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Based on observations and confirmed by staff, the facility failed to ensure that corridor walls are constructed as required.

THE FINDINGS INCLUDE:
Observations while touring the facility on the afternoon 10/07/14 revealed the kitchen corridor wall, located on the ground floor level leading to the main North Building corridor, is not smoke tight. The wall in question had formally had a pass though door that was used to accept soiled dietary trays. The door is no longer in use and was removed and sealed with Gypsum wall board (GWB) on both the corridor side and the kitchen side. There is a gap approximately 1/2 inch around the new GWB in the existing corridor and kitchen wall.


This was acknowledged at the exit interview conference by the hospital management team.

Based on observations, the facility failed to assure that smoke barriers are constructed to restrict the movement of smoke. Section 8.3.6.1 requires pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers to be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier or to be protected by an approved device that is designed for the specific purpose.

THE FINDINGS INCLUDE:

Observations while touring the facility on 10/7/14 revealed that the smoke barrier walls have voids above the suspended ceiling in the following areas:

1st floor South
- The smoke barrier wall by South Stair 1 was not smoke tight due to an approximate 2' x 2" void around a wire penetration.

2nd floor West
- The smoke barrier wall which is located at the 2nd floor entrance to the Derenzo Patient Care Unit is not constructed to restrict the movement of smoke due to an approximate 3" x 12" void adjacent to the ventilation duct.

- The smoke barrier wall which is located between the Resource Nurse room and the corridor is not smoke tight due to a void around the BX conduit.

This was acknowledged by Maintenance personnel during the survey.

Based on observations, the facility failed to ensure that smoke barriers are constructed to restrict the movement of smoke. Section 8.3.6.1 requires pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers to be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier or to be protected by an approved device that is designed for the specific purpose.

THE FINDINGS INCLUDE:

Observations while touring the facility on 10/7/14 revealed that the smoke barrier walls have voids above the suspended ceilings in the following areas:

1st floor
- The smoke barrier wall which is located at the 1st floor entrance of the Cancer Center from the Main Building is not constructed to restrict the movement of smoke due to four approximate 2" voids above the suspended ceiling.

- The smoke barrier wall on the 1st floor which separates the Cancer Center from the North Wing is not smoke tight due to an approximate 10" x 10" void around a 4" sewer line in the Linear Accelerator Equipment Room.

2nd floor
- The smoke barrier wall which is located at the 2nd floor entrance of the Cancer Center from the Main Building is not constructed to restrict the movement of smoke due to a void around the 6 inch sprinkler pipe and an approximate 10" x 10" void in the area of the Delivery Entrance (NB 235). In addition, the smoke barrier in this same area, above the brick portion of the wall, is only provided with sheet rock on one side of the metal studs. The smoke barrier wall is required to provide a one hour fire resistance rating.

This was acknowledged by Maintenance personnel during the survey.

Based on observation and confirmed by staff, the facility failed to ensure that smoke barrier doors are installed as required in accordance with Section 18.3.7.5 and 18.3.7.7.

Section 18.3.7.5 states doors in smoke barriers shall be substantial doors, such as 1 3/4-in. 4.4-cm thick, solid-bonded wood core doors, or shall be of construction that resists fire for not less than 20 minutes. Cross-corridor openings in smoke barriers shall be protected by a pair of swinging doors or a horizontal sliding door complying with 7.2.1.14. Swinging doors shall be arranged so that each door swings in a direction opposite from the other.

Section 18.3.7.7 states vision panels consisting of fire-rated glazing or wire glass panels in approved frames shall be provided in each cross-corridor swinging door and at each cross-corridor horizontal sliding door in a smoke barrier.

THE FINDINGS INCLUDE:

Plans dated 4/17/13 were provided identifying smoke and fire barriers throughout the facility. Observations while touring the building on 10/7/14 and inspecting the identified smoke barriers revealed the following:

Ground Floor -
- The single leaf cross corridor smoke barrier door located by the reception area is provided with a plain glass vision panel. In addition, the approximate 2' x 6' sidelight is a plain glass. As a result, this door assembly does not meet the requirements of Section 18.3.7.7.

- The approximately 2' x 6' side light vision panel, located adjacent to the reception area, is a plain glass vision panel which does not meet the requirements of Section 18.3.7.7.

First Floor
- The smoke barrier doors which lead from the hospital into the Cancer Center do not swing in the opposite direction as required by Section 18.3.7.5, nor are they equipped with vision panels in accordance with Section 18.3.7.7.

