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Based on observation and interview, it was determined that the facility did not ensure that all doors opening onto and protecting the corridors from fire/smoke were kept free of impediments to ensure positive latching and quick closing of the doors in case of an emergency.

Findings include:

During the tour of the facility on 05/29/13 between 11:30 AM to 3:00 PM, it was noted that some of the rooms opening into the common exit corridor ( in the 2nd and 3rd floor) had the latching hardware obstructed with paper thus impeding the positive latching of the doors.


All findings were verified with Director of Engineering on 5/29/13 between 11:30 AM to 3:00 PM.

NFPA 101 (2000 edition) 19.2.1, 19.3.6.3, (19.3.6.3.6), 7.2.

A. Based on observations, the facility did not ensure that all exit passageways are maintained free of obstruction or impediments to full and instant use, in the case of fire or other emergency. NFPA 101 Sub-Section 7.1.10.1 requires that:
Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency, and, NFPA 101 Sub-Section 7.5.1.1 requires that:
Exits shall be located and exit access shall be arranged so that exits are readily accessible at all times.


Findings include:

On 05/29/13 at 11:15 AM, it was observed that the corridor by the Radiology department had five to six of linen and mop heads. These carts were being stored in the corridor as no other staff member was near by moving or having the carts in use.

Storage of such items in exit corridors may lead to impediment and/or full use of exit corridors in case of emergency.

Findings were verified with Director of Engineering at the time of Observation.


B. Based on observations, it was determined that the facility did not ensure that all doors in the facility were operable with no more than one releasing option. NFPA 101 Sub Section 7.2.1.5.4 requires that:
"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 in. (86 cm), and not more than 48 in. (122 cm), above the finished floor. Doors shall be operable with not more than one releasing operation".


Findings Include

On 05/29/13 at 11:30 AM, during the tour of the Morgue and Room #100 on first floor, it was noted that the exit doors from both area/rooms had a thumb-twisting latching/locking device installed on the doors. When fully engaged, the thumb-twisting latching device prevents the doors from opening in an obvious, one step operation required during a fire/emergency evacuation.

The finding was verified with Director of Engineering at 05/29/13 at 11:30 AM.

Based on document review and staff interview, the facility did not ensure that the fire drills were conducted under varying conditions and that planning / evaluation of fire drills were done as per NFPA 101.

Findings include:

1. A review of the fire drill record on 05/30/13 at 11:55 AM indicated that the facility has instituted a checklist highlighting the points of the drill on which the staff conducting the drill/observer checks off "yes" or "no".

Review of fire drill records indicated that the hospital did not conduct fire drills that include 'simulation of various types of emergency fire conditions' to ensure that each staff has a full and clear understanding of the facility's fire safety plan and how to execute it successfully under the varying conditions.

The fire drills checklist or report did not indicate under what scenario the fire drill was initiated.

2. The facility's fire drill records included staff sign-in sheets, the facility failed to document in the records, a critique of the drill, the staff's fire drill response, and the staff knowledge of evacuation procedure to ensure that the staff was fully aware of fire drill/evacuation protocols.

3. During review of the Disaster drill records, it was noted that the facility did not ensure that it incorporated the internal and external disaster scenarios respectively for its bi-annual disaster drills . The policy of the facility titled 'Emergency Operation Plan' on page #44 indicates that the facility is required to conduct disaster drill twice a year. Furthermore, the policy also indicates that the facility is required to conduct a drill with "influx of actual or simulated patients".

At interview with the Director of Engineering , it was stated that this 'influx' is not possible since the facility is a small hospital with no emergency department.

Thus based on the interview, the policy was not comprehensive and site specific to the facility and its needs. The policy also did not define step by step how a disaster drill will be conducted and evaluated.

Findings were verified with the Director of Engineering.

Based on staff interview and review of the records, the facility did not ensure that all the components of the fire alarm system are tested in accordance with the requirements of NFPA 101 and NFPA 72, National Fire Alarm Code. In addition, the facility did not ensure that the sensitivity test is performed on all smoke detectors and the system is maintained in accordance with NFPA 72.


Findings include

1. On 05/30/13 at 11:00 AM, during the document review of the fire alarm and the test of its different components, it was noted that the report did not include the annual test information for the Fire panel and Remote annunciator as per NFPA 72 (1999) 7-1 and 7-3.2.

The reports did not include any information on the testing of the batteries of the fire alarm system as required by the above code.

