HospitalInspections.org

Based on observations and confirmed by staff, the facility failed to ensure that buildings are properly separated. Section 19.1.1.4.1 states additions shall be separated from any existing structure not conforming to the provisions within Chapter 19 by a fire barrier having not less than a 2-hour fire resistance rating and constructed of materials as required for the addition.

THE FINDINGS INCLUDE:

- During the morning hours of 8/22/12 while touring the facility, the flowing were observed regarding the ground floor two hour fire rated wall that separates the health care occupancy from the business occupancy.

1) The door to the financial area is missing.

2) The door to the computed tomography (CT) work room does not have a rating tag to confirm that the door is rated for 90 minutes.

This was observed by hospital administration staff while touring the facility.

Based on observations and confirmed by staff, the facility failed to ensure compliance with chapter 19. Section 19.3.6.1 states corridors shall be separated from all other areas by partitions complying with 19.3.6.2 through 19.3.6.5. Section 19.3.6.3.1 states doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 1-3/4 in. thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke.

THE FINDINGS INCLUDE:

- During the morning & afternoon hours of 8/20/12 & 8/21/12, the following items were observed regarding corridor walls:

1) In the Emergency Department (ED), the registration and triage rooms have sliding glass windows and there is no smoke detection in either room.
2) In the Lab area, the Lab waiting room is open to the corridor, the Phlebotomy office is open to the Lab waiting room with a sliding glass window, and the Phlebotomy office has a door to the main Lab area which is missing. There is no smoke detection in both the Lab waiting room and the Phlebotomy office
3) There are two (2) holding rooms open to the corridor in the radiology and the ultrasound areas.

Note: The plans provided by the hospital identified the above area's as utilizing corridors in lieu of suite designations.

This was observed by hospital administration staff while touring the facility.

Based on observations and confirmed by staff, the facility failed to ensure compliance with chapter 19. Section 19.3.6.3 requires corridor doors other than vertical openings, exits or hazards areas to be 1-3/4" thick, solid-bonded core wood or of construction that resists fire for at least 20 minutes and shall be constructed to resist the passage of smoke. There shall be no impediment to closing the door, only approved hold open devices may be used.

THE FINDINGS INCLUDE:

- During the morning & afternoon hours of 8/20/12 and 8/21/12 while touring the facility, it was observed that not all doors close & latch as required. These include but are not limited to the following locations:

1) The rear door of the Computed Tomography (CT) is equipped with a manually operated dead-bolt device.
2) The Stress Lab rooms #1 & #2 are equipped with a manually operated dead-bolt devices.
3) The patient waiting room for the CT/Stress Lab is equipped with a non-latching sliding glass door.

These were each acknowledged by the Director of Facilities during the building tour.

Based on observations the facility failed to ensure that egress doors are maintained as required. Section 19.2.2.2.5 states doors located in the means of egress that are permitted to be locked under other provisions of this chapter shall have adequate provisions made for the rapid removal of occupants by means such as remote control of locks, keying of all locks to keys carried by staff at all times, or other such reliable means available to the staff at all times. Only one such locking device shall be permitted on each door.

THE FINDING INCLUDE:

- During the morning hours of 8/20/12 while touring the Psychiatric Unit, it was observed that the two stairwell doors are locked with magnetic devices. Upon closer examination, it was observed that the door locks do not have the delayed egress feature but are controlled (released) from a remote location. The remote release feature is activated by a keyed switch mounted at the nursing station. However, three of four staff members which were asked if they knew how to release (over-ride) the doors if necessary did not have knowledge of the procedures. They did not know the switch was provided for release nor where the key to activate the switch is located.

This was acknowledged by the Director of Facilities during the building tour.

Based on record review and staff interview, the facility failed to conduct fire drills as required.

