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Based on observations, the facility failed to ensure that proper smoke barrier walls are provided as required. Section 8.3.6.1 requires pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers to be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier or to be protected by an approved device that is designed for the specific purpose.

THE FINDINGS INCLUDE:

While touring the facility on the morning and afternoon of 6/8/15, it was noted that the smoke barrier walls on each of the 4th, 5th and 8th floor levels are not continuous above the ceiling to the deck above. Unsealed penetrations exist above the in-lay ceiling tiles, located at the smoke barrier doors, around electrical metal tubing (EMT) and conduit, heating, ventilation and air conditioning (HVAC) ducts, sprinkler piping and similar utilities that exist in each of the smoke barriers noted.

This was also noted by the facility's Director of Security and Maintenance Director and reviewed with hospital personnel at a summary of survey findings.

Based on observations and records provided, the facility failed to properly maintain the sprinkler system. NFPA 25 section 1-4.2 states the responsibility for properly maintaining a water-based fire protection system shall be that of the owner(s) of the property. By means of periodic inspections, tests, and maintenance, the equipment shall be shown to be in good operating condition, or any defects or impairments shall be revealed.

Inspection, testing, and maintenance shall be implemented in accordance with procedures meeting or exceeding those established in this document and in accordance with the manufacturer ' s instructions. These tasks shall be performed by personnel who have developed competence through training and experience.

Section 5-3.2.1 states a weekly test of electric motor-driven pump assemblies shall be conducted without flowing water. This test shall be conducted by starting the pump automatically. The pump shall run a minimum of 10 minutes.

Section 5-3.2.4 states the pertinent visual observations or adjustments specified in the following checklists shall be conducted while the pump is running.

Section 5-3.2.4.1 outlines the Pump System Procedure and what must be documented.
(a) Record the system suction and discharge pressure gauge readings.
(b) Check the pump packing glands for slight discharge.
(c) Adjust gland nuts if necessary.
(d) Check for unusual noise or vibration.
(e) Check packing boxes, bearings, or pump casing for overheating.
(f) Record the pump starting pressure.
Section 5-3.2.4.2 outlines the Electrical System Procedure and what must be documented.
(a) Observe the time for motor to accelerate to full speed.
(b) Record the time controller is on first step (for reduced voltage or reduced current starting).
(c) Record the time pump runs after starting (for automatic stop controllers).

THE FINDINGS INCLUDE:

While conducting a record review of the facility's automatic sprinkler system inspection and testing documentation on the morning of 6/08/15, at approximately 11:45 A.M., the following was indicated. The facility's 1500 GPM electric fire pump is neither tested nor inspected weekly in accordance with the regulations set forth in NFPA 25. The facility's chief engineer stated that the pump was run on a monthly basis and detailed inspection documentation was not recorded.

The findings were confirmed by the Director of Safety and Security during the exit conference.

Based on observations, the facility failed to ensure that proper smoke barrier walls are provided as required. Section 8.3.6.1 requires pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers to be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier or to be protected by an approved device that is designed for the specific purpose.

THE FINDINGS INCLUDE:

While touring the facility on the morning and afternoon of 6/8/15, it was noted that the smoke barrier walls on each of the 4th, 5th and 8th floor levels are not continuous above the ceiling to the deck above. Unsealed penetrations exist above the in-lay ceiling tiles, located at the smoke barrier doors, around electrical metal tubing (EMT) and conduit, heating, ventilation and air conditioning (HVAC) ducts, sprinkler piping and similar utilities that exist in each of the smoke barriers noted.

This was also noted by the facility's Director of Security and Maintenance Director and reviewed with hospital personnel at a summary of survey findings.

Based on observations and records provided, the facility failed to properly maintain the sprinkler system. NFPA 25 section 1-4.2 states the responsibility for properly maintaining a water-based fire protection system shall be that of the owner(s) of the property. By means of periodic inspections, tests, and maintenance, the equipment shall be shown to be in good operating condition, or any defects or impairments shall be revealed.

Inspection, testing, and maintenance shall be implemented in accordance with procedures meeting or exceeding those established in this document and in accordance with the manufacturer ' s instructions. These tasks shall be performed by personnel who have developed competence through training and experience.

Section 5-3.2.1 states a weekly test of electric motor-driven pump assemblies shall be conducted without flowing water. This test shall be conducted by starting the pump automatically. The pump shall run a minimum of 10 minutes.

Section 5-3.2.4 states the pertinent visual observations or adjustments specified in the following checklists shall be conducted while the pump is running.

Section 5-3.2.4.1 outlines the Pump System Procedure and what must be documented.
(a) Record the system suction and discharge pressure gauge readings.
(b) Check the pump packing glands for slight discharge.
(c) Adjust gland nuts if necessary.
(d) Check for unusual noise or vibration.
(e) Check packing boxes, bearings, or pump casing for overheating.
(f) Record the pump starting pressure.
Section 5-3.2.4.2 outlines the Electrical System Procedure and what must be documented.
(a) Observe the time for motor to accelerate to full speed.
(b) Record the time controller is on first step (for reduced voltage or reduced current starting).
(c) Record the time pump runs after starting (for automatic stop controllers).

THE FINDINGS INCLUDE:

While conducting a record review of the facility's automatic sprinkler system inspection and testing documentation on the morning of 6/08/15, at approximately 11:45 A.M., the following was indicated. The facility's 1500 GPM electric fire pump is neither tested nor inspected weekly in accordance with the regulations set forth in NFPA 25. The facility's chief engineer stated that the pump was run on a monthly basis and detailed inspection documentation was not recorded.

The findings were confirmed by the Director of Safety and Security during the exit conference.