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Based on observation and interview at time of verification visit, the facility did not provide a 'common separation wall' with 90 minute fire-rated doors & closers on all doors in the separation wall from outside building to outside building. This deficiency occurred in 1 of the 12 smoke compartments, and had the potential to affect 6 of the 39 staff that were working.

FINDINGS INCLUDE:
The Verification Visit follow-up on July 23rd, after the original survey on May 10, 2012, at 11:20 am surveyor #18107 observed in the SC-20 smoke compartment on the 1st floor in the Corridor between Child & Adolescent Center (CBRF) and Existing (Vacated) Psych Hospital, that the separation wall was still non-compliant because it was not built to a 2-hour fire assembly requirement where two different Occupancies occur per 19.1.2.3 and 19.1.1.4. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.1.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (CFO), staff B (Senior Director of Finance) and staff C (Environmental Srvcs Mgr).

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Based on observation and interview, the facility did not provide corridor separation doors with compliant corridor doors, and double doors with an astragal seal. This deficiency occurred in 1 of the 9 smoke compartments, and had the potential to affect 15 of the patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. corrected July 23, 2012.

2. The follow-up Verification Visit on July 23, 2012 to the original survey on 05/10/2012 at 11:00 am, surveyor #18107 observed in the SC-6 smoke compartment on the 1st floor in the Closet of the Experimental Therapy area, that the room had double corridor doors with a gap greater than 1/8 inch at their meeting edges that was not sealed with an astragal to resist the passage of smoke. The astragal installed could not be proven to meet the required 'flame spread' and 'smoke development' requirements for a storage closet meeting NFPA 80. This observed situation was not compliant with NFPA 101 (2000 edition), 18.2.3.5-exception 4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (CFO), staff B (Senior Director of Finance) and staff C (Environmental Srvcs Mgr).

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Item #1
NFPA 101, 2000 edition 38.3.4.1 " General. A fire alarm system in accordance with Section 9.6 shall be provided in any business occupancy where any one of the following conditions exist:
(1) The building is two or more stories in height above the level of exit discharge.
(2) The occupancy is subject to 50 or more occupants above or below the level of exit discharge.
(3) The occupancy is subject1to 300 or more total occupants "
Section 9.6 states " ...9.6.1.9 For the purpose of this Code, a complete fire alarm system shall be used for initiation, notification, and control and shall provide the following.
(a) Initiation The initiation function provides the input signal to the system.
(b) Notification The notification function is the means by which the system, advises that human action is required in response to a particular condition.
(c) Control The control function provides outputs to control building equipment to enhance protection of life.

Bases on observation, and staff interview (P and Q) the facility failed to provide a complete fire alarm system in accordance section 9.6.

FINDINGS INCLUDE
1) During of tour of the facility with staff P and Q on May 10, 2012, Surveyor 12187 observed: There are four occupied stores with a basement in the building with the first floor being the level of exit discharge. There are 3 pull stations and strobes and horns located at the 3 exit doors of the building. There are no other manual pull stations, horns or strobes in the lobby stair or in the ' business suite ' occupied by the provider. The horns and strobes by the 3 exits would not notify all persons in the ' suite ' . This is not a complete fire alarm system. This was observed at 9:37 AM on May 10, 2012 with staff P and Q present.
2) During a tour of the facility and review of the maintenance records, there was no record of testing of the fire alarm system. This was observed at 9:37 AM on May 10, 2012 with staff P and Q present.

Item #2
NPFA 101, 2000 edition 38.5.2 state " Heating, Ventilating and Air Conditioning. Heating, ventilating, and air conditioning equipment shall comply with the provisions of Section 9.2 "
Section 9.2.1 states " Air Conditioning, Heating, Ventilating Ductwork, and Related Equipment. Air conditioning, heating, ventilating ductwork and related equipment shall be in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems ... "
NFPA 90A, 1999 edition 3-4.7 states " Maintenance. At least every 4 years fusible links (where applicable) shall be removed, all dampers shall be operated to verify that they fully close, the latch, if provided, shall be checked, and moving parts shall be lubricated as necessary. "

Based on observation, staff interview and record review, the facility failed to provide maintenance on the fire dampers in accordance with NFPA 90A.

FINDINGS INCLUDE
During the tour the facility with staff P, Q, and R on May 10, 2012 at 10:20 AM, staff R stated to Surveyor 12187 that there were no records of testing of the fire dampers. No records were produced. Staff R stated that no fire damper tests were done since his company owned the building and the previous owner did not leave any record of test of the fire dampers.


Item #3
NFPA 101, 2000 edition, 38.2.8 states " Illumination of Means of Egress. Means of Egress shall be illuminated in accordance with Section 7.8. Section 7.8.1.2 states " Illumination of the means of egress shall be continuous during the time that the conditions of occupancy require that the means of egress shall be available for use. Artificial lighting shall be employed at such locations and for such periods of time as required to maintain the illumination to the minimum criteria value herein specified.

Based on observation and record review and interviews, the facility failed to provide operating light and provide maintenance on the emergency lights in the path of egress.

