Non-compliance with NFPA 70 Standards for Electrical Systems
Penalty
Summary
During the Life Safety Recertification survey conducted from (MONTH) 4, 2024, through (MONTH) 10, 2024, the facility was found to be non-compliant with NFPA 70 standards regarding the use of extension cords and power strips. Specifically, surveyors observed unmounted power strips in use within the IT Room, Accounting Office, and other administrative areas. Additionally, in the Nursing Office located in 2West, a green extension cord was found under a desk, powering equipment. These observations indicate that the facility did not ensure that electrical systems were used in accordance with the National Electrical Code, as required by NFPA 101:9.1.2 and NFPA 70:400.8. At the time of the survey findings, the Director of Maintenance acknowledged the use of the extension cord, stating it was a temporary measure, and assured that all power strips would be mounted. However, the report does not provide any further details on corrective actions or the impact of these deficiencies on residents or staff. The deficiency highlights a failure to adhere to established electrical safety standards, which are critical for ensuring the safety and functionality of electrical systems within the facility.
Plan Of Correction
Plan of Correction: Approved December 31, 2024 1. What corrective actions will be accomplished for those residents found to have been affected by the deficient practice? a. No residents were identified as affected by the deficient practice. b. To comply with 2012 NFPA 101 and 2011 NFPA 70, the Director of Engineering immediately instructed the Engineering staff to: 1. Mount the unmounted power strip in use in the IT room, Accounting office and other administrative areas. 2. Remove the extension cord in the 2 West Nursing office. 2. How would you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? a. The facility respectfully states that all residents have the potential to be affected by deficient practice. b. The Engineering staff performed an inspection throughout the facility to ensure that extension cords in use are appropriate and power strips in use are mounted in accordance with the 2011 National Electric Code. All findings were deemed to be in compliance. 3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur? a. The Director of Engineering, Administrator and QA Director created a policy on use of extension cords and power strips. b. All staff will be informed and educated regarding this new policy, use of extension cords and power strips. c. A copy of the attendance will be maintained for reference and validation. 4. How the corrective actions will be monitored to ensure the deficient practice will not recur, i.e. what quality assurance program will be put into practice: a. The Director of Engineering will develop an audit tool to monitor use of extension cords and power strips. b. Audits will be performed monthly by the Engineering staff x 5 months and then annually thereafter to ensure compliance. c. Any issues identified by the audit will be corrected immediately by the Engineering Department. d. Audit findings will be presented to the QA Committee quarterly for evaluation. 5. Completion Date: (MONTH) 7, 2025 Responsible Person: Director of Engineering