THE FINDINGS INCLUDE:

- A record review of fire drill reports for the last fourteen (14) months conducted on the morning of 8/22/12 revealed that fire drills are not conducted at varied times on the second (3 p.m. - 11 p.m.) and third (11 p.m. to 7 a.m.) shifts covering the entire eight (8) hours of each shift.
- The last six (6) second shift fire drills were conducted 1-hour 5-minutes apart as follows:
at 3:10 p.m. on 5/24/11
at 4:05 p.m. on 8/18/11
at 3:00 p.m. on 11/29/11
at 3:12 p.m. on 12/13/11
at 3:05 p.m. on 2/23/12
at 3:07 p.m. on 5/25/12
- The last five (5) third shift fire drills were conducted 1-hour 25 minutes apart as follows:
at 6:20 a.m. on 6/28/11
at 6:15 a.m. on 9/21/11
at 5:55 a.m. on 12/21/11
at 6:10 a.m. on 3/23/12
at 6:20 a.m. on 6/26/12

This was confirmed by the physical plant director.

Based on record review and staff interview, the facility failed to conduct fire drills as required. Section 20.7.1.2 requires fire drills in ambulatory health care facilities to include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions.

THE FINDINGS INCLUDE:

- A record review of fire drill reports made available on the morning of 8/22/12 revealed that the ambulatory surgical center is conducting one fire drill per year. The Section 20.7.1.2 requirement of one drill per quarter per shift is not being met.
This finding was confirmed by the Physical Plant Director during the exit conference.

Based on record review and confirmed by interview with the physical plant director, the facility failed to ensure that a 30 minute discharge test is performed on the fire alarm system backup batteries annually. LSC Section 4.6.12.1 requires fire alarm systems to be continuously maintained in proper operating condition. NFPA 72, Section 7.5.2.2 requires permanent records of all inspections, testing, and maintenance of the fire alarm system be provided including detailed information as to the results. Section 7.3.2 and Table 7.3.2 require systems with sealed batteries to have the battery charger tested annually, to conduct a 30 minute battery discharge test annually, and to conduct a load voltage test semi-annually. Annually is defined as periods of approximately 12 months.

THE FINDINGS INCLUDE:

- Record review of the quarterly fire alarm system inspection reports available on 8/21/12, revealed that the vendor contracted to maintain, test and inspect the fire alarm system failed to provide detailed information as to the results of the tests and inspections as required by NFPA 72.
Inspection reports dated 5/10/12, 2/13/12 and 12/22/11 do not indicate that an annual 30 minute battery discharge test or a semi-annual load voltage test is conducted.

When questioned, the Physical Plant Director stated that the fire alarm inspection contractor does not conduct the aforementioned tests.

Based on record review and confirmed by interview with the physical plant director, the facility failed to ensure that the fire alarm system is maintained and tested in accordance with NFPA 72. LSC Section 4.6.12.1 requires fire alarm systems to be continuously maintained in proper operating condition. NFPA 72, Section 7.5.2.2 requires permanent records of all inspections, testing, and maintenance of the fire alarm system be provided including detailed information as to the results. Section 7.3.2 and Table 7.3.2 require systems with sealed batteries to have the battery charger tested annually, to conduct a 30 minute battery discharge test annually, and to conduct a load voltage test semi-annually. Annually is defined as periods of approximately 12 months.

THE FINDINGS INCLUDE:

- Record review of the quarterly fire alarm system inspection reports available on 8/21/12, revealed that the vendor contracted to maintain, test and inspect the fire alarm system failed to provide detailed information as to the results of the tests and inspections as required by NFPA 72.
Inspection reports dated 6/14/12, 3/15/12, 12/14/12 and 9/14/11 do not indicate that an annual 30 minute battery discharge test or a semi-annual load voltage test was conducted.

When questioned the Physical Plant Director stated that the fire alarm inspection contractor does not conduct the aforementioned tests.

Based on observations and confirmed by staff, the facility failed to ensure that non-sprinklered electrical rooms/closets are properly separated. NFPA 13 section 5-13.11 states that sprinkler protection shall be required in electrical equipment rooms. Hoods or shields installed to protect important electrical equipment from sprinkler discharge shall be noncombustible.
The exception states sprinklers shall not be required where all of the following conditions are met:
(a) The room is dedicated to electrical equipment only.
(b) Only dry-type electrical equipment is used.
(c) Equipment is installed in a 2-hour fire-rated enclosure including protection for penetrations.
(d) No combustible storage is permitted to be stored in the room.
NFPA 101 Section 8.2.3.2.3.1 requires openings in 2-hour rated fire barriers to be protected by doors having at least a 90 minute fire protection rating.

