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Based on observation and staff interview, the facility failed to maintain fire doors in a two-hour fire barrier that separated two non-conforming occupancies. This condition would allow smoke or fire to spread between the two occupancies. Facility census was 20.

Findings are:
Observation during the facility tour on 12/15/14, at 10:54 am revealed the 90-minute fire doors in the 2-hour fire barrier that separated the Hospital from the MOB failed to positively latch when the powered doors swung shut.
In an interview conducted at the time of observation, (12/15/14, at 10:54 am), Maintenance B confirmed the doors failed to latch.

NFPA 80, 1999, 2-1.2 Components.
A fire door assembly shall consist of components that are separate products incorporated into the assembly and allowed to have their own subcomponents. The normal components of a fire door assembly include a door, a door frame, hinges, a lock or latch, and a closing device. They also include, but are not limited to, an astragal, an automatic louver, a coordinator, flush or surface bolts, gasketing, a holder/release device, protection plates, and glazing materials.



34122

Based on observations, record review and interviews the facility failed to seal penetrations in a two hour barrier to Underwriter Laboratories (UL) and manufacture standards. This practice would allow smoke and heat to migrate between the healthcare and business occupancies. The facility census was 20.

Findings are:
Observations during the facility tour on 12/15/14 at 2:12 pm revealed gaps between fire bricks installed in the conduit that penetrated the two hour barrier between the Hospital and the Medical Office Building.
Record review on 12/16/14 at 11:17 am of UL 3L73 and manufacturer instructions revealed bricks are to be tightly compressed and all voids are to be closed.
During interviews on 12/15/14 at 2:12 pm and 12/16/14 at 11:58 am, Maintenance A confirmed the gaps in the fire bricks.

Based on observations and interviews the facility failed to ensure that corridor walls used for fire separation did not contain openings or penetrations. This practice would allow smoke to migrate into the exit corridor. The facility census was 20.

Findings are:
Observations during the facility tour on 12/15/14 between 1:30 pm and 2:06 pm of above ceilings revealed:
1. The wall near the stairwell for Pod 2 had a penetration that failed to be sealed.
2. The west door by the Cath Lab had a penetration that failed to be sealed.
3. The wall behind the nurse ' s station in Pod 0 had two penetrations that failed to be sealed.
During interviews on 12/15/14 between 1:30 pm and 2:06 pm, Maintenance C confirmed the unsealed penetrations.

Based on observation and interview, the facility failed to maintain or provide latching hardware on corridor doors or to ensure that corridor doors would resist the passage of smoke. These deficient practices have the potential to allow smoke or fire to migrate into exit corridors. The facility census was 20 patients.

Findings are:
Observations on 12-15-14 between 9:36 am and 10:56 am revealed:
1. The west Cath. Lab 2 door failed to close and latch within the door frame.
2. Three Diagnostic sliding glass doors on the corridor failed to provide latching hardware.
3. The west Cat. Scan door held open with soiled linen cart, when cart was removed the door closed on its own.
4. Operating Room doors 1, 2, and 3 had a gap greater than 1/8 inch between two doors.

During an interview on 12-15-14 between 9:36 am and 10:56 am, Maintenance A confirmed all the findings.



34122

Based on observations and interviews the facility failed to ensure that there were no impediment to the closing of corridor doors. This practice would allow smoke to migrate into the exit corridor. The facility census was 20.

Findings are:
Observations during the facility tour on 12/15/14 at 11:08 am revealed the door leading from the data center to the corridor failed to close and latch due to catching on a rug under the door. In addition, the timing of the door closures prevented the doors from closing in the correct sequence and positively latching.
During interviews on 12/15/14 at 11:08 am, Maintenance C confirmed the failure of the door to close.

Based on observation and staff interview, the facility failed to mark exits by approved, readily visible signs in all cases where the exit or way to reach the exit was not readily apparent to the occupants. This condition would not allow occupants to efficiently evacuate the facility during a fire or other emergency. Facility census was 20.

Findings are:
Observations during the facility tour on 12/15/14, from 9:33 am to 10:18 am revealed two exit signs failed to be visible on the 2nd Floor Pods 1 and 4 when standing by the nurse ' s station.
In an interview conducted at the time of observations (12/15/14, from 9:33 am to 10:18 am), Maintenance B acknowledged the findings.

Based on observations and interview, the facility failed to assure that doors to hazardous areas equipped with self-closing devices would latch within the door frame, and failed to provide self-closing device on doors to hazardous areas. The facility failed to provide fire separation between hazardous areas and the corridor and failed to assure the undercut to storage area was less than an inch. These deficient practices have the potential to allow smoke, fire and gas to migrate into the exit corridors. The facility census was 20 patients.

Findings are:
Observations on 12-15-14 between 9:42 am and 2:16 pm revealed:
1. Soiled utility room door in the Cath. Lab area failed to latch within the door frame.
2. Pathology Room door held open with a rubber door chock.
3. Respiratory Therapy room used as a storage room, the north door failed to provide a self-closure.
4. The south MRI storage room door 1.043 failed to latch within the door frame.
5. Unsealed penetration above the ceiling tile in the corridor above Cath. Lab 3.
6. Double doors into garage 1.194 failed to latch within the door frame.
7. Storage room door in the dock 1.193 failed to latch within the door frame.
8. Housekeeping storage room within Sterile Processing failed to provide a self-closure on the door, the room is over 50 square feet.
9. The facility failed to provide fire rated separation between the corridor and the Clean Core storage area.
10. The VDA storage closet door undercut was 2 inches.

During an interview on 12-15-14 between 9:42 am and 2:16 pm, Maintenance A confirmed all the findings.




27395

Based on observation and staff interview, the facility failed to separate hazardous areas from use areas. This condition had the potential to allow smoke and fire to migrate into other areas of the facility. Facility census was 20.

Findings are:
Observations during the facility tour on 12/15/14, from 9:51 am to 11:09 am revealed:
1. A hole in the wall around a fire alarm conduit failed to be sealed in the 2nd Floor Main Electrical Room.
2. The Pod O Clean Supply Room Door failed to auto-close and latch. A cabinet was wedged against the door, and prevented the door from auto-closing.
In an interview conducted at the time of observations (12/15/14, from 9:51 am to 11:09 am), Maintenance B acknowledged the findings.

Based on observation and interview, the facility failed to assure the magnetically locked door in the Surgery Corridor was not locked against egress and failed to provide a delayed operation or signage. This deficient practice would delay egress in the event of an emergency. The facility census was 20.

Findings are:
Observations on 12-15-14 at 10:47 am revealed, the double doors from the Surgery Corridor into 0 Pod were locked with a magnetic lock, the door failed to provide delayed hardware or signage to have the ability to exit from the corridor.

During an interview on 12-15-14 at 10:47 am, Maintenance A confirmed the findings.

NFPA Standard:
A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 inches and not more than 48 inches above the finished floor. Doors shall be operable with not more than one releasing operation. 2000 NFPA 101, 7.2.1.5.4

Based on observation and interview, the facility failed to verify the illumination of the exit discharge, so that the failure of any single lighting fixture (bulb) will not leave the area in darkness, for all exits. This deficient practice would delay egress from the building. The facility census was 20 patients.

Findings are:
Observations on 12-15-14 at 3:23 pm, revealed the facility failed to verify a two bulb light fixture at all exterior exit from the building.

During an interview on 12-15-14 at time of observation, Maintenance A confirmed that the facility could not verify two bulbs in all lights at exit doors.

NFPA Standard:
Required illumination shall be arranged so that the failure of any single bulb or unit does not result in less than .2 foot-candles of illumination in any designated area. 2000 NFPA 101, 7.8.1.4

Based on observation and interview, the facility failed to provide the correct directional sign to indicate the continuous path of egress. This deficient practice would cause confusion and delay exiting. The facility census was 20 patients.

Findings are:
Observations on 12-15-14 at 11:07 am revealed, the exit sign in the OR coridor had two directional chevrons, one which directed occupants in a direction where there was no exit available.

During an interview on 12-15-14 at 11:07 am, Maintenance A confirmed the findings

Based on record review and staff interview, the facility failed to conduct quarterly fire drills on each shift for 1 of 3 shifts. This condition would not provide the required training for staff to respond to a fire emergency. Facility census was 20.

Findings are:
Record review of fire drills on 12/15/14, at 1:37 pm revealed the facility failed to document a fire drill for the 3rd shift in the 3rd Quarter of 2014.
In an interview conducted at the time of record review (12/15/14, at 1:37 pm), Maintenance B acknowledged the missing fire drill.

