Department of Health & Human Services

Centers for Medicare & Medicaid Services
Form Approved

OMB No. 0938-0391
Statement of Deficiencies (X1) Provider/Supplier/CLIA Identification Number 65C0001001 (X3) Date Survey Completed 02/08/2019
Name of Provider or Supplier Hafa Adai Specialist Group, Llp Street Address, City, State Sunflower Villa, 280 Pale San Vitores, Tamuning, GU
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
(X4) ID Prefix Tag Summary Statement of Deficiencies

(Each deficiency should be preceded by full regulatory or LSC identifying information)
K0920 Electrical Equipment – Power Cords and Extension Cords
CFR(s): NFPA 101

Electrical Equipment - Power Cords and Extension Cords Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4. 10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5


This STANDARD is not met as evidenced by:
Based on observation the facility was using two extension cords as a substitute for fixed wiring. This could cause an increased risk for fire due to the possibility that a high draw electrical device could be plugged into the extension cord and thus overloading it. This could cause injury or death to patients and staff.



The facility also used power strips without considering general precautions. This could increase the risk of fire due to the possibility of overloading the power strip. This could cause injury or death to patients and staff.



Findings include:



1. On January 31, 2019, during a walk-through of the facility with the maintenance employee and the CMS Health Surveyor it was observed that two extension cords had been dropped from the space above the suspended ceiling in the recovery room. One was plugged into a power strip and the other was plugged into a reclining bed. The CMS Surveyor confirmed the observation.



2. On January 31, 2019, during a walk-through of the operating room with the CMS Health Surveyor and the Operating Room Technician it was observed that a medical suction machine was plugged into power strip 1. Also plugged into power strip 1 was power strip 2. Power strip 2 was mounted on a movable cart assembly onto which were mounted several medical devices. The CMS Health Surveyor confirmed the observation.