HospitalInspections.org

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

8.2.1, NFPA 101, LIFE SAFETY CODE
Construction: Buildings or structures occupied or used in accordance with the individual occupancy chapters (Chapters 12 through 42) shall meet the minimum construction requirements of those chapters. NFPA 220, Standard on Types of Building Construction, shall be used to determine the requirements for the construction classification...

4.6.12.1, NFPA 101, LIFE SAFETY CODE
Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

Based on observation and interview the facility failed to ensure that the fire resistive coating applied to structural steel is properly maintained.

Findings include:

Observation during tour on 6/20/12 with Staff B (Facility Services Director) and Staff D (Maintenance Supervisor) revealed that one structural steel beam has approximately 5 linear feet of the fire resistive coating missing from the edge of the beam and at least one other steel beam has smaller portions of fire resistive coating that are missing in room N1505.

Interview during tour on 6/20/12 with Staff B confirmed the findings.

19.3.1.1, NFPA 101, LIFE SAFETY CODE
Any vertical opening shall be enclosed or protected in accordance with 8.2.5. Where enclosure is provided, the construction shall have not less than a 1-hour fire resistance rating.

8.2.3.2.1, NFPA 101, LIFE SAFETY CODEDoor assemblies in fire barriers shall be of an approved type with the appropriate fire protection rating for the location in which they are installed and shall comply with the following.
(a) Fire doors shall be installed in accordance with NFPA 80, Standard for Fire Doors and Fire Windows. Fire doors shall be of a design that has been tested to meet the conditions of acceptance of NFPA 252, Standard Methods of Fire Tests of Door Assemblies.
(b) Fire doors shall be self-closing or automatic-closing in accordance with 7.2.1.8 and, where used within the means of egress, shall comply with the provisions of 7.2.1.

1-6.1, NFPA 80, FIRE DOORS AND FIRE WINDOWS
Only labeled fire doors shall be used.

2-3.1.1, NFPA 80, FIRE DOORS AND FIRE WINDOWS
Only labeled door frames shall be used.

15-2.5.4, NFPA 80, FIRE DOORS AND FIRE WINDOWS
When holes are left in a door or frame due to changes or removal of hardware or plant-ons, the holes shall be repaired by the following methods:
(a) Install steel fasteners that adequately fill the holes
(b) Fill the screw or bolt holes with the same material as the door or frame

Based on observation and interview the facility failed to ensure that all doors in vertical openings have a label to demonstrate the fire resistance rating and that the doors are properly maintained.

Findings include:

Observation during tour on 6/20/12 between 12:00 p.m. and 2:00 p.m. with Staff B (Facility Services Director) and Staff D (Maintenance Supervisor) revealed the following:

1. Second floor, west stair: One door leaf without a label that demonstrates the fire resistance rating of the door leaf and the frame has unsealed penetration(s).

2. Second floor, south stair: One door leaf without a label that demonstrates the fire resistance rating of the door leaf.

Interview during tour on 6/20/12 with Staff B and Staff D at the time of discovery confirmed the findings.

19.3.7.6, NFPA 101, LIFE SAFETY CODE
Doors in smoke barriers shall comply with 8.3.4 and shall be self-closing or automatic-closing in accordance with 19.2.2.2.6. Such doors in smoke barriers shall not be required to swing with egress travel. Positive latching hardware shall not be required.

8.3.4.1, NFPA 101, LIFE SAFETY CODE
Doors in smoke barriers shall close the opening leaving only the minimum clearance necessary for proper operation and shall be without undercuts, louvers, or grilles.

A.8.3.4.1, NFPA 101, LIFE SAFETY CODE
The clearance for proper operation of smoke doors is defined as 1/8 in. (0.3 cm). For additional information on the installation of smoke-control door assemblies, see NFPA 105, Recommended Practice for the Installation of Smoke-Control Door Assemblies.

8.3.4.3, NFPA 101, LIFE SAFETY CODE
Doors in smoke barriers shall be self-closing or automatic-closing in accordance with 7.2.1.8 and shall comply with the provisions of 7.2.1.

19.2.2.2.6, NFPA 101, LIFE SAFETY CODE
Any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8.2. The automatic sprinkler system, if provided, and the fire alarm system, and the systems required by 7.2.1.8.2 shall be arranged to initiate the closing action of all such doors throughout the smoke compartment or throughout the entire facility.