Based on observations and interviews the facility failed to ensure sprinkler coverage under the Receiving Overhead Door. This practice would allow fire development under the door, if the door was in the open position. The facility census was 20.

Findings are:
Observations during the facility tour on 12/15/14 at 10:53 am revealed the facility failed to provide sprinkler coverage under the overhead door when it was in the open position.
During interviews on 12/15/14 at 10:53 am, Maintenance C confirmed no sprinkler was present under the door.

Based on observation and interview, the facility failed to provide an unobstructed path to fire extinguishers. The deficient practice would delay the attempt to extinguish a fire. The facility census was 20 patients.

Findings are:
Observations on 12-15-14 at 10:00 am and 11:00 am revealed:
1. Surgical equipment obstructed 2 of 2 fire extinguishers in OR 1.
2. A large trash can obstructed the fire extinguisher in Sterile Processing.

During an interview on 12-15-14 at 10:00 am and 11:00 am, Maintenance A confirmed the findings.

NFPA Standard:
Fire extinguishers shall be conspicuously located where they will be readily accessible and immediately available in the event of fire. Preferably they shall be located along normal paths of travel, including exits from areas. 1998 NFPA 10, 1-6.3




34122

Based on observations and interviews the facility failed to maintain fire extinguishers in accordance with National Fire Protection Association (NFPA) 10. This practice would increase the likelihood that a fire extinguisher would fail to operate in the event of a fire. The facility census was 20.

Findings are:
Observations during the facility tour on 12/15/14 at 10:59 am revealed that the fire extinguisher located in the Data Center failed to be inspected on an annual and monthly basis.
During interviews on 12/15/14 at 10:59 am, Maintenance C confirmed the fire extinguisher was not being checked.

Based on observation, record review and staff interview, the facility failed to meet all requirements of the CMS waiver to allow furniture to be placed in exit corridors. This condition would allow furniture to obstruct the exit corridor during evacuation. Facility census was 20.

Findings are:
Observation during the facility tour on 12/15/14, at 9:38 am revealed chairs and tables were placed in the East Waiting Area Exit Corridor.
1. The furniture failed to be attached to the floor or wall.
2. The furniture failed to be arranged so that the grouping did not exceed 50 square feet.
Record review on 12/15/14, at 11:46 am revealed the facility had adopted the CMS Categorical Waiver: Corridor Projections for Fixed Furniture, NFPA 101, 2012, 19.2.3.4(5).
In an interview conducted at the time of observation and record review (12/15/14, from 9:38 am to 11:46 am), Maintenance B confirmed the furniture arrangement failed to meet the waiver requirements.

NFPA 101, 2012, 19.2.3.4(5)
(a) The fixed furniture is securely attached to the floor or to the wall.
(d) The fixed furniture is grouped such that each grouping does not exceed an area of 50 ft2.

Based on record review and staff interview, the facility failed to maintain all operating room (OR) line isolation panels. This condition would allow an electrical fault to occur during an operation without notification to staff. Facility census was 20.

Findings are:
Record review on 12/15/14, at 1:07 pm revealed documentation of monthly testing for the line isolation panels in the ORs failed to be provided for review.
In an interview conducted at the time of observation, (12/15/14, at 1:07 pm), Maintenance B confirmed the findings.

Actual NFPA Standard:
NFPA 99, 1999 Edition, 3-3.3.4.2 Line Isolation Monitor Tests.
(a) The LIM circuit shall be tested after installation, and prior to being placed in service, by successively grounding each line of the energized distribution system through a resistor of 200 X V ohms, where V = measured line voltage. The visual and audible alarms [see 3-3.2.2.3(b)] shall be activated.
(b) The LIM circuit shall be tested at intervals of not more than 1 month by actuating the LIM test switch [see 3-3.2.2.3(f)]. For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months. Actuation of the test switch shall activate both visual and audible alarm indicators.
(c) After any repair or renovation to an electrical distribution system and at intervals of not more than 6 months, the LIM circuit shall be tested in accordance with paragraph (a) above and only when the circuit is not otherwise in use. For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months.



34122

K130A - Industrial Occupancy

Based on observations and interviews the facility failed to maintain electrical wiring in accordance with National Fire Protection Association (NFPA) 70. This practice created a higher potential for an electrical fire. The facility census was 20.

Findings are:
Observations during the facility tour on 12/15/14 at 9:33 am revealed that a junction box for Air Handler 2 failed to have a cover plate.
During interviews on 12/15/14 at 9:33 am, Maintenance C confirmed the missing cover plate.

K130B - Industrial Occupancy

Based on observations and interviews the facility failed to install notification devices in all required areas. This practice would not provide notification to occupants inside of the room. The facility census was 20.

Findings are:
Observations during the facility tour on 12/15/14 at 9:38 revealed the facility failed to provide a fire alarm notification device in the newly constructed plant services bathroom.
During interviews on 12/15/14 at 9:38 am, Maintenance C confirmed no notification device was present.

NFPA 72, 1999 ed, 4-5
Visible notification appliances used in the private mode shall be of a sufficient quantity and intensity, and located so as to meet the intent of the user and the authority having jurisdiction.

K130C - Industrial Occupancy

Based on observations and interviews the facility failed to ensure sprinkler coverage in all required areas in the fully sprinkled facility. This practice would allow fire development in the non-sprinkled room. The facility census was 20.

Findings are:
Observations during the facility tour on 12/15/14 between 9:37 am and 9:56 am revealed:
1. The facility failed to provide sprinkler coverage in the newly constructed plant services bathroom.
2. The facility failed to provide unobstructed coverage in the custodial storage room. Ductwork was installed close to the sprinkler head and obstructed the spray pattern.
During interviews on 12/15/14 between 9:37 am and 9:56 am, Maintenance C confirmed the findings.

NFPA 13, 1999 ed, 5-5.1
Sprinklers shall be located, spaced, and positioned in accordance with the requirements of this section. Sprinklers shall be positioned to provide protection of the area consistent with the overall objectives of this standard by controlling the positioning and allowable area of coverage for each sprinkler. The requirements of 5-5.2 through 5-5.6 shall apply to all sprinkler types unless modified by more restrictive rules in Sections 5-6 through 5-11.

NFPA 13, 1999 ed, 5-5.5.2.2
Sprinklers shall be positioned in accordance with the minimum distances and special exceptions of sections 5-6 through 5-11 so that they are located sufficiently away from obstructions such as truss webs and chords, pipes, columns, and fixtures.

NFPA 13, 1999 ed, 5-6.5.1.2
Sprinklers shall be arranged to comply with 5-5.5.2, Table 5-6.5.1.2, and Figure 5-6.5.1.2(a).

K130D - Industrial Occupancy

Based on observations and interviews the facility failed to ensure compressed gas cylinders were restrained to prevent falling over. This practice would allow the compressed gas cylinders to tip over and become a projectile. The facility census was 20.

Findings are:
Observations during the facility tour on 12/15/14 at 10:02 am revealed three gas cylinders failed to be restrained in the Plant Services Shop.
During interviews on 12/15/14 at 10:02 am, Maintenance C confirmed the cylinders were not restrained.

NFPA 55, 1999, 6-6 Securing Cylinders.
Compressed or liquefied gas cylinders in use or in storage shall be secured to prevent them from falling or being knocked over.

K130E - Industrial Occupancy

Based on observations and interviews the facility failed to provide handrails on a set of stairs. This practice does not meet the stair requirements stated in NFPA 101. The facility census was 20.

Findings are:
Observations during the facility tour on 12/15/14 at 10:08 am revealed handrails failed to be installed on the stairs going from the mechanical/chiller room to the outside chiller.
During interviews on 12/15/14 at 10:08 am, Maintenance C confirmed hand rails were not present.

NFPA 101, 2000 ed, 7.2.2.4.2*
Stairs and ramps shall have handrails on both sides. In addition, handrails shall be provided within 30 in. (76 cm) of all portions of the required egress width of stairs. The required egress width shall be provided along the natural path of travel. (See also 7.2.2.4.5.)
Exception No. 1: On existing stairs, handrails shall be provided within 44 in. (112 cm) of all portions of the required egress width of stairs.

K130F - Industrial Occupancy

Based on observations and interviews the facility failed to ensure that doors in hazard areas positively latched. This practice would allow smoke to migrate into the exit corridor. The facility census was 20.