- The smoke barrier doors which lead form the the Cancer Center to the Administration wing are not provided with vision panels in accordance with Section 18.3.7.7.
Second Floor
- The smoke barrier doors which lead from the hospital into the Cancer Center do not swing in the opposite direction as required by Section 18.3.7.5, nor are they equipped with vision panels in accordance with Section 18.3.7.7.
This was acknowledged by facility personnel during the tour and by Engineering and the Director of Engineering during the exit interview process.

Based on observations the facility failed to ensure that door openings in smoke barriers are self-closing or automatic closing in accordance with NFPA #101 Life Safety Code 2000 Edition. Chapter 8. Section 8.3.4.3. states doors in smoke barriers shall be self-closing or automatic-closing in accordance with 7.2.1.8 and shall comply with the provisions of 7.2.1.

Observations while touring the facility on the afternoon of 10/07/14, revealed the following:

Ground Floor Level

1) The door to the room identified as Ultrasound #2 is part of the smoke barrier that separates the Radiology Department from the main entrance and it does not have a self closing or automatic closing device.

2) The door to the room identified as a coffee/lunch room is part of the smoke barrier that separates the North and the South Buildings and it does not have a self closing or automatic closing device. The room is located behind the check-in area to the Oncology/Hematology Department.

This was acknowledged at the exit interview conference by the hospital management team.

Based on observations, the facility failed to ensure that the discharge from exits is in accordance with Chapter 7 and means of egress components in accordance with Section 7-2. Section 7.1.10.1 requires every exit, exit access and exit discharge to be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

THE FINDINGS INCLUDE:

Observations while touring the facility on the afternoon 10/7/14 revealed the north stair "G" exterior exit discharge has a broken concrete stair tread. The front edge of the concrete tread has broken free, rendering the path of exit unsafe due to a tripping hazard.

This was acknowledged at the exit interview conference by the hospital management team.

Based on observations and confirmed by staff, the facility failed to ensure that fire drills are conducted as required.

THE FINDINGS INCLUDE:

During the afternoon hours of 10/6/14, the facility's documentation regarding fire drills was reviewed for code compliance. During review, it was noted that the fire drills are not performed as required. Although the facility is meeting the minimum requirements for the amounts of drills performed, the drills during the 2nd Shift (3:00 P.M.-11:00P.M.) and the 3rd Shift (11:00 P.M.-7:00 AM.) are not performed in the correct manner. The drills performed during these time periods are conducted as in-services on fire safety. It was noted after documentation review that the staff member responsible for conducting these drills travels from unit to unit performing a 5-minute in-service in each location. An in-service on fire safety does not constitute an actual fire drill and credit is not given as such. The drills on the 2nd Shift do not utilize the alarm system to initiate the drill as required prior to 9:00 P.M. In addition, the remaining drills for these two shifts are not initiated by a coded announcement as required. It was stated by hospital staff that over head paging is not permitted, and that it is controlled from an outside source only. As a result, the fire drills for the 2nd & 3rd Shifts are not performed as required by 19.7.1.2.

This was acknowledged at the exit interview conference by the hospital management team.

Based on record review and confirmed by staff, it was revealed that the facility failed to ensure the fire alarm system is maintained as required. NFPA #72 (National Fire Alarm Code) section 7-1.2 states the owner or the owner's designated representative shall be responsible for inspection, testing, and maintenance of the system and alterations or additions to this system. The delegation of responsibility shall be in writing, with a copy of such delegation provided to the authority having jurisdiction upon request. Section 7-1.2.2 states service personnel shall be qualified and experienced in the inspection, testing, and maintenance of fire alarm systems.
NFPA 72 section 4-3.2.1 states that audible notification appliances intended for operation in the public mode shall have a sound level of not less than 75 dBA at 10 ft (3 m) or more than 120 dBA at the minimum hearing distance from the audible appliance.
Section 4-3.2.2 states to ensure that audible public mode signals are clearly heard, they shall have a sound level at least 15 dBA above the average ambient sound level or 5 dBA above the maximum sound level having a duration of at least 60 seconds, whichever is greater, measured 5 ft (1.5 m) above the floor in the occupiable area.

THE FINDINGS INCLUDE:

During the afternoon hours of 10/6/14, the facility's documentation regarding fire drills was reviewed for code compliance. During review, it was noted that there are numerous staff complaints of the fire alarm system being too loud during the fire drills. The fire drill dated 7/25/14 states that to alleviate the sound issues, a total of 40 horn strobe devices were removed. It further states that the devices were replaced with strobe only devices eliminating the audible capability. In addition, the local Fire Department stated that a sound decibel test must be provided to them in order to ensure their requirements are being met. The facility stated that in-house staff took sound level reading (dBA) after the replacement of these audible devices to ensure the proper levels. After reviewing the latest fire alarm report dated 9/16/14 and confirming with facility staff, a proper sound decibel test from a qualified & experienced vendor has not been performed as of the survey date.