A.19.2.2.2.6, NFPA 101, LIFE SAFETY CODE
It is desirable to keep doors in exit passageways, stair enclosures, horizontal exits, smoke barriers, and required enclosures around hazardous areas closed at all times to impede the travel of smoke and fire gases. Functionally, however, this involves decreased efficiency and limits patient supervision by the staff of a facility. To accommodate such needs, it is practical to presume that such doors will be kept open, even to the extent of employing wood chocks and other makeshift devices. Doors in exit passageways, horizontal exits, and smoke barriers should, therefore, be equipped with automatic hold-open devices actuated by the methods described regardless of whether the original installation of the doors was predicated on a policy of keeping them closed.

7.2.1.8.1, NFPA 101, LIFE SAFETY CODE
A door normally required to be kept closed shall not be secured in the open position at any time and shall be self-closing or automatic-closing in accordance with 7.2.1.8.2.

7.2.1.8.2, NFPA 101, LIFE SAFETY CODE
In any building of low or ordinary hazard contents, as defined in 6.2.2.2 and 6.2.2.3, or where approved by the authority having jurisdiction, doors shall be permitted to be automatic-closing, provided that the following criteria are met:
(1) Upon release of the hold-open mechanism, the door becomes self-closing.
(2) The release device is designed so that the door instantly releases manually and upon release becomes self-closing, or the door can be readily closed.
(3) The automatic releasing mechanism or medium is activated by the operation of approved smoke detectors installed in accordance with the requirements for smoke detectors for door release service in NFPA 72, National Fire Alarm Code.
(4) Upon loss of power to the hold-open device, the hold-open mechanism is released and the door becomes self-closing.
(5) The release by means of smoke detection of one door in a stair enclosure results in closing all doors serving that stair.

Based on record review, observation, and interview the facility failed to ensure that all doors in smoke barriers are self-closing doors.

Record review of the current floor plans of the facility provided by Staff B (Facility Services Director) during tour on 6/20/12 revealed the locations of smoke barriers and fire barriers in the facility.

Interview during tour on 6/20/12 with Staff B and Staff D (Maintenance Supervisor) confirmed the locations of the smoke barriers.

Observation during tour on 6/20/12 with Staff B and Staff D revealed that the following doors located in smoke barriers do not have self-closing devices installed:

1. First floor, Family Consultation Room.
2. First floor, mens locker room, door #S1206.
3. First floor, womens locker room, door #S1205.

Interview during tour on 6/20/12 with Staff B confirmed the findings.

19.3.2.6, NFPA 101, LIFE SAFETY CODECooking Facilities: Cooking facilities shall be protected in accordance with 9.2.3.

9.2.3, NFPA 101, LIFE SAFETY CODE
Commercial Cooking Equipment: Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

8-3.1, NFPA 96, VENTILATION CONTROL AND FIRE PROTECTION OF COMMERCIAL COOKING OPERATIONS
Hoods, grease removal devices, fans, ducts, and other appurtenances shall be cleaned to bare metal at frequent intervals prior to surfaces becoming heavily contaminated with grease or oily sludge. After the exhaust system is cleaned to bare metal, it shall not be coated with powder or other substance. The entire exhaust system shall be inspected by a properly trained, qualified, and certified company or person(s) acceptable to the authority having jurisdiction in accordance with Table 8-3.1.

Table 8-3.1 Exhaust System Inspection Schedule
Type or Volume of Cooking: Systems serving solid fuel cooking operations
Frequency: Monthly
Type or Volume of Cooking: Systems serving high-volume cooking operations such as 24-hour cooking, charbroiling or wok cooking
Frequency: Quarterly
Type or Volume of Cooking: Systems serving moderate-volume cooking operations
Frequency: Semiannually
Type or Volume of Cooking: Systems serving low-volume cooking operations, such as churches, day camps, seasonal businesses, or senior centers
Frequency: Annually

8-3.1.1, NFPA 96, VENTILATION CONTROL AND FIRE PROTECTION OF COMMERCIAL COOKING OPERATIONS
Upon inspection, if found to be contaminated with deposits from grease-laden vapors, the entire exhaust system shall be cleaned by a properly trained, qualified, and certified company or person(s) acceptable to the authority having jurisdiction in accordance with Section 8-3.

Based on record review and interview the facility failed to ensure that kitchen hood systems are properly maintained.