Findings are:
Observations during the facility tour on 12/15/14 at 10:15 am revealed the door for the switchgear room did not positive latch when the door was closed.
During interviews on 12/15/14 at 10:15 am, Maintenance C confirmed the door did not positive latch.

NFPA 101, 2000, 8.4.1.1*
Protection from any area having a degree of hazard greater than that normal to the general occupancy of the building or structure shall be provided by one of the following means:
(1) Enclose the area with a fire barrier without windows that has a 1-hour fire resistance rating in accordance with Section 8.2.
(2) Protect the area with automatic extinguishing systems in accordance with Section 9.7.
(3) Apply both 8.4.1.1(1) and (2) where the hazard is severe or where otherwise specified by Chapters 12 through 42.

K130G - Industrial Occupancy

Based on observations, record review and interviews the facility failed to ensure that corridor walls used for fire separation did not contain openings or penetrations. This practice would allow smoke to migrate into the exit corridor. The facility census was 20.

Findings are:
Observations during the facility tour on 12/15/14 at 10:31 am of above ceilings revealed the wall across from the Plant Services Bathroom had a penetration that failed to be sealed.
Record review on 12/15/14, at 10:31 am of the provided life safety drawings revealed the corridor wall was classified as a one-hour fire barrier.
During interviews on 12/15/14 at 10:31 am, Maintenance C confirmed the unsealed penetration.

K130H - Industrial Occupancy

Based on observations and interviews the facility failed to ensure a path for safe access to a public way. This practice would increase the likelihood that a delay would occur in the event of a building evacuation. The facility census was 20.

Findings are:
Observations during the facility tour on 12/15/14 at 2:57 pm revealed that the path outside the doors by the Plant Services Office was obstructed by two vehicles.
During interviews on 12/15/14 at 2:57 pm, Maintenance C confirmed the exit was obstructed.

NFPA 101, 2000 ed, 7-7.7.1*
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 of required width and size to provide all occupants with a safe access to a public way.

Based on observation and interview, the facility failed to maintain the Type I essential electrical system of the facility by having loads intermixed between the Life Safety Branch, The Critical Branch, and the Equipment System. This deficient practice has the potential to affect all residents, staff and visitors of the facility by affecting the egress lighting and emergency systems of the facility. The facility census is 20.

Findings are:
Observations on 12-15-14 between 11:31 am and 2:30 pm revealed:
1. The following non-Life Safety loads connected to the Life Safety branch panel LLS1; (7) Rec Rm 1.127 switch board, (21) Rec Rm. 1.038, (27) Doors 5 and 8, (2) Cafeteria, (26) VAV power supply.
2. The following Life Safety loads were located in the Equipment branch panel LEQ2; (7) Fire Dampers.
3. The following Life Safety loads were located in the Equipment branch panel LEQ1; (8) Fire Damper, (41) Fire Damper, (34) Fire Damper.
4. The following non-Life Safety loads connected to the Life Safety branch panel HLS1; (5) Reflection Room.
5. The following Life Safety loads were located in the Equipment branch panel LEQB; (30) Fire Dampers.
6. The following non-Critical loads were located in the Critical branch panel LCB1; (34) Doctors Quarters, (21) Pharmacist Office, (15) Cath Lab Commoons, (7) Education, (8) Health Nurse Office.
7. The following non-Life Safety loads were located in the Life Safety branch panel LLS2; (13) Photo Eye parking lot clear story, (8) DSX Panels in 2091.

During an interview on 12-15-14 between 11:31 am and 2:30 pm, Maintenance A confirmed the findings.

