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The facility failed to maintain the fire walls. Findings include: During the survey, the following is an example of what was observed:

1. Unsealed penetrations around a group of four sections of conduit, in the two hour wall, in front of the Print Shop.

2. Unsealed penetrations around a group of wiring, in the two hour wall, by Central Processing.



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NFPA 101 2000, 8.2.3.2.3.1 Every openings in a fire barrier shall be protected to limit the spread of fire and restrict the movement of smoke from one side of the fire barrier to the other.

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Failed to provide compatible building construction types for a three story partially sprinklered structure without two hour fire barrier separation between the different types of construction was observed. Findings include:

During the survey, the following are examples of what was observed:
The facility appears to have three different construction types, without seperation, which were:
I (332) - poured in place concrete
II (222) - sprayed on fire protection on steel beams
II (000) - exposed steel beams above a lay-in ceiling (observed in the administration part of the first floor and only in the single story part of this facility)



1. The surveyor could not verify that the one story building was a Type II (222) as indicated on documentation provided by the facility staff.
2. The surveyor could not verify that the ceiling tiles for this section were the type of ceiling tiles to be used in a rated ceiling assembly.
3. The surveyor could not verify that the ceiling grid was the type of grid to be used in a rated ceiling assembly.
4. A two hour fire rated barrier separarting construction types was not observed during the survey.
5. There was not a two hour fire rated barrier separating the single story from the three story

A three story Type II (000) is not allowed per code.
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2000 NFPA 101, 8.2.1* Construction.
Buildings or structures occupied or used in accordance with the individual occupancy chapters (Chapters 12 through 42) shall meet the minimum construction requirements of those chapters. NFPA 220, Standard on Types of Building Construction, shall be used to determine the requirements for the construction classification. Where the building or facility includes additions or connected structures of different construction types, the rating and classification of the structure shall be based on either of the following:
(1) Separate buildings if a 2-hour or greater vertically-aligned fire barrier wall in accordance with NFPA 221, Standard for Fire Walls and Fire Barrier Walls, exists between the portions of the building
Exception: The requirement of 8.2.1(1) shall not apply to previously approved separations between buildings.
(2) The least fire-resistive type of construction of the connected portions, if no such separation is provided

2000 NFPA 101, 19.1.6.2 Health care occupancies shall be limited to the types of building construction shown in Table 19.1.6.2. (See 8.2.1.)

Table 19.1.6.2 Construction Type Limitations
Construction Stories
Type
1 2 3 4 or
More
I(443) X X X X
I(332) X X X X
II(222) X X X X
II(111) X X* X* NP
II(000) X* X* NP NP
III(211) X* X* NP NP
III(200) X* NP NP NP
IV(2HH) X* X* NP NP
V(111) X* X* NP NP
V(000) X* NP NP NP
X: Permitted type of construction.
NP: Not permitted.
*Building requires automatic sprinkler protection. (See 19.3.5.1.)
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The facility failed to maintain the corridor walls in the unsprinklered part of the facility per code. Findings include:

During the survey, the following are examples of what was observed:
The following corridor walls had unsealed penetrations:
First Floor
1. E.R. - penetration at Trauma Room
2. E.R. - at HVAC duct penetration at the Trauma Room
3. E.R. - three penetrations at Exam Room 1
4. Lab corridor across from the bathrooms -
a. Unsealed penetration at a wire
b. Open HVAC duct above ceiling
5. Lab corridor outside the E.R. -
a. Unsealed penetration at flex conduit, on the left side
b. Missing sheetrock approximately 2' x 2' on the right side
6. Respiratory Therapy corridor - several unsealed conduit penetrations on both sides
7. O.R. corridor by the Recovery Room - unsealed penetration at a group of wires



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2000 NFPA 101, 19.3.6.2.1 Corridor walls shall be continuous from the floor to the underside of the floor or roof deck above, through any concealed spaces, such as those above suspended ceilings, and through interstitial structural and mechanical spaces, and they shall have a fire resistance rating of not less than 1/2 hour.


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The facility failed to provide corridor doors that would close and resist the passage of smoke. Findings include: During the survey, the following are examples of what was observed:

7. The door failed to positive latch, this door opens from the Kitchen into the corridor.

8. Four holes approximatley half the size of a dime,around the handle Patient Room 224.

9. Gap between Mechanical Room doors which opens into the corridor in the Basement.

10. Gap between the door at the Nurses Station in the Geri-Psych, door opens into corridor.


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First Floor
11. Outpatient Observation Room #6 - had 4 holes in the corridor door at the door handle
12. Outpatient Examination Room #2 - the corridor door was not positive latching
13. Public Relations - the corridor door had 2 holes at the door handle

Basement
14. Hospital Classroom corridor door on the side corridor was not positive latching

Third Floor
15. Pantry corridor door the positive latching hardware had been removed
16. Room 300 had 4 holes in the corridor door at the door handle


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2000 NFPA 101, 19.3.6.3.1 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 13/4-in. (4.4-cm) 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. Compliance with NFPA 80, Standard for Fire Doors and Fire Windows, shall not be required. Clearance between the bottom of the door and the floor covering not exceeding 1 in. (2.5 cm) shall be permitted for corridor doors.

2000 NFPA 101, 19.3.6.3.2 Doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door. Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.2.
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The facility failed to provide smoke barriers that would provide at least a half hour fire resistance rating. Findings include: During the survey, the following are examples of what was observed:

1. Large hole in the Smoke Barrier at the Oneology.

2. Unsealed penetrations at the end of a sleeve, and around a water line, in the Smoke Barrier, at the Outpatient Center.

3. Unsealed penetrations around a section of flex conduit, in the Smoke Barrier near Stairwell A.

4. Unsealed penetrations at the end of a sleeve, in the Smoke Barrier, by Patient Room 203.

5. Unsealed penetrations at the end of a sleeve, in the Smoke Barrier, by Technician Room Second Floor.



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The facility failed to maintain the smoke barriers per code. Findings include:

During the survey, the following are examples of what was observed:
Unsealed penetrations were observed in the following smoke barriers:
First Floor
6. File Room/Registration/Financial Counseling - electrical conduit
7. Men's Locker Room in the Doctor's Lounge -
a. Around a conduit
b. The end of the same conduit
8. Social Services -
a. Group of white wires
b. End of a conduit
9. Recovery Room for the O.R.s -
a. Two 2' x 2' penetrations in the left wall
b. Around a flex conduit
10. O.R. fire doors - around the water lines
11. O.R. Family Consultation Room - several penetrations
12. E.R. Trauma Room -
a. Around a regular size conduit
b. Around a large size conduit
c. Two pieces of conduit were not sealed
13. E.R. Triage - three penetrations
Third Floor
14. At room 317 - around wires

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2000 NFPA 101, 8.3.6.1 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows: (1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions: a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier. b. It shall be protected by an approved device that is designed for the specific purpose. (2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions: a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier. b. It shall be protected by an approved device that is designed for the specific purpose. (3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions: a. It shall be made on either side of the smoke barrier. b. It shall be made by an approved device that is designed for the specific purpose.