Findings include:

Record review of kitchen hood cleaning vendor reports during tour on 6/20/12 revealed that the dates of the kitchen hood cleanings were on 5/25/11 and 5/21/12 without any documentation present for a hood cleaning conducted semi-annually.

Interview during tour on 6/20/12 with Staff B (Facility Services Director), Staff D (Maintenance Supervisor), and Staff E (Dietary Manager) confirmed that the cleaning of the kitchen hood system has only been cleaned on an annual basis.

8.2.2.2, NFPA 101, LIFE SAFETY CODE
Fire compartments shall be formed with fire barriers that are continuous from outside wall to outside wall, from one fire barrier to another, or a combination thereof, including continuity through all concealed spaces, such as those found above a ceiling, including interstitial spaces. Walls used as fire barriers shall comply with Chapter 3 of NFPA 221, Standard for Fire Walls and Fire Barrier Walls. The NFPA 221 limitation on percentage width of openings shall not apply.

8.2.3.2.1, NFPA 101, LIFE SAFETY CODE
Door assemblies in fire barriers shall be of an approved type with the appropriate fire protection rating for the location in which they are installed and shall comply with the following.
(a) Fire doors shall be installed in accordance with NFPA 80, Standard for Fire Doors and Fire Windows. Fire doors shall be of a design that has been tested to meet the conditions of acceptance of NFPA 252, Standard Methods of Fire Tests of Door Assemblies.
(b) Fire doors shall be self-closing or automatic-closing in accordance with 7.2.1.8 and, where used within the means of egress, shall comply with the provisions of 7.2.1.

Based on record review, observation, and interview the facility failed to ensure that all doors in fire barriers are self-closing doors.

Record review of the current floor plans of the facility provided by Staff B (Facility Services Director) during tour on 6/20/12 revealed the locations of smoke barriers and fire barriers in the facility.

Interview during tour on 6/20/12 with Staff B and Staff D (Maintenance Supervisor) confirmed the locations of the fire barriers.

Observation during tour on 6/20/12 with Staff B and Staff D revealed that the following doors located in fire barriers do not have self-closing devices installed:

1. First floor, door #E1502.
2. First floor, door #E1503.
3. First floor, door #E1302.

Interview during tour on 6/20/12 with Staff B confirmed the findings.

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

8.2.1, NFPA 101, LIFE SAFETY CODE
Construction: Buildings or structures occupied or used in accordance with the individual occupancy chapters (Chapters 12 through 42) shall meet the minimum construction requirements of those chapters. NFPA 220, Standard on Types of Building Construction, shall be used to determine the requirements for the construction classification...

4.6.12.1, NFPA 101, LIFE SAFETY CODE
Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

Based on observation and interview the facility failed to ensure that the fire resistive coating applied to structural steel is properly maintained.

Findings include:

Observation during tour on 6/20/12 with Staff B (Facility Services Director) and Staff D (Maintenance Supervisor) revealed that one structural steel beam has approximately 5 linear feet of the fire resistive coating missing from the edge of the beam and at least one other steel beam has smaller portions of fire resistive coating that are missing in room N1505.

Interview during tour on 6/20/12 with Staff B confirmed the findings.

19.3.1.1, NFPA 101, LIFE SAFETY CODE
Any vertical opening shall be enclosed or protected in accordance with 8.2.5. Where enclosure is provided, the construction shall have not less than a 1-hour fire resistance rating.

8.2.3.2.1, NFPA 101, LIFE SAFETY CODEDoor assemblies in fire barriers shall be of an approved type with the appropriate fire protection rating for the location in which they are installed and shall comply with the following.
(a) Fire doors shall be installed in accordance with NFPA 80, Standard for Fire Doors and Fire Windows. Fire doors shall be of a design that has been tested to meet the conditions of acceptance of NFPA 252, Standard Methods of Fire Tests of Door Assemblies.
(b) Fire doors shall be self-closing or automatic-closing in accordance with 7.2.1.8 and, where used within the means of egress, shall comply with the provisions of 7.2.1.

1-6.1, NFPA 80, FIRE DOORS AND FIRE WINDOWS
Only labeled fire doors shall be used.

2-3.1.1, NFPA 80, FIRE DOORS AND FIRE WINDOWS
Only labeled door frames shall be used.