This was acknowledged at the exit interview conference by the hospital management team.

Based on observations and records provided, the facility failed to properly maintain the sprinkler system. NFPA #25 section 1-4.2 states the responsibility for properly maintaining a water-based fire protection system shall be that of the owner(s) of the property. By means of periodic inspections, tests, and maintenance, the equipment shall be shown to be in good operating condition, or any defects or impairments shall be revealed.
Inspection, testing, and maintenance shall be implemented in accordance with procedures meeting or exceeding those established in this document and in accordance with the manufacturer's instructions. These tasks shall be performed by personnel who have developed competence through training and experience.
NFPA 25 section 9-2.6 states a main drain test shall be conducted annually at each water-based fire protection system riser to determine whether there has been a change in the condition of the water supply piping and control valves.
Section 9-4.1.2 states alarm valves and their associated strainers, filters, and restriction orifices shall be inspected internally every 5 years unless tests indicate a greater frequency is necessary.
Section 2-3.2 states gauges on sprinkler systems shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge. Gauges not accurate to within 3 percent of the full scale shall be recalibrated or replaced.
Section 9-3.5 states the operating stems of outside screw and yoke valves shall be lubricated annually.
Section 2-2.4.1 states that gauges on wet pipe sprinkler systems shall be inspected monthly to ensure that they are in good condition and that normal water supply pressure is being maintained. Section 2-2.4.2 states that gauges on dry, preaction, and deluge systems shall be inspected weekly to ensure that normal air and water pressures are being maintained.

THE FINDINGS INCLUDE:

During the morning and afternoon hours of 10/6/14, the facility's documentation regarding the inspection and maintenance of the sprinkler system was reviewed for code compliance. After reviewing the sprinkler system inspection reports dated 9/16/14; 6/5/14; 3/21/14; 12/5/13; 9/11/13 and 6/12/13, the following deficiencies were observed:

1) The main drain test of the riser in the sub-basement has not been performed. Each of the inspections state that the test can not be performed due to the floor drain not being able to handle the water flow. It was stated that the room will flood if a main drain test is performed.

2) The internal valve inspections are not documented as being performed on any of the valves. Each of the inspection reports listed above states the test date is unknown for internal inspections of the valves which have dates of 1965 and 2008.

3) According to the inspection reports, all of the sprinkler gauges are greater than 5-years in age and have not had a calibration test performed.

4) According to the inspection reports, none of the OS&Y valves have been lubricated during the past year.

5) The OS&Y valve located in Fan Room #4 is noted on each of the inspections as leaking and in need of repair and/or replacement. As of the survey date, the valve is still in need of repair and/or replacement.

6) Weekly pressure readings are not documented/recorded as required for the two dry type sprinkler systems. It was stated by staff that pressure readings are recorded daily for wet systems, but that the dry pipe systems were inadvertently left off the preventative maintenance schedule.

This was acknowledged at the exit interview conference by the hospital management team.

Based on observation, the facility was not in compliance with NFPA 90A. Section 2-3.10.2 states the space between the top of the finished ceiling and the underside of the floor or roof above shall be permitted to be used to supply air to the occupied area, or return or exhaust air from or return and exhaust air from the occupied area, provided that the following conditions are met:
(a) All materials exposed to the airflow shall be noncombustible or limited combustible and have a maximum smoke developed index of 50.
Exception No. 1: The following materials shall be permitted in the ceiling cavity plenum where listed as having a maximum peak optical density of 0.5 or less, an average optical density of 0.15 or less, and a maximum flame spread distance of 5 ft (1.5 m) or less when tested in accordance with the specified test method:
(a) Electrical wires and cables and optical fiber cables - NFPA 262, Standard Method of Test for Flame Travel and Smoke of Wires and Cables for Use in Air- Handling Spaces
(b) Pneumatic tubing for control systems - UL 1820, Standard for Safety Fire Test of Pneumatic Tubing for Flame and Smoke Characteristics
(c) Fire sprinkler piping - UL 1887, Standard for Safety Fire Test of Plastic Sprinkler Pipe for Visible Flame and Smoke Characteristics
(d) Optical-fiber and communication raceways - UL 2024, Standard for Safety Optical-Fiber Cable Raceway
Exception No. 2: Smoke detectors.
Exception No. 3: Loudspeakers and recessed lighting fixtures, including their assemblies and accessories, shall be permitted in the ceiling cavity plenum where listed as having a maximum peak optical density of 0.5 or less, an average optical density of 0.15 or less, and a peak heat release rate of 100 kW or less when tested in accordance with UL 2043, Standard for Safety Fire Test for Heat and Visible Smoke Release for Discrete Products and Their Accessories Installed in Air-Handling Spaces.
Exception No. 4: Supplementary materials for air distribution systems in accordance with 2-3.3.
(b) The integrity of the fire stopping for penetrations shall be maintained.
(c) Light diffusers, other than those made of metal or glass, used in air-handling light fixtures shall be listed and marked "Fixture Light Diffusers for Air-Handling Fixtures."
(d) The temperature of air delivered to these plenums shall not exceed 250°F (121°C).
(e) Materials used in the construction of a ceiling plenum shall be suitable for continuous exposure to the temperature and humidity conditions of the environmental air in the plenum.
(f) Where the plenum is a part of a floor-ceiling or roof-ceiling assembly that has been tested or investigated and assigned a fire resistance rating of 1 hour or more, the assembly shall meet the requirements of 3-3.3.