2000 NFPA 101, 8.3.2 Smoke barriers required by this Code shall be continuous from an outside wall to an outside wall, from a floor to a floor, or from a smoke barrier to a smoke barrier or a combination thereof. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces.
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The facility failed to maintain the smoke barrier doors per code. Findings include:

During the survey, the following are examples of what was observed:
First Floor
1. File Room/Registration/Financial Counseling corridor door is in a smoke barrier without a self-closing device
2. Second Registration Office corridor door is in a smoke barrier without a self-closing device
3. O.R. Family Consultation Room corridor door is in a smoke barrier without a self-closing device

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2000 NFPA 101, 19.3.7.6 Doors in smoke barriers shall comply with 8.3.4 and shall be self-closing or automatic-closing in accordance with 19.2.2.2.6.

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The facility failed to maintain the hazardous areas per code. Findings include:

During the survey, the following are examples of what was observed:
First Floor
1. Gift Shop Storage Room - approximately 96 sq. ft. with combustibles - self-closing device had been removed from the door
2. Medical Records - approximately 600 sq. ft. with combustibles -
a. No self-closing device on one of the doors
b. Unsealed penetration in wall below ceiling
3. Mechanical Room by H.I.M. - unsealed penetration of wires in the back wall.
4. Biomed Work Area/Storage Room - approximately 900 sq. ft. with combustibles - no self-closing device on the two doors
5. Public Relations Storage Room - approximately 64 sq. ft. with combustibles - no self-closing device on the door
6. Auxiliary Storage Room over 50 sq. ft. with combustibles - wall was not sealed at corrugated roof deck
7. E.R. Soiled Utility -
a. Unsealed penetration of a grey wire in two walls
b. Corridor door latching hardware was not positive latching
8. Mechanical Room at X-ray -
a. Missing sheetrock
b. Unsealed penetrations
Third Floor
9. Consultation Room being used for storage - approximately 80 sq. ft. with combustibles - no self-closing device on the door

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2000 NFPA 101, 19.3.2.1 Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing.

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The facility failed to provide continuous lighting for means of egress. Findings include: During the survey, the following are examples of what was observed:


1. The Exit Discharge had a single bulb fixture for the East Administration Exit.

2. The Exit Discharge had a single bulb fixture for the Wellness Center Exit.

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NFPA 101, 19.2.8 and 7.8.1.2 Illumination of means of egress shall be continuous.

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The facility failed to provide a complete fire safety plan. Findings include: Documentation of the fire safety plan provided by the facility during the survey was observed incomplete, not including all eight items required.

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NFPA 101, 19.7.2.2 A written health care occupancy fire safety plan shall provide for the following: (1) Use of alarms, (2) Transmission of alarm to fire department, (3) Response to alarms, (4) Isolation of fire, (5) Evacuation of immediate area, (6) Evacuation of smoke compartment, (7) Preparation of floors and building for evacuation, and (8) Extinguishment of fire.

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The facility failed to conduct fire drills per code. Findings include:

During the survey, the following are examples of what was observed:
1. Per documentation and interview -
a. Signatures of staff participating in the fire drills for the last three years was not provided
b. Not all staff are participating in the fire drills
2. Per documentation - not conducting fire drills at unexpected times under varying conditions:
First Shift
11/30/11 - 2:00 pm
09/26/11 - 2:15 pm
06/16/11 - 10:00 am
03/27/11 - 2:00 pm
Second Shift
12/27/11 - 4:15 pm
09/28/11 - 4:40 pm
06/29/11 - 4:15 pm
03/30/11 - 5:20 pm
Third Shift
12/22/11 - 6:42 am
09/28/11 - 6:45 am
06/28/11 - 6:45 am
03/16/11 - 6:39 am

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2000 NFPA 101, 19.7.1.2 Fire drills in health care occupancies shall 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. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
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Facility failed to maintain the Digital Alarm Communicator Transmitter in the fire alarm system. Findings include: During the survey, the following are examples of what was observed:

1. When the Auto Dialer was tested for phone line 1, failure was not indicated at the protected premise within the allotted four (4) minute time frame. wait (5)

2. When the Auto Dialer was tested for phone line 2, failure was not indicated at the protected premise within the allotted four (4) minute time frame.

3. When the Auto Dialer was tested for Communication Failure, failure was not indicated at the protected premise within the allotted fifteen (15) minute time frame (5 minimum to 10 maximum attempts for signal transmission). (Surveyor waited 16 minutes.)

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1999 NFPA 72, Section 1-5.4.6, 5-5.3.2.1.5, and 5-5.3.2.1.6.2. Phone line and communication failure shall be indicated at the facility.

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The facility failed to maintain the fire alarm system in proper working order. Findings include: During the survey, the following is an example of what was observed:

Documentation for the annual fire alarm system for 1/18/2012 indicated that a audio/visual signal device located in the Outpatient Building failed. The facility could not provide documentation that this had been corrected.

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NFPA 101, 9.6.1.4 The fire alarm system to be installed, tested, and maintained in accordance with the requirements of NFPA 70 and NFPA 72.

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Sprinkler coverage was observed during the survey not adequately provided. Findings include: During the survey, the following are examples of what was observed:


1. Corrosion build up around the seat of a sprinkler in Environmetal Services Storeroom.

2. Corrosion build up around the seat/link of a sprinkler top of Stairwell B Second Floor.

3. Corrosion build up around the seat/link in the Mechanical Room Second Floor.

4. Escutcheon plate missing on a sprinkler in the Outpatient Waiting Room.

5. Escutcheon plate missing on a sprinkler in the Linear Accelerator Area.

6. Ceiling tile missing in the Environmetal Services Storeroom.

7. The storage room across from Patient Room 222, was not provided with sprinkler coverage. This floor is protected with sprinklers in all another areas this surveyor observed.

