Volume 2025 | No. 2
SURVEYOR
PHYSICAL ENVIRONMENT AND LIFE SAFETY
Compliance tips for:
Examples of ACHC Surveyor findings: ■ Above the ceiling near patient room 328, a flexible electric cable was observed to have live electric wires not terminated in a required junction box or device, along with an open junction box in the same area. ■ An electrical junction box missing its cover was observed in the ED near exam room 21. ■ Several low-voltage data cables were found zip-tied to the electrical conduit in the clean linen receiving area. ■ Line isolation monitors located in the surgery department were not functional. ■ The exterior light fixture protective globe was broken, and the fixture did not appear functional at elevator 1 machine room. Another broken light fixture with exposed wiring was noted at the same location. ■ Equipment room light fixtures were hanging from electrical conduits rather than properly installed to structural supports. ■ In OR3 a non-compliant relocatable power tap was observed on the floor. UL 1363A or 60601-1 is required. ■ In the microbiology laboratory, a microwave next to a personal refrigerator was electrically connected via an ungrounded electrical extension cord using a two prong adapter. ■ Electrical panels CR-1-A and CR-1-B contained multiple circuits which were not labeled as to their use and circuits were missing protective cover plates. ■ In the basement electrical room, breakers 7 and 8 were observed in the on position and should be off, or identified appropriately for the load served. Compliance tips for:
Generators must be installed in protected areas (whether inside or outside the hospital building) with a remote manual stop station located separately. Routine inspection and testing occurs weekly. For lead-acid batteries, electrolyte specific gravity levels or conductive readings are recorded based on battery type. In addition, a fuel quality test is performed at least annually. ■ Confirm that generators located indoors are separated within a two-hour fire-rated barrier. ■ Audit for weekly inspection logs for battery tests. ■ Audit for annual fuel quality tests. ■ Develop a generator compliance dashboard that tracks weekly, monthly, and annual testing requirements in one view, ensuring no inspection or fuel quality test is ever missed. ■ Create a generator compliance quick-guide for engineering staff that outlines all NFPA 110 testing intervals and documentation requirements, then use it to train others and standardize practices across your organization.
Nerd Newbies (understand the requirement)
Nerd Apprentices (audit for excellence)
Nerd Trailblazers (prepare the path for others)
14.05.10 (CAH) 13.05.10*
Utility systems
*For surveys that took place between June 1, 2024, and April 6, 2025, this standard was numbered 13.05.09.
Frequency of the citation: 14.05.10 67%, 13.05.10 61%
Electrical control panels must be accessible with all circuits labeled. Junction boxes must be covered. Electrical fixtures must be properly installed.
Nerd Newbies (understand the requirement)
Overview of the requirement: Electrical utilities are maintained in fire-safe condition with unobstructed access to electrical control panels.
■ Cover all junction boxes, even those above ceiling level. ■ Label all circuit breakers and keep those that are unused in the off position. ■ Audit relocatable power taps (surge protectors/power strips) against inventory. ■ Ensure all electrical panels are accessible but protected from unauthorized access—in other words, locked if in an unsecured space. ■ Educate staff that relocatable power taps must be special-use type and permanently mounted (requiring a tool for removal).
Nerd Apprentices (audit for excellence)
Comment on deficiencies: Compliance is assessed through observation. Most deficiencies cited issues with: ■ Open and improperly protected electrical wiring.
Nerd Trailblazers (prepare the path for others)
■ Improper cable support and installation. ■ Nonfunctional or unsafe equipment. ■ Improper use of extension cords and power taps. ■ Panel identification and circuit protection.
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