THE FINDINGS INCLUDE:

- During the morning & afternoon hours of 8/20/12 and 8/21/12 while touring the facility, it was observed that not all electrical closets are designed as required. These include but are not limited to the following locations:

1) The non-sprinklered electrical room located outside of the Operating area is equipped with a 45-minute rated door.
2) The non-sprinklered electrical room located on the 2nd floor of Granger West is equipped with a non-labeled door.

These were each acknowledged by the Director of Facilities during the building tour.

Based on observations and confirmed by staff, the facility failed to ensure that all sprinkler control valves are properly supervised. Section 9.7.2.1 states where supervised automatic sprinkler systems are required by another section of this Code, supervisory attachments shall be installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm Code, and a distinctive supervisory signal shall be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system. Monitoring shall include, but shall not be limited to, monitoring of control valves, fire pump power supplies and running conditions, water tank levels and temperatures, tank pressure, and air pressure on dry-pipe valves. Supervisory signals shall sound and shall be displayed either at a location within the protected building that is constantly attended by qualified personnel or at an approved, remotely located receiving facility.

THE FINDINGS INCLUDE:

- During the afternoon hours of 8/20/12 it was observed that not all sprinkler valves are electronically supervised as required. These include but not limited to the following valves:

1) The main back flow preventer located on the sprinkler system has two (2) Outside Screw & Yolk Valves (OS&Y) which are not supervised.

2) The main sprinkler valve location has a total of five (5) Outside Screw & Yolk Valves (OS&Y) which are not supervised.

These were each acknowledged by the Director of Facilities during the building tour.

Based on record review and confirmed by interview, the facility failed to ensure that the automatic sprinkler system is maintained, tested, and inspected as required. NFPA 25, Section 5.3.2.1 requires a weekly test of electric motor-driven pump assemblies to be conducted without flowing water for a minimum of 10 minutes.

THE FINDINGS INCLUDE:

- A record review of the facilities weekly fire pump inspection/test log on the morning of 8/22/12 revealed that the fire pump is run weekly for a total of five (5) minutes as opposed to a full ten (10) minutes as required by NFPA 25, Section 5.3.2.1.

Based on observations and confirmed by staff, the facility failed to ensure that a 1-hour fire barrier is provided separating the facility from the remaining portion of the building. CMS
S&C-10-20-ASC dated 5/21/10 states:
ASC Waiting Area Requirements: ASC regulations require these facilities to be distinct entities, solely providing surgical services, and containing separate waiting areas which must meet Life Safety Code (LSC) requirements for Ambulatory Health Care (ASC) occupancies.

42 CFR 416.44(b) - Environment CfC - Life Safety Code (LSC) Requirements As part of the ASC, a waiting area must meet the provisions applicable to Ambulatory Health Care, Chapters 20 and 21 in the National Fire Protection Association (NFPA) 101:2000 edition of the LSC. According to sections 20.3.7.1 and 21.3.7.1 of the LSC, an "ambulatory health care facility shall be separated from other tenants and occupancies by walls having not less than a 1-hour fire resistance rating. Such walls shall extend from the floor slab below to the floor or roof slab above. Doors shall be constructed of not less than 1 ¾ inch thick solid-bonded wood core or the equivalent and shall be equipped with positive latches. These doors shall be self closing and shall be kept in the closed position except when in use. Any vision panels shall be of fixed fire window assemblies in accordance with 8.2.3.2.2." This requirement applies regardless of whether or not an ASC is "temporally" distinct, i.e., it shares its space with another occupancy(ies) but does not have concurrent or overlapping hours of operation.

THE FINDINGS INCLUDE:

- During the afternoon hours of 8/21/12 while performing the facility tour, it was noted that the ASC suite is not separated from the remaining building by a 1-hour fire barrier. The waiting area has a wall and door with approximately thirty (30) square feet of non-rated tempered glass. In addition, the wall which extends parallel to the outside walkway is equipped with nine (9) non-rated tempered glass windows which are approximately 5' x 2' in size each.