FINDINGS INCLUDE
During the tour of the facility with staff P, Q, and R at 10:30 AM on May 10, 2012 it was observed that the emergency light near the nurse station did not light up when the test button was pushed by Surveyor 12187. Surveyor then asked for records of testing of the emergency lights. Staff P, Q, and R did not know of any testing that was done.


Item #4
NFPA 101, 2000 edition, 38.2.7 states " Discharge from Exits. Exit discharge shall comply with Section 7.7. Section 7.71 states, " Exits shall terminate directly at a public way or at an exterior exit discharge. Yards, courts, open spaces, or other portions of the exit discharge shall be required width and size to provide all occupants with a safe access to a public way. "

Based on observation, and interviews the facility failed to provide a safe path to a public way out of the 2 stairs (exits) to the north of the building.

FINDING INCLUDE
During a tour of the facility with staff P, Q and R, at 10:40 AM , on May 10, 2012, it was observed that both stair exits to the north of the building went to a concrete pad, 8 feet by 8 feet. The nearest public way was approximately 100 feet to the north, Mineral Point Rd. The terrain would not allow a safe path to a public way since the surface is not an all weather hard surface.
When Surveyor 12187 asked if there was a path cleared of snow, staff R told Surveyor 12187 that no path to the north of building from the stairwells was cleared in the winter.


Item #5
NFPA 101, 2000 edition, 38.5.1 states " Utilities. Utilities shall comply with the provisions of Section 9.1. Section 9.1.2 states " Electric. Electrical wire and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction. NFPA 70, 1999 edition, section 110-22 states " Identification of Disconnecting Means. Each disconnecting means shall be legibly marked to indicate its purpose unless located and arranged so the purpose is evident. The marking shall be of sufficient durability to withstand the environment involved .... "

Based on observation and staff interview, the facility failed to provide labeled circuit breakers in the electrical panel.

FINDING INCLUDE
During a tour of the facility with staff P, and Q, at 9:20 AM , on May 10, 2012, it was observed that the circuit breaker box in the I.T. Room did not have identification as to what circuits the circuit breakers served.

Item #6NFPA 101, 2000 edition, 38.3.6.1 states " Where access to exits is provided by corridors, such corridors shall be separated from use areas by halls having a fire resistance rating of not less than 1 hour in accordance with 8.2.3 ... ...
Exception No. 3: Within buildings protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7 " Section 9.7.1.1 states " Each automatic sprinkler system required by another section of this Code shall be in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. "

Based on observation and staff interview, the corridor walls are not built to a fire resistance of 1 hour because they are built out of glass. In addition, the facility failed to have a building that is fully sprinkled as noted with the findings.

FINDINGS INCLUDE:
During a tour of the facility with staff P, and Q, on May 10, 2012, it was observed that:
1) Full sprinkler coverage was not provided in the E.T. Consult room and Consult room #1 because a water shadow, where sprinkler coverage of the floor area did not happen, was formed by a wing wall blocking the spray pattern of the sprinkler. This was observed at 9:00 AM.
2) In the bottom of both stairs full sprinkler coverage was not provided because sprinkler coverage was not provided underneath the stairs. This was observed at 8:55 AM.

Item #7
NFPA 101, 2000 edition, 38.2.1.1 States " All means of egress shall be in accordance with Chapter 7 and this chapter. " Section 7.1.3.2.3 states " An exit enclosure shall not be used for any purpose that has the potential to interfere with it use as an exit and if so designated, an area of refuge.

Based on observation and staff interview, the exit stairs was used for other purposes other than exiting.

FINDINGS INCLUDE:
During a tour of the facility with staff P, Q and R on May 10, 2012 at 8:45 AM, it was observed that the west stair well had a bicycle being store in the stairwell at the main floor, which impeded the path of egress out of the stairs. In addition, the east stair well had a storage box containing an artificial Christmas tree stored underneath the stairs. Storage is not a purpose for the stairs.

Based on observation and interview, the facility did not provide a code compliant second exit access from a 'corridor system' per Miscellaneous Deficiencies. This deficiency occurred in 1 of the 12 smoke compartments, and had the potential to affect 3 of the 39 staff that were working this day.

FINDINGS INCLUDE:
Follow-up Verification Visit on June 23, 2012, to the original survey on May 10, 2012, at 3:40 pm surveyor #18107 observed in the SC-17 smoke compartment on the Ground, and at other locations at 1st, 2nd and 3rd Floors next to the New Inpatient Building Stair'A', that this New Stairway was suppose to be operational upon opening the New Inpatient Building (5/8/2012), based on the last construction inspection discussion on (4/28/2012), since the Annex Stairway was removed from service. If the Materials Management Suite (Ground Floor) is larger than 2,500 square feet, two (2) exits are required out of the Suite per 2000 NFPA 101, Section 19.2.5.3. This building is still considered a hospital after talking with the Chief Financial Officer and understanding the Building is holding Child and Adolescent Center (CAC) Programs at 2nd & 1st Floors of the South Wing within the Building and they plan to continue using a portion of the building for clinical and consultive care support to the patients in the future. This observed situation was not compliant with 3 of 39 staff persons present at the time of the finding. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (CFO), staff B (Senior Director of Finance) and staff C (Environmental Srvcs Mgr).

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