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Based on observations made and interviews with facility staff, the facility failed to maintain construction, protection, and occupancy features necessary to minimize danger to life from smoke, fumes or panic should a fire or similar emergency occur. The facility failed to maintain existing fire protection and life safety features such as smoke compartments and smoke construction per NFPA 101-2000 , 4.6.12.1-.4, "Features required by the Code...shall be thereafter permanently maintained." Two (2) out of 11 sampled smoke compartments had improperly sealed penetrations.

Findings are:

During the life safety tour and observations on October 26, 2011 with the director of facilities, the engineering manager, the safety coordinator and the administrative director of facilities at Florida Hospital - Winter Park, the following corridor barrier wall was not maintained to limit the transfer of smoke / heated gases should a fire occur:

At 8:50 a.m., observed that the rated cross corridor fire wall (K-7EA-03-A-65--0) that separates a 3rd floor corridor was not sealed to limit the transfer of smoke / heated gases. There were two (2) unsealed penetrations (unsealed 2 inch pipe vents) through this rated fire wall. There appeared to be a fiberglass/mineral wool material that was pulled away from the penetrations (2 inch holes). Note: Penetrations must be resealed with an Underwriters Laboratory (UL) listed fire rated caulking compound. Interview of the engineering manager revealed that this area will be properly sealed (on both sides of the wall).

These findings were confirmed during the exit conference with Nursing Administrator, the Manager of Engineering, the Administrative Director of Facilities, Facilities Educator/Safety, the Safety Coordinator and the Director of Facilities at 3:45 p.m. on October 26, 2011.

NOTE: These examples are not to be considered as the only penetrations of the building's fire/smoke barrier walls / ceilings. A thorough inspection of each fire/smoke barrier must be made along the full length and height of the wall to ensure that all penetrations are found and properly sealed.

The findings were re-confirmed with the Director of Environment Accreditation on October 28, 2011 at 3:45 PM.

59A-3.077/.078/.079, F.A.C.
NFPA 101-2000, 4.6.12.1-.4, 19.3.2, 19.3.3, 19.3.6, 19.3.7, 19.2.2.2.6, 8.3, 19.2.11.5, 7.2.1.8
Correction Date: 11/28/2011

Based on observations, testing and interviews with facility staff, the facility failed to maintain fire protection and occupancy features necessary to minimize danger to residents from smoke, fumes or panic should a fire occur. The facility did not maintain five (5) of 20 plus sampled hazardous room doors to prevent impediments to closing them to limit the transfer of smoke / heated gases should a fire occur. NFPA 101-2000, 4.6.12.1 requires that "every...item of equipment / system required by this Code shall be continuously maintained in proper operating condition." Also, per NFPA 101-2000, 19.3.6.3 "must provide a means suitable for keeping the door closed (tightly closed in the frame)." This condition could allow smoke and fire gases to quickly spread, in the event of a fire, endangering building occupants.

Findings are:

During the general life safety tour of Florida Hospital - East on October 27, 2017 with the Facilities Manager, observed that the following doors had an impediment to self closing and/or latching:

1. Direct observation / testing of the self closing corridor door to the 6th floor's storage room at 10:30 a.m., revealed that it would not self close and latch per requirements. It was equipped with a self closing mechanism as required. Testing revealed that this door's self closing mechanism would not allow this door to close and latch. This condition creates an impediment to closing / latching these doors so they work as intended / required (maintains positive latching).

2. Direct observation / testing of the corridor door to the central control monitoring room at 1:15 p.m., revealed that it would not self close and latch per requirements. It was not equipped with a self closing mechanism as required. Since this room was over 50 square feet and contained combustible material (trash), a self closer is needed for this door.

3. Direct observation / testing of the corridor door to the clean utility storage room in the Pre-Op area at 2:10 p.m., revealed that it would not self-close and latch per requirements. It was not equipped with a self closing mechanism as required. Since this room was over 50 square feet and contained combustible material (trash), a self closer is needed for this door.

