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Based on observation and staff interview, the facility failed to ensure the 2-hour rating of the exit passageways used in the facility.

Finding:

On 03/19/2018 at 11:58 AM, one approximately 4 inches by 4 inches hole was observed in the 2-hour fire rated enclosure of the exit passageway in the vicinity of the CPEP (Comprehensive Psychiatric Emergency Program) building.

Staff Ff (Associate Director, Facilities) confirmed this finding at the time of observation.

Based on observation and staff interview, the facility failed to ensure that stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with constructions having a fire resistance rating of at least 2 hours.

Findings:

On 03/23/2018 at approximately 10:30AM, a conduit penetration on the two (2) hour fire rated stair enclosure was observed by stair B on the 6th floor of the facility's extension clinic in the Hope Pavilion.

On 03/23/2018 at approximately 11:24 AM, a conduit penetration in the 2 hour fire rated elevator shaft was observed by the elevator lobby corridor on the 6th floor of the facility's extension clinic, the Hope Pavilion .

Staff Ff (Associate Director, Facilities) confirmed these findings at the time of observation.

Based on observation and staff interview, the facility failed to ensure that fire alarm system is maintained in accordance with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code.

Findings include:

On 03/19/2018 at 1:08 PM, it was observed that the smoke detector inside the electrical room in Adult Emergency room area was broken.

Staff Ff (Associate Director, Facilities) confirmed this finding at the time of observation.

Based on observation and staff interview, the facility failed to ensure that automatic sprinkler systems are maintained in accordance with NFPA 25, Standard for Inspection, Testing, and Maintaining of Water-based Fire Protection Systems.

Findings include:

On 03/20/2018 at 10:24 AM, it was observed that four (4) escutcheon cover plates of the sprinkler head inside Operation room #1 were painted.

On 03/22/2018 at 3:00PM, it was observed that there was no battery back up light in the facility's fire pump room/area.

Staff Ff (Associate Director, Facilities) confirmed these findings at the time of observation.

Based on observation and staff interview, the facility failed to ensure that smoke barriers are constructed to a ½ hour fire resistance rating.

Findings:

On 03/19/2018 at approximately 12:05 PM, one unsealed conduit penetration was observed on the 2-hour fire rated smoke barrier wall in the vicinity of electrical closet B1-144-1.

On 03/20/2018 at 2:00PM, one partially sealed cable penetration was observed in the 2-hour fire rated smoke wall above the Fire door by the Endo suite.

On 03/20/2018 at 2:00PM, one hole approximately 10 inches by 10 inches was observed in the 2-hour fire rated smoke wall above the Fire door by the Endo suite.

On 03/20/2018 at 2:10PM, one unsealed conduit penetration was observed in the 2-hour fire smoke wall by room E2-35.

Staff Ff (Associate Director, Facilities) confirmed these findings at the time of observation.

Based on observation and staff interview, the facility failed to ensure that electrical panels and electrical junction boxes are constantly maintained.

Findings:

On 03/20/2018 at 12:00PM, it was observed that electrical panel 'PP2EMQA' in room B2-242 was missing 11 electrical panel breaker blanks.

On 03/23/2018 at 10:45AM, it was observed that the unlabeled electrical panel in room 307 at the hospital extension clinic (Hope Pavilion) has 1 electrical panel breaker blank.

On 03/26/2018 at 10:16 AM, it was observed that electrical panel labelled 'ESBS' in the basement has 2 missing electrical breaker blanks.

On 03/26/2018 at 10:16 AM, it was observed that electrical panel labelled 'ESBK' in the basement has 1 missing electrical breaker blanks.

On 03/26/2018 at 10:16 AM, it was observed that electrical panel labelled 'SBK' in the basement has 2 broken electrical breaker blanks.

On 03/20/2018 at 2:12 PM, an electrical junction box above the suspended ceiling by patient waiting area -room E2-18 was observed to lack cover plate.

On 03/23/2018 at 11:24 AM, an electrical junction box above the suspended ceiling by patient waiting area -room E 2-18 was observed to lack cover plate.

Staff Ff (Associate Director, Facilities) confirmed these findings at the time of observation.

Based on observation and staff interview, the facility failed to ensure that the required additional testing of the hospital-grade receptacles after initial installation testing is performed at intervals defined by documented performance data.

On 03/26/2018 at approximately 11:45 AM, during document review, it was revealed that the facility did not have a documented performance data to accurately determine the interval at which the required testing of the hospital-grade receptacles in the facility should be done.

Staff Ff (Associate Director, Facilities) confirmed these findings at the time of observation.

Based on observation, document review and staff interview, it was revealed that the facility did not have a type 1 Essential Electrical System (EES) in the facility.

Findings

On 03/19/2018 between 11:23 AM and 2:30 PM during the tour of the facility and staff interview, it was discovered that the facility did not have a Type 1 compliant EES system.

For example, panel 'LP-EDA 2' (Emergency) contained both life safety loads, critical load and equipment loads. Also panel 'LP1EM' contained both critical loads and life safety loads mixed together.

During interview with Staff Ff and Staff Gg (Associate Directors, Facilities) on 03/19/2018 at approximately 2:35 PM, they both acknowledged these findings.

Based on observation and staff interview, the facility failed to ensure that Essential Electrical System electrical panels and circuits are marked and readily identifiable.

Findings:

On 03/23/2018 at approximately 10:45AM, it was observed that the electrical panel in the electrical closet 307 was not labeled.

Staff Ff (Associate Director, Facilities) confirmed this finding at the time of observation.