Statement of Deficiencies

Statement of Deficiencies	(X1) Provider/Supplier/CLIA Identification Number 010006	(X3) Date Survey Completed 07/15/2010
Name of Provider or Supplier North Alabama Medical Center	Street Address, City, State 1701 Veterans Drive, Florence, AL
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)
A0505	UNUSABLE DRUGS NOT USED CFR(s): 482.25(b)(3) Outdated, mislabeled, or otherwise unusable drugs and biologicals must not be available for patient use. This STANDARD is not met as evidenced by: Based on observation, the facility failed to assure all medications available for patient use in the Pyxis System on the Medical Unit were not expired. This had the potential to affect all patients. Findings include: A tour of the Medical Unit was conducted on 7/14/10 at 12:40 PM. During this tour the surveyor and Employee Identifier (E.I.) # 1, RN Manager 3 West, observed the following medications in the Pyxis System with expired dates: Dextrose 5% 100cc times (x) 4 expired 4/1/08 Dextrose 5% with 1/4 Normal Saline 1000cc x 3 expired 3/1/08 Dextrose 5% with 1/4 Normal Saline 1000cc x 3 expired 4/1/09 Dextrose 5% with 1/2 Normal Saline 1000cc x 3 expired 7/1/10
A0700	PHYSICAL ENVIRONMENT CFR(s): 482.41 The hospital must be constructed, arranged, and maintained to ensure the safety of the patient, and to provide facilities for diagnosis and treatment and for special hospital services appropriate to the needs of the community. This CONDITION is not met as evidenced by: Based on observations during facility tour with hospital staff by the Fire Safety Compliance Officer and staff interviews, it was determined that the facility was not constructed, arranged and maintained to ensure patient safety. Findings include: Refer to Life Safety Code violations.
A0726	VENTILATION, LIGHT, TEMPERATURE CONTROLS CFR(s): 482.41(c)(4) There must be proper ventilation, light, and temperature controls in pharmaceutical, food preparation, and other appropriate areas. This STANDARD is not met as evidenced by: On 7/14/10 at 9:00 AM, the surveyor observed medication pass on 6 West. During this observation, Employee Identifier (EI) # 5, the Registered Nurse obtained Intravenous (IV) Venofer from a medication refrigerator. The surveyor observed an excessive amount of ice accumulation on the freezer portion of the refrigerator. On 7/14/10 at 9:30 AM, the surveyor showed the ice accumulation on the freezer portion of this refrigerator to EI # 7, the Nurse Manager, who verified it was excessive and would call maintenance to replace the refrigerator. 28327 Based on observation and policy review, the facility failed to assure all medications requiring refrigeration were stored properly in the Pharmacy, 3 West and 6 West. This had the potential to affect all patients. Findings Include: Policy: Medication Storage ... Medications requiring refrigeration will be stored in a refrigerator which will be used exclusively for this purpose and refrigerator temperatures will be set at 2-8 degrees Celsius (C) and monitored daily on medication refrigeration log... If temperature falls outside this range, the refrigerator temperature control will be adjusted and the temperature rechecked. If the temperature still is out of range, Plant Operations will be called. Refrigerator/Freezer Temperature Log Appropriate Refrigerator Range = 32 degrees Fahrenheit (F) to 41 degrees F. Appropriate Freezer = less than (<) 32 degrees F. A tour of the Pharmacy conducted on 7/13/10 at 2:00 P.M. by the surveyor, Employee Identifier (E.I.) # 3, Case Management Manager, and E.I. # 6, Assistant Director of Pharmacy, revealed the following: a. medications stored in the Break Room freezer with no temperature log found. b. medications stored in the main room freezer with no temperature log completed since May 25, 2010. A tour of 3 West conducted on 7/14/10 at 12:40 P.M. by the surveyor and E.I. # 1, the RN manager 3 West, revealed medications stored in the Pyxis refrigerator. The freezer compartment of the refrigerator was found to have an excessive ice buildup. A review of the temperature log revealed the following temperatures logged: a. 7/13/10 = 60 b. 7/14/10 = 59 There was no documentation that the temperature had been adjusted or that Plant Operations had been notified.
