tour, showed a Dutch door separating the central sterile from the designated exit corridor. The Dutch door did not have both upper and lower leaves latching devices and the door did not have a rabbet, bevel or astragal between the upper and lower leaves.


During an interview on 12/10/2019 at 9:48 A.M., the Maintenance Director said the Dutch doors were installed during building construction between 1970-1972.

NFPA 101, section 19.3.6.3 states:

19.3.6.3* Corridor Doors.
19.3.6.3.1* Doors protecting corridor openings in other than
required enclosures of vertical openings, exits, or hazardous
areas shall be doors constructed to resist the passage of smoke
and shall be constructed of materials such as the following:
(1) 13.4 in. (44 mm) thick, solid-bonded core wood
(2) Material that resists fire for a minimum of 20 minutes

19.3.6.3.2 The requirements of 19.3.6.3.1 shall not apply
where otherwise permitted by either of the following:
(1) Doors to toilet rooms, bathrooms, shower rooms, sink
closets, and similar auxiliary spaces that do not contain
flammable or combustible materials shall not be required
to comply with 19.3.6.3.1.

(2) In smoke compartments protected throughout by an approved,
supervised automatic sprinkler system in accordance
with 19.3.5.7, the door construction materials requirements
of 19.3.6.3.1 shall not be mandatory, but the doors
shall be constructed to resist the passage of smoke.

19.3.6.3.10* Doors shall not be held open by devices other
than those that release when the door is pushed or pulled.

19.3.6.3.5* Doors shall be provided with a means for keeping
the door closed that is acceptable to the authority having jurisdiction,
and the following requirements also shall apply:
(1) The device used shall be capable of keeping the door fully
closed if a force of 5 lbf (22 N) is applied at the latch edge
of the door.
(2) Roller latches shall be prohibited on corridor doors in
buildings not fully protected by an approved automatic
sprinkler system in accordance with 19.3.5.7.

19.3.6.3.13 Dutch doors shall be permitted where they conform
to 19.3.6.3 and meet all of the following criteria:
(1) Both the upper leaf and lower leaf are equipped with a
latching device.
(2) The meeting edges of the upper and lower leaves are
equipped with an astragal, a rabbet, or a bevel.
(3) Where protecting openings in enclosures around hazardous
areas, the doors comply with NFPA80, Standard for Fire
Doors and Other Opening Protectives.

Based on facility staff interview and record review, facility staff failed to inspect, test and maintain the fire egress doors in accordance with the 2010 Editions of NFPA 80 (Standard for Fire Doors and Other Opening Protectives) and NFPA 105 (Standard for Fire Doors and Other Opening Protectives). Facility staff failed to conduct an annual inspection of the non rated doors in the building. The facility census was one.

1. Review of the facility's inspection, testing and maintenance records did not show documentation of an annual inspection of the fire egress doors and non rated doors in the building.

During an interview on 12/10/2019 at 1:01 P.M., the Director of Facilities said the door inspections were missed.


NFPA 101, 2012 Edition states:

19.2.2.2.1 Doors complying with 7.2.1 shall be permitted.

7.2.1.15 Inspection of Door Openings.

7.2.1.15.1* Where required by Chapters 11 through 43, the
following door assemblies shall be inspected and tested not
less than annually in accordance with 7.2.1.15.2 through
7.2.1.15.8:
(1) Door leaves equipped with panic hardware or fire exit
hardware in accordance with 7.2.1.7
(2) Door assemblies in exit enclosures
(3) Electrically controlled egress doors
(4) Door assemblies with special locking arrangements subject
to 7.2.1.6

7.2.1.15.2 Fire-rated door assemblies shall be inspected and
tested in accordance with NFPA 80, Standard for Fire Doors and
Other Opening Protectives. Smoke door assemblies shall be inspected
and tested in accordance with NFPA 105, Standard for
Smoke Door Assemblies and Other Opening Protectives.