8. The Linen storage room, and the Janitor storage room, by Patient Room 200, not provided with sprinkler coverage. This floor is protected with sprinklers in all another areas this surveyor observed.


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First Floor
9. Mechanical Room (I.T. Closet) by H.I.M. - in sprinklered part of the facility, did not have sprinkler protection

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NFPA 19.3.5.1 Where required by 19.1.6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.
1999 NFPA 25, 2-2.1.1 and 2-4.1.2 Sprinklers that are painted, corroded or damaged shall be replaced with new listed sprinklers of the same characteristics, including orifice size, thermal response, and water distribution.

2000 NFPA 13, 3-2.7.2 Escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly.

NFPA 13 5-6., Sprinklers shall be arranged to be in compliance.

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The facility failed to perform the required maintenance of the facility sprinkler system. Findings include: During the survey, the following are examples of what was observed:


Documentation provided during the survey indicated quarterly sprinkler system inspections were conducted 12/27/2010, 3/26/2011, 6/13/2011.

1. The 3/26/2011 inspection noted the (5) year internal inspection was due.

2. The 6/13/2011 inspection noted the gauges were due for (5) year calibration, or replacement.

3. Inspection of the dry riser on 12/27/2011 indicated a trip test was conducted, but failed to provide if partial trip, or full trip. Also the results of the trip test was not provided.

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NFPA 101, 4.6.12, and NFPA 25, 2-2 and Table 2-1 Requires an inspection every quarter (three months).

NFPA 25,1998 Edition, 9-5.2.3 A partial flow trip test adequate to move the valve from its seat shall be conducted annually.
NFPA 25, 1998 Edition, 9-4.4.2.2.2 Every 3 years and whenever the system is altered, the dry pipe valve shall be trip tested with the control valve fully open and the quick-opening device, if provided, in service.
NFPA 25, 9-2.8.2: Gauges 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.

NFPA 25, 9-2.8.1: Gauges shall be inspected monthly to verify that they are in good condition and that normal pressure is being maintained.

















Exception: When other sections of this standard have different frequency requirements for specific gauges.


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4. The following locations were missing sprinkler head escutcheon plates:
First Floor
a. Women's Bathroom at Physical Therapy
b. Entrance to Outpatient/Physical Therapy
Basement
c. Oncology corridor by Hospital Classroom
d. In Hospital Classroom


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2000 NFPA 13, 3-2.7.2 Escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly



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The facility failed to maintain the fire extinguishers per code. Findings include:

During the survey, the following is an example of what was observed:
First Floor
Fire Extinguisher #51 at Auxiliary Storage last hydrostatic test was in 2005

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1998 NFPA 10, 4-4.3 Every 6 years, stored-pressure fire extinguishers that require a 12-year hydrostatic test shall be emptied and subjected to the applicable maintenance procedures. The removal of agent from halon agent fire extinguishers shall only be done using a listed halon closed recovery system. When the applicable maintenance procedures are performed during periodic recharging or hydrostatic testing, the 6-year requirement shall begin from that date.
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The facility failed to provide metal self-closing containers for disposing of cigarette butts and ashes from ashtrays. Findings include: During the survey, the following are examples of what was observed:


1. The designated smoking area provided for the "Self-Help" patients, was not provided with a metal container which was self-closing, as required in NFPA 101, 19.7.4.(4).


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2. The facility's smoking policy states that there is no smoking, but the facility does allow the "Self-Help" patients to smoke in a designated area.

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2000 NFPA 101, 19.7.4 Smoking regulations shall be adopted and shall include not less than the following provisions: (1) Smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such areas shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking. Exception: In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required. (2) Smoking by patients classified as not responsible shall be prohibited. Exception: The requirement of 19.7.4(2) shall not apply where the patient is under direct supervision. (3) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted. (4) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted.
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Facility failed to maintain the protection for the cooking area per NFPA standards. The following is an example of what was observed:

1. During the survey, the K-extinguisher in the kitchen was not provided with a placard.
2. The facility failed to maintain the dietary hood. Findings include: During the survey, a filter was observed not to be tight fitting, and firmly held in place, the filter appeared to be bend.

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NFPA 96 7-2.1.1 A placard identifying the use of the extinguisher as a secondary backup means to the automatic fire suppression system shall be conspicuously placed near each portable fire extinguisher in the cooking area.


NFPA 96, 3-2.3 Grease filters shall be listed and constructed of steel or listed equivalent material and shall be of rigid construction that will not distort or crush under normal operation, handling, and cleaning conditions. Filters shall be tight fitting and firmly held in place.

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The facility failed to prohibit portable space heating devices per code. Findings include:

During the survey, the following are examples of what was observed:
Portable space heating devices were observed in the following locations:
First Floor
1. Sleep Study Office
2. Sleep Study Tech. Room
3. Program Director's Office for Behavioral Health
Third Floor
4. OB Suppervisor/Work Room

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2000 NFPA 101, 19.7.8 Portable space-heating devices shall be prohibited in all health care occupancies.
Exception: Portable space-heating devices shall be permitted to be used in nonsleeping staff and employee areas where the heating elements of such devices do not exceed 212?F (100?C).
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The facility failed to provide a readily accessible means of egress pathway at all times. Findings include: During the survey, the following are examples of what was observed:


1. Three freezers located in the kitchen were obsructing clear/accessible means of egress to the Exit.

2. The sub-basement is provided with two means of egress, this surveyor observed one of the exits to have a hasp with a lock in place. This exit opens into an area behind the Central supply, in order to continue to move to an exit from this area, you have to open a door into central suppy, which is locked from the inside, thus preventing travel through this door. If this door is accessible you egress through central suppy to an exit that opens into the corridor of the basement, which will direct you to an exit that exits from the facility. The hasp/lock was removed by maintenance once this surveyor made him aware this could never be locked, also the door to central suppy was unlocked.

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NFPA 101, 7.1.10.1 Means of egress shall be continuously maintained free of all obstructions or impediments for full instant use in case of fire or other emergencies.

NFPA 101, 7.1.10 and 7.5.1.1 Exit access shall be arranged so that exits are readily accessible at all times.

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The facility failed to maintain the curtains/draperies per code. Findings include:

During the survey, the folowing are examples of what was observed:
The facility failed to provide flame resistant documentation on the curtains/draperies in the following locations:
1. Labor and Delivery Rooms
2. Nursery

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2000 NFPA 101, 10.3.1 Where required by the applicable provisions of this Code, draperies, curtains, and other similar loosely hanging furnishings and decorations shall be flame resistant as demonstrated by testing in accordance with NFPA 701, Standard Methods of Fire Tests for Flame Propagation of Textiles and Films.
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The facility failed to provide proper storage of oxygen cylinders. Findings include: During the survey, the following are examples of what was observed:


Eight unsecured oxygen cylinders, and signage was not provided for the full cylinders.

