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K-130 Not Met. Reference MRSA Title 25 Section 2452 ( NFPA 101 Life Safety Code 2009 Edition) for offsite inspections of hospital auxiliary sites as listed in the following numbered deficiencies observed by this Inspector on November 19 2013.

Stockton Springs Regional Healthcare.
1. NFPA Life Safety 101 section 4.6.13.5 Testing and maintenance of required systems.
Findings: Records for testing of life safety systems were not available onsite for review.
2.Required emergency egress lighting were not operable in corridors. ( batteries dead)
3. Exit access was obstructed in north exit corridor by tools and other storage items.
4.NFPA Life Safety Code 101 section 39.3.2 Hazard area protection required.
Findings: Boiler room has a vent in the face of door,air for combustion was being taken from inside of basement with louvers in the walls.
Basement storage room does not have a 1 hour fire rated door as required, and the ceiling is not 1 hr fire rated as required.
Penetrations were observed in the wall of the storage room to occupied spaces in the basement.

Searsport Health Center.
1. NFPA Life Safety Code 101 section 39.3.2 Hazard area Protection.
Findings: The boiler room door has a louver installed on face of door.

Cobb Medical Center 16 Fahey Street.
1. NFPA Life safety Code 101 section 39.2.9.1 Emergency Lighting.
Findings: Required emergency lighting in corridors and suites not functioning.
2. NFPA Life Safety Code 101 section 39.3.1.1 Vertical openings.
Findings: Fire rated doors bottom of stairs to first floor level north end have a gap between doors that is more than allowed by NFPA 80.
Findings: Mechanical room ceiling second floor has penetrations in the sheetrock.

Waldo (NPA) Office suites and ESRD unit.
1. NFPA Life Safety Code 101 section 39.3.1.1 Vertical openings.
Findings: Doors at top of all 3 stairway enclosures do not positive latch as required.
2. Combustible storage observed in the south stairway second floor landing.
3. NFPA 99 Medical gases.
Findings: Newly installed suction air pump and piping and associated components for dentist suite require Certification by and independent certification technician.
4. NFPA 25 Sprinkler maintenance service standard.
Findings: Sprinkler system quarterly service not done from 2010 until August 2013 according to the service tag at the riser.


Arthur Jewell Health Center.
NFPA Life Safety Code 101 Section 39.2..9 Emergency Lighting.
Findings: Emergency lighting in waiting room not functioning. ( dead battery).
2. NFPA 99 Medical gases.
Findings: 2 portable oxygen tank cylinders found unsecured in the ambulance garage.
3. NFPA Life Safety Code 101 section 39.3.2 Hazard Area protection.
Findings: The self-closing device on tank room door was found disconnected.






16776

1. Main Kitchen in Hospital. Kitchen hood and duct need to be cleaned. As per NFPA 96 Section 11.4 part 11.4.1 11.4* Inspection for Grease Buildup.
The entire exhaust system shall be inspected for grease buildup by a properly trained, qualified, and certified company or person(s) acceptable to the authority having jurisdiction and in accordance with Table 11.4.

Table 11.4 Schedule of Inspection for Grease Buildup
Type or Volume
of Cooking Inspection
Frequency
Systems serving solid fuel cooking operations Monthly
Systems serving high-volume cooking operations, such as 24-hour cooking, charbroiling, or wok cooking Quarterly
Systems serving moderate-volume cooking operations Semiannually
Systems serving low-volume cooking operations, such as churches, day camps, seasonal businesses, or senior centers Annually Hood and Duct has not been cleaned.

2. In main hospital; the enclosed stair towers; No storage under the stairs found in two locations one in the basement and one on the first floor found to have items left under the stairs.. LSC 101 Chapter 7 section 7.2.2.5.3 Usable Space. Noted all items had been removed during my inspection.

3. In main hospital on the first floor Door leading from hall-way into stairs Need to be marked NO EXIT staff Only. LSC 101 Chapter 7 Section 7.10.8 & 7.10.8.1. This is for the public not to mistaken it as an Exit.

4. In hospital first floor Corridor mounted monitor extened out more than 3.5" ( about 7" and lower than the 60" above the floor.) LSC Sections 18.2.3.3 and 19.2.3.3. and CMS S&C -04-41. Note item was in the process of being moved.

5. In hospital basement; electrial room rated wall had hole from utilities pipes and filled with a rag. 2hr rateing needed to be maintained with properly rated / sealed material. Note this item was done before I finnished my inspection.