7.2.1.15.3 The inspection and testing interval for fire-rated
and nonrated door assemblies shall be permitted to exceed 12
months under a written performance-based program in accordance
with 5.2.2 of NFPA 80, Standard for Fire Doors and Other
Opening Protectives.

7.2.1.15.4 A written record of the inspections and testing
shall be signed and kept for inspection by the authority having
jurisdiction.

7.2.1.15.5 Functional testing of door assemblies shall be performed
by individuals who can demonstrate knowledge and
understanding of the operating components of the type of
door being subjected to testing.

7.2.1.15.6 Door assemblies shall be visually inspected from
both sides of the opening to assess the overall condition of the
assembly.

7.2.1.15.7 As a minimum, the following items shall be verified:
(1) Floor space on both sides of the openings is clear of obstructions,
and door leaves open fully and close freely.
(2) Forces required to set door leaves in motion and move to
the fully open position do not exceed the requirements
in 7.2.1.4.5.
(3) Latching and locking devices comply with 7.2.1.5.
(4) Releasing hardware devices are installed in accordance
with 7.2.1.5.10.1.
(5) Door leaves of paired openings are installed in accordance
with 7.2.1.5.11.
(6) Door closers are adjusted properly to control the closing
speed of door leaves in accordance with accessibility requirements.
(7) Projection of door leaves into the path of egress does not
exceed the encroachment permitted by 7.2.1.4.3.
(8) Powered door openings operate in accordance with
7.2.1.9.
(9) Signage required by 7.2.1.4.1(3), 7.2.1.5.5, 7.2.1.6, and
7.2.1.9 is intact and legible.
(10) Door openings with special locking arrangements function
in accordance with 7.2.1.6
(11) Security devices that impede egress are not installed on
openings, as required by 7.2.1.5.12.

Based on record review and facility staff interview, the facility staff failed to provide fundamental risk assessments and formally documented risk assessment procedures for all building systems categories. Failure to have the building systems risk assessments puts patients at risk for a potential negative outcome if category one systems (Category 1 system in which a failure of such equipment or system is likely to cause major injury or death of patients or caregivers) fail with no plan on how to respond if the system fails. The facility census was one.


1. Review of the facility documents for fire safety, building system tests, and policies did not show categorical risk assessments.

During an interview on 12/10/2019 at 2:29 P.M., with the Director of Facilities, he/she said he/she did not know the categorical risk assessment regulations.


The National Fire Protection Association 99 Health Care Facilities Code, 2012 edition, Chapter 4 states:

"Chapter 4 Fundamentals

4.1* Building System Categories. Building systems in health
care facilities shall be designed to meet system Category 1
through Category 4 requirements as detailed in this code.

4.1.1* Category 1. Facility systems in which failure of such equipment
or system is likely to cause major injury or death of patients
or caregivers shall be designed to meet system Category 1 requirements
as defined in this code.

4.1.2* Category 2. Facility systems in which failure of such equipment
is likely to cause minor injury to patients or caregivers shall
be designed to meet system Category 2 requirements as defined
in this code.

4.1.3 Category 3. Facility systems in which failure of such equipment
is not likely to cause injury to patients or caregivers, but can
cause patient discomfort, shall be designed to meet system Category
3 requirements as defined in this code.

4.1.4 Category 4. Facility systems in which failure of such equipment
would have no impact on patient care shall be designed to
meet system Category 4 requirements as defined in this code.

4.2* Risk Assessment. Categories shall be determined by following
and documenting a defined risk assessment procedure.

4.3 Application. The Category definitions in Chapter 4 shall
apply to Chapters 5 through 11."

A.4.2 Risk assessment should follow procedures such as those
outlined in ISO/IEC 31010, Risk Management-Risk Assessment
Techniques, NFPA 551, Guide for the Evaluation of Fire Risk Assessments,
Guide for the Evaluation of Fire Risk Assessments, SEMI S10-
0307E, Safety Guideline for Risk Assessment and Risk Evaluation
Process, or other formal process. The results of the assessment
procedure should be documented and records retained.