This was acknowledged by the Director of Facilities during the building tour.

Based on record review and confirmed by staff, the facility failed to assure that the automatic sprinkler system is maintained and inspected as required by LSC Section 4.6.12.1. 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 2.3.3.1 requires alarm devices on wet pipe systems to be tested at least quarterly by opening the inspectors test connection.
Section 2.2.4.1 requires gauges on wet pipe sprinkler systems to be inspected monthly to ensure that they are in good condition and that normal water supply pressure is being maintained.
Section 9.3.4.3 requires valve supervisory switches to be tested at least semi-annually.

THE FINDINGS INCLUDE:

- A review of the records available on 8/22/12 revealed that maintenance testing and inspection of the automatic sprinkler system is performed annually. The following deficiencies were observed:
1. The flow switch is not tested at least quarterly by opening the inspectors test connection.
2. The sprinkler system pressure gauge is not inspected monthly.
3. Control valve supervisory (tamper) switches are not tested at least semi-annually.
These were confirmed by the Physical Plant Director during an interview on the afternoon of 8/22/12.

Based on record review and confirmed by interview with the physical plant director, the facility failed to ensure that the fire alarm system is maintained and tested in accordance with NFPA 72. LSC Section 4.6.12.1 requires fire alarm systems to be continuously maintained in proper operating condition. NFPA 72, Section 7.5.2.2 requires permanent records of all inspections, testing, and maintenance of the fire alarm system be provided including detailed information as to the results. Section 7.3.2 and Table 7.3.2 require systems with sealed batteries to have the battery charger tested annually, to conduct a 30 minute battery discharge test annually, and to conduct a load voltage test semi-annually. Annually is defined as periods of approximately 12 months.

THE FINDINGS INCLUDE:

- Record review of the fire alarm system inspection report available on 8/21/12, revealed that the vendor contracted to maintain, test and inspect the fire alarm system failed to provide detailed information as to the results of the tests and inspections as required by NFPA 72.
The annual fire alarm test/inspection report does not indicate that an annual 30 minute battery discharge test or a semi-annual load voltage test was conducted.
When questioned the Physical Plant Director stated that the fire alarm inspection contractor does not conduct the aforementioned tests.

********************************


Based on record review and confirmed by staff, the facility failed to assure that the automatic sprinkler system is maintained and inspected as required by LSC Section 4.6.12.1.
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 2.3.3.1 requires alarm devices on wet pipe systems to be tested at least quarterly by opening the inspectors test connection.
Section 2.2.4.1 requires gauges on wet pipe sprinkler systems to be inspected monthly to ensure that they are in good condition and that normal water supply pressure is being maintained.
Section 9.3.4.1 requires each control valve to be operated annually through its full range and returned to its normal position.
Section 9.3.4.3 requires valve supervisory switches to be tested at least semi-annually.
Section 9.3.5 requires the operating stems of outside screw and yoke valves (OS&Y) to be lubricated annually.
Section 2.3.2 requires pressure gauges to be replace or tested every 5 years.
Section 9.4.1.2 requires alarm valves and their associated strainers, filters, and restriction orifices to be inspected internally every 5 years.

THE FINDINGS INCLUDE:

- A review of the records available on 8/22/12 revealed that maintenance testing and inspection of the automatic sprinkler system is performed annually. The following deficiencies were observed:
1. The flow switch is not tested at least quarterly by opening the inspectors test connection.
2. The sprinkler system pressure gauge is not inspected monthly.
3. Control valves are not operated annually through their full range and returned their normal position.
4. Control valve supervisory (tamper) switches are not tested at least semi-annually.
5. OS&Y are not lubricated annually.
6. The facility does not have documentation substantiating that the pressure gages have been tested or calibrated in the last 5 years.
7. The facility does not have documentation substantiating that the alarm valve has been internally inspected in the last 5 years.
These were confirmed by the Physical Plant Director during an interview on the afternoon of 8/22/12.