15-2.5.4, NFPA 80, FIRE DOORS AND FIRE WINDOWS
When holes are left in a door or frame due to changes or removal of hardware or plant-ons, the holes shall be repaired by the following methods:
(a) Install steel fasteners that adequately fill the holes
(b) Fill the screw or bolt holes with the same material as the door or frame

Based on observation and interview the facility failed to ensure that all doors in vertical openings have a label to demonstrate the fire resistance rating and that the doors are properly maintained.

Findings include:

Observation during tour on 6/20/12 between 12:00 p.m. and 2:00 p.m. with Staff B (Facility Services Director) and Staff D (Maintenance Supervisor) revealed the following:

1. Second floor, west stair: One door leaf without a label that demonstrates the fire resistance rating of the door leaf and the frame has unsealed penetration(s).

2. Second floor, south stair: One door leaf without a label that demonstrates the fire resistance rating of the door leaf.

Interview during tour on 6/20/12 with Staff B and Staff D at the time of discovery confirmed the findings.

19.3.7.6, NFPA 101, LIFE SAFETY CODE
Doors in smoke barriers shall comply with 8.3.4 and shall be self-closing or automatic-closing in accordance with 19.2.2.2.6. Such doors in smoke barriers shall not be required to swing with egress travel. Positive latching hardware shall not be required.

8.3.4.1, NFPA 101, LIFE SAFETY CODE
Doors in smoke barriers shall close the opening leaving only the minimum clearance necessary for proper operation and shall be without undercuts, louvers, or grilles.

A.8.3.4.1, NFPA 101, LIFE SAFETY CODE
The clearance for proper operation of smoke doors is defined as 1/8 in. (0.3 cm). For additional information on the installation of smoke-control door assemblies, see NFPA 105, Recommended Practice for the Installation of Smoke-Control Door Assemblies.

8.3.4.3, NFPA 101, LIFE SAFETY CODE
Doors in smoke barriers shall be self-closing or automatic-closing in accordance with 7.2.1.8 and shall comply with the provisions of 7.2.1.

19.2.2.2.6, NFPA 101, LIFE SAFETY CODE
Any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8.2. The automatic sprinkler system, if provided, and the fire alarm system, and the systems required by 7.2.1.8.2 shall be arranged to initiate the closing action of all such doors throughout the smoke compartment or throughout the entire facility.

A.19.2.2.2.6, NFPA 101, LIFE SAFETY CODE
It is desirable to keep doors in exit passageways, stair enclosures, horizontal exits, smoke barriers, and required enclosures around hazardous areas closed at all times to impede the travel of smoke and fire gases. Functionally, however, this involves decreased efficiency and limits patient supervision by the staff of a facility. To accommodate such needs, it is practical to presume that such doors will be kept open, even to the extent of employing wood chocks and other makeshift devices. Doors in exit passageways, horizontal exits, and smoke barriers should, therefore, be equipped with automatic hold-open devices actuated by the methods described regardless of whether the original installation of the doors was predicated on a policy of keeping them closed.

7.2.1.8.1, NFPA 101, LIFE SAFETY CODE
A door normally required to be kept closed shall not be secured in the open position at any time and shall be self-closing or automatic-closing in accordance with 7.2.1.8.2.

7.2.1.8.2, NFPA 101, LIFE SAFETY CODE
In any building of low or ordinary hazard contents, as defined in 6.2.2.2 and 6.2.2.3, or where approved by the authority having jurisdiction, doors shall be permitted to be automatic-closing, provided that the following criteria are met:
(1) Upon release of the hold-open mechanism, the door becomes self-closing.
(2) The release device is designed so that the door instantly releases manually and upon release becomes self-closing, or the door can be readily closed.
(3) The automatic releasing mechanism or medium is activated by the operation of approved smoke detectors installed in accordance with the requirements for smoke detectors for door release service in NFPA 72, National Fire Alarm Code.
(4) Upon loss of power to the hold-open device, the hold-open mechanism is released and the door becomes self-closing.
(5) The release by means of smoke detection of one door in a stair enclosure results in closing all doors serving that stair.

Based on record review, observation, and interview the facility failed to ensure that all doors in smoke barriers are self-closing doors.

Record review of the current floor plans of the facility provided by Staff B (Facility Services Director) during tour on 6/20/12 revealed the locations of smoke barriers and fire barriers in the facility.

Interview during tour on 6/20/12 with Staff B and Staff D (Maintenance Supervisor) confirmed the locations of the smoke barriers.