A0748	INFECTION CONTROL OFFICER(S) CFR(s): 482.42(a) A person or persons must be designated as infection control officer or officers to develop and implement policies governing control of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observation and review of facility's policies, it was determined the facility failed to ensure blood products were handled according to the facility policy by the laboratory staff. This had the potential to effect all laboratory staff. Findings include: Facility Policy Dept. Laboratory Title: Glove usage - Removal and Disposal Gloves are required when obtaining, handling or distributing all specimens... Gloves in the clinical areas should be replaced when they become torn, soiled or contaminated. Facility Policy Exposure Control Plan Policy: Exposure Control Plan Statement of Purpose: The purpose of the plan is to: Establish individual responsibilities to minimize the risk for healthcare workers of acquiring bloodborne disease to occupational exposure. Definitions: Standard Precautions and Respiratory Hygiene/Cough Etiquette: ... All human blood and certain human fluids are treated as if known blood and can cause disease in humans. Contaminated: The presence or the reasonable anticipated presence of blood or other potentially infectious materials on an item or surface. Exposure Determination: This exposure determination shall be made without regard to the use of personal protective equipment: Category I: Jobs with tasks that routinely involve exposure or potential exposure to blood, body fluids or tissues... (Laboratory/Pathology Department is included in the Category I list) Methods of compliance: General: Standard Precautions and Respiratory Hygiene/Cough Etiquette are observed to prevent contact with blood or other potentially infectious materials. Under circumstances in which differentiation between body fluid type is difficult or impossible, all body fluids shall be considered potentially infectious materials. Engineering and Work Practice Controls - used to eliminate or minimize staff member exposure... The following engineering/work practice controls are used throughout the facility: Hand cleansing facilities - (or alcohol-based hand), which are readily accessible to all staff members who have potential for exposure... Following any contact of body areas with blood or any other infectious materials, staff members wash their hands or any other exposed skin with soap and water as soon as possible: they also flush exposed mucous membranes with water... Personal Protective Equipment: Personal protective equipment is the "last line of defense" against bloodborne pathogens... This equipment includes, but is not limited to: ... gloves (latex or vinyl), in all sizes and hypoallergenic ... Gloves are worn in the following circumstances: Whenever staff members anticipate contact with potentially infectious materials When performing vascular access procedures When handling or touching contaminated items or surfaces Facility Policy Hand Hygiene in Healthcare setting Manual: Infection Control Purpose To provide procedure for correctly performing hand antisepsis. Policy Appropriate hand hygiene is performed to reduce the potential risks of transmission of microorganisms to patients and to reduce the potential risks of health-care worker colonization or infection caused by organisms acquired from the patient. The following are indications for performing appropriate hand hygiene procedure (either handwashing with hospital approved agent or using the hospital approved alcohol-based product - as indicated). ... After contact with body fluids or excretions, mucous membranes, non-intact skin, and wound dressings If moving from a contaminated- body site to a clean body site during patient care After removing gloves... An initial tour of the facility laboratory was conducted on 7/13/10 at 2:10 PM. During this tour at 2:30 PM, the surveyor observed Employee Identifier (EI) # 8, the laboratory staff member reach into the "Blood Bank" refrigerator and removed a unit of blood that had been typed and cross matched with her bare hand. After explaining to the surveyor the procedure for blood that had been assigned to a patient, she placed this bag back into the refrigerator. The surveyor did not observe the staff member wash her hands.