Based on observations and confirmed by staff, the facility failed to ensure that buildings are properly separated. Section 19.1.1.4.1 states additions shall be separated from any existing structure not conforming to the provisions within Chapter 19 by a fire barrier having not less than a 2-hour fire resistance rating and constructed of materials as required for the addition.

THE FINDINGS INCLUDE:

- During the morning hours of 8/22/12 while touring the facility, the flowing were observed regarding the ground floor two hour fire rated wall that separates the health care occupancy from the business occupancy.

1) The door to the financial area is missing.

2) The door to the computed tomography (CT) work room does not have a rating tag to confirm that the door is rated for 90 minutes.

This was observed by hospital administration staff while touring the facility.

Based on observations and confirmed by staff, the facility failed to ensure compliance with chapter 19. Section 19.3.6.1 states corridors shall be separated from all other areas by partitions complying with 19.3.6.2 through 19.3.6.5. Section 19.3.6.3.1 states doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 1-3/4 in. thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke.

THE FINDINGS INCLUDE:

- During the morning & afternoon hours of 8/20/12 & 8/21/12, the following items were observed regarding corridor walls:

1) In the Emergency Department (ED), the registration and triage rooms have sliding glass windows and there is no smoke detection in either room.
2) In the Lab area, the Lab waiting room is open to the corridor, the Phlebotomy office is open to the Lab waiting room with a sliding glass window, and the Phlebotomy office has a door to the main Lab area which is missing. There is no smoke detection in both the Lab waiting room and the Phlebotomy office
3) There are two (2) holding rooms open to the corridor in the radiology and the ultrasound areas.

Note: The plans provided by the hospital identified the above area's as utilizing corridors in lieu of suite designations.

This was observed by hospital administration staff while touring the facility.

Based on observations and confirmed by staff, the facility failed to ensure compliance with chapter 19. Section 19.3.6.3 requires corridor doors other than vertical openings, exits or hazards areas to be 1-3/4" thick, solid-bonded core wood or of construction that resists fire for at least 20 minutes and shall be constructed to resist the passage of smoke. There shall be no impediment to closing the door, only approved hold open devices may be used.

THE FINDINGS INCLUDE:

- During the morning & afternoon hours of 8/20/12 and 8/21/12 while touring the facility, it was observed that not all doors close & latch as required. These include but are not limited to the following locations:

1) The rear door of the Computed Tomography (CT) is equipped with a manually operated dead-bolt device.
2) The Stress Lab rooms #1 & #2 are equipped with a manually operated dead-bolt devices.
3) The patient waiting room for the CT/Stress Lab is equipped with a non-latching sliding glass door.

These were each acknowledged by the Director of Facilities during the building tour.

Based on observations the facility failed to ensure that egress doors are maintained as required. Section 19.2.2.2.5 states doors located in the means of egress that are permitted to be locked under other provisions of this chapter shall have adequate provisions made for the rapid removal of occupants by means such as remote control of locks, keying of all locks to keys carried by staff at all times, or other such reliable means available to the staff at all times. Only one such locking device shall be permitted on each door.

THE FINDING INCLUDE:

- During the morning hours of 8/20/12 while touring the Psychiatric Unit, it was observed that the two stairwell doors are locked with magnetic devices. Upon closer examination, it was observed that the door locks do not have the delayed egress feature but are controlled (released) from a remote location. The remote release feature is activated by a keyed switch mounted at the nursing station. However, three of four staff members which were asked if they knew how to release (over-ride) the doors if necessary did not have knowledge of the procedures. They did not know the switch was provided for release nor where the key to activate the switch is located.

This was acknowledged by the Director of Facilities during the building tour.

Based on record review and staff interview, the facility failed to conduct fire drills as required.