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1999 NFPA 99, 4-3.1.1.1 and 4-5.1.1.1 Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over.


CGA G-4, 4.1.10, and 1999 NFPA 99, 4-3.5.2.2(b)2 and 4-5.5.2.2(b)2 Full and empty cylinders shall be stored separately, with appropriate signage.

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The facility failed to provide smoke venting in anesthetizing locations per code. Findings include:

During the survey, the following are examples of what was observed:
O.R.'s 1 and 2 - per observation and interview did not have exhaust fans in the O.R.s to vent the smoke. The O.R.'s HVAC system did shut down under general alarm.

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1999 NFPA 99, 5-4.1.2 Supply and exhaust systems for windowless anesthetizing locations shall be arranged to automatically vent smoke and products of combustion.
1999 NFPA 99, 5-4.1.3 Ventilating systems for anesthetizing locations shall be provided that automatically (a) prevent recirculation of smoke originating within the surgical suite and (b) prevent the circulation of smoke entering the system intake, without in either case interfering with the exhaust function of the system.
1999 NFPA 99, 5-4.1.4 The electric supply to the ventilating system shall be served by the equipment system of the essential electrical system specified in Chapter 3, " Electrical Systems. "
1999 NFPA 99, 5-6.1.1 Ventilating and humidifying equipment for anesthetizing locations shall be kept in operable condition and be continually operating during surgical procedures (see A-5-4.1).
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The facility did provide proper emergency lighting at the generator set and controls. Findings include: During the survey, the following are examples of what was observed:


A battery-powered emergency light was not provided in the generator set and control room.

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1999 NFPA 99, 3-6.1.1 and 3-4.1.1.4, and 1999 NFPA 110, 5-3.1. Emergency generator equipment locations.

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The facility failed to maintain the generator per code. Findings include:

During the survey, the following are examples of what was observed:
1. While testing the generators the generator remote annunciators did not indicate "generator on load"
2. Per documentation and interview the facility was not conducting weekly inspections on the generators

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1999 NFPA 99, 3-4.1.1.15 A remote annunciator, storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station (see NFPA 70, National Electrical Code, Section 700-12.) The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows: (a) Individual visual signals shall indicate the following: 1. When the emergency or auxiliary power source is operating to supply power to load 2. When the battery charger is malfunctioning (b) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following: 1. Low lubricating oil pressure 2. Low water temperature (below those required in 3-4.1.1.9) 3. Excessive water temperature 4. Low fuel - when the main fuel storage tank contains less than a 3-hour operating supply 5. Overcrank (failed to start) 6. Overspeed Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions in 3-4.1.1.15(a) and (b) occur, but need not display these conditions individually. [110: 3-5.5.2]
1999 NFPA 110, 6-4.1 Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.
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The facility utilized extension cords without overcurrent protection. Findings include: During the survey, the following are examples of what was observed:


1. Extension in use without overcurrent protection in the Boiler Room.

2. Refrigerator plugged into an extension without overcurrent protection, in the Pharmacy.

3. Two freezers plugged into an extension cord without overcurrent protection, in the kitchen. The extension cord ran through the ceiling tile, across the the kitchen, then back down through the ceiling tile, where it was plugged into an electrical outlet.

4. Overcurrent protection plugged into an overcurrent protection, then plugged into an extension cord, which was plugged into an electrical outlet.

5. Freezer, and milk box plugged into a three way adapter.

6. Extension cords behind the deep fryers in use without overcurrent protection.

7. Junction box missing the cover above the ceiling in the Envirometal Storeroom.

8. Junction box missing the cover in the walk in freezer, and cooler.

9. Junction box missing the cover in the OR Breakroom.

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1999 NFA 70, Article 240-4, and HFCA Transmittal Notice 22-99 prohibit the use of extension cords without overcurrent protection.

1999 NFPA 70, 370-25 and 410-12. Each box in completed installations to have a cover, face plate, or fixture canopy.

Appliances, such as air conditioners and refrigerators, shall plug directly into a receptacle. 1999 NFPA 70, 400-7 and 400-8, and HCFA Transmittal Notice 22-99.




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The facility failed to maintain the electrical system per code. Findings include:

During the survey, the following are examples of what was observed:
First Floor
10. Nursing Supervisor's Office - microwave plugged into an overcurrent device
11. H.I.M. Medical Records - refrigerator plugged into an overcurrent device
12. Medical Records - microwave and refrigerator plugged into an overcurrent device
13. Outpatient Surgery Nurses' Station Breakroom -
a. Refrigerator plugged into an overcurrent device
b. Microwave plugged into another overcurrent device
14. Doctor's Lounge in O.R. had an extension cord in use
15. E.R. Admissions Office had an extension cord in use
16. E.R. Triage - electrical junction box above the ceiling was missing it's cover plate
17. E.R. Med. Room - refrigerator plugged into an extension cord
18. Main Lab - refrigerator plugged into an extension cord
19. Lab Breakroom - refrigerator plugged into an extension cord
20. Blood Gas Room/Oxygen Storage Room - had two extension cords
21. Mechanical Room at X-ray - spliced wiring for light fixtures and other things in several locations
22. Room 300 - microwave plugged into an overcurrent device
23. OB Supervisor/Work Room - refrigerator plugged into an extension cord

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1999 NFPA 70, 400-7 and 400-8, and HCFA Transmittal Notice 22-99 The 1984 edition of the National Electric Code restricts the use of extension cords to temporary short term uses. It is the policy of HCFA to prohibit non-circuit breaker protected extension cords in health care. The limited use of circuit breaker protected power strips is acceptable, provided the current is limited to 15 amps or less, and no major appliances such as air conditioners, refrigerators, or heating units are connected to the power strip.


1999 NFPA 70, 370-28. Pull and Junction Boxes
Boxes and conduit bodies used as pull or junction boxes shall comply with (a) through (d).
(a) Covers. All pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use. Where metal covers are used, they shall comply with the grounding requirements of Section 250-110. An extension from the cover of an exposed box shall comply with Section 370-22, Exception.