K0011	LIFE SAFETY CODE STANDARD CFR(s): NFPA 101 If the building has a common wall with a nonconforming building, the common wall is a fire barrier having at least a two-hour fire resistance rating constructed of materials as required for the addition. Communicating openings occur only in corridors and are protected by approved self-closing fire doors. 19.1.1.4.1, 19.1.1.4.2 This STANDARD is not met as evidenced by: 1. During the survey, the following was observed: A. Unsealed penetrations around flex conduit, and around a group of wiring, in the Fire Wall (2hr), by Cath Lab Waiting Basement. B. Unsealed penetrations around conduit, in the Fire Wall (2hr), at Radiology. C. Unsealed penetrations around flex conduit, in the Fire Wall (2hr), at Progressive Care Unit. 8.2.2.2* Fire compartments shall be formed with fire barriers that are continuous from outside wall to outside wall, from one fire barrier to another, or a combination thereof, including continuity through all concealed spaces, such as those found above a ceiling, including interstitial spaces. Walls used as fire barriers shall comply with Chapter 3 of NFPA 221, Standard for Fire Walls and Fire Barrier Walls. The NFPA 221 limitation on percentage width of openings shall not apply. 27382 The facility failed to maintain the two hour fire/smoke barriers per code. Findings include: During the survey, the following was observed: Fourth Floor A. Two hour fire/smoke barrier by Labor and Delivery (4-F-S) at the fire doors - one unsealed conduit with red wires. B. Fire doors in front of the Nurses' Station - the left leaf did not latch when tested. Third Floor The fire doors in front of the Nurses' Station the left leaf fire door did not latch when tested. Fifth Floor The fire doors in front of room 577 - the right leaf did not latch when tested. 2000 NFPA 101, 8.2.3.2.4.2 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through fire barriers shall be protected as follows: (1) The space between the penetrating item and the fire barrier shall meet one of the following conditions: a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier. b. It shall be protected by an approved device that is designed for the specific purpose. (2) Where the penetrating item uses a sleeve to penetrate the fire barrier, the sleeve shall be solidly set in the fire barrier, and the space between the item and the sleeve shall meet one of the following conditions: a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier. b. It shall be protected by an approved device that is designed for the specific purpose. (3) * Insulation and coverings for pipes and ducts shall not pass through the fire barrier unless one of the following conditions is met: a. The material shall be capable of maintaining the fire resistance of the fire barrier. b. The material shall be protected by an approved device that is designed for the specific purpose. (4) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions: a. It shall be made on either side of the fire barrier. b. It shall be made by an approved device that is designed for the specific purpose. 2000 NFPA 101, 8.2.3.2.1 Door assemblies in fire barriers shall be of an approved type with the appropriate fire protection rating for the location in which they are installed and shall comply with the following. (a) * Fire doors shall be installed in accordance with NFPA 80, Standard for Fire Doors and Fire Windows. Fire doors shall be of a design that has been tested to meet the conditions of acceptance of NFPA 252, Standard Methods of Fire Tests of Door Assemblies. Exception: The requirement of 8.2.3.2.1(a) shall not apply where otherwise specified by 8.2.3.2.3.1. (b) Fire doors shall be self-closing or automatic-closing in accordance with 7.2.1.8 and, where used within the means of egress, shall comply with the provisions of 7.2.1.
K0017	LIFE SAFETY CODE STANDARD CFR(s): NFPA 101 Corridors are separated from use areas by walls constructed with at least ½ hour fire resistance rating. In sprinklered buildings, partitions are only required to resist the passage of smoke. In non-sprinklered buildings, walls properly extend above the ceiling. (Corridor walls may terminate at the underside of ceilings where specifically permitted by Code. Charting and clerical stations, waiting areas, dining rooms, and activity spaces may be open to the corridor under certain conditions specified in the Code. Gift shops may be separated from corridors by non-fire rated walls if the gift shop is fully sprinklered.) 19.3.6.1, 19.3.6.2.1, 19.3.6.5 This STANDARD is not met as evidenced by: The facility failed to provide corridor walls that would provide at least a 30 minute fire resistance rating. Findings include: During the survey, unsealed penetrations were observed, at the deck, of the corridor wall, by Patient Room 374. NFPA 101, 19.3.6.1 Corridors in unsprinklered smoke compartments shall be separated from all other areas by partitions having a fire resistance rating of at least 30 minutes.
