Non-compliance with Essential Electrical System Requirements
Penalty
Summary
During a Life Safety Code recertification survey conducted on the 23rd of the month in 2025, it was observed that the facility did not maintain its Type 2 Essential Electrical System in accordance with NFPA 99 and NFPA 70 standards. Specifically, the surveyors noted that the Emergency (Life Safety) Branch wiring was not separated from the Critical Branch wiring. This issue was identified in the Emergency Power panels labeled as LPEDD and LPEHH, located on the first and second floors of the facility, respectively. The panel labeled LPEHH, situated in the soiled room on the second floor, contained circuits from both the Emergency and Critical Branches. Emergency circuits such as circuit#20 F/A Door Holder and circuit#22 F/A Control Panel were found alongside Critical Branch circuits, including Nurse Station Receptacles, Room Receptacles, and Nurse Station Refrigerator. Similarly, the panel labeled LPEDD on the first floor also mixed Emergency circuits like circuit#20 F/A Mag Door Holder and circuit#22 F/A Control Panel with Critical Branch circuits such as Nurse Station Receptacles, Room Receptacles, and Kitchen AC. These findings were acknowledged by the facility's Administrator and the Director of Building Services during the exit interview on the 24th of the month in 2025. The lack of separation between the Emergency and Critical Branch circuits in the electrical panels represents a failure to comply with the specified electrical system requirements, potentially impacting the facility's ability to maintain essential services during power interruptions.
Plan Of Correction
Plan of Correction: Approved February 26, 2025 I. The facility contacted electrical company on 2/12/25 to separate the branch circuits; completion date of 3/17/25. II. Anyone has the potential to be affected. III. The maintenance department were educated on NFPA 101 Electrical System – Essential Electrical systems on 2/12/25 by the Director of Maintenance. IV. The maintenance director will monitor the work to ensure successful relocation of the branch circuits to the proper panels. Any findings will be reported to QAPI. V. Responsible party: Director of Maintenance/ Designee.