N2FPA Standard:
NFPA 70, 1999ed.
517.30 Essential Electrical Systems for Hospitals.
(A) Applicability. The requirements of Part III, 517.30 through 517.35, shall apply to hospitals where an essential electrical system is required.
(B) General.
(1) Separate Systems. Essential electrical systems for hospitals shall be comprised of two separate systems capable of supplying a limited amount of lighting and power service, which is considered essential for life safety and effective hospital operation during the time the normal electrical service is interrupted for any reason. These two systems shall be the emergency system and the equipment system.
(2) Emergency Systems. The emergency system shall be limited to circuits essential to life safety and critical patient care. These are designated the life safety branch and the critical branch.
(3) Equipment System. The equipment system shall supply major electrical equipment necessary for patient care and basic hospital operation.
(4) Transfer Switches. The number of transfer switches to be used shall be based on reliability, design, and load considerations. Each branch of the emergency system and each equipment system shall have one or more transfer switches. One transfer switch shall be permitted to serve one or more branches or systems in a facility with a maximum demand on the essential electrical system of 150 kVA.
(5) Other Loads. Loads served by the generating equipment not specifically named in Article 517 shall be served by their own transfer switches such that these loads:
(1) Shall not be transferred if the transfer will overload the generating equipment.
(2) Shall be automatically shed upon generating equipment overloading.
(6) Contiguous Facilities. Hospital power sources and alternate power sources shall be permitted to serve the essential electrical systems of contiguous or same site facilities. [NFPA 99, 3.4.2.2.1, 12.3.3.2]
(C) Wiring Requirements.
(1) Separation from Other Circuits. The life safety branch and critical branch of the emergency system shall be kept entirely independent of all other wiring and equipment and shall not enter the same raceways, boxes, or cabinets with each other or other wiring.
Wiring of the life safety branch and the critical branch shall be permitted to occupy the same raceways, boxes, or cabinets of other circuits not part of the branch where such wiring is as follows:
(1) In transfer equipment enclosures, or
(2) In exit or emergency luminaires (lighting fixtures) supplied from two sources, or
(3) In a common junction box attached to exit or emergency luminaires (lighting fixtures) supplied from two sources, or
(4) For two or more emergency circuits supplied from the same branch
The wiring of the equipment system shall be permitted to occupy the same raceways, boxes, or cabinets of other circuits that are not part of the emergency system.
(2) Isolated Power Systems. Where isolated power systems are installed in any of the areas in 517.33(A)(1) and (A)(2), each system shall be supplied by an individual circuit serving no other load.
(3) Mechanical Protection of the Emergency System. The wiring of the emergency system of a hospital shall be mechanically protected by installation in nonflexible metal raceways, or shall be wired with Type MI cable.
Exception No. 1: Flexible power cords of appliances, or other utilization equipment, connected to the emergency system shall not be required to be enclosed in raceways.
Exception No. 2: Secondary circuits of transformer-powered communications or signaling systems shall not be required to be enclosed in raceways unless otherwise specified by Chapters 7 or 8.
Exception No. 3: Schedule 80 rigid nonmetallic conduit shall be permitted if the branch circuits do not serve patient care areas and it is not prohibited elsewhere in this Code.
Exception No. 4: Where encased in not less than 50 mm (2 in.) of concrete, Schedule 40 rigid nonmetallic conduit or electrical nonmetallic tubing shall be permitted if the branch circuits do not serve patient care areas.
Exception No. 5: Flexible metal raceways and cable assemblies shall be permitted to be used in listed prefabricated medical headwalls, listed office furnishings, or where necessary for flexible connection to equipment.
(D) Capacity of Systems. The essential electrical system shall have adequate capacity to meet the demand for the operation of all functions and equipment to be served by each system and branch.
Feeders shall be sized in accordance with Articles 215 and 220. The generator set(s) shall have sufficient capacity and proper rating to meet the demand produced by the load of the essential electrical system(s) at any given time.
Demand calculations for sizing of the generator set(s) shall be based on the following:
(1) Prudent demand factors and historical data, or
(2) Connected load, or
(3) Feeder calculation procedures described in Article 220, or
(4) Any combination of the above
The sizing requirements in 700.5 and 701.6 shall not apply to hospital generator set(s).
(E) Receptacle Identification. The cover plates for the electrical receptacles or the electrical receptacles themselves supplied from the emergency system shall have a distinctive color or marking so as to be readily identifiable. [NFPA 99, 3.4.2.2.4(b)2]
517.31 Emergency System.
Those functions of patient care depending on lighting or appliances that are connected to the emergency system shall be divided into two mandatory branches: the life safety branch and the critical branch, described in 517.32 and 517.33. The branches of the emergency system shall be installed and connected to the alternate power source so that all functions specified herein for the emergency system shall be automatically restored to operation within 10 seconds after interruption of the normal source. [NFPA 99, 3.4.2.2.2(a), 3.5.2.2.2]
517.32 Life Safety Branch.
No function other than those listed in 517.32(A) through (G) shall be connected to the life safety branch. The life safety branch of the emergency system shall supply power for the following lighting, receptacles, and equipment.
(A) Illumination of Means of Egress. Illumination of means of egress, such as lighting required for corridors, passageways, stairways, and landings at exit doors, and all necessary ways of approach to exits. Switching arrangements to transfer patient corridor lighting in hospitals from general illumination circuits to night illumination circuits shall be permitted, provided only one of two circuits can be selected and both circuits cannot be extinguished at the same time.
(B) Exit Signs. Exit signs and exit directional signs.
(C) Alarm and Alerting Systems. Alarm and alerting systems including the following:
(1) Fire alarms
(2) Alarms required for systems used for the piping of nonflammable medical gases
(D) Communications Systems. Hospital communications systems, where used for issuing instructions during emergency conditions.
(E) Generator Set Location. Task illumination battery charger for emergency battery-powered lighting unit(s) and selected receptacles at the generator set location.
(F) Elevators. Elevator cab lighting, control, communications, and signal systems.
(G) Automatic Doors. Automatically operated doors used for building egress. [NFPA 99, 3.4.2.2.2(b)]
517.33 Critical Branch.
(A) Task Illumination and Selected Receptacles. The critical branch of the emergency system shall supply power for task illumination, fixed equipment, selected receptacles, and special power circuits serving the following areas and functions related to patient care:
(1) Critical care areas that utilize anesthetizing gases - task illumination, selected receptacles, and fixed equipment
(2) The isolated power systems in special environments
(3) Patient care areas - task illumination and selected receptacles in the following:
a. Infant nurseries
b. Medication preparation areas
c. Pharmacy dispensing areas
d. Selected acute nursing areas
e. Psychiatric bed areas (omit receptacles)
f. Ward treatment rooms
g. Nurses ' stations (unless adequately lighted by corridor luminaires)
(4) Additional specialized patient care task illumination and receptacles, where needed
(5) Nurse call systems
(6) Blood, bone, and tissue banks
(7) Telephone equipment rooms and closets
(8) Task illumination, selected receptacles, and selected power circuits for the following:
a. General care beds (at least one duplex receptacle per patient bedroom)
b. Angiographic labs
c. Cardiac catheterization labs
d. Coronary care units
e. Hemodialysis rooms or areas
f. Emergency room treatment areas (selected)
g. Human physiology labs
h. Intensive care units
i. Postoperative recovery rooms (selected)
(9) Additional task illumination, receptacles, and selected power circuits needed for effective hospital operation. Single-phase fractional horsepower motors shall be permitted to be connected to the critical branch. [NFPA 99, 3.4.2.2.2(c)]
(B) Subdivision of the Critical Branch. It shall be permitted to subdivide the critical branch into two or more branches.
517.34 Equipment System Connection to Alternate Power Source.
The equipment system shall be installed and connected to the alternate power source such that the equipment described in 517.34(A) is automatically restored to operation at appropriate time-lag intervals following the energizing of the emergency system. Its arrangement shall also provide for the subsequent connection of equipment described in 517.34(B). [NFPA 99, 3.4.2.2.3(b)]
Exception: For essential electrical systems under 150 kVA, deletion of the time-lag intervals feature for delayed automatic connection to the equipment system shall be permitted.
(A) Equipment for Delayed Automatic Connection. The following equipment shall be arranged for delayed automatic connection to the alternate power source.
(1) Central suction systems serving medical and surgical functions, including controls. Such suction systems shall be permitted on the critical branch.
(2) Sump pumps and other equipment required to operate for the safety of major apparatus, including associated control systems and alarms.
(3) Compressed air systems serving medical and surgical functions, including controls. Such air systems shall be permitted on the critical branch.
(4) Smoke control and stair pressurization systems, or both.
(5) Kitchen hood supply or exhaust systems, or both, if required to operate during a fire in or under the hood. [NFPA 99, 3.4.2.2.3(d)]
Exception: Sequential delayed automatic connection to the alternate power source to prevent overloading the generator shall be permitted where engineering studies indicate it is necessary.
(B) Equipment for Delayed Automatic or Manual Connection. The following equipment shall be arranged for either delayed automatic or manual connection to the alternate power source:
(1) Heating equipment to provide heating for operating, delivery, labor, recovery, intensive care, coronary care, nurseries, infection/isolation rooms, emergency treatment spaces, and general patient rooms and pressure maintenance (jockey or make-up) pump(s) for water-based fire protection systems.
Exception: Heating of general patient rooms and infection/isolation rooms during disruption of the normal source shall not be required under any of the following conditions:
(a) The outside design temperature is higher than -6.7°C (20°F).
(b) The outside design temperature is lower than -6.7°C (20°F), and where a selected room(s) is provided for the needs of all confined patients, only such room(s) need be heated.
(c) The facility is served by a dual source of normal power.
(2) An elevator(s) selected to provide service to patient, surgical, obstetrical, and ground floors during interruption of normal power. In instances where interruption of normal power would result in other elevators stopping between floors, throw-over facilities shall be provided to allow the temporary operation of any elevator for the release of patients or other persons who may be confined between floors.
(3) Supply, return, and exhaust ventilating systems for airborne infectious/isolation rooms, protective environment rooms, exhaust fans for laboratory fume hoods, nuclear medicine areas where radioactive material is used, ethylene oxide evacuation and anesthesia evacuation. Where delayed automatic connection is not appropriate, such ventilation systems shall be permitted to be placed on the critical branch. [NFPA 99, 3.4.2.2.3(e)(4)]
(4) Hyperbaric facilities.
(5) Hypobaric facilities.
(6) Automatically operated doors.
(7) Minimal electrically heated autoclaving equipment shall be permitted to be arranged for either automatic or manual connection to the alternate source.
(8) Controls for equipment listed in 517.34.
(9) Other selected equipment shall be permitted to be served by the equipment system. [NFPA 99, 3.4.2.2.3(e)]

Based on observation and interview, the facility failed to assure that power strips were installed to manufactures instructions and failed to maintain an unobstructed space in front of the line isolation monitors in the OR ' s. These deficient practices would increase the potential for an electrical fire. The facility census was 20 patients.

Findings are:
Observations on 12-15-14 between 9:40 am and 2:16 pm revealed:
1. Two power strips hanging from the electrical cords under the desk in Operations Cath. Lab office.
2. The line isolation monitors in 4 of 4 Operating Rooms were blocked with carts and other surgical items.
3. Power strip in OR 4 failed to be secured to an IV pole.
4. Power-strips in the Data Room were " daisy-chained " together at the IT equipment next to the panel boxes.

During an interview on 12-15-14 between 9:40 am and 2:16 pm, Maintenance A confirmed the findings.



27395

Based on observation, record review and staff interview, the facility failed to use electrical wiring and equipment in accordance with the National Fire Protection Association (NFPA), 70. This condition had the potential to cause an electrical fire. Facility census was 20.

Findings are:
Observation during the facility tour on 12/15/14, from 9:50 am to 11:14 am revealed:
1. A power strip that was permanently attached to wheeled pedestal inside of the patient care vicinity in Patient Room 207 was observed. In addition, a power strip was permanently attached to crash carts for each pod as well.
Record review on 12/15/14, at 9:56 am revealed the facility failed to have adopted the CMS Categorical Waiver for Power Strips Use in Patient Care Areas, and follow all of the requirements of 10.2.3.6 within the waiver.
2. The TV in the 2nd Floor Fish Bowl failed to be plugged in without the use of an extension cord used in lieu of permanent wiring.
3. Power strips in the 2nd Floor DON Office failed to be plugged directly into a wall outlet.
4. Four power strips were daisy chained, and failed to be plugged directly into a wall outlet in the 2nd Floor House Supervisor Office.
5. The ice machine in the Kitchen failed to be plugged in without the use of an extension cord used in lieu of permeant wiring.
6. Two coffee makers in the Pharmacy by the North Entrance failed to be plugged in directly to a wall outlet so a power strip was not used with the heat producing appliances.
In an interview conducted at the time of observation (12/15/14, from 9:50 am to 11:14 am), Maintenance B acknowledged the findings.

Based on observation and interview, the facility failed to install alcohol based hand rub dispensers at least 12 inches adjacent to an ignition source, , which increased the potential for electrical ignition for a fire in OR 4. The facility census was 20 patients.