THE FINDINGS INCLUDE:

- A record review of fire drill reports for the last fourteen (14) months conducted on the morning of 8/22/12 revealed that fire drills are not conducted at varied times on the second (3 p.m. - 11 p.m.) and third (11 p.m. to 7 a.m.) shifts covering the entire eight (8) hours of each shift.
- The last six (6) second shift fire drills were conducted 1-hour 5-minutes apart as follows:
at 3:10 p.m. on 5/24/11
at 4:05 p.m. on 8/18/11
at 3:00 p.m. on 11/29/11
at 3:12 p.m. on 12/13/11
at 3:05 p.m. on 2/23/12
at 3:07 p.m. on 5/25/12
- The last five (5) third shift fire drills were conducted 1-hour 25 minutes apart as follows:
at 6:20 a.m. on 6/28/11
at 6:15 a.m. on 9/21/11
at 5:55 a.m. on 12/21/11
at 6:10 a.m. on 3/23/12
at 6:20 a.m. on 6/26/12

This was confirmed by the physical plant director.

Based on record review and staff interview, the facility failed to conduct fire drills as required. Section 20.7.1.2 requires fire drills in ambulatory health care facilities to include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions.

THE FINDINGS INCLUDE:

- A record review of fire drill reports made available on the morning of 8/22/12 revealed that the ambulatory surgical center is conducting one fire drill per year. The Section 20.7.1.2 requirement of one drill per quarter per shift is not being met.
This finding was confirmed by the Physical Plant Director during the exit conference.

Based on record review and confirmed by interview with the physical plant director, the facility failed to ensure that a 30 minute discharge test is performed on the fire alarm system backup batteries annually. LSC Section 4.6.12.1 requires fire alarm systems to be continuously maintained in proper operating condition. NFPA 72, Section 7.5.2.2 requires permanent records of all inspections, testing, and maintenance of the fire alarm system be provided including detailed information as to the results. Section 7.3.2 and Table 7.3.2 require systems with sealed batteries to have the battery charger tested annually, to conduct a 30 minute battery discharge test annually, and to conduct a load voltage test semi-annually. Annually is defined as periods of approximately 12 months.

THE FINDINGS INCLUDE:

- Record review of the quarterly fire alarm system inspection reports available on 8/21/12, revealed that the vendor contracted to maintain, test and inspect the fire alarm system failed to provide detailed information as to the results of the tests and inspections as required by NFPA 72.
Inspection reports dated 5/10/12, 2/13/12 and 12/22/11 do not indicate that an annual 30 minute battery discharge test or a semi-annual load voltage test is conducted.

When questioned, the Physical Plant Director stated that the fire alarm inspection contractor does not conduct the aforementioned tests.

Based on record review and confirmed by interview with the physical plant director, the facility failed to ensure that the fire alarm system is maintained and tested in accordance with NFPA 72. LSC Section 4.6.12.1 requires fire alarm systems to be continuously maintained in proper operating condition. NFPA 72, Section 7.5.2.2 requires permanent records of all inspections, testing, and maintenance of the fire alarm system be provided including detailed information as to the results. Section 7.3.2 and Table 7.3.2 require systems with sealed batteries to have the battery charger tested annually, to conduct a 30 minute battery discharge test annually, and to conduct a load voltage test semi-annually. Annually is defined as periods of approximately 12 months.

THE FINDINGS INCLUDE:

- Record review of the quarterly fire alarm system inspection reports available on 8/21/12, revealed that the vendor contracted to maintain, test and inspect the fire alarm system failed to provide detailed information as to the results of the tests and inspections as required by NFPA 72.
Inspection reports dated 6/14/12, 3/15/12, 12/14/12 and 9/14/11 do not indicate that an annual 30 minute battery discharge test or a semi-annual load voltage test was conducted.

When questioned the Physical Plant Director stated that the fire alarm inspection contractor does not conduct the aforementioned tests.

Based on observations and confirmed by staff, the facility failed to ensure that non-sprinklered electrical rooms/closets are properly separated. NFPA 13 section 5-13.11 states that sprinkler protection shall be required in electrical equipment rooms. Hoods or shields installed to protect important electrical equipment from sprinkler discharge shall be noncombustible.
The exception states sprinklers shall not be required where all of the following conditions are met:
(a) The room is dedicated to electrical equipment only.
(b) Only dry-type electrical equipment is used.
(c) Equipment is installed in a 2-hour fire-rated enclosure including protection for penetrations.
(d) No combustible storage is permitted to be stored in the room.
NFPA 101 Section 8.2.3.2.3.1 requires openings in 2-hour rated fire barriers to be protected by doors having at least a 90 minute fire protection rating.