K0018	LIFE SAFETY CODE STANDARD CFR(s): NFPA 101 Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas are substantial doors, such as those constructed of 1¾ inch solid-bonded core wood, or capable of resisting fire for at least 20 minutes. Doors in sprinklered buildings are only required to resist the passage of smoke. There is no impediment to the closing of the doors. Doors are provided with a means suitable for keeping the door closed. Dutch doors meeting 19.3.6.3.6 are permitted. 19.3.6.3 Roller latches are prohibited by CMS regulations in all health care facilities. This STANDARD is not met as evidenced by: The facility failed to maintain the corridor openings per code. Findings include: During the survey, on the third floor at the 'old' Heart Health now Storage Room the corridor door was blocked from being able to close by two carts. 2007 CMS - 2786R There is no impediment to the closing of the corridor doors.
K0025	LIFE SAFETY CODE STANDARD CFR(s): NFPA 101 Smoke barriers are constructed to provide at least a one half hour fire resistance rating in accordance with 8.3. Smoke barriers may terminate at an atrium wall. Windows are protected by fire-rated glazing or by wired glass panels and steel frames. A minimum of two separate compartments are provided on each floor. Dampers are not required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air conditioning systems. 19.3.7.3, 19.3.7.5, 19.1.6.3, 19.1.6.4 This STANDARD is not met as evidenced by: The facility failed to provide smoke barriers that would provide at least a half hour fire resistance rating. Findings include: During the survey, the following was observed: 1. Unsealed penetrations around a sprinkler line, in the Smoke Barrier, by Cardiouascular Ultrasound Basement. 2. Unsealed penetrations at the end of a sleeve, in the Smoke Barrier, by Patient Room 177. 3. Unsealed penetrations around conduit, and at the end of a sleeve, in the Smoke Barrier, by the Monitor Room Third Floor West. NFPA 101, 19.3.7.3 Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1/2 hour. NFPA 101, 8.3.2 Smoke barriers required by this Code shall be continuous from an outside wall to an outside wall, from a floor to a floor, or from a smoke barrier to a smoke barrier or a combination thereof. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces.
K0054	LIFE SAFETY CODE STANDARD CFR(s): NFPA 101 All required smoke detectors, including those activating door hold-open devices, are approved, maintained, inspected and tested in accordance with the manufacturer's specifications. 9.6.1.3 This STANDARD is not met as evidenced by: The facility failed to perform sensitivity testing of the smoke detectors. Findings include: Documentation provided by the facility during the survey did not indicate sensitivity testing of the smoke detectors. Detector sensitivity shall be checked with one year after installation and every alternate year thereafter per 72, 7-3.2.1. (Up to 5 years permitted under certain circumstances. See 7-3.2.1).
K0056	LIFE SAFETY CODE STANDARD CFR(s): NFPA 101 If there is an automatic sprinkler system, it is installed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, to provide complete coverage for all portions of the building. The system is properly maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. It is fully supervised. There is a reliable, adequate water supply for the system. Required sprinkler systems are equipped with water flow and tamper switches, which are electrically connected to the building fire alarm system. 19.3.5 This STANDARD is not met as evidenced by: Sprinkler coverage was observed during the survey not adequately provided. Findings include: During the survey, the following was observed: A) Missing ceiling tiles in the Nitrous Oxide Room. NFPA 13 5-6., Sprinklers shall be arranged to be in compliance. B) Escutcheon plate missing on a sprinkler at the main entrance of the facility. 2000 NFPA 13, 3-2.7.2 Escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly. 27382 The facility failed to maintain the sprinkler system per code. Findings include: C) During the survey, the following was observed: 1. Second Floor - Break Down Box Room in the O.R. - the attic access in the closet is falling out of the ceiling. 2. Third Floor - Old Heart Health now Storage - was missing ceiling tile. 1999 NFPA 13, 5-8.4.2 Deflectors of sprinklers shall be aligned parallel to ceilings or roofs.