Findings are:
Observations on 12-15-14 at 10:45 am revealed, a hand sanitizer in OR 4 located within 12 inches of an electrical outlet on the north wall.

During an interview on 12-15-14 at 10:45 am, Maintenance A confirmed the findings.

Based on observation and staff interview, the facility failed to maintain fire doors in a two-hour fire barrier that separated two non-conforming occupancies. This condition would allow smoke or fire to spread between the two occupancies. Facility census was 20.

Findings are:
Observation during the facility tour on 12/15/14, at 10:54 am revealed the 90-minute fire doors in the 2-hour fire barrier that separated the Hospital from the MOB failed to positively latch when the powered doors swung shut.
In an interview conducted at the time of observation, (12/15/14, at 10:54 am), Maintenance B confirmed the doors failed to latch.

NFPA 80, 1999, 2-1.2 Components.
A fire door assembly shall consist of components that are separate products incorporated into the assembly and allowed to have their own subcomponents. The normal components of a fire door assembly include a door, a door frame, hinges, a lock or latch, and a closing device. They also include, but are not limited to, an astragal, an automatic louver, a coordinator, flush or surface bolts, gasketing, a holder/release device, protection plates, and glazing materials.



34122

Based on observations, record review and interviews the facility failed to seal penetrations in a two hour barrier to Underwriter Laboratories (UL) and manufacture standards. This practice would allow smoke and heat to migrate between the healthcare and business occupancies. The facility census was 20.

Findings are:
Observations during the facility tour on 12/15/14 at 2:12 pm revealed gaps between fire bricks installed in the conduit that penetrated the two hour barrier between the Hospital and the Medical Office Building.
Record review on 12/16/14 at 11:17 am of UL 3L73 and manufacturer instructions revealed bricks are to be tightly compressed and all voids are to be closed.
During interviews on 12/15/14 at 2:12 pm and 12/16/14 at 11:58 am, Maintenance A confirmed the gaps in the fire bricks.

Based on observations and interviews the facility failed to ensure that corridor walls used for fire separation did not contain openings or penetrations. This practice would allow smoke to migrate into the exit corridor. The facility census was 20.

Findings are:
Observations during the facility tour on 12/15/14 between 1:30 pm and 2:06 pm of above ceilings revealed:
1. The wall near the stairwell for Pod 2 had a penetration that failed to be sealed.
2. The west door by the Cath Lab had a penetration that failed to be sealed.
3. The wall behind the nurse ' s station in Pod 0 had two penetrations that failed to be sealed.
During interviews on 12/15/14 between 1:30 pm and 2:06 pm, Maintenance C confirmed the unsealed penetrations.

Based on observation and interview, the facility failed to maintain or provide latching hardware on corridor doors or to ensure that corridor doors would resist the passage of smoke. These deficient practices have the potential to allow smoke or fire to migrate into exit corridors. The facility census was 20 patients.

Findings are:
Observations on 12-15-14 between 9:36 am and 10:56 am revealed:
1. The west Cath. Lab 2 door failed to close and latch within the door frame.
2. Three Diagnostic sliding glass doors on the corridor failed to provide latching hardware.
3. The west Cat. Scan door held open with soiled linen cart, when cart was removed the door closed on its own.
4. Operating Room doors 1, 2, and 3 had a gap greater than 1/8 inch between two doors.

During an interview on 12-15-14 between 9:36 am and 10:56 am, Maintenance A confirmed all the findings.



34122

Based on observations and interviews the facility failed to ensure that there were no impediment to the closing of corridor doors. This practice would allow smoke to migrate into the exit corridor. The facility census was 20.

Findings are:
Observations during the facility tour on 12/15/14 at 11:08 am revealed the door leading from the data center to the corridor failed to close and latch due to catching on a rug under the door. In addition, the timing of the door closures prevented the doors from closing in the correct sequence and positively latching.
During interviews on 12/15/14 at 11:08 am, Maintenance C confirmed the failure of the door to close.

Based on observation and staff interview, the facility failed to mark exits by approved, readily visible signs in all cases where the exit or way to reach the exit was not readily apparent to the occupants. This condition would not allow occupants to efficiently evacuate the facility during a fire or other emergency. Facility census was 20.

Findings are:
Observations during the facility tour on 12/15/14, from 9:33 am to 10:18 am revealed two exit signs failed to be visible on the 2nd Floor Pods 1 and 4 when standing by the nurse ' s station.
In an interview conducted at the time of observations (12/15/14, from 9:33 am to 10:18 am), Maintenance B acknowledged the findings.

Based on observations and interview, the facility failed to assure that doors to hazardous areas equipped with self-closing devices would latch within the door frame, and failed to provide self-closing device on doors to hazardous areas. The facility failed to provide fire separation between hazardous areas and the corridor and failed to assure the undercut to storage area was less than an inch. These deficient practices have the potential to allow smoke, fire and gas to migrate into the exit corridors. The facility census was 20 patients.

Findings are:
Observations on 12-15-14 between 9:42 am and 2:16 pm revealed:
1. Soiled utility room door in the Cath. Lab area failed to latch within the door frame.
2. Pathology Room door held open with a rubber door chock.
3. Respiratory Therapy room used as a storage room, the north door failed to provide a self-closure.
4. The south MRI storage room door 1.043 failed to latch within the door frame.
5. Unsealed penetration above the ceiling tile in the corridor above Cath. Lab 3.
6. Double doors into garage 1.194 failed to latch within the door frame.
7. Storage room door in the dock 1.193 failed to latch within the door frame.
8. Housekeeping storage room within Sterile Processing failed to provide a self-closure on the door, the room is over 50 square feet.
9. The facility failed to provide fire rated separation between the corridor and the Clean Core storage area.
10. The VDA storage closet door undercut was 2 inches.

During an interview on 12-15-14 between 9:42 am and 2:16 pm, Maintenance A confirmed all the findings.




27395

Based on observation and staff interview, the facility failed to separate hazardous areas from use areas. This condition had the potential to allow smoke and fire to migrate into other areas of the facility. Facility census was 20.

Findings are:
Observations during the facility tour on 12/15/14, from 9:51 am to 11:09 am revealed:
1. A hole in the wall around a fire alarm conduit failed to be sealed in the 2nd Floor Main Electrical Room.
2. The Pod O Clean Supply Room Door failed to auto-close and latch. A cabinet was wedged against the door, and prevented the door from auto-closing.
In an interview conducted at the time of observations (12/15/14, from 9:51 am to 11:09 am), Maintenance B acknowledged the findings.

Based on observation and interview, the facility failed to assure the magnetically locked door in the Surgery Corridor was not locked against egress and failed to provide a delayed operation or signage. This deficient practice would delay egress in the event of an emergency. The facility census was 20.

Findings are:
Observations on 12-15-14 at 10:47 am revealed, the double doors from the Surgery Corridor into 0 Pod were locked with a magnetic lock, the door failed to provide delayed hardware or signage to have the ability to exit from the corridor.

During an interview on 12-15-14 at 10:47 am, Maintenance A confirmed the findings.

NFPA Standard:
A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 inches and not more than 48 inches above the finished floor. Doors shall be operable with not more than one releasing operation. 2000 NFPA 101, 7.2.1.5.4

Based on observation and interview, the facility failed to verify the illumination of the exit discharge, so that the failure of any single lighting fixture (bulb) will not leave the area in darkness, for all exits. This deficient practice would delay egress from the building. The facility census was 20 patients.

Findings are:
Observations on 12-15-14 at 3:23 pm, revealed the facility failed to verify a two bulb light fixture at all exterior exit from the building.

During an interview on 12-15-14 at time of observation, Maintenance A confirmed that the facility could not verify two bulbs in all lights at exit doors.

NFPA Standard:
Required illumination shall be arranged so that the failure of any single bulb or unit does not result in less than .2 foot-candles of illumination in any designated area. 2000 NFPA 101, 7.8.1.4

Based on observation and interview, the facility failed to provide the correct directional sign to indicate the continuous path of egress. This deficient practice would cause confusion and delay exiting. The facility census was 20 patients.

Findings are:
Observations on 12-15-14 at 11:07 am revealed, the exit sign in the OR coridor had two directional chevrons, one which directed occupants in a direction where there was no exit available.

During an interview on 12-15-14 at 11:07 am, Maintenance A confirmed the findings

Based on record review and staff interview, the facility failed to conduct quarterly fire drills on each shift for 1 of 3 shifts. This condition would not provide the required training for staff to respond to a fire emergency. Facility census was 20.