THE FINDINGS INCLUDE:

- During the morning & afternoon hours of 8/20/12 and 8/21/12 while touring the facility, it was observed that not all electrical closets are designed as required. These include but are not limited to the following locations:

1) The non-sprinklered electrical room located outside of the Operating area is equipped with a 45-minute rated door.
2) The non-sprinklered electrical room located on the 2nd floor of Granger West is equipped with a non-labeled door.

These were each acknowledged by the Director of Facilities during the building tour.

Based on observations and confirmed by staff, the facility failed to ensure that all sprinkler control valves are properly supervised. Section 9.7.2.1 states where supervised automatic sprinkler systems are required by another section of this Code, supervisory attachments shall be installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm Code, and a distinctive supervisory signal shall be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system. Monitoring shall include, but shall not be limited to, monitoring of control valves, fire pump power supplies and running conditions, water tank levels and temperatures, tank pressure, and air pressure on dry-pipe valves. Supervisory signals shall sound and shall be displayed either at a location within the protected building that is constantly attended by qualified personnel or at an approved, remotely located receiving facility.

THE FINDINGS INCLUDE:

- During the afternoon hours of 8/20/12 it was observed that not all sprinkler valves are electronically supervised as required. These include but not limited to the following valves:

1) The main back flow preventer located on the sprinkler system has two (2) Outside Screw & Yolk Valves (OS&Y) which are not supervised.

2) The main sprinkler valve location has a total of five (5) Outside Screw & Yolk Valves (OS&Y) which are not supervised.

These were each acknowledged by the Director of Facilities during the building tour.

Based on record review and confirmed by interview, the facility failed to ensure that the automatic sprinkler system is maintained, tested, and inspected as required. NFPA 25, Section 5.3.2.1 requires a weekly test of electric motor-driven pump assemblies to be conducted without flowing water for a minimum of 10 minutes.

THE FINDINGS INCLUDE:

- A record review of the facilities weekly fire pump inspection/test log on the morning of 8/22/12 revealed that the fire pump is run weekly for a total of five (5) minutes as opposed to a full ten (10) minutes as required by NFPA 25, Section 5.3.2.1.

Based on observations and confirmed by staff, the facility failed to ensure that a 1-hour fire barrier is provided separating the facility from the remaining portion of the building. CMS
S&C-10-20-ASC dated 5/21/10 states:
ASC Waiting Area Requirements: ASC regulations require these facilities to be distinct entities, solely providing surgical services, and containing separate waiting areas which must meet Life Safety Code (LSC) requirements for Ambulatory Health Care (ASC) occupancies.

42 CFR 416.44(b) - Environment CfC - Life Safety Code (LSC) Requirements As part of the ASC, a waiting area must meet the provisions applicable to Ambulatory Health Care, Chapters 20 and 21 in the National Fire Protection Association (NFPA) 101:2000 edition of the LSC. According to sections 20.3.7.1 and 21.3.7.1 of the LSC, an "ambulatory health care facility shall be separated from other tenants and occupancies by walls having not less than a 1-hour fire resistance rating. Such walls shall extend from the floor slab below to the floor or roof slab above. Doors shall be constructed of not less than 1 ¾ inch thick solid-bonded wood core or the equivalent and shall be equipped with positive latches. These doors shall be self closing and shall be kept in the closed position except when in use. Any vision panels shall be of fixed fire window assemblies in accordance with 8.2.3.2.2." This requirement applies regardless of whether or not an ASC is "temporally" distinct, i.e., it shares its space with another occupancy(ies) but does not have concurrent or overlapping hours of operation.

THE FINDINGS INCLUDE:

- During the afternoon hours of 8/21/12 while performing the facility tour, it was noted that the ASC suite is not separated from the remaining building by a 1-hour fire barrier. The waiting area has a wall and door with approximately thirty (30) square feet of non-rated tempered glass. In addition, the wall which extends parallel to the outside walkway is equipped with nine (9) non-rated tempered glass windows which are approximately 5' x 2' in size each.