Based on record review and facility staff interview, facility staff failed to categorize the medical gas, med air, surgical vacuum, WAGD, and supply air systems. The facility census was one.

1. Review of the facility documents for fire safety, building system tests, and policies did not show categorical risk assessments for the gas, air and vacuum systems.

During an interview on 12/10/2019 at 2:29 P.M., with the Director of Facilities, he/she said he/she did not know the categorical risk assessment regulations.

Based on record review and facility staff interview, facility staff failed to provide a medical gas warning system in compliance with NFPA 99, 2012 edition. The facility census was one.

1. Review of the facility documents for fire safety, building system tests, and policies did not show categorical risk assessments for the gas, air and vacuum systems.

2. Record review of the 2018 Annual Medical Gas and Medical Vacuum Inspection dated October 29th, 2018 (2019 was unavailable), showed the following deficiencies with the alarm warning systems for medical gas systems :

-Medical Vacuum pump in the boiler room: "Missing alarm signal at both master alarm panels (lag pump in use)",

-Medical Air Compressor in the boiler room: "CO & dew point monitors out of calibration", "High & low alarm switch needs retesting", "Missing alarm signal at both master alarm panels (see note on alarm)",

-Medical N20 Manifold room: "Missing alarm signal at both master alarm panels (secondary bank in use)",

-Medical Area Alarm Panels Surgery & PACU: "No area alarm panel for OR-Surgery", "No area alarm panel for PACU-Recovery",

-Medical Master Alarm System Nursing Station South & PBX: "No alarm for secondary bank in use nitrous oxide manifold", "No alarm for medical air high dew point", "No alarm for medical air high CO", "No alarm for medical air lag compressor in use", "No alarm for medical vacuum lag pump in use".


During an interview on 12/10/2019 at 1:12 P.M., the Director of Facilities said he/she did not know the gas and vacuum system inspection and testing requirements.

Refer to NFPA 99, 2012 edition chapter 5 for additional requirements.

Based on interview and record review the facility failed to develop a maintenance program for the medical gas, vacuum, WAGD (Waste Anesthetic Gas Disposal), or support gas system within the facility. The facility census was one.

1. Review of the facility maintenance program documentation did not show the facility had a program in place which includes an inventory of all source systems, control valves, alarms, manufactured assemblies, and outlets, and an inspection and maintenance schedule for this system.

During an interview on 12/10/2019 at 1:12 P.M., the Director of Facilities said he/she did not know the gas and vacuum system inspection and testing requirements.

Section 5.1.14.2.2.1 of the National Fire Protection Association (NFPA 99) states: Health care facilities with installed medical gas, vacuum, WAGD, or medical support gas systems, or combinations thereof, shall develop and document periodic maintenance programs for these systems and their subcomponents as appropriate to the equipment installed.

Based on record review and facility staff interview, the facility staff failed to maintain records of inspections and testing of their piped in oxygen systems in accordance with National Fire Protection Association (NFPA) 99, 2012 edition. The facility census was one.

1. Review of the facility's maintenance program documentation showed the last inspection and testing of the piped-in oxygen system completed October 29th, 2018.

2. Record review the 2018 Annual Medical Gas and Medical Vacuum Inspection dated October 29th, 2018 (2019 inspection records were unavailable) showed the following deficiencies:

A) OUTLETS & INLETS & ZONE VALVE BOXES

- "Bad Oxygen gauge ED (Emergency Department) zone valve box",

- R.T. TX Room:
"Could not find zone valve box for oxygen this room",

-Leaking Outlets OR bad outlets:
"Patient rooms 109, 127, 177 (leaking oxygen)",
"Medical air bad outlets (R.T. TX and 123)",

-Surgery / OR #A, B, Cysto:
"Review the FGI Guidelines for minimum outlets and inlets for surgery & operating",
"There are no WAGD inlets in these rooms",
"OR #B also missing hose drops",