Findings are:
Record review of fire drills on 12/15/14, at 1:37 pm revealed the facility failed to document a fire drill for the 3rd shift in the 3rd Quarter of 2014.
In an interview conducted at the time of record review (12/15/14, at 1:37 pm), Maintenance B acknowledged the missing fire drill.

Based on observations and interviews the facility failed to ensure sprinkler coverage under the Receiving Overhead Door. This practice would allow fire development under the door, if the door was in the open position. The facility census was 20.

Findings are:
Observations during the facility tour on 12/15/14 at 10:53 am revealed the facility failed to provide sprinkler coverage under the overhead door when it was in the open position.
During interviews on 12/15/14 at 10:53 am, Maintenance C confirmed no sprinkler was present under the door.

Based on observation and interview, the facility failed to provide an unobstructed path to fire extinguishers. The deficient practice would delay the attempt to extinguish a fire. The facility census was 20 patients.

Findings are:
Observations on 12-15-14 at 10:00 am and 11:00 am revealed:
1. Surgical equipment obstructed 2 of 2 fire extinguishers in OR 1.
2. A large trash can obstructed the fire extinguisher in Sterile Processing.

During an interview on 12-15-14 at 10:00 am and 11:00 am, Maintenance A confirmed the findings.

NFPA Standard:
Fire extinguishers shall be conspicuously located where they will be readily accessible and immediately available in the event of fire. Preferably they shall be located along normal paths of travel, including exits from areas. 1998 NFPA 10, 1-6.3




34122

Based on observations and interviews the facility failed to maintain fire extinguishers in accordance with National Fire Protection Association (NFPA) 10. This practice would increase the likelihood that a fire extinguisher would fail to operate in the event of a fire. The facility census was 20.

Findings are:
Observations during the facility tour on 12/15/14 at 10:59 am revealed that the fire extinguisher located in the Data Center failed to be inspected on an annual and monthly basis.
During interviews on 12/15/14 at 10:59 am, Maintenance C confirmed the fire extinguisher was not being checked.

Based on observation, record review and staff interview, the facility failed to meet all requirements of the CMS waiver to allow furniture to be placed in exit corridors. This condition would allow furniture to obstruct the exit corridor during evacuation. Facility census was 20.

Findings are:
Observation during the facility tour on 12/15/14, at 9:38 am revealed chairs and tables were placed in the East Waiting Area Exit Corridor.
1. The furniture failed to be attached to the floor or wall.
2. The furniture failed to be arranged so that the grouping did not exceed 50 square feet.
Record review on 12/15/14, at 11:46 am revealed the facility had adopted the CMS Categorical Waiver: Corridor Projections for Fixed Furniture, NFPA 101, 2012, 19.2.3.4(5).
In an interview conducted at the time of observation and record review (12/15/14, from 9:38 am to 11:46 am), Maintenance B confirmed the furniture arrangement failed to meet the waiver requirements.

NFPA 101, 2012, 19.2.3.4(5)
(a) The fixed furniture is securely attached to the floor or to the wall.
(d) The fixed furniture is grouped such that each grouping does not exceed an area of 50 ft2.

Based on record review and staff interview, the facility failed to maintain all operating room (OR) line isolation panels. This condition would allow an electrical fault to occur during an operation without notification to staff. Facility census was 20.

Findings are:
Record review on 12/15/14, at 1:07 pm revealed documentation of monthly testing for the line isolation panels in the ORs failed to be provided for review.
In an interview conducted at the time of observation, (12/15/14, at 1:07 pm), Maintenance B confirmed the findings.

Actual NFPA Standard:
NFPA 99, 1999 Edition, 3-3.3.4.2 Line Isolation Monitor Tests.
(a) The LIM circuit shall be tested after installation, and prior to being placed in service, by successively grounding each line of the energized distribution system through a resistor of 200 X V ohms, where V = measured line voltage. The visual and audible alarms [see 3-3.2.2.3(b)] shall be activated.
(b) The LIM circuit shall be tested at intervals of not more than 1 month by actuating the LIM test switch [see 3-3.2.2.3(f)]. For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months. Actuation of the test switch shall activate both visual and audible alarm indicators.
(c) After any repair or renovation to an electrical distribution system and at intervals of not more than 6 months, the LIM circuit shall be tested in accordance with paragraph (a) above and only when the circuit is not otherwise in use. For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months.



34122

K130A - Industrial Occupancy

Based on observations and interviews the facility failed to maintain electrical wiring in accordance with National Fire Protection Association (NFPA) 70. This practice created a higher potential for an electrical fire. The facility census was 20.

Findings are:
Observations during the facility tour on 12/15/14 at 9:33 am revealed that a junction box for Air Handler 2 failed to have a cover plate.
During interviews on 12/15/14 at 9:33 am, Maintenance C confirmed the missing cover plate.

K130B - Industrial Occupancy

Based on observations and interviews the facility failed to install notification devices in all required areas. This practice would not provide notification to occupants inside of the room. The facility census was 20.

Findings are:
Observations during the facility tour on 12/15/14 at 9:38 revealed the facility failed to provide a fire alarm notification device in the newly constructed plant services bathroom.
During interviews on 12/15/14 at 9:38 am, Maintenance C confirmed no notification device was present.

NFPA 72, 1999 ed, 4-5
Visible notification appliances used in the private mode shall be of a sufficient quantity and intensity, and located so as to meet the intent of the user and the authority having jurisdiction.

K130C - Industrial Occupancy

Based on observations and interviews the facility failed to ensure sprinkler coverage in all required areas in the fully sprinkled facility. This practice would allow fire development in the non-sprinkled room. The facility census was 20.

Findings are:
Observations during the facility tour on 12/15/14 between 9:37 am and 9:56 am revealed:
1. The facility failed to provide sprinkler coverage in the newly constructed plant services bathroom.
2. The facility failed to provide unobstructed coverage in the custodial storage room. Ductwork was installed close to the sprinkler head and obstructed the spray pattern.
During interviews on 12/15/14 between 9:37 am and 9:56 am, Maintenance C confirmed the findings.

NFPA 13, 1999 ed, 5-5.1
Sprinklers shall be located, spaced, and positioned in accordance with the requirements of this section. Sprinklers shall be positioned to provide protection of the area consistent with the overall objectives of this standard by controlling the positioning and allowable area of coverage for each sprinkler. The requirements of 5-5.2 through 5-5.6 shall apply to all sprinkler types unless modified by more restrictive rules in Sections 5-6 through 5-11.

NFPA 13, 1999 ed, 5-5.5.2.2
Sprinklers shall be positioned in accordance with the minimum distances and special exceptions of sections 5-6 through 5-11 so that they are located sufficiently away from obstructions such as truss webs and chords, pipes, columns, and fixtures.

NFPA 13, 1999 ed, 5-6.5.1.2
Sprinklers shall be arranged to comply with 5-5.5.2, Table 5-6.5.1.2, and Figure 5-6.5.1.2(a).

K130D - Industrial Occupancy

Based on observations and interviews the facility failed to ensure compressed gas cylinders were restrained to prevent falling over. This practice would allow the compressed gas cylinders to tip over and become a projectile. The facility census was 20.

Findings are:
Observations during the facility tour on 12/15/14 at 10:02 am revealed three gas cylinders failed to be restrained in the Plant Services Shop.
During interviews on 12/15/14 at 10:02 am, Maintenance C confirmed the cylinders were not restrained.

NFPA 55, 1999, 6-6 Securing Cylinders.
Compressed or liquefied gas cylinders in use or in storage shall be secured to prevent them from falling or being knocked over.

K130E - Industrial Occupancy

Based on observations and interviews the facility failed to provide handrails on a set of stairs. This practice does not meet the stair requirements stated in NFPA 101. The facility census was 20.

Findings are:
Observations during the facility tour on 12/15/14 at 10:08 am revealed handrails failed to be installed on the stairs going from the mechanical/chiller room to the outside chiller.
During interviews on 12/15/14 at 10:08 am, Maintenance C confirmed hand rails were not present.

NFPA 101, 2000 ed, 7.2.2.4.2*
Stairs and ramps shall have handrails on both sides. In addition, handrails shall be provided within 30 in. (76 cm) of all portions of the required egress width of stairs. The required egress width shall be provided along the natural path of travel. (See also 7.2.2.4.5.)
Exception No. 1: On existing stairs, handrails shall be provided within 44 in. (112 cm) of all portions of the required egress width of stairs.