These findings were verified with Director of Engineering at the time of observation.
2.The facility did not ensure that the sensitivity test is performed on all smoke detectors and the system is maintained in accordance with NFPA 72.

a. On 05/30/13 at 11:45 AM, during review of the fire alarm test reports, the Director of Engineering was requested to indicate/provide the reports for the sensitivity test of all the smoke detectors. The report from 'High Rise Fire protection Corp' dated 01/17/2013 was provided for review, but in the report there was no indication that apart from the functional status of the detectors , the sensitivity test is conducted on them too.

Note: Section -7-3.2.1* NFPA 72 requires that detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.
To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method;
(2) Manufacturer's calibrated sensitivity test instrument;
(3) Listed control equipment arranged for the purpose;
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit to indicate if its sensitivity is outside its listed sensitivity range;
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction;
Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and re-calibrated or be replaced.


b. No information was provided regarding the annual or 5 year testing of the restorable heat detectors as required by NFPA 72 1999 7.3.2.3

NOTE: Section 7-3.2.3 states:-
For restorable fixed-temperature, spot-type heat detectors, two or more detectors shall be tested on each initiating circuit annually. Different detectors shall be tested each year, with records kept by the building owner specifying which detectors have been tested. Within 5 years, each detector shall have been tested.

Based on document review and interview, it was determined that the hospital did not ensure that the sprinkler system is maintained in accordance with NFPA 25 1998 Table 2-1 and Table 9-1 . In addition, the facility did not ensure that all sprinkler pipes are free of any foreign material and paints as per NFPA 25 and NFPA 13.

Findings include:

1. On 05/30/13 at 11:30 AM, during document review for the sprinkler test it was noted that no documentation or report was available to show that five (5) year internal inspections for obstructions on the sprinkler piping, alarm valves, and associated trim and check valves were conducted. It could not also be verified if the gauges were recalibrated or replaced in the past five years.

Note: As per NFPA, there are two activities that are related to obstructions in Chapter 13 that require attention. The first is an investigation that is actually more of an "inspection" as described in Section 13.2.1 that must be conducted every five years. While the sprinkler system is shut down for the purpose of internal valve inspections (See Table 12.1), the flushing connection at the end of one cross main and a single sprinkler at the end of one branch line must be removed and the inside of the piping is then "inspected" for the presence of organic and inorganic material. In Section 13.2.2 a more comprehensive obstruction "investigation" must be conducted when any of the 14 conditions listed in that section are present. This more comprehensive obstruction "investigation" is conducted by internally examining the following four points in a system: system valve, riser, crossmain and, branchline.

Findings were verified with the Director of Engineering at the time of observation.

2. It was determined that the facility did not ensure that all sprinkler pipes are free of any foreign material and paints as per NFPA 25 and NFPA 13, Standard for the Inspection, Testing and Maintenance of Water Based Fire and Protection System.


During the tour of the facility on 05/29/13 at 11;00 AM, it was observed that the exposed sprinkler pipes in the Kitchen exhibited accumulation of lint and dust.

Note: Section 2-2.1.1* of NFPA 25 states that, "Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation."

Findings were verified with the Director of Engineering at the time of observation.

Based on observation, it was determined that the facility failed to ensure that all its portable fire extinguishers are installed such that the top of the fire extinguisher is not more than 5 feet (60 inches) above the floor (see reference NFPA 10, 1-6.10). Additionally, the facility did not ensure that the fire extinguishers are stored in such a manner that they are easily accessible.

Findings include:

1. During survey of facility on 05/29/13 at 10:45 AM, it was noted that in the kitchen, the fire extinguisher was installed in is such a way that its top most portion was greater than the required 5 ft. (60 inches).

2. The fire extinguisher in Room #100 was noted blocked by a stack of chairs stored in front.

This finding was observed and verified with Director of Engineering at the time of survey on 05/29/13 at 10:45 AM.

Based on observation and staff interview, the facility failed to ensure that the artificial decorative plants displayed in the facility are not constructed of combustible material, unless otherwise rendered flame retardant.

The findings include:

During the survey on 05/29/13 to 05/31/13 between 11:00 AM to 4:00 PM, it was observed that the facility had provided various decorative artificial plants about 4.0-5.0 feet tall in the main lobby/waiting room of the facility

During the tour of the patient floors, it was noted that the Day rooms/ Therapeutic Activities rooms on the floors ( such as 4th floor) had artificial flowers and trees in the rooms.