THE FINDINGS INCLUDE:

During a tour of the facility on 10/7/14. it was observed that a portable air conditioning unit was in use in the Director of Pharmacy's office on the 1st floor. The exhaust vent from the air conditioning unit is ducted to the space between the top of the finished ceiling and the underside of the floor utilizing the space as a plenum. There is no confirmation that the conditions of NFPA 90A, Section 2-3.10.2 are met allowing the use of a plenum.

This was acknowledged by Maintenance personnel during the survey.

Based on observations, the facility failed to ensure that oxygen is stored in accordance with NFPA 99. Sections 16.3.8, 8.3.1.11.2(h), and 4.3.5.2.1(b)27 require freestanding cylinders to be properly chained or supported in a proper cylinder stand or cart.

THE FINDINGS INCLUDE:

Observations while touring the facility on the afternoon of 10/7/14 revealed nine (9) "E" cylinders of oxygen standing upright unsupported (not in a stand or rack) in the oxygen closet, located in the main "Medgas" storage room on the ground floor level of the North Building.


This was acknowledged at the exit interview conference by the hospital management team.

Based on observations and record review and confirmed by staff interview, the facility failed to ensure that the medical gas systems are maintained, tested, and inspected in accordance with NFPA 99. NFPA 99, Section 4.3.5.2.3(d) requires the responsible authority of the facility to establish procedures to ensure that all signal warnings are promptly evaluated and that all necessary measures are taken to reestablish the proper functions of the medical gas system. Section 4.3.5.2.3(g) requires a periodic testing procedure for nonflammable medical gas and related alarm systems to be implemented. Section 4.3.5.2.3(i) requires periodic retesting of audible and visual alarm indicators to be performed to determine that they are functioning properly, and records of the test shall be maintained until the next test.

THE FINDINGS INCLUDE:

During the morning and afternoon hours of 10/6/14, the facility's documentation regarding the inspection and maintenance of the medical gas systems was reviewed for code compliance. According to the testing report dated 9/5/13, a total of 19 items were noted as being deficient. The items noted include but are not limited to the following: operating pressures being to low (47-49 psi); missing valves; leaking valves; wrong location of valves; unsecured oxygen cylinders, improper venting; labeling of valves incomplete; alarms non-functioning; improper wiring of panels; and leaking oxygen outlets.

The facility was asked for documentation ensuring that the above noted deficiencies have been corrected. It was stated by facility staff that the items had yet to be addressed by the facility and appropriate vendor. It was further stated that the vendor was contacted during survey and was currently in the facility correcting the above noted items. A time period of over 1-year has passed before the facility took the corrective action on these 19 noted items.

This was acknowledged at the exit interview conference by the hospital management team.

Based on observation on 10/8/14, it was revealed that the facility was not in compliance with NFPA 99. Section 12-3.3.1 states the electrical distribution system for patient care areas shall conform to the requirements in Chapter 3, " Electrical Systems. " Section 12-3.3.2 states the essential electrical distribution system shall conform to a Type 1 system, as described in Chapter 3, " Electrical Systems. " Section 3-3.2.1.2 5. e. states one or more battery-powered emergency lighting units shall be provided in Anesthetizing Locations in accordance with NFPA 70, National Electrical Code, Section 700-12(e).
THE FINDINGS INCLUDE:
Battery-powered emergency lightning is not provided in Operating Room numbers 5 and 6 in accordance with NFPA 99, Section 3-3.2.1.2 5. e.