K130F - Industrial Occupancy

Based on observations and interviews the facility failed to ensure that doors in hazard areas positively latched. This practice would allow smoke to migrate into the exit corridor. The facility census was 20.

Findings are:
Observations during the facility tour on 12/15/14 at 10:15 am revealed the door for the switchgear room did not positive latch when the door was closed.
During interviews on 12/15/14 at 10:15 am, Maintenance C confirmed the door did not positive latch.

NFPA 101, 2000, 8.4.1.1*
Protection from any area having a degree of hazard greater than that normal to the general occupancy of the building or structure shall be provided by one of the following means:
(1) Enclose the area with a fire barrier without windows that has a 1-hour fire resistance rating in accordance with Section 8.2.
(2) Protect the area with automatic extinguishing systems in accordance with Section 9.7.
(3) Apply both 8.4.1.1(1) and (2) where the hazard is severe or where otherwise specified by Chapters 12 through 42.

K130G - Industrial Occupancy

Based on observations, record review and interviews the facility failed to ensure that corridor walls used for fire separation did not contain openings or penetrations. This practice would allow smoke to migrate into the exit corridor. The facility census was 20.

Findings are:
Observations during the facility tour on 12/15/14 at 10:31 am of above ceilings revealed the wall across from the Plant Services Bathroom had a penetration that failed to be sealed.
Record review on 12/15/14, at 10:31 am of the provided life safety drawings revealed the corridor wall was classified as a one-hour fire barrier.
During interviews on 12/15/14 at 10:31 am, Maintenance C confirmed the unsealed penetration.

K130H - Industrial Occupancy

Based on observations and interviews the facility failed to ensure a path for safe access to a public way. This practice would increase the likelihood that a delay would occur in the event of a building evacuation. The facility census was 20.

Findings are:
Observations during the facility tour on 12/15/14 at 2:57 pm revealed that the path outside the doors by the Plant Services Office was obstructed by two vehicles.
During interviews on 12/15/14 at 2:57 pm, Maintenance C confirmed the exit was obstructed.

NFPA 101, 2000 ed, 7-7.7.1*
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 of required width and size to provide all occupants with a safe access to a public way.

Based on observation and interview, the facility failed to maintain the Type I essential electrical system of the facility by having loads intermixed between the Life Safety Branch, The Critical Branch, and the Equipment System. This deficient practice has the potential to affect all residents, staff and visitors of the facility by affecting the egress lighting and emergency systems of the facility. The facility census is 20.

Findings are:
Observations on 12-15-14 between 11:31 am and 2:30 pm revealed:
1. The following non-Life Safety loads connected to the Life Safety branch panel LLS1; (7) Rec Rm 1.127 switch board, (21) Rec Rm. 1.038, (27) Doors 5 and 8, (2) Cafeteria, (26) VAV power supply.
2. The following Life Safety loads were located in the Equipment branch panel LEQ2; (7) Fire Dampers.
3. The following Life Safety loads were located in the Equipment branch panel LEQ1; (8) Fire Damper, (41) Fire Damper, (34) Fire Damper.
4. The following non-Life Safety loads connected to the Life Safety branch panel HLS1; (5) Reflection Room.
5. The following Life Safety loads were located in the Equipment branch panel LEQB; (30) Fire Dampers.
6. The following non-Critical loads were located in the Critical branch panel LCB1; (34) Doctors Quarters, (21) Pharmacist Office, (15) Cath Lab Commoons, (7) Education, (8) Health Nurse Office.
7. The following non-Life Safety loads were located in the Life Safety branch panel LLS2; (13) Photo Eye parking lot clear story, (8) DSX Panels in 2091.

During an interview on 12-15-14 between 11:31 am and 2:30 pm, Maintenance A confirmed the findings.

