Volume 2024 | No. 2
SURVEYOR
PHYSICAL ENVIRONMENT AND LIFE SAFETY
n Testing failures must be immediately corrected with an ALSM when repair is pending.
13.05.09 Utility systems Overview of the requirement:
Electrical utilities are maintained in fire-safe condition.
When planning to repurpose a room as a hazardous area under the Life Safety Code, refer to NFPA 101-2012: 43.7.1.2(2) for requirements.
Comment on deficiencies:
Compliance is assessed through observation. Most deficiencies cited issues with electrical panels, with uncovered junction boxes, and with power strips.
Frequency of citation:
28%
13.04.09 Ceilings Overview of the requirement:
Examples of surveyor findings:
n Electrical junction boxes were open in the generator room. n Low voltage cables were zip-tied to electrical conduit near the nurse station. n Outlets near the sink in radiology were not GFCI type. n Electrical panel circuit labeling was incomplete. n Circuit breakers labeled as spares, were energized in the “on” position. n Electrical panels were obstructed by equipment, supplies, and furniture. n Two ORs and a C-section room had outlet strips on the floor. They were special purpose UL 1363A or UL 60601-1 but were not permanently mounted to equipment, cart, or pole. n The second floor ICU has a blue pull station labeled “pull in case of emergency.” Staff do not know the purpose or function of this pull station. n Cover all junction boxes, even those above ceiling level. n Label all circuit breakers and keep those that are unused in the off position. n Ensure all electrical panels are accessible but protected from unauthorized access—in other words, locked if in an unsecured space. n Relocatable power taps (RPT or power strips) must be special use type and permanently mounted (requiring a tool for removal).
Ceilings designed to limit the passage of smoke are free from cracks, holes, and gaps greater than 1/8 inch. Compliance is assessed through observation. Deficiencies noted unsealed penetrations in “back of house” locations, but observations were not limited to these spaces.
Comment on deficiencies:
Frequency of citation:
29%
Examples of surveyor findings:
n In the biomed office/electrical room/telephone equipment room/ mechanical room, a cable/ cable bundle/conduit was observed penetrating a ceiling tile with greater than a 1/8 inch gap. n In the first floor main corridor, several two-foot by four-foot tiles were observed to be unseated in the ceiling grid, leaving gaps. n In the pulmonary department blood gas lab, five ceiling tiles were observed with greater than 1/8 inch gaps around a smoke detector, a two-inch conduit, an exhaust vent, a conduit from an electric box and a sprinkler head. n In room [number], a cracked ceiling tile requiring replacement. n Radiology department ceiling tiles were removed due to an ongoing leak. n The clean linen storage area in the basement, an approximately one-foot long dry crack and stain was observed, possibly from a past water leak. n Monitor ceilings as part of environmental rounding, examining them from the perspective of preventing the passage of smoke. Drop-in acoustical ceilings are not fire barriers, and do not require fire caulking. n Focus on “back of the house” spaces where deficiencies are less likely to be caught. n Replace and reseat tiles that are damaged or had been temporarily removed. n Seal around penetrations to reduce or eliminate gaps greater than 1/8 of an inch. Latex caulk or mineral wool are acceptable materials for this use.
Tips for compliance:
Tips for compliance:
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