K0067	LIFE SAFETY CODE STANDARD CFR(s): NFPA 101 Heating, ventilating, and air conditioning comply with the provisions of section 9.2 and are installed in accordance with the manufacturer's specifications. 19.5.2.1, 9.2, NFPA 90A, 19.5.2.2 This STANDARD is not met as evidenced by: The facility failed to maintain the smoke dampers per code. Findings include: During the survey, the following was observed: 1. Fifth Floor - the smoke damper at the smoke doors in front of the Nurses' Station did not close when the fire alarm was tested. 2. Fourth Floor - the smoke damper for the fire/smoke barrier at the fire doors (4-F-S-70) at room 460 did not close when the fire alarm was tested. 3. Third Floor - the fire/smoke barrier at the Pharmacy/the entrance to C.C.U. (A-3-18) access panel could not be found. 4. Second Floor - the fire/smoke barrier at the fire doors (2-F-31) had a fire damper, but no smoke damper. 1999 NFPA 90A, 3-3.5.1 Smoke dampers shall be installed at or adjacent to the point where air ducts pass through required smoke barriers, but in no case shall a smoke damper be installed more than 2 ft (0.6 m) from the barrier or after the first air duct inlet or outlet, whichever is closer to the smoke barrier. 1999 NFPA 90A, 2-3.4.1 A service opening shall be provided in air ducts adjacent to each fire damper, smoke damper, and smoke detector. The opening shall be large enough to permit maintenance and resetting of the device.
K0069	LIFE SAFETY CODE STANDARD CFR(s): NFPA 101 Cooking facilities are protected in accordance with 9.2.3. 19.3.2.6, NFPA 96 This STANDARD is not met as evidenced by: The facility failed to maintain the dietary hood. Findings include: A) During the survey, the filters in the dietary hood in the Short Line Grill, were observed to be damaged, causing the filters not to be held tight and firmly in place. NFPA 96, 3-2.3 Grease filters shall be listed and constructed of steel or listed equivalent material and shall be of rigid construction that will not distort or crush under normal operation, handling, and cleaning conditions. Filters shall be tight fitting and firmly held in place. B) During survey, the provided documentation for the monthly inspection of the hood system was the inspection card attached to the pull station of the hood extinguishing system. This card was observed with space on the reverse side to date and initial each month an inspection was conducted by facility staff. This side of the inspection card was blank. For the Main Kitchen, and the Short Line Grill, which is two separate extinguishing sytems. NFPA 17, 9-2.1- On a monthly basis, inspection shall be conducted in accordance with the manufacturer 's listed installation and maintenance manual or owner 's manual. As a minimum, this "quick check " or inspection shall include verification of the following: (a) The extinguishing system is in its proper location. (b) The manual actuators are unobstructed. (c) The tamper indicators and seals are intact. (d) The maintenance tag or certificate is in place. (e) The system shows no physical damage or condition that might prevent operation. (f) The pressure gauge(s), if provided, is in operable range. (g) The nozzle blow-off caps, where provided, are intact and undamaged. (h) Neither the protected equipment nor the hazard has been replaced, modified, or relocated.
K0076	LIFE SAFETY CODE STANDARD CFR(s): NFPA 101 Medical gas storage and administration areas are protected in accordance with NFPA 99, Standards for Health Care Facilities. (a) Oxygen storage locations of greater than 3,000 cu.ft. are enclosed by a one-hour separation. (b) Locations for supply systems of greater than 3,000 cu.ft. are vented to the outside. NFPA 99 4.3.1.1.2, 19.3.2.4 This STANDARD is not met as evidenced by: The facility failed to provide proper storage of oxygen cylinders. Findings include: A) During the survey, appropriate signage was not provided, no smoking sign was displaced in room, or on the door as you entered. CGA G-4, 4.1.10, and 1999 NFPA 99, 4-3.5.2.2(b)2 and 4-5.5.2.2(b)2 Full and empty cylinders shall be stored separately, with appropriate signage.