N2FPA Standard:
NFPA 70, 1999ed.
517.30 Essential Electrical Systems for Hospitals.
(A) Applicability. The requirements of Part III, 517.30 through 517.35, shall apply to hospitals where an essential electrical system is required.
(B) General.
(1) Separate Systems. Essential electrical systems for hospitals shall be comprised of two separate systems capable of supplying a limited amount of lighting and power service, which is considered essential for life safety and effective hospital operation during the time the normal electrical service is interrupted for any reason. These two systems shall be the emergency system and the equipment system.
(2) Emergency Systems. The emergency system shall be limited to circuits essential to life safety and critical patient care. These are designated the life safety branch and the critical branch.
(3) Equipment System. The equipment system shall supply major electrical equipment necessary for patient care and basic hospital operation.
(4) Transfer Switches. The number of transfer switches to be used shall be based on reliability, design, and load considerations. Each branch of the emergency system and each equipment system shall have one or more transfer switches. One transfer switch shall be permitted to serve one or more branches or systems in a facility with a maximum demand on the essential electrical system of 150 kVA.
(5) Other Loads. Loads served by the generating equipment not specifically named in Article 517 shall be served by their own transfer switches such that these loads:
(1) Shall not be transferred if the transfer will overload the generating equipment.
(2) Shall be automatically shed upon generating equipment overloading.
(6) Contiguous Facilities. Hospital power sources and alternate power sources shall be permitted to serve the essential electrical systems of contiguous or same site facilities. [NFPA 99, 3.4.2.2.1, 12.3.3.2]
(C) Wiring Requirements.
(1) Separation from Other Circuits. The life safety branch and critical branch of the emergency system shall be kept entirely independent of all other wiring and equipment and shall not enter the same raceways, boxes, or cabinets with each other or other wiring.
Wiring of the life safety branch and the critical branch shall be permitted to occupy the same raceways, boxes, or cabinets of other circuits not part of the branch where such wiring is as follows:
(1) In transfer equipment enclosures, or
(2) In exit or emergency luminaires (lighting fixtures) supplied from two sources, or
(3) In a common junction box attached to exit or emergency luminaires (lighting fixtures) supplied from two sources, or
(4) For two or more emergency circuits supplied from the same branch
The wiring of the equipment system shall be permitted to occupy the same raceways, boxes, or cabinets of other circuits that are not part of the emergency system.
(2) Isolated Power Systems. Where isolated power systems are installed in any of the areas in 517.33(A)(1) and (A)(2), each system shall be supplied by an individual circuit serving no other load.
(3) Mechanical Protection of the Emergency System. The wiring of the emergency system of a hospital shall be mechanically protected by installation in nonflexible metal raceways, or shall be wired with Type MI cable.
Exception No. 1: Flexible power cords of appliances, or other utilization equipment, connected to the emergency system shall not be required to be enclosed in raceways.
Exception No. 2: Secondary circuits of transformer-powered communications or signaling systems shall not be required to be enclosed in raceways unless otherwise specified by Chapters 7 or 8.
Exception No. 3: Schedule 80 rigid nonmetallic conduit shall be permitted if the branch circuits do not serve patient care areas and it is not prohibited elsewhere in this Code.
Exception No. 4: Where encased in not less than 50 mm (2 in.) of concrete, Schedule 40 rigid nonmetallic conduit or electrical nonmetallic tubing shall be permitted if the branch circuits do not serve patient care areas.
Exception No. 5: Flexible metal raceways and cable assemblies shall be permitted to be used in listed prefabricated medical headwalls, listed office furnishings, or where necessary for flexible connection to equipment.
(D) Capacity of Systems. The essential electrical system shall have adequate capacity to meet the demand for the operation of all functions and equipment to be served by each system and branch.
Feeders shall be sized in accordance with Articles 215 and 220. The generator set(s) shall have sufficient capacity and proper rating to meet the demand produced by the load of the essential electrical system(s) at any given time.
Demand calculations for sizing of the generator set(s) shall be based on the following:
(1) Prudent demand factors and historical data, or
(2) Connected load, or
(3) Feeder calculation procedures described in Article 220, or
(4) Any combination of the above
The sizing requirements in 700.5 and 701.6 shall not apply to hospital generator set(s).
(E) Receptacle Identification. The cover plates for the electrical receptacles or the electrical receptacles themselves supplied from the emergency system shall have a distinctive color or marking so as to be readily identifiable. [NFPA 99, 3.4.2.2.4(b)2]
517.31 Emergency System.
Those functions of patient care depending on lighting or appliances that are connected to the emergency system shall be divided into two mandatory branches: the life safety branch and the critical branch, described in 517.32 and 517.33. The branches of the emergency system shall be installed and connected to the alternate power source so that all functions specified herein for the emergency system shall be automatically restored to operation within 10 seconds after interruption of the normal source. [NFPA 99, 3.4.2.2.2(a), 3.5.2.2.2]
517.32 Life Safety Branch.
No function other than those listed in 517.32(A) through (G) shall be connected to the life safety branch. The life safety branch of the emergency system shall supply power for the following lighting, receptacles, and equipment.
(A) Illumination of Means of Egress. Illumination of means of egress, such as lighting required for corridors, passageways, stairways, and landings at exit doors, and all necessary ways of approach to exits. Switching arrangements to transfer patient corridor lighting in hospitals from general illumination circuits to night illumination circuits shall be permitted, provided only one of two circuits can be selected and both circuits cannot be extinguished at the same time.
(B) Exit Signs. Exit signs and exit directional signs.
(C) Alarm and Alerting Systems. Alarm and alerting systems including the following:
(1) Fire alarms
(2) Alarms required for systems used for the piping of nonflammable medical gases
(D) Communications Systems. Hospital communications systems, where used for issuing instructions during emergency conditions.
(E) Generator Set Location. Task illumination battery charger for emergency battery-powered lighting unit(s) and selected receptacles at the generator set location.
(F) Elevators. Elevator cab lighting, control, communications, and signal systems.
(G) Automatic Doors. Automatically operated doors used for building egress. [NFPA 99, 3.4.2.2.2(b)]
517.33 Critical Branch.
(A) Task Illumination and Selected Receptacles. The critical branch of the emergency system shall supply power for task illumination, fixed equipment, selected receptacles, and special power circuits serving the following areas and functions related to patient care:
(1) Critical care areas that utilize anesthetizing gases - task illumination, selected receptacles, and fixed equipment
(2) The isolated power systems in special environments
(3) Patient care areas - task illumination and selected receptacles in the following:
a. Infant nurseries
b. Medication preparation areas
c. Pharmacy dispensing areas
d. Selected acute nursing areas
e. Psychiatric bed areas (omit receptacles)
f. Ward treatment rooms
g. Nurses ' stations (unless adequately lighted by corridor luminaires)
(4) Additional specialized patient care task illumination and receptacles, where needed
(5) Nurse call systems
(6) Blood, bone, and tissue banks
(7) Telephone equipment rooms and closets
(8) Task illumination, selected receptacles, and selected power circuits for the following:
a. General care beds (at least one duplex receptacle per patient bedroom)
b. Angiographic labs
c. Cardiac catheterization labs
d. Coronary care units
e. Hemodialysis rooms or areas
f. Emergency room treatment areas (selected)
g. Human physiology labs
h. Intensive care units
i. Postoperative recovery rooms (selected)
(9) Additional task illumination, receptacles, and selected power circuits needed for effective hospital operation. Single-phase fractional horsepower motors shall be permitted to be connected to the critical branch. [NFPA 99, 3.4.2.2.2(c)]
(B) Subdivision of the Critical Branch. It shall be permitted to subdivide the critical branch into two or more branches.
517.34 Equipment System Connection to Alternate Power Source.
The equipment system shall be installed and connected to the alternate power source such that the equipment described in 517.34(A) is automatically restored to operation at appropriate time-lag intervals following the energizing of the emergency system. Its arrangement shall also provide for the subsequent connection of equipment described in 517.34(B). [NFPA 99, 3.4.2.2.3(b)]
Exception: For essential electrical systems under 150 kVA, deletion of the time-lag intervals feature for delayed automatic connection to the equipment system shall be permitted.
(A) Equipment for Delayed Automatic Connection. The following equipment shall be arranged for delayed automatic connection to the alternate power source.
(1) Central suction systems serving medical and surgical functions, including controls. Such suction systems shall be permitted on the critical branch.
(2) Sump pumps and other equipment required to operate for the safety of major apparatus, including associated control systems and alarms.
(3) Compressed air systems serving medical and surgical functions, including controls. Such air systems shall be permitted on the critical branch.
(4) Smoke control and stair pressurization systems, or both.
(5) Kitchen hood supply or exhaust systems, or both, if required to operate during a fire in or under the hood. [NFPA 99, 3.4.2.2.3(d)]
Exception: Sequential delayed automatic connection to the alternate power source to prevent overloading the generator shall be permitted where engineering studies indicate it is necessary.
(B) Equipment for Delayed Automatic or Manual Connection. The following equipment shall be arranged for either delayed automatic or manual connection to the alternate power source:
(1) Heating equipment to provide heating for operating, delivery, labor, recovery, intensive care, coronary care, nurseries, infection/isolation rooms, emergency treatment spaces, and general patient rooms and pressure maintenance (jockey or make-up) pump(s) for water-based fire protection systems.
Exception: Heating of general patient rooms and infection/isolation rooms during disruption of the normal source shall not be required under any of the following conditions:
(a) The outside design temperature is higher than -6.7°C (20°F).
(b) The outside design temperature is lower than -6.7°C (20°F), and where a selected room(s) is provided for the needs of all confined patients, only such room(s) need be heated.
(c) The facility is served by a dual source of normal power.
(2) An elevator(s) selected to provide service to patient, surgical, obstetrical, and ground floors during interruption of normal power. In instances where interruption of normal power would result in other elevators stopping between floors, throw-over facilities shall be provided to allow the temporary operation of any elevator for the release of patients or other persons who may be confined between floors.
(3) Supply, return, and exhaust ventilating systems for airborne infectious/isolation rooms, protective environment rooms, exhaust fans for laboratory fume hoods, nuclear medicine areas where radioactive material is used, ethylene oxide evacuation and anesthesia evacuation. Where delayed automatic connection is not appropriate, such ventilation systems shall be permitted to be placed on the critical branch. [NFPA 99, 3.4.2.2.3(e)(4)]
(4) Hyperbaric facilities.
(5) Hypobaric facilities.
(6) Automatically operated doors.
(7) Minimal electrically heated autoclaving equipment shall be permitted to be arranged for either automatic or manual connection to the alternate source.
(8) Controls for equipment listed in 517.34.
(9) Other selected equipment shall be permitted to be served by the equipment system. [NFPA 99, 3.4.2.2.3(e)]

Based on observation and interview, the facility failed to assure that power strips were installed to manufactures instructions and failed to maintain an unobstructed space in front of the line isolation monitors in the OR ' s. These deficient practices would increase the potential for an electrical fire. The facility census was 20 patients.

Findings are:
Observations on 12-15-14 between 9:40 am and 2:16 pm revealed:
1. Two power strips hanging from the electrical cords under the desk in Operations Cath. Lab office.
2. The line isolation monitors in 4 of 4 Operating Rooms were blocked with carts and other surgical items.
3. Power strip in OR 4 failed to be secured to an IV pole.
4. Power-strips in the Data Room were " daisy-chained " together at the IT equipment next to the panel boxes.

During an interview on 12-15-14 between 9:40 am and 2:16 pm, Maintenance A confirmed the findings.



27395

Based on observation, record review and staff interview, the facility failed to use electrical wiring and equipment in accordance with the National Fire Protection Association (NFPA), 70. This condition had the potential to cause an electrical fire. Facility census was 20.

Findings are:
Observation during the facility tour on 12/15/14, from 9:50 am to 11:14 am revealed:
1. A power strip that was permanently attached to wheeled pedestal inside of the patient care vicinity in Patient Room 207 was observed. In addition, a power strip was permanently attached to crash carts for each pod as well.
Record review on 12/15/14, at 9:56 am revealed the facility failed to have adopted the CMS Categorical Waiver for Power Strips Use in Patient Care Areas, and follow all of the requirements of 10.2.3.6 within the waiver.
2. The TV in the 2nd Floor Fish Bowl failed to be plugged in without the use of an extension cord used in lieu of permanent wiring.
3. Power strips in the 2nd Floor DON Office failed to be plugged directly into a wall outlet.
4. Four power strips were daisy chained, and failed to be plugged directly into a wall outlet in the 2nd Floor House Supervisor Office.
5. The ice machine in the Kitchen failed to be plugged in without the use of an extension cord used in lieu of permeant wiring.
6. Two coffee makers in the Pharmacy by the North Entrance failed to be plugged in directly to a wall outlet so a power strip was not used with the heat producing appliances.
In an interview conducted at the time of observation (12/15/14, from 9:50 am to 11:14 am), Maintenance B acknowledged the findings.