The facility failed to maintain the fire walls. Findings include: During the survey, the following is an example of what was observed:

1. Unsealed penetrations around a group of four sections of conduit, in the two hour wall, in front of the Print Shop.

2. Unsealed penetrations around a group of wiring, in the two hour wall, by Central Processing.



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NFPA 101 2000, 8.2.3.2.3.1 Every openings in a fire barrier shall be protected to limit the spread of fire and restrict the movement of smoke from one side of the fire barrier to the other.

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Failed to provide compatible building construction types for a three story partially sprinklered structure without two hour fire barrier separation between the different types of construction was observed. Findings include:

During the survey, the following are examples of what was observed:
The facility appears to have three different construction types, without seperation, which were:
I (332) - poured in place concrete
II (222) - sprayed on fire protection on steel beams
II (000) - exposed steel beams above a lay-in ceiling (observed in the administration part of the first floor and only in the single story part of this facility)



1. The surveyor could not verify that the one story building was a Type II (222) as indicated on documentation provided by the facility staff.
2. The surveyor could not verify that the ceiling tiles for this section were the type of ceiling tiles to be used in a rated ceiling assembly.
3. The surveyor could not verify that the ceiling grid was the type of grid to be used in a rated ceiling assembly.
4. A two hour fire rated barrier separarting construction types was not observed during the survey.
5. There was not a two hour fire rated barrier separating the single story from the three story

A three story Type II (000) is not allowed per code.
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2000 NFPA 101, 8.2.1* Construction.
Buildings or structures occupied or used in accordance with the individual occupancy chapters (Chapters 12 through 42) shall meet the minimum construction requirements of those chapters. NFPA 220, Standard on Types of Building Construction, shall be used to determine the requirements for the construction classification. Where the building or facility includes additions or connected structures of different construction types, the rating and classification of the structure shall be based on either of the following:
(1) Separate buildings if a 2-hour or greater vertically-aligned fire barrier wall in accordance with NFPA 221, Standard for Fire Walls and Fire Barrier Walls, exists between the portions of the building
Exception: The requirement of 8.2.1(1) shall not apply to previously approved separations between buildings.
(2) The least fire-resistive type of construction of the connected portions, if no such separation is provided

2000 NFPA 101, 19.1.6.2 Health care occupancies shall be limited to the types of building construction shown in Table 19.1.6.2. (See 8.2.1.)

Table 19.1.6.2 Construction Type Limitations
Construction Stories
Type
1 2 3 4 or
More
I(443) X X X X
I(332) X X X X
II(222) X X X X
II(111) X X* X* NP
II(000) X* X* NP NP
III(211) X* X* NP NP
III(200) X* NP NP NP
IV(2HH) X* X* NP NP
V(111) X* X* NP NP
V(000) X* NP NP NP
X: Permitted type of construction.
NP: Not permitted.
*Building requires automatic sprinkler protection. (See 19.3.5.1.)
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The facility failed to maintain the corridor walls in the unsprinklered part of the facility per code. Findings include:

During the survey, the following are examples of what was observed:
The following corridor walls had unsealed penetrations:
First Floor
1. E.R. - penetration at Trauma Room
2. E.R. - at HVAC duct penetration at the Trauma Room
3. E.R. - three penetrations at Exam Room 1
4. Lab corridor across from the bathrooms -
a. Unsealed penetration at a wire
b. Open HVAC duct above ceiling
5. Lab corridor outside the E.R. -
a. Unsealed penetration at flex conduit, on the left side
b. Missing sheetrock approximately 2' x 2' on the right side
6. Respiratory Therapy corridor - several unsealed conduit penetrations on both sides
7. O.R. corridor by the Recovery Room - unsealed penetration at a group of wires



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2000 NFPA 101, 19.3.6.2.1 Corridor walls shall be continuous from the floor to the underside of the floor or roof deck above, through any concealed spaces, such as those above suspended ceilings, and through interstitial structural and mechanical spaces, and they shall have a fire resistance rating of not less than 1/2 hour.


.

The facility failed to provide corridor doors that would close and resist the passage of smoke. Findings include: During the survey, the following are examples of what was observed:

7. The door failed to positive latch, this door opens from the Kitchen into the corridor.

8. Four holes approximatley half the size of a dime,around the handle Patient Room 224.

9. Gap between Mechanical Room doors which opens into the corridor in the Basement.

10. Gap between the door at the Nurses Station in the Geri-Psych, door opens into corridor.


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First Floor
11. Outpatient Observation Room #6 - had 4 holes in the corridor door at the door handle
12. Outpatient Examination Room #2 - the corridor door was not positive latching
13. Public Relations - the corridor door had 2 holes at the door handle

Basement
14. Hospital Classroom corridor door on the side corridor was not positive latching

Third Floor
15. Pantry corridor door the positive latching hardware had been removed
16. Room 300 had 4 holes in the corridor door at the door handle


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2000 NFPA 101, 19.3.6.3.1 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 13/4-in. (4.4-cm) 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. Compliance with NFPA 80, Standard for Fire Doors and Fire Windows, shall not be required. Clearance between the bottom of the door and the floor covering not exceeding 1 in. (2.5 cm) shall be permitted for corridor doors.

2000 NFPA 101, 19.3.6.3.2 Doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door. Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.2.
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The facility failed to provide smoke barriers that would provide at least a half hour fire resistance rating. Findings include: During the survey, the following are examples of what was observed:

1. Large hole in the Smoke Barrier at the Oneology.

2. Unsealed penetrations at the end of a sleeve, and around a water line, in the Smoke Barrier, at the Outpatient Center.

3. Unsealed penetrations around a section of flex conduit, in the Smoke Barrier near Stairwell A.

4. Unsealed penetrations at the end of a sleeve, in the Smoke Barrier, by Patient Room 203.

5. Unsealed penetrations at the end of a sleeve, in the Smoke Barrier, by Technician Room Second Floor.



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The facility failed to maintain the smoke barriers per code. Findings include:

During the survey, the following are examples of what was observed:
Unsealed penetrations were observed in the following smoke barriers:
First Floor
6. File Room/Registration/Financial Counseling - electrical conduit
7. Men's Locker Room in the Doctor's Lounge -
a. Around a conduit
b. The end of the same conduit
8. Social Services -
a. Group of white wires
b. End of a conduit
9. Recovery Room for the O.R.s -
a. Two 2' x 2' penetrations in the left wall
b. Around a flex conduit
10. O.R. fire doors - around the water lines
11. O.R. Family Consultation Room - several penetrations
12. E.R. Trauma Room -
a. Around a regular size conduit
b. Around a large size conduit
c. Two pieces of conduit were not sealed
13. E.R. Triage - three penetrations
Third Floor
14. At room 317 - around wires

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2000 NFPA 101, 8.3.6.1 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows: (1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions: a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier. b. It shall be protected by an approved device that is designed for the specific purpose. (2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions: a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier. b. It shall be protected by an approved device that is designed for the specific purpose. (3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions: a. It shall be made on either side of the smoke barrier. b. It shall be made by an approved device that is designed for the specific purpose.