-Zones: RT TX, Out Patient hold#141-procedure, PACU, OR #A, B, Cysto:
"Medical Vacuum Zone Valve only 1/2" inch and under sized per (NFPA 99 code which requires 3/4" inch minimum",

-Medical Air Outlets:
"There is water in the medical air system & patient outlets",

-EOSC Oxygen:
"Outside oxygen lines need protection location at or near EOSC box",


B) MEDICAL VACUUM PUMP

-Boiler room: "Missing drip leg on exhaust line",
"Missing alarm signal at both master alarm panels (lag pump in use)",

C) MEDICAL AIR COMPRESSOR

-Boiler Room: "This system is not per NFPA 99 code/Many items out of compliance:

1) Medical air intake in wrong location,
2) No duplex filters,
3) No duplex regulators,
4) No duplex dryers,
5) No 75 PSIG relief vent,
6) CO & Dew point monitors out of calibration,
7) High & Low alarm switch need re-testing,
8) Missing alarm signals at both master alarms (see note on alarms),
9) The medical air lines have water",

D) MEDICAL N20 MANIFOLD

-N20 Manifold room:
"Missing header service shut off valve both sides of N20 manifold",
"Missing 2 by 2 cylinder connections for each side of of the N20 manifold",
"Missing proper outside signages on N20 manifold room door",
"Relief vent line needs screen",
"Missing alarm signal at both master alarm panels (Secondary bank in use)",

E) MEDICAL MASTER ALARM SYSTEM

-Nursing station South & PBX: "No alarm for secondary bank min use nitrous oxide manifold",
"No alarm for medical air high dew point",
"No alarm for medical air high CO",
"No alarm for medical air lag compressor in use",
"No alarm for medical vacuum lag pump in use".

3. Record review did not show repair records from deficiencies stated on the 2018 Annual Medical Gas and Medical Vacuum Inspection dated October 29th, 2018 (2019 inspection records were unavailable).

During an interview on 12/10/2019 at 1:12 P.M., the Director of Facilities said he/she did not know the gas and vacuum system inspection and testing requirements.

Refer to NFPA 99, 2012 edition chapter 5 for additional requirements.

Based on observation, facility staff interview and record review, facility staff failed to provide continuing education regarding the safety guidelines and usage requirements for medical gases and their cylinders to staff involved with the application, handling and maintenance of medical gases and their cylinders. Failure to provide education has the potential for improper handling of medical gases and cylinders which poses an increased risk of fire and injury to patients and staff. This failure has the potential to affect all facility occupants. The facility census one.

1. Observation on 12/9-10/2019, during the build tour, showed all the patient rooms equipped with a piped vacuum/oxygen system.

Review of the facility's personnel continuing education records did not contain documentation of education provided to the facility staff involved with the application, handling and maintenance of medical gases regarding the safety guidelines and usage requirements for medical gases or their cylinders.

During an interview on 12/10/2019 at 1:12 P.M., the Director of Facilities said he/she did not know the gas and vacuum system inspection and testing requirements.


NFPA 99, 2012 Edition, Section 11.5.2.1 (Qualifications and Training of Personnel), states:

"11.5.2 Gases in Cylinders and Liquefied Gases in Containers.

11.5.2.1 Qualification and Training of Personnel.

11.5.2.1.1* Personnel concerned with the application and
maintenance of medical gases and others who handle medical
gases and the cylinders that contain the medical gases shall be
trained on the risks associated with their handling and use.

11.5.2.1.2 Health care facilities shall provide programs of continuing
education for their personnel.

11.5.2.1.3 Continuing education programs shall include periodic
review of safety guidelines and usage requirements for
medical gases and their cylinders.

11.5.2.1.4 Equipment shall be serviced only by personnel
trained in the maintenance and operation of the equipment.

11.5.2.1.5 If a bulk cryogenic system is present, the supplier
shall provide annual training on its operation."