An interview with Director of Engineering at the time of observations revealed that he could not confirm the non-combustible nature or the flame-retardant properties of these artificial trees. He stated that he did not think that those plants were rendered flame retardant by any chemical treatment and stated that he will try to look for the specifications.

Based on observation and interview, the facility failed to ensure a complete automatic sprinkler system was installed in accordance with NFPA 13 1999 [Standard for the Installation of Sprinkler Systems], to provide complete coverage in the fully sprinklered building. In addition, the facility did not ensure that the transfer switch of the emergency generator is tested and maintained as per NFPA 110 (1999).

Findings include:

1. On 05/29/13 at 10:45 AM during the tour of the kitchen, it was noted that the walk-in-cooler/refrigerators were not equipped with any sprinkler head, thus the kitchen/building is not considered fully sprinklered.

On 05/30/13 at 1:45 PM, during the tour of the 3rd floor, it was noted that a storage closet in the corridor also did not have any sprinkler head.

Findings were observed and verified with Director of Engineering.

2. The facility did not ensure that the transfer switch of the emergency generator is tested and maintained as per NFPA 110 (1999).

During the document review of the monthly emergency generator reports on 05/30/13 at 11:45 AM, it was noted that the logs did not include/indicate that the transfer switches were visually inspected or any other kind of monthly preventive maintenance is done on them.

NOTE: As per NFPA 110
1. Transfer switches are required to be operated monthly NFPA 110(99), Sec. 6-4.5
2. This monthly test must consist of electrically operating the transfer switch from the
normal/standard position to the alternate position and then a return to the normal/standard position NFPA 110(99), Sec. 6-4.5
3. Transfer switches must also be inspected monthly to ensure that they are maintained free from
accumulated dust and dirt and to check for deterioration of the transfer switch contacts
NFPA 110(99), Sec. 6-3.5

Findings were verified with Director of Engineering.

Based on staff interview, facility does not have the elevators equipped with fire fighter recall Phase I and Phase II.

Findings include:

On 05/29/13 at 11:00 AM, Director of Engineering was requested to provide information regarding the fire fighter recall feature of the elevators in the facility. The Director of Engineering stated that the elevators currently have the recall from the lobby only and thus are not equipped with both phases as required by the code.

As per the Director of Engineering, the elevators are being upgraded, however no time frame for the completion of work was provided during survey.

Based on observation and interview, it was determined that the facility did not ensure that all doors opening onto and protecting the corridors from fire/smoke were kept free of impediments to ensure positive latching and quick closing of the doors in case of an emergency.

Findings include:

During the tour of the facility on 05/29/13 between 11:30 AM to 3:00 PM, it was noted that some of the rooms opening into the common exit corridor ( in the 2nd and 3rd floor) had the latching hardware obstructed with paper thus impeding the positive latching of the doors.


All findings were verified with Director of Engineering on 5/29/13 between 11:30 AM to 3:00 PM.

NFPA 101 (2000 edition) 19.2.1, 19.3.6.3, (19.3.6.3.6), 7.2.

A. Based on observations, the facility did not ensure that all exit passageways are maintained free of obstruction or impediments to full and instant use, in the case of fire or other emergency. NFPA 101 Sub-Section 7.1.10.1 requires that:
Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency, and, NFPA 101 Sub-Section 7.5.1.1 requires that:
Exits shall be located and exit access shall be arranged so that exits are readily accessible at all times.


Findings include:

On 05/29/13 at 11:15 AM, it was observed that the corridor by the Radiology department had five to six of linen and mop heads. These carts were being stored in the corridor as no other staff member was near by moving or having the carts in use.

Storage of such items in exit corridors may lead to impediment and/or full use of exit corridors in case of emergency.

Findings were verified with Director of Engineering at the time of Observation.


B. Based on observations, it was determined that the facility did not ensure that all doors in the facility were operable with no more than one releasing option. NFPA 101 Sub Section 7.2.1.5.4 requires that:
"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 in. (86 cm), and not more than 48 in. (122 cm), above the finished floor. Doors shall be operable with not more than one releasing operation".


Findings Include

On 05/29/13 at 11:30 AM, during the tour of the Morgue and Room #100 on first floor, it was noted that the exit doors from both area/rooms had a thumb-twisting latching/locking device installed on the doors. When fully engaged, the thumb-twisting latching device prevents the doors from opening in an obvious, one step operation required during a fire/emergency evacuation.

The finding was verified with Director of Engineering at 05/29/13 at 11:30 AM.

Based on document review and staff interview, the facility did not ensure that the fire drills were conducted under varying conditions and that planning / evaluation of fire drills were done as per NFPA 101.