2000 NFPA 101, 8.3.2 Smoke barriers required by this Code shall be continuous from an outside wall to an outside wall, from a floor to a floor, or from a smoke barrier to a smoke barrier or a combination thereof. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces.
.

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The facility failed to maintain the smoke barrier doors per code. Findings include:

During the survey, the following are examples of what was observed:
First Floor
1. File Room/Registration/Financial Counseling corridor door is in a smoke barrier without a self-closing device
2. Second Registration Office corridor door is in a smoke barrier without a self-closing device
3. O.R. Family Consultation Room corridor door is in a smoke barrier without a self-closing device

_________________
2000 NFPA 101, 19.3.7.6 Doors in smoke barriers shall comply with 8.3.4 and shall be self-closing or automatic-closing in accordance with 19.2.2.2.6.

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The facility failed to maintain the hazardous areas per code. Findings include:

During the survey, the following are examples of what was observed:
First Floor
1. Gift Shop Storage Room - approximately 96 sq. ft. with combustibles - self-closing device had been removed from the door
2. Medical Records - approximately 600 sq. ft. with combustibles -
a. No self-closing device on one of the doors
b. Unsealed penetration in wall below ceiling
3. Mechanical Room by H.I.M. - unsealed penetration of wires in the back wall.
4. Biomed Work Area/Storage Room - approximately 900 sq. ft. with combustibles - no self-closing device on the two doors
5. Public Relations Storage Room - approximately 64 sq. ft. with combustibles - no self-closing device on the door
6. Auxiliary Storage Room over 50 sq. ft. with combustibles - wall was not sealed at corrugated roof deck
7. E.R. Soiled Utility -
a. Unsealed penetration of a grey wire in two walls
b. Corridor door latching hardware was not positive latching
8. Mechanical Room at X-ray -
a. Missing sheetrock
b. Unsealed penetrations
Third Floor
9. Consultation Room being used for storage - approximately 80 sq. ft. with combustibles - no self-closing device on the door

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2000 NFPA 101, 19.3.2.1 Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing.

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The facility failed to provide continuous lighting for means of egress. Findings include: During the survey, the following are examples of what was observed:


1. The Exit Discharge had a single bulb fixture for the East Administration Exit.

2. The Exit Discharge had a single bulb fixture for the Wellness Center Exit.

____________________-


NFPA 101, 19.2.8 and 7.8.1.2 Illumination of means of egress shall be continuous.

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The facility failed to provide a complete fire safety plan. Findings include: Documentation of the fire safety plan provided by the facility during the survey was observed incomplete, not including all eight items required.

_________________

NFPA 101, 19.7.2.2 A written health care occupancy fire safety plan shall provide for the following: (1) Use of alarms, (2) Transmission of alarm to fire department, (3) Response to alarms, (4) Isolation of fire, (5) Evacuation of immediate area, (6) Evacuation of smoke compartment, (7) Preparation of floors and building for evacuation, and (8) Extinguishment of fire.

.

The facility failed to conduct fire drills per code. Findings include:

During the survey, the following are examples of what was observed:
1. Per documentation and interview -
a. Signatures of staff participating in the fire drills for the last three years was not provided
b. Not all staff are participating in the fire drills
2. Per documentation - not conducting fire drills at unexpected times under varying conditions:
First Shift
11/30/11 - 2:00 pm
09/26/11 - 2:15 pm
06/16/11 - 10:00 am
03/27/11 - 2:00 pm
Second Shift
12/27/11 - 4:15 pm
09/28/11 - 4:40 pm
06/29/11 - 4:15 pm
03/30/11 - 5:20 pm
Third Shift
12/22/11 - 6:42 am
09/28/11 - 6:45 am
06/28/11 - 6:45 am
03/16/11 - 6:39 am

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2000 NFPA 101, 19.7.1.2 Fire drills in health care occupancies shall 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. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
.

Facility failed to maintain the Digital Alarm Communicator Transmitter in the fire alarm system. Findings include: During the survey, the following are examples of what was observed:

1. When the Auto Dialer was tested for phone line 1, failure was not indicated at the protected premise within the allotted four (4) minute time frame. wait (5)

2. When the Auto Dialer was tested for phone line 2, failure was not indicated at the protected premise within the allotted four (4) minute time frame.

3. When the Auto Dialer was tested for Communication Failure, failure was not indicated at the protected premise within the allotted fifteen (15) minute time frame (5 minimum to 10 maximum attempts for signal transmission). (Surveyor waited 16 minutes.)

________________

1999 NFPA 72, Section 1-5.4.6, 5-5.3.2.1.5, and 5-5.3.2.1.6.2. Phone line and communication failure shall be indicated at the facility.

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The facility failed to maintain the fire alarm system in proper working order. Findings include: During the survey, the following is an example of what was observed:

Documentation for the annual fire alarm system for 1/18/2012 indicated that a audio/visual signal device located in the Outpatient Building failed. The facility could not provide documentation that this had been corrected.

______________________


NFPA 101, 9.6.1.4 The fire alarm system to be installed, tested, and maintained in accordance with the requirements of NFPA 70 and NFPA 72.

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Sprinkler coverage was observed during the survey not adequately provided. Findings include: During the survey, the following are examples of what was observed:


1. Corrosion build up around the seat of a sprinkler in Environmetal Services Storeroom.

2. Corrosion build up around the seat/link of a sprinkler top of Stairwell B Second Floor.

3. Corrosion build up around the seat/link in the Mechanical Room Second Floor.

4. Escutcheon plate missing on a sprinkler in the Outpatient Waiting Room.

5. Escutcheon plate missing on a sprinkler in the Linear Accelerator Area.

6. Ceiling tile missing in the Environmetal Services Storeroom.

7. The storage room across from Patient Room 222, was not provided with sprinkler coverage. This floor is protected with sprinklers in all another areas this surveyor observed.

8. The Linen storage room, and the Janitor storage room, by Patient Room 200, not provided with sprinkler coverage. This floor is protected with sprinklers in all another areas this surveyor observed.