This was acknowledged at the exit interview conference by the hospital management team.

A. Based on record review and confirmed by staff, it was revealed that the facility failed to ensure compliance with NFPA 101. Section 4.6.12.1 states whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction. NFPA 72 (National Fire Alarm Code). Section 7-1.2 states the owner or the owner's designated representative shall be responsible for inspection, testing, and maintenance of the system and alterations or additions to this system. The delegation of responsibility shall be in writing, with a copy of such delegation provided to the authority having jurisdiction upon request. Table 7-3.2 #20 states Off-Premises Transmission Equipment shall be tested on a quarterly basis. Section 7.3.2 and Table 7.3.2 require systems with sealed batteries to have the battery charger tested annually, replace the battery every 4 years, to conduct a 30 minute battery discharge test annually, and to conduct a load voltage test semi-annually.

THE FINDINGS INCLUDE:

During the morning hours of 10/08/14 while performing the record review, it was observed that the facility does not maintain/inspect the fire alarm system as required. The only fire alarm vendor inspection report available for review was dated 8/01/13. As a result of the annual testing, the following items were noted as being deficient:

1. The off-premise testing is not performed quarterly as required.

2. The fire alarm batteries are not dated or documented as being tested as required. There are no line items pertaining to the testing of batteries for either annual or semi-annual tests.

B. Based on record review and confirm by interview, the facility failed ensure that the bulk oxygen tank is maintained in accordance with NFPA 50 and 99. NFPA 99, Section 4.3.1.1.2(a)10b. requires bulk oxygen systems to be in accordance with NFPA 50. Section 4.2.1 requires each bulk oxygen system installed on consumer premises to be inspected annually and maintained by a qualified representative of the equipment owner.

THE FINDINGS INCLUDE:

Observations while touring the facility on the morning of 10/08/14 revealed that the facility does not have documentation available to substantiate that the bulk oxygen tank is inspected annually. According to records available on the day of survey the last annual inspection of the bulk oxygen tank was performed on 7/23/13.

This was acknowledged at the exit interview conference by the hospital management team.

Based on record review and confirmed by staff, the facility failed to ensure that the generator is run monthly under a load condition for the required 30-minutes. NFPA 110 section 6-4.1 states level 1 and level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly. NFPA 99 3-4.4.1.1 states generator sets shall be tested twelve (12) times a year with testing intervals not less than 20 days or exceeding 40 days.
NFPA 110 section 6-4.2 states generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating.
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer.
The date and time of day for required testing shall be decided by the owner, based on facility operations.
Section 6-4.3 states load tests of generator sets shall include complete cold starts.
Section 6-4.2.2 states diesel-powered EPS installations that do not meet the requirements of 6-4.2 shall be exercised monthly with the available EPSS load and exercised annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of 2 continuous hours.
Section 6-4.5 states level 1 and level 2 transfer switches shall be operated monthly. The monthly test of a transfer switch shall consist of electrically operating the transfer switch from the standard position to the alternate position and then a return to the standard position.

THE FINDINGS INCLUDE:

During the morning and afternoon hours of 10/6/14, the facility's documentation regarding the generator testing was reviewed for code compliance. It was noted that the generator is not tested monthly and weekly as required. After reviewing the generator log book, it was observed that the generator did not have a documented load test performed during February 2014. The weekly tests during February 2014 were not conducted/documented as required. In addition, the transfer switches were not tested/documented during February 2014. It was stated by hospital staff that the position of Director of Facilities Management and numerous maintenance positions were changed during this time period.

This was acknowledged at the exit interview conference by the hospital management team.

Based on observations and confirmed by staff, the facility failed to ensure that elevators are tested as required. Section 9.4.6 states elevators shall be subject to routine and periodic inspections and tests as specified in ASME/ANSI A17.1, Safety Code for Elevators and Escalators. All elevators equipped with fire fighter service in accordance with 9.4.4 and 9.4.5 shall be subject to a monthly operation with a written record of the findings made and kept on the premises as required by ASME/ANSI A17.1, Safety Code for Elevators and Escalators.

THE FINDINGS INCLUDE:

During the morning hours of 10/7/14, the facility was asked for documentation regarding the testing of the multiple elevators. The facility provided documentation for annual testing only and staff stated that monthly testing is not performed. Each of the facility's elevator is equipped with a fire fighter service and not tested monthly as required.

This was acknowledged at the exit interview conference by the hospital management team.