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Based on observations, the facility failed to ensure that the building is of a
conforming construction type. Section 19.1.6.2 requires buildings 3-stories in height to be of at least Type I (443), Type I (332) or Type II (222). Type II (111) are allowed to be 3-stories in height if fully protected by an automatic sprinkler system. Buildings classified as Type III (211) are not allowed to be greater than 2-stories in height and must be fully protected by an automatic sprinkler system.

Findings Include:

A review of facility construction documentation conducted on the morning of 9/03/14, at approximately 10:30 A.M., indicated that the facility's West Wing (building #1) is of a non-conforming construction type. Documentation presented and observations made revealed the building to be 3-stories in height and of Type III (211) construction. Type III (211) buildings are not allowed to be greater than 2-stories in height. As a result the building is found to be non-compliant with the regulations set forth in Chapter 19 Section 19.1.6.2.

The finding was acknowledged by the Director of Plant Services and the Administrator during the exit conference.

NOTE: This item does not meet NFPA 101 Life Safety Code, 2000 edition; however it would meet an alternative compliance with the Code (Fire Safety Evaluation System - FSES) under equivalency concepts of NFPA 101A, Guide on Alternative Approaches to Life Safety, 2001 edition where such equivalency is requested and approved.

Based on observations, the facility failed to ensure that corridors are at least 4 feet wide.

THE FINDINGS INCLUDE:

Building #11 - West Building
Observations while touring the facility on 9/3/14 revealed that the basement corridor is 43" wide which does not meet the four foot requirements of Section 19.2.3.3.

NOTE: This item does not meet NFPA 101 Life Safety Code, 2000 edition; however it would meet an alternative compliance with the Code (Fire Safety Evaluation System - FSES) under equivalency concepts of NFPA 101A, Guide on Alternative Approaches to Life Safety, 2001 edition where such equivalency is requested and approved.


The findings were confirmed by the Director of Plant Services during the exit conference.

Based on observations, the facility failed to ensure that the building is of a
conforming construction type. Section 19.1.6.2 requires buildings 3-stories in height to be of at least Type I (443), Type I (332) or Type II (222). Type II (111) are allowed to be 3-stories in height if fully protected by an automatic sprinkler system. Buildings classified as Type III (211) are not allowed to be greater than 2-stories in height and must be fully protected by an automatic sprinkler system.

Findings Include:

A review of facility construction documentation conducted on the morning of 9/03/14, at approximately 10:30 A.M., indicated that the facility's West Wing (building #1) is of a non-conforming construction type. Documentation presented and observations made revealed the building to be 3-stories in height and of Type III (211) construction. Type III (211) buildings are not allowed to be greater than 2-stories in height. As a result the building is found to be non-compliant with the regulations set forth in Chapter 19 Section 19.1.6.2.

The finding was acknowledged by the Director of Plant Services and the Administrator during the exit conference.

NOTE: This item does not meet NFPA 101 Life Safety Code, 2000 edition; however it would meet an alternative compliance with the Code (Fire Safety Evaluation System - FSES) under equivalency concepts of NFPA 101A, Guide on Alternative Approaches to Life Safety, 2001 edition where such equivalency is requested and approved.

Based on observations, the facility failed to ensure that corridors are at least 4 feet wide.

THE FINDINGS INCLUDE:

Building #11 - West Building
Observations while touring the facility on 9/3/14 revealed that the basement corridor is 43" wide which does not meet the four foot requirements of Section 19.2.3.3.

NOTE: This item does not meet NFPA 101 Life Safety Code, 2000 edition; however it would meet an alternative compliance with the Code (Fire Safety Evaluation System - FSES) under equivalency concepts of NFPA 101A, Guide on Alternative Approaches to Life Safety, 2001 edition where such equivalency is requested and approved.


The findings were confirmed by the Director of Plant Services during the exit conference.

Based on record review and confirmed by staff interview, the facility failed to ensure that the automatic sprinkler system is maintained, tested and inspected per the requirements of the 1998 Edition of NFPA #25 "Standard for Inspection, Testing and Maintenance of Water-Based Fire Protection Systems".
NFPA #25, Sections 1.9 and 1.10 require system components to be inspected and tested in accordance with the intervals specified in the appropriate chapters. Section 2.2.6 requires alarm devices to be inspected quarterly to verify that they are free of physical damage. Section 2.3.3 requires waterflow alarm devices including, but not limited to, mechanical water motor gongs, vane-type waterflow devices, and pressure switches that provide audible or visual signals to be tested quarterly. Section 2.3.3.1 requires alarm devices on wet pipe systems to be tested at least quarterly by opening the inspectors test connection. Section 9.2.6 requires the main drain to be tested quarterly. Section 9.5.1.1 requires all valves to be inspected quarterly.
NFPA #25 Section 9.4.1.2 requires alarm valves and their associated strainers, filters, and restriction orifices to be inspected internally every 5 years.

Findings Include:

A review of the facility's automatic sprinkler system inspection reports made available on the morning of 9/02/14, at approximately 11:00 A.M. revealed the following:

Finding #1
There is no documentation to substantiate the conducting of a first quarter sprinkler system inspection during 2014. Records indicate that an inspection was conducted on 10/24/13 ( the last quarter of 2013) and 4/03/14 (the second quarter of 2014). The length of time between inspections is in excess of one hundred and sixty (160) days. Quarterly is defined as a period of time that is (plus or minus) ninety (90) days in length. When questioned the Director of Plant Services stated that the vendor had missed the first quarter inspection.
As a result of the excessive period of time between inspections the facility is found to be non-compliant with the quarterly inspection requirements outlined in the following sections of NFPA 25:
a) Section 2.2.6 (verification of alarm device integrity)
b) Section 2.3.3 (verification of alarm device a/v signals)
c) Section 2.3.3.1 (test of alarm device via inspectors test connection)
d) Section 9.2.6 (main drain test)
e) Section 9.5.1.1 (valve inspection)
Finding #2
There is no documentation which would indicate that the required internal inspections of the automatic sprinkler system's two (2) main alarm valves have been conducted within the past five (5) years. When questioned the Director of Plant Services confirmed that the inspections had not been conducted. As a result the facility is found to be non-compliant with NFPA #25 Section 9.4.1.2.

The findings were confirmed by the Director of Plant Services during the exit conference.

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 at not less than 30 percent of the EPS nameplate rating.
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.

Findings Include:

During the morning hours of 9/02/14, at approximately 11:00 A.M., while conducting the record review process, it was noted that the generator is not maintained as required. After reviewing the generator monthly load test documentation for the twelve (12) month period starting in 8/13 and commencing in 8/14 the following was revealed. The average amperage reading of the three (3) generator legs varies from a monthly high of 80 amps to a monthly low of 50 amps. A conversion of amps to kilowatts reveals that the generator has not been exercised beyond 23 Kw which equates to an approximate 8% of the 275 Kw nameplate rating. The load testing performed during the past twelve (12) months does not achieve at least 30% of the Kw name plate rating. In addition, the facility has no records to substantiate a supplemental load (bank test) test has been performed per Section 6-4.2.2. during the past year. As a result of the finding the facility is found to be non-compliant with NFPA 110 section 6-4.2 and Section 6-4.2.2.

This was acknowledged by the Hospital President & Director of Plant Services during the survey exit conference.