4. At 1:50 p.m.-3:45 p.m., tested / observed that the following patient care room corridor doors were in need of an adjustment / repair:
a. Storage room door in the sterile core area of Pre-Op
b. Operating room door number 9.

These findings were confirmed during the exit conference with the manager of facilities, the administrative director of facilities and the facilities director at 4:25 p.m. on October 27, 2011.

The general findings were re-confirmed with the Director of Environment Accreditation on October 28, 2011 at 3:45 PM.

59A-3.077/.078/.079, F.A.C.
NFPA 101-2000, 19.3.2.1, 19.3.2.1.5, 19.3.6.3, 7.2.1.8 & 4.6.12.1; NFPA 90A & NFPA 80
Correction Date: 11/28/2011

Based on observations the facility failed to maintain protection, and occupancy features necessary to minimize danger to life from, smoke, fumes or panic should a fire or similar emergency occur. This includes maintaining egress (access) to one exit door per NFPA 101-2000, 7.6; 7.3, 7.7.1 and per 19.2.3.3, "avoid any obstructions to the convenient removal of non-ambulatory persons on stretchers." Two (2) of 14 building exit ways (exit discharge) were so affected.

Findings are:

During the life safety tour of the main campus with the engineering representatives on October 24, 2011, observed the following:

1. At 1 p.m. on the 6th floor of the Patient Tower (Old Tower) outside the pharmacy area
in the corridor were stored pallets of supplies stored in the required clear corridor
width.

2. At 3:22 p.m. on the ground floor in corridor D were three large trash containers
stored in the required clear corridor width. They were each larger than 32 gallons and should be stored inside of a protected room.

These findings were confirmed during the exit conference with the manager of facilities, the administrative director of facilities, Orlando facilities director / assistant director, the system safety director and the director of environment accreditation at 5:25 p.m. on October 25, 2011

The findings were re-confirmed with the Director of Environment Accreditation on October 28, 2011 at 3:45 PM.

59A-3.077/.078/.079, F.A.C.
NFPA 101-2000, 7.1, 7.5, 7.6, 7.7; 19.7, 19.2.1/7, 19.1.2; 8.2.2.9; & NFPA 1-2000, 3-5
Correction Date: 11/28/2011

Based on observations, testing and interviews with facility staff, it was determined that the facility failed to maintain protection, and occupancy features necessary to minimize danger to life from, smoke, fumes or panic should a fire or similar emergency occur. This includes maintaining egress from patient care areas/patient room doors per NFPA 101-2000 and per 7.1.9, "Impediments to egress . . . .Any devise installed to restrict the means of egress shall be installed so it cannot prevent emergency use." Five (5) patient room doors out of 40 plus sampled doors were so affected.

Findings are:

During the life safety tour of Florida Hospital-East on the 5th floor (old tower) on October 27, 2011 at 10:20 a.m., observed that patient room door 506 was equipped with a deadbolt lock and if locked...could not be opened from the inside without using a key. Upon interview of the facilities manager it was determined that this door along with four others on this unit had been used as secured/locked units (clinical needs of the patient required specialized security measures). However, "this (locked units) was discontinued and no one has a key to either lock or unlock these doors". "They will be removed."

These findings were confirmed during the exit conference with the manager of facilities, the administrative director of facilities and the facilities director at 4:25 p.m. on October 27, 2011.

The general findings were re-confirmed with the Director of Environment Accreditation on October 28, 2011 at 3:45 PM.

NFPA 101-2000; 19.2.2.2.2, 19.1.1.1.5, & NFPA 1...5-7.3;
Correction Date: 11/28/2011

Based on interviews and observations, the facility did not maintain / inspect the fire notification system in accordance with NFPA 72 and with NFPA 101-2000, 9.6. & 4.6.12.1, "every...item of equipment required by this Code shall be continuously maintained in proper operating condition' and available."