Findings include:

1. A review of the fire drill record on 05/30/13 at 11:55 AM indicated that the facility has instituted a checklist highlighting the points of the drill on which the staff conducting the drill/observer checks off "yes" or "no".

Review of fire drill records indicated that the hospital did not conduct fire drills that include 'simulation of various types of emergency fire conditions' to ensure that each staff has a full and clear understanding of the facility's fire safety plan and how to execute it successfully under the varying conditions.

The fire drills checklist or report did not indicate under what scenario the fire drill was initiated.

2. The facility's fire drill records included staff sign-in sheets, the facility failed to document in the records, a critique of the drill, the staff's fire drill response, and the staff knowledge of evacuation procedure to ensure that the staff was fully aware of fire drill/evacuation protocols.

3. During review of the Disaster drill records, it was noted that the facility did not ensure that it incorporated the internal and external disaster scenarios respectively for its bi-annual disaster drills . The policy of the facility titled 'Emergency Operation Plan' on page #44 indicates that the facility is required to conduct disaster drill twice a year. Furthermore, the policy also indicates that the facility is required to conduct a drill with "influx of actual or simulated patients".

At interview with the Director of Engineering , it was stated that this 'influx' is not possible since the facility is a small hospital with no emergency department.

Thus based on the interview, the policy was not comprehensive and site specific to the facility and its needs. The policy also did not define step by step how a disaster drill will be conducted and evaluated.

Findings were verified with the Director of Engineering.

Based on staff interview and review of the records, the facility did not ensure that all the components of the fire alarm system are tested in accordance with the requirements of NFPA 101 and NFPA 72, National Fire Alarm Code. In addition, the facility did not ensure that the sensitivity test is performed on all smoke detectors and the system is maintained in accordance with NFPA 72.


Findings include

1. On 05/30/13 at 11:00 AM, during the document review of the fire alarm and the test of its different components, it was noted that the report did not include the annual test information for the Fire panel and Remote annunciator as per NFPA 72 (1999) 7-1 and 7-3.2.

The reports did not include any information on the testing of the batteries of the fire alarm system as required by the above code.

These findings were verified with Director of Engineering at the time of observation.
2.The facility did not ensure that the sensitivity test is performed on all smoke detectors and the system is maintained in accordance with NFPA 72.

a. On 05/30/13 at 11:45 AM, during review of the fire alarm test reports, the Director of Engineering was requested to indicate/provide the reports for the sensitivity test of all the smoke detectors. The report from 'High Rise Fire protection Corp' dated 01/17/2013 was provided for review, but in the report there was no indication that apart from the functional status of the detectors , the sensitivity test is conducted on them too.

Note: Section -7-3.2.1* NFPA 72 requires that detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.
To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method;
(2) Manufacturer's calibrated sensitivity test instrument;
(3) Listed control equipment arranged for the purpose;
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit to indicate if its sensitivity is outside its listed sensitivity range;
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction;
Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and re-calibrated or be replaced.


b. No information was provided regarding the annual or 5 year testing of the restorable heat detectors as required by NFPA 72 1999 7.3.2.3

NOTE: Section 7-3.2.3 states:-
For restorable fixed-temperature, spot-type heat detectors, two or more detectors shall be tested on each initiating circuit annually. Different detectors shall be tested each year, with records kept by the building owner specifying which detectors have been tested. Within 5 years, each detector shall have been tested.

Based on document review and interview, it was determined that the hospital did not ensure that the sprinkler system is maintained in accordance with NFPA 25 1998 Table 2-1 and Table 9-1 . In addition, the facility did not ensure that all sprinkler pipes are free of any foreign material and paints as per NFPA 25 and NFPA 13.

Findings include:

1. On 05/30/13 at 11:30 AM, during document review for the sprinkler test it was noted that no documentation or report was available to show that five (5) year internal inspections for obstructions on the sprinkler piping, alarm valves, and associated trim and check valves were conducted. It could not also be verified if the gauges were recalibrated or replaced in the past five years.

Note: As per NFPA, there are two activities that are related to obstructions in Chapter 13 that require attention. The first is an investigation that is actually more of an "inspection" as described in Section 13.2.1 that must be conducted every five years. While the sprinkler system is shut down for the purpose of internal valve inspections (See Table 12.1), the flushing connection at the end of one cross main and a single sprinkler at the end of one branch line must be removed and the inside of the piping is then "inspected" for the presence of organic and inorganic material. In Section 13.2.2 a more comprehensive obstruction "investigation" must be conducted when any of the 14 conditions listed in that section are present. This more comprehensive obstruction "investigation" is conducted by internally examining the following four points in a system: system valve, riser, crossmain and, branchline.