K0077	LIFE SAFETY CODE STANDARD CFR(s): NFPA 101 Piped in medical gas systems comply with NFPA 99, Chapter 4. This STANDARD is not met as evidenced by: The facility failed to maintain the medical gas systems per code. Findings include: During the survey, the following was observed: 1. Fourth Floor - the medical gas alarm panel at the Nurses' Station (MGA 4-01), the oxygen did not give an audible alarm when tested. 2. According to the documentation provided by the facility from the 02/22/2010 medical gas system inspection report, the medical gas system did not comply with NFPA 99. 1999 NFPA 99, 4-3.1.2.2 Gas Warning Systems. (a) * General. 1. All local, master, and area alarm panels used for medical gas systems shall provide the following: a. Separate visual indicators for each condition monitored, b. Cancelable audible indication of an alarm condition. The audible indicator shall produce a minimum of 80 dBA measured at 3 ft (1 m). A second indicated condition occurring while the alarm is silenced shall reinitiate the audible signal, c. A means to visually indicate a lamp or LED failure 2. Local, master, and area alarms shall indicate visually and audibly if, a. The monitored condition occurs b The wiring to the sensor or switch is disconnected. 1999 NFPA 99 Piped medical gas systems shall meet all requirements of NFPA 99.
K0104	LIFE SAFETY CODE STANDARD CFR(s): NFPA 101 Penetrations of smoke barriers by ducts are protected in accordance with 8.3.6. This STANDARD is not met as evidenced by: The facility failed to maintain a smoke barrier per code. Findings include: During the survey, on the Sixth Floor at the smoke doors on the left side in front of the Nurses' Station (6 - F - S - 23) the smoke barrier had an unsealed conduit with several blue wires. 2000 NFPA 101, 8.3.6.1 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows: (1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions: a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier. b. It shall be protected by an approved device that is designed for the specific purpose. (2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions: a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier. b. It shall be protected by an approved device that is designed for the specific purpose.
K0130	MISCELLANEOUS CFR(s): NFPA 101 OTHER LSC DEFICIENCY NOT ON 2786 This STANDARD is not met as evidenced by: The facility failed to maintain the Line Isolation Monitors (L.I.M.) per code. Findings include: During the survey, the following L.I.M. in the O.R. on the Second Floor were observed not to alarm when tested: 1. L.I.M. marked "Aramark 0519" 2. L.I.M. marked "Aramark 0510" 1999 NFPA 99, 3-3.2.2.3 Line Isolation Monitor. (a) * In addition to the usual control and protective devices, each isolated power system shall be provided with an approved continually operating line isolation monitor that indicates possible leakage or fault currents from either isolated conductor to ground. (b) The monitor shall be designed such that a green signal lamp, conspicuously visible to persons in the anesthetizing location, remains lighted when the system is adequately isolated from ground; and an adjacent red signal lamp and an audible warning signal (remote if desired) shall be energized when the total hazard current (consisting of possible resistive and capacitive leakage currents) from either isolated conductor to ground reaches a threshold value of 5.0 mA under normal line voltage conditions. The line isolation monitor shall not alarm for a fault hazard current of less than 3.7 mA. (c) The line isolation monitor shall have sufficient internal impedance such that, when properly connected to the isolated system, the maximum internal current that will flow through the line isolation monitor, when any point of the isolated system is grounded, shall be 1 mA. 1999 NFPA 99, 3-3.3.4.2 Line Isolation Monitor Tests. The proper functioning of each line isolation monitor (LIM) circuit shall be ensured by the following: (a) The LIM circuit shall be tested after installation, and prior to being placed in service, by successively grounding each line of the energized distribution system through a resistor of 200 V ohms, where V = measured line voltage. The visual and audible alarms [see 3-3.2.2.3(b)] shall be activated. (b) The LIM circuit shall be tested at intervals of not more than 1 month by actuating the LIM test switch [see 3-3.2.2.3(f)]. For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months. Actuation of the test switch shall activate both visual and audible alarm indicators. (c) After any repair or renovation to an electrical distribution system and at intervals of not more than 6 months, the LIM circuit shall be tested in accordance with paragraph (a) above and only when the circuit is not otherwise in use. For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months.