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First Floor
9. Mechanical Room (I.T. Closet) by H.I.M. - in sprinklered part of the facility, did not have sprinkler protection

__________________

NFPA 19.3.5.1 Where required by 19.1.6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.
1999 NFPA 25, 2-2.1.1 and 2-4.1.2 Sprinklers that are painted, corroded or damaged shall be replaced with new listed sprinklers of the same characteristics, including orifice size, thermal response, and water distribution.

2000 NFPA 13, 3-2.7.2 Escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly.

NFPA 13 5-6., Sprinklers shall be arranged to be in compliance.

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The facility failed to perform the required maintenance of the facility sprinkler system. Findings include: During the survey, the following are examples of what was observed:


Documentation provided during the survey indicated quarterly sprinkler system inspections were conducted 12/27/2010, 3/26/2011, 6/13/2011.

1. The 3/26/2011 inspection noted the (5) year internal inspection was due.

2. The 6/13/2011 inspection noted the gauges were due for (5) year calibration, or replacement.

3. Inspection of the dry riser on 12/27/2011 indicated a trip test was conducted, but failed to provide if partial trip, or full trip. Also the results of the trip test was not provided.

_______________________


NFPA 101, 4.6.12, and NFPA 25, 2-2 and Table 2-1 Requires an inspection every quarter (three months).

NFPA 25,1998 Edition, 9-5.2.3 A partial flow trip test adequate to move the valve from its seat shall be conducted annually.
NFPA 25, 1998 Edition, 9-4.4.2.2.2 Every 3 years and whenever the system is altered, the dry pipe valve shall be trip tested with the control valve fully open and the quick-opening device, if provided, in service.
NFPA 25, 9-2.8.2: Gauges 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.

NFPA 25, 9-2.8.1: Gauges shall be inspected monthly to verify that they are in good condition and that normal pressure is being maintained.

















Exception: When other sections of this standard have different frequency requirements for specific gauges.


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4. The following locations were missing sprinkler head escutcheon plates:
First Floor
a. Women's Bathroom at Physical Therapy
b. Entrance to Outpatient/Physical Therapy
Basement
c. Oncology corridor by Hospital Classroom
d. In Hospital Classroom


________________



2000 NFPA 13, 3-2.7.2 Escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly



.

.


The facility failed to maintain the fire extinguishers per code. Findings include:

During the survey, the following is an example of what was observed:
First Floor
Fire Extinguisher #51 at Auxiliary Storage last hydrostatic test was in 2005

___________________

1998 NFPA 10, 4-4.3 Every 6 years, stored-pressure fire extinguishers that require a 12-year hydrostatic test shall be emptied and subjected to the applicable maintenance procedures. The removal of agent from halon agent fire extinguishers shall only be done using a listed halon closed recovery system. When the applicable maintenance procedures are performed during periodic recharging or hydrostatic testing, the 6-year requirement shall begin from that date.
.

The facility failed to provide metal self-closing containers for disposing of cigarette butts and ashes from ashtrays. Findings include: During the survey, the following are examples of what was observed:


1. The designated smoking area provided for the "Self-Help" patients, was not provided with a metal container which was self-closing, as required in NFPA 101, 19.7.4.(4).


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2. The facility's smoking policy states that there is no smoking, but the facility does allow the "Self-Help" patients to smoke in a designated area.

___________________

2000 NFPA 101, 19.7.4 Smoking regulations shall be adopted and shall include not less than the following provisions: (1) Smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such areas shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking. Exception: In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required. (2) Smoking by patients classified as not responsible shall be prohibited. Exception: The requirement of 19.7.4(2) shall not apply where the patient is under direct supervision. (3) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted. (4) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted.
.

Facility failed to maintain the protection for the cooking area per NFPA standards. The following is an example of what was observed:

1. During the survey, the K-extinguisher in the kitchen was not provided with a placard.
2. The facility failed to maintain the dietary hood. Findings include: During the survey, a filter was observed not to be tight fitting, and firmly held in place, the filter appeared to be bend.

____________________

NFPA 96 7-2.1.1 A placard identifying the use of the extinguisher as a secondary backup means to the automatic fire suppression system shall be conspicuously placed near each portable fire extinguisher in the cooking area.


NFPA 96, 3-2.3 Grease filters shall be listed and constructed of steel or listed equivalent material and shall be of rigid construction that will not distort or crush under normal operation, handling, and cleaning conditions. Filters shall be tight fitting and firmly held in place.

.

The facility failed to prohibit portable space heating devices per code. Findings include:

During the survey, the following are examples of what was observed:
Portable space heating devices were observed in the following locations:
First Floor
1. Sleep Study Office
2. Sleep Study Tech. Room
3. Program Director's Office for Behavioral Health
Third Floor
4. OB Suppervisor/Work Room

_______________

2000 NFPA 101, 19.7.8 Portable space-heating devices shall be prohibited in all health care occupancies.
Exception: Portable space-heating devices shall be permitted to be used in nonsleeping staff and employee areas where the heating elements of such devices do not exceed 212?F (100?C).
.

The facility failed to provide a readily accessible means of egress pathway at all times. Findings include: During the survey, the following are examples of what was observed:


1. Three freezers located in the kitchen were obsructing clear/accessible means of egress to the Exit.

2. The sub-basement is provided with two means of egress, this surveyor observed one of the exits to have a hasp with a lock in place. This exit opens into an area behind the Central supply, in order to continue to move to an exit from this area, you have to open a door into central suppy, which is locked from the inside, thus preventing travel through this door. If this door is accessible you egress through central suppy to an exit that opens into the corridor of the basement, which will direct you to an exit that exits from the facility. The hasp/lock was removed by maintenance once this surveyor made him aware this could never be locked, also the door to central suppy was unlocked.

____________________


NFPA 101, 7.1.10.1 Means of egress shall be continuously maintained free of all obstructions or impediments for full instant use in case of fire or other emergencies.

NFPA 101, 7.1.10 and 7.5.1.1 Exit access shall be arranged so that exits are readily accessible at all times.

.

The facility failed to maintain the curtains/draperies per code. Findings include:

During the survey, the folowing are examples of what was observed:
The facility failed to provide flame resistant documentation on the curtains/draperies in the following locations:
1. Labor and Delivery Rooms
2. Nursery

_____________________


2000 NFPA 101, 10.3.1 Where required by the applicable provisions of this Code, draperies, curtains, and other similar loosely hanging furnishings and decorations shall be flame resistant as demonstrated by testing in accordance with NFPA 701, Standard Methods of Fire Tests for Flame Propagation of Textiles and Films.
.