Observation during tour on 6/20/12 with Staff B and Staff D revealed that the following doors located in smoke barriers do not have self-closing devices installed:

1. First floor, Family Consultation Room.
2. First floor, mens locker room, door #S1206.
3. First floor, womens locker room, door #S1205.

Interview during tour on 6/20/12 with Staff B confirmed the findings.

19.3.2.6, NFPA 101, LIFE SAFETY CODECooking Facilities: Cooking facilities shall be protected in accordance with 9.2.3.

9.2.3, NFPA 101, LIFE SAFETY CODE
Commercial Cooking Equipment: Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

8-3.1, NFPA 96, VENTILATION CONTROL AND FIRE PROTECTION OF COMMERCIAL COOKING OPERATIONS
Hoods, grease removal devices, fans, ducts, and other appurtenances shall be cleaned to bare metal at frequent intervals prior to surfaces becoming heavily contaminated with grease or oily sludge. After the exhaust system is cleaned to bare metal, it shall not be coated with powder or other substance. The entire exhaust system shall be inspected by a properly trained, qualified, and certified company or person(s) acceptable to the authority having jurisdiction in accordance with Table 8-3.1.

Table 8-3.1 Exhaust System Inspection Schedule
Type or Volume of Cooking: Systems serving solid fuel cooking operations
Frequency: Monthly
Type or Volume of Cooking: Systems serving high-volume cooking operations such as 24-hour cooking, charbroiling or wok cooking
Frequency: Quarterly
Type or Volume of Cooking: Systems serving moderate-volume cooking operations
Frequency: Semiannually
Type or Volume of Cooking: Systems serving low-volume cooking operations, such as churches, day camps, seasonal businesses, or senior centers
Frequency: Annually

8-3.1.1, NFPA 96, VENTILATION CONTROL AND FIRE PROTECTION OF COMMERCIAL COOKING OPERATIONS
Upon inspection, if found to be contaminated with deposits from grease-laden vapors, the entire exhaust system shall be cleaned by a properly trained, qualified, and certified company or person(s) acceptable to the authority having jurisdiction in accordance with Section 8-3.

Based on record review and interview the facility failed to ensure that kitchen hood systems are properly maintained.

Findings include:

Record review of kitchen hood cleaning vendor reports during tour on 6/20/12 revealed that the dates of the kitchen hood cleanings were on 5/25/11 and 5/21/12 without any documentation present for a hood cleaning conducted semi-annually.

Interview during tour on 6/20/12 with Staff B (Facility Services Director), Staff D (Maintenance Supervisor), and Staff E (Dietary Manager) confirmed that the cleaning of the kitchen hood system has only been cleaned on an annual basis.

8.2.2.2, NFPA 101, LIFE SAFETY CODE
Fire compartments shall be formed with fire barriers that are continuous from outside wall to outside wall, from one fire barrier to another, or a combination thereof, including continuity through all concealed spaces, such as those found above a ceiling, including interstitial spaces. Walls used as fire barriers shall comply with Chapter 3 of NFPA 221, Standard for Fire Walls and Fire Barrier Walls. The NFPA 221 limitation on percentage width of openings shall not apply.

8.2.3.2.1, NFPA 101, LIFE SAFETY CODE
Door assemblies in fire barriers shall be of an approved type with the appropriate fire protection rating for the location in which they are installed and shall comply with the following.
(a) Fire doors shall be installed in accordance with NFPA 80, Standard for Fire Doors and Fire Windows. Fire doors shall be of a design that has been tested to meet the conditions of acceptance of NFPA 252, Standard Methods of Fire Tests of Door Assemblies.
(b) Fire doors shall be self-closing or automatic-closing in accordance with 7.2.1.8 and, where used within the means of egress, shall comply with the provisions of 7.2.1.

Based on record review, observation, and interview the facility failed to ensure that all doors in fire barriers are self-closing doors.

Record review of the current floor plans of the facility provided by Staff B (Facility Services Director) during tour on 6/20/12 revealed the locations of smoke barriers and fire barriers in the facility.

Interview during tour on 6/20/12 with Staff B and Staff D (Maintenance Supervisor) confirmed the locations of the fire barriers.

Observation during tour on 6/20/12 with Staff B and Staff D revealed that the following doors located in fire barriers do not have self-closing devices installed:

1. First floor, door #E1502.
2. First floor, door #E1503.
3. First floor, door #E1302.

Interview during tour on 6/20/12 with Staff B confirmed the findings.