K-130 Not Met. Reference MRSA Title 25 Section 2452 ( NFPA 101 Life Safety Code 2009 Edition) for offsite inspections of hospital auxiliary sites as listed in the following numbered deficiencies observed by this Inspector on November 19 2013.

Stockton Springs Regional Healthcare.
1. NFPA Life Safety 101 section 4.6.13.5 Testing and maintenance of required systems.
Findings: Records for testing of life safety systems were not available onsite for review.
2.Required emergency egress lighting were not operable in corridors. ( batteries dead)
3. Exit access was obstructed in north exit corridor by tools and other storage items.
4.NFPA Life Safety Code 101 section 39.3.2 Hazard area protection required.
Findings: Boiler room has a vent in the face of door,air for combustion was being taken from inside of basement with louvers in the walls.
Basement storage room does not have a 1 hour fire rated door as required, and the ceiling is not 1 hr fire rated as required.
Penetrations were observed in the wall of the storage room to occupied spaces in the basement.

Searsport Health Center.
1. NFPA Life Safety Code 101 section 39.3.2 Hazard area Protection.
Findings: The boiler room door has a louver installed on face of door.

Cobb Medical Center 16 Fahey Street.
1. NFPA Life safety Code 101 section 39.2.9.1 Emergency Lighting.
Findings: Required emergency lighting in corridors and suites not functioning.
2. NFPA Life Safety Code 101 section 39.3.1.1 Vertical openings.
Findings: Fire rated doors bottom of stairs to first floor level north end have a gap between doors that is more than allowed by NFPA 80.
Findings: Mechanical room ceiling second floor has penetrations in the sheetrock.

Waldo (NPA) Office suites and ESRD unit.
1. NFPA Life Safety Code 101 section 39.3.1.1 Vertical openings.
Findings: Doors at top of all 3 stairway enclosures do not positive latch as required.
2. Combustible storage observed in the south stairway second floor landing.
3. NFPA 99 Medical gases.
Findings: Newly installed suction air pump and piping and associated components for dentist suite require Certification by and independent certification technician.
4. NFPA 25 Sprinkler maintenance service standard.
Findings: Sprinkler system quarterly service not done from 2010 until August 2013 according to the service tag at the riser.


Arthur Jewell Health Center.
NFPA Life Safety Code 101 Section 39.2..9 Emergency Lighting.
Findings: Emergency lighting in waiting room not functioning. ( dead battery).
2. NFPA 99 Medical gases.
Findings: 2 portable oxygen tank cylinders found unsecured in the ambulance garage.
3. NFPA Life Safety Code 101 section 39.3.2 Hazard Area protection.
Findings: The self-closing device on tank room door was found disconnected.






16776

1. Main Kitchen in Hospital. Kitchen hood and duct need to be cleaned. As per NFPA 96 Section 11.4 part 11.4.1 11.4* Inspection for Grease Buildup.
The entire exhaust system shall be inspected for grease buildup by a properly trained, qualified, and certified company or person(s) acceptable to the authority having jurisdiction and in accordance with Table 11.4.

Table 11.4 Schedule of Inspection for Grease Buildup
Type or Volume
of Cooking Inspection
Frequency
Systems serving solid fuel cooking operations Monthly
Systems serving high-volume cooking operations, such as 24-hour cooking, charbroiling, or wok cooking Quarterly
Systems serving moderate-volume cooking operations Semiannually
Systems serving low-volume cooking operations, such as churches, day camps, seasonal businesses, or senior centers Annually Hood and Duct has not been cleaned.

2. In main hospital; the enclosed stair towers; No storage under the stairs found in two locations one in the basement and one on the first floor found to have items left under the stairs.. LSC 101 Chapter 7 section 7.2.2.5.3 Usable Space. Noted all items had been removed during my inspection.

3. In main hospital on the first floor Door leading from hall-way into stairs Need to be marked NO EXIT staff Only. LSC 101 Chapter 7 Section 7.10.8 & 7.10.8.1. This is for the public not to mistaken it as an Exit.

4. In hospital first floor Corridor mounted monitor extened out more than 3.5" ( about 7" and lower than the 60" above the floor.) LSC Sections 18.2.3.3 and 19.2.3.3. and CMS S&C -04-41. Note item was in the process of being moved.

5. In hospital basement; electrial room rated wall had hole from utilities pipes and filled with a rag. 2hr rateing needed to be maintained with properly rated / sealed material. Note this item was done before I finnished my inspection.