K0144	LIFE SAFETY CODE STANDARD CFR(s): NFPA 101 Generators are inspected weekly and exercised under load for 30 minutes per month in accordance with NFPA 99. 3.4.4.1. This STANDARD is not met as evidenced by: The facility failed to maintain the generator per code. Findings include: During the survey, the facility failed to provide documentation of weekly visual inspections on all three of the generators. 1999 NFPA 110, 6-4.1 Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.
K0147	LIFE SAFETY CODE STANDARD CFR(s): NFPA 101 Electrical wiring and equipment is in accordance with NFPA 70, National Electrical Code. 9.1.2 This STANDARD is not met as evidenced by: A) During the survey, two junctions boxes were observed to be missing the covers, in the Housekeeping Storage Room. 1999 NFPA 70, 370-25 and 410-12. Each box in completed installations to have a cover, face plate, or fixture canopy. 27382 B) The facility failed to maintain the electrical system per code. Findings include: During the survey, the following was observed: 1. Fourth Floor the fire/smoke barrier at Labor and Delivery had two junction boxes without cover plates. 2. Fourth Floor - Manager's Office had a refrigerator plugged into a surge protector. 3. Fourth Floor - Call Room 1 in O.B. - had a homemade extension cord with an an electrical four gang outlet on one end with an extension cord and a surge protector were plugged into it. 4. Second Floor - O.R. Scheduling had an extension cord plugged into a surge protector. 5. Second Floor - O.R. Breakroom had a homemade extension cord with an an electrical outlet on one end; a microwave was plugged into it and it was laying on the microwave. 6. Second Floor - Medical Records had several surge protectors plugged into other surge protectors. 7. Seventh Floor - Radio Room had a microwave plugged into a surge protector, that surge protector was plugged into another surge protector, that also had a refrigerator plugged into it. 8. Sixth Floor - Case Management Office had a refrigerator plugged into one surge protector and a microwave plugged into another surge protector. 9. Third Floor - Maintenance Break Room had a homemade extension cord with an an electrical outlet on one end; a refrigerator was plugged into it. 10. Third Floor - Respiratory Therapy Break Room had a microwave plugged into a surge protector. 11. Third Floor - Utilization Review - had a microwave and a refrigerator plugged into a surge protector. 1999 NFPA 70, 370-28 Boxes and conduit bodies used as pull or junction boxes shall comply with (a) through (d). (c) Covers. All pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use. Where metal covers are used, they shall comply with the grounding requirements of Section 250-110. An extension from the cover of an exposed box shall comply with Section 370-22, Exception. 1999 NFPA 70, 400-7 and 400-8, and HCFA Transmittal Notice 22-99 Appliances, such as air conditioners and refrigerators, shall plug directly into a receptacle. 1999 NFPA 70, 400-7 Uses Permitted (a) Uses. Flexible cords and cables shall be used only for the following: 1. Pendants 2. Wiring of fixtures 3. Connection of portable lamps, portable and mobile signs, or appliances 4. Elevator cables 5. Wiring of cranes and hoists 6. Connection of stationary equipment to facilitate their frequent interchange 7.Prevention of the transmission of noise or vibration 8. Appliances where the fastening means and mechanical connections are specifically designed to permit ready removal for maintenance and repair, and the appliance is intended or identified for flexible cord connection 9. Data processing cables as permitted by Section 645-5 10. Connection of moving parts 11. Temporary wiring as permitted in Sections 305-4(b) and 305-4(c) (b) Attachment Plugs. Where used as permitted in subsections (a)(3), (a)(6), and (a)(8), each flexible cord shall be equipped with an attachment plug and shall be energized from a receptacle outlet. 2000 NFPA 101, 9.1.2 Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.