Findings were verified with the Director of Engineering at the time of observation.

2. It was determined that the facility did not ensure that all sprinkler pipes are free of any foreign material and paints as per NFPA 25 and NFPA 13, Standard for the Inspection, Testing and Maintenance of Water Based Fire and Protection System.


During the tour of the facility on 05/29/13 at 11;00 AM, it was observed that the exposed sprinkler pipes in the Kitchen exhibited accumulation of lint and dust.

Note: Section 2-2.1.1* of NFPA 25 states that, "Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation."

Findings were verified with the Director of Engineering at the time of observation.

Based on observation, it was determined that the facility failed to ensure that all its portable fire extinguishers are installed such that the top of the fire extinguisher is not more than 5 feet (60 inches) above the floor (see reference NFPA 10, 1-6.10). Additionally, the facility did not ensure that the fire extinguishers are stored in such a manner that they are easily accessible.

Findings include:

1. During survey of facility on 05/29/13 at 10:45 AM, it was noted that in the kitchen, the fire extinguisher was installed in is such a way that its top most portion was greater than the required 5 ft. (60 inches).

2. The fire extinguisher in Room #100 was noted blocked by a stack of chairs stored in front.

This finding was observed and verified with Director of Engineering at the time of survey on 05/29/13 at 10:45 AM.

Based on observation and staff interview, the facility failed to ensure that the artificial decorative plants displayed in the facility are not constructed of combustible material, unless otherwise rendered flame retardant.

The findings include:

During the survey on 05/29/13 to 05/31/13 between 11:00 AM to 4:00 PM, it was observed that the facility had provided various decorative artificial plants about 4.0-5.0 feet tall in the main lobby/waiting room of the facility

During the tour of the patient floors, it was noted that the Day rooms/ Therapeutic Activities rooms on the floors ( such as 4th floor) had artificial flowers and trees in the rooms.

An interview with Director of Engineering at the time of observations revealed that he could not confirm the non-combustible nature or the flame-retardant properties of these artificial trees. He stated that he did not think that those plants were rendered flame retardant by any chemical treatment and stated that he will try to look for the specifications.

Based on observation and interview, the facility failed to ensure a complete automatic sprinkler system was installed in accordance with NFPA 13 1999 [Standard for the Installation of Sprinkler Systems], to provide complete coverage in the fully sprinklered building. In addition, the facility did not ensure that the transfer switch of the emergency generator is tested and maintained as per NFPA 110 (1999).

Findings include:

1. On 05/29/13 at 10:45 AM during the tour of the kitchen, it was noted that the walk-in-cooler/refrigerators were not equipped with any sprinkler head, thus the kitchen/building is not considered fully sprinklered.

On 05/30/13 at 1:45 PM, during the tour of the 3rd floor, it was noted that a storage closet in the corridor also did not have any sprinkler head.

Findings were observed and verified with Director of Engineering.

2. The facility did not ensure that the transfer switch of the emergency generator is tested and maintained as per NFPA 110 (1999).

During the document review of the monthly emergency generator reports on 05/30/13 at 11:45 AM, it was noted that the logs did not include/indicate that the transfer switches were visually inspected or any other kind of monthly preventive maintenance is done on them.

NOTE: As per NFPA 110
1. Transfer switches are required to be operated monthly NFPA 110(99), Sec. 6-4.5
2. This monthly test must consist of electrically operating the transfer switch from the
normal/standard position to the alternate position and then a return to the normal/standard position NFPA 110(99), Sec. 6-4.5
3. Transfer switches must also be inspected monthly to ensure that they are maintained free from
accumulated dust and dirt and to check for deterioration of the transfer switch contacts
NFPA 110(99), Sec. 6-3.5

Findings were verified with Director of Engineering.

Based on staff interview, facility does not have the elevators equipped with fire fighter recall Phase I and Phase II.

Findings include:

On 05/29/13 at 11:00 AM, Director of Engineering was requested to provide information regarding the fire fighter recall feature of the elevators in the facility. The Director of Engineering stated that the elevators currently have the recall from the lobby only and thus are not equipped with both phases as required by the code.

As per the Director of Engineering, the elevators are being upgraded, however no time frame for the completion of work was provided during survey.