The findings are:

During the life safety tour of the main campus on October 24 & 25, 2011, observed the following issue:

1. Observed at 1:30 p.m. on October 24, 2011 that the fire alarm pull station located on the ground floor near door K-1WE-GR-A-57-0 was taped over and not readily available. The note on the tape read "Fire alarm off line . . . . Not working." Interview of the manager of facilities on October 25, 2011 at 3:45 p.m. revealed that this unit is not functioning and has been replaced with a new unit which was located around the corner. Per NFPA 101 (2000) Chapter 4.6.12.2, "existing life safety features...if not required by the code, shall be either maintained or removed."

2. At 2:39 p.m. on October 24, 2011 - missing smoke detector (SC.G11/N21L09D127) Ground Floor.

3. At 12:50 p.m. on October 25, 2011, observed in Ambulatory Surgery
/Hyperbaric /Endoscopy Center that a smoke detector near EEG (K-1AN-03-B-10-L) was not secured to the ceiling (hanging loose)

4. On October 25, 2011 at 9 a.m. at the main corridor of the Cath lab storage area on the 2nd floor, observed that the strobe light was incorrectly placed, (too low on the wall). It was blocked by a cart. Interview of the facility manager at 3:45 p.m. on October 25, 2011 revealed that a ceiling mount type will be installed.

5. On October 24, 2011 at 3:02 p.m. observed inside of the mechanical room (K-1SO-02-B-97-0) had an open pipe chase that ran up to the 4th floor. This open chase could create improper response to the smoke detector nearby. Interview of the Facility manager at 3:45 p.m. on October 25, 2011 revealed that this condition would be evaluated.

These findings were confirmed during the exit conference with the manager of facilities, the administrative director of facilities, the Orlando facilities director / assistant director, the system safety director and the director of environment accreditation at 5:25 p.m. on October 25, 2011.

The findings were re-confirmed with the Director of Environment Accreditation on October 28, 2011 at 3:45 PM.

59A-3.077/.078/.079, F.A.C.
NFPA 101-2000, 19-3.4.4, 9-6.1.2/.3 /.6 & 4.6.12.11; NFPA 72, 4.4.1.8.1, 7-3 & NFPA 70
Correction Date: 11/28/2011

Based on interviews and observations, the facility did not maintain / inspect the fire notification system in accordance with NFPA 72 and with NFPA 101-2000, 9.6. & 4.6.12.1, "every . . . .item of equipment required by this Code shall be continuously maintained in proper operating condition" and available.

The findings are:

During the life safety tour of Celebration Health on October 27, 2011, observed the following issue:

At 10 a.m. - missing smoke detector inside of electrical room K-9SW-03-P-60-A.

This finding was confirmed during the exit conference with the manager of facilities, the administrative director of facilities, the system safety director, the facilities director and the medical director/patient safety officer at 11:45 a.m. on October 27, 2011.

The findings were re-confirmed with the Director of Environment Accreditation on October 28, 2011 at 3:45 PM.

59A-3.077/.078/.079, F.A.C.
NFPA 101-2000, 19-3.4.4, 9-6.1.2/.3 /.6 & 4.6.12.11; NFPA 72, 4.4.1.8.1, 7-3 & NFPA 70
Correction Date: 11/28/2011

Based on observation the facility and interview failed to maintain the electronic supervisory devices in accordance with NFPA 72 and NFPA 25. Also, per NFPA 101-2000, 9.7.5 require that "all automatic sprinkler systems required by this Code shall be continuously maintained in reliable operating condition at all times."