This was acknowledged by the Director of Facilities during the building tour.

Based on record review and confirmed by staff, the facility failed to assure that the automatic sprinkler system is maintained and inspected as required by LSC Section 4.6.12.1. 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 2.3.3.1 requires alarm devices on wet pipe systems to be tested at least quarterly by opening the inspectors test connection.
Section 2.2.4.1 requires gauges on wet pipe sprinkler systems to be inspected monthly to ensure that they are in good condition and that normal water supply pressure is being maintained.
Section 9.3.4.3 requires valve supervisory switches to be tested at least semi-annually.

THE FINDINGS INCLUDE:

- A review of the records available on 8/22/12 revealed that maintenance testing and inspection of the automatic sprinkler system is performed annually. The following deficiencies were observed:
1. The flow switch is not tested at least quarterly by opening the inspectors test connection.
2. The sprinkler system pressure gauge is not inspected monthly.
3. Control valve supervisory (tamper) switches are not tested at least semi-annually.
These were confirmed by the Physical Plant Director during an interview on the afternoon of 8/22/12.

Based on record review and confirmed by interview with the physical plant director, the facility failed to ensure that the fire alarm system is maintained and tested in accordance with NFPA 72. LSC Section 4.6.12.1 requires fire alarm systems to be continuously maintained in proper operating condition. NFPA 72, Section 7.5.2.2 requires permanent records of all inspections, testing, and maintenance of the fire alarm system be provided including detailed information as to the results. Section 7.3.2 and Table 7.3.2 require systems with sealed batteries to have the battery charger tested annually, to conduct a 30 minute battery discharge test annually, and to conduct a load voltage test semi-annually. Annually is defined as periods of approximately 12 months.

THE FINDINGS INCLUDE:

- Record review of the fire alarm system inspection report available on 8/21/12, revealed that the vendor contracted to maintain, test and inspect the fire alarm system failed to provide detailed information as to the results of the tests and inspections as required by NFPA 72.
The annual fire alarm test/inspection report does not indicate that an annual 30 minute battery discharge test or a semi-annual load voltage test was conducted.
When questioned the Physical Plant Director stated that the fire alarm inspection contractor does not conduct the aforementioned tests.

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Based on record review and confirmed by staff, the facility failed to assure that the automatic sprinkler system is maintained and inspected as required by LSC Section 4.6.12.1.
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 2.3.3.1 requires alarm devices on wet pipe systems to be tested at least quarterly by opening the inspectors test connection.
Section 2.2.4.1 requires gauges on wet pipe sprinkler systems to be inspected monthly to ensure that they are in good condition and that normal water supply pressure is being maintained.
Section 9.3.4.1 requires each control valve to be operated annually through its full range and returned to its normal position.
Section 9.3.4.3 requires valve supervisory switches to be tested at least semi-annually.
Section 9.3.5 requires the operating stems of outside screw and yoke valves (OS&Y) to be lubricated annually.
Section 2.3.2 requires pressure gauges to be replace or tested every 5 years.
Section 9.4.1.2 requires alarm valves and their associated strainers, filters, and restriction orifices to be inspected internally every 5 years.

THE FINDINGS INCLUDE:

- A review of the records available on 8/22/12 revealed that maintenance testing and inspection of the automatic sprinkler system is performed annually. The following deficiencies were observed:
1. The flow switch is not tested at least quarterly by opening the inspectors test connection.
2. The sprinkler system pressure gauge is not inspected monthly.
3. Control valves are not operated annually through their full range and returned their normal position.
4. Control valve supervisory (tamper) switches are not tested at least semi-annually.
5. OS&Y are not lubricated annually.
6. The facility does not have documentation substantiating that the pressure gages have been tested or calibrated in the last 5 years.
7. The facility does not have documentation substantiating that the alarm valve has been internally inspected in the last 5 years.
These were confirmed by the Physical Plant Director during an interview on the afternoon of 8/22/12.