The facility failed to provide proper storage of oxygen cylinders. Findings include: During the survey, the following are examples of what was observed:


Eight unsecured oxygen cylinders, and signage was not provided for the full cylinders.

___________________


1999 NFPA 99, 4-3.1.1.1 and 4-5.1.1.1 Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over.


CGA G-4, 4.1.10, and 1999 NFPA 99, 4-3.5.2.2(b)2 and 4-5.5.2.2(b)2 Full and empty cylinders shall be stored separately, with appropriate signage.

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The facility failed to provide smoke venting in anesthetizing locations per code. Findings include:

During the survey, the following are examples of what was observed:
O.R.'s 1 and 2 - per observation and interview did not have exhaust fans in the O.R.s to vent the smoke. The O.R.'s HVAC system did shut down under general alarm.

________________

1999 NFPA 99, 5-4.1.2 Supply and exhaust systems for windowless anesthetizing locations shall be arranged to automatically vent smoke and products of combustion.
1999 NFPA 99, 5-4.1.3 Ventilating systems for anesthetizing locations shall be provided that automatically (a) prevent recirculation of smoke originating within the surgical suite and (b) prevent the circulation of smoke entering the system intake, without in either case interfering with the exhaust function of the system.
1999 NFPA 99, 5-4.1.4 The electric supply to the ventilating system shall be served by the equipment system of the essential electrical system specified in Chapter 3, " Electrical Systems. "
1999 NFPA 99, 5-6.1.1 Ventilating and humidifying equipment for anesthetizing locations shall be kept in operable condition and be continually operating during surgical procedures (see A-5-4.1).
.

The facility did provide proper emergency lighting at the generator set and controls. Findings include: During the survey, the following are examples of what was observed:


A battery-powered emergency light was not provided in the generator set and control room.

_________________________

1999 NFPA 99, 3-6.1.1 and 3-4.1.1.4, and 1999 NFPA 110, 5-3.1. Emergency generator equipment locations.

.

The facility failed to maintain the generator per code. Findings include:

During the survey, the following are examples of what was observed:
1. While testing the generators the generator remote annunciators did not indicate "generator on load"
2. Per documentation and interview the facility was not conducting weekly inspections on the generators

__________________

1999 NFPA 99, 3-4.1.1.15 A remote annunciator, storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station (see NFPA 70, National Electrical Code, Section 700-12.) The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows: (a) Individual visual signals shall indicate the following: 1. When the emergency or auxiliary power source is operating to supply power to load 2. When the battery charger is malfunctioning (b) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following: 1. Low lubricating oil pressure 2. Low water temperature (below those required in 3-4.1.1.9) 3. Excessive water temperature 4. Low fuel - when the main fuel storage tank contains less than a 3-hour operating supply 5. Overcrank (failed to start) 6. Overspeed Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions in 3-4.1.1.15(a) and (b) occur, but need not display these conditions individually. [110: 3-5.5.2]
1999 NFPA 110, 6-4.1 Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.
.

The facility utilized extension cords without overcurrent protection. Findings include: During the survey, the following are examples of what was observed:


1. Extension in use without overcurrent protection in the Boiler Room.

2. Refrigerator plugged into an extension without overcurrent protection, in the Pharmacy.

3. Two freezers plugged into an extension cord without overcurrent protection, in the kitchen. The extension cord ran through the ceiling tile, across the the kitchen, then back down through the ceiling tile, where it was plugged into an electrical outlet.

4. Overcurrent protection plugged into an overcurrent protection, then plugged into an extension cord, which was plugged into an electrical outlet.

5. Freezer, and milk box plugged into a three way adapter.

6. Extension cords behind the deep fryers in use without overcurrent protection.

7. Junction box missing the cover above the ceiling in the Envirometal Storeroom.

8. Junction box missing the cover in the walk in freezer, and cooler.

9. Junction box missing the cover in the OR Breakroom.

_________________________

1999 NFA 70, Article 240-4, and HFCA Transmittal Notice 22-99 prohibit the use of extension cords without overcurrent protection.

1999 NFPA 70, 370-25 and 410-12. Each box in completed installations to have a cover, face plate, or fixture canopy.

Appliances, such as air conditioners and refrigerators, shall plug directly into a receptacle. 1999 NFPA 70, 400-7 and 400-8, and HCFA Transmittal Notice 22-99.




27382


The facility failed to maintain the electrical system per code. Findings include:

During the survey, the following are examples of what was observed:
First Floor
10. Nursing Supervisor's Office - microwave plugged into an overcurrent device
11. H.I.M. Medical Records - refrigerator plugged into an overcurrent device
12. Medical Records - microwave and refrigerator plugged into an overcurrent device
13. Outpatient Surgery Nurses' Station Breakroom -
a. Refrigerator plugged into an overcurrent device
b. Microwave plugged into another overcurrent device
14. Doctor's Lounge in O.R. had an extension cord in use
15. E.R. Admissions Office had an extension cord in use
16. E.R. Triage - electrical junction box above the ceiling was missing it's cover plate
17. E.R. Med. Room - refrigerator plugged into an extension cord
18. Main Lab - refrigerator plugged into an extension cord
19. Lab Breakroom - refrigerator plugged into an extension cord
20. Blood Gas Room/Oxygen Storage Room - had two extension cords
21. Mechanical Room at X-ray - spliced wiring for light fixtures and other things in several locations
22. Room 300 - microwave plugged into an overcurrent device
23. OB Supervisor/Work Room - refrigerator plugged into an extension cord

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1999 NFPA 70, 400-7 and 400-8, and HCFA Transmittal Notice 22-99 The 1984 edition of the National Electric Code restricts the use of extension cords to temporary short term uses. It is the policy of HCFA to prohibit non-circuit breaker protected extension cords in health care. The limited use of circuit breaker protected power strips is acceptable, provided the current is limited to 15 amps or less, and no major appliances such as air conditioners, refrigerators, or heating units are connected to the power strip.


1999 NFPA 70, 370-28. Pull and Junction Boxes
Boxes and conduit bodies used as pull or junction boxes shall comply with (a) through (d).
(a) Covers. All pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use. Where metal covers are used, they shall comply with the grounding requirements of Section 250-110. An extension from the cover of an exposed box shall comply with Section 370-22, Exception.