Findings include:

At Florida Hospital Altamonte on October 26, 2011 at 3:15 PM while on tour of the facility with facility staff at the sprinkler water supply valves near the med gas farm, a test of the supervisory switches on the valves was performed. Staff was asked to close the OS and Y main sprinkler control valve to perform a supervisory test of the valve tamper switch. After two rotations of the valve wheel the alarm panel was observed and no supervisory signal had been received at the panel. The main control valve of the fire sprinkler system shall be electrically supervised with fire alarm zone trouble signal activation upon closing. NFPA 72(1999) 2-9.1.1, NFPA 101(2000) 9.7.2.1
This finding was confirmed during the exit conference with the manager of facilities, the administrative director of facilities, the Altamonte facilities director and the director, the system safety director at 3:45 p.m. on October 24, 2011.

The general findings were re-confirmed with the Director of Environment Accreditation on October 28, 2011 at 3:45 PM.

59A-3.077/.078/.079, F.A.C.
NFPA 101-2000, 9.7.2.1 & 4.6.12.11; NFPA 72(1999), 2-9.1.1; NFPA 25 & NFPA 70
Correction Date: 11/28/2011

Based on observations and interviews, the facility did not maintain sprinkler piping and fittings per NFPA 101-2000, 9.7.5 require that "all automatic sprinkler systems required by this Code shall be continuously maintained in reliable operating condition at all times." Also, and per NFPA 25, 2-4.1.8, "Sprinklers shall not have any type of paint or coatings applied." This includes not maintaining portions of the fire sprinkler system operational at optimal conditions alterations per NFPA 1, chapter 29. Eight (8) of 40 plus sampled fire sprinkler heads were so affected.

The findings are:

The following observations were made during the life safety tour of the Winter Park campus on October 26, 2011:

Observed at 1:30 p.m. on 11/26/2011 that eight (8) concealed fire sprinkler heads located in operating rooms (ORs) 3 and 4 had white paint like material/substance on their covers. Such a condition could possibly increase the response / reaction time by raising (increasing) the temperature range necessary to set off this fire sprinkler head during fire conditions. Again, per NFPA 25, 2-4.1.8, "sprinklers shall not have any type of paint or coatings applied . . . ."

These findings were confirmed during the exit conference with Nursing Administrator, the Manager of Engineering, the Administrative Director of Facilities, Facilities Educator/Safety, the Safety Coordinator and the Director of Facilities at 3:45 p.m. on October 26, 2011.

NOTE: These examples are not to be considered as the only examples. A thorough inspection of each fire/smoke compartment must be made along the full length of the corridors/atriums to ensure that all fire sprinkler heads are in compliance.

The findings were re-confirmed with the Director of Environment Accreditation on October 28, 2011 at 3:45 PM.

NFPA 101 (2000), 19.7.6, 9.7.5, 4.6.12.1; NFPA 13, 6.2.7.2; NFPA 25, 5.1 and Table 5.1.; NFPA 25, Chapter 2, Table 2-1
F.S. 395.001-3953041, Part 1
Correction Date: 11/28/2011

Based on an observations and interviews, determined that the use of commercial cooking equipment did not comply with specific requirements of NFPA 96, "Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations." Also, per NFPA 101-2000, 4.6.12.1, "every...item of equipment required by this Code shall be continuously maintained in proper operating condition." The facility failed to ensure that the kitchen hood's exhaust system was functioning as required / intended. This situation could possibly allow for grease-laden vapors to be exhausted through the filtration system. Also per NFPA 96: 11.6.2, "Hoods, grease removal devices, fans, ducts, and other appurtenances shall be cleaned to remove combustible contaminants prior to surfaces becoming heavily contaminated with grease or oily sludge." Two (2) out of 5 sampled devices were so affected.

The findings are:

During a life safety tour of the kitchens on the main campus on October 24, 2011 with the engineering representatives, observed the following:

1. Lakeside Café's kitchen: At 1:48 p.m., observed that the suppression filters/baffles were caked with grease laden material. They were located above the grill. They needed to be cleaned. Record review revealed they had last been cleaned on August 14, 2011. It could not be evidenced that a monthly visual check (quick check) of the hood system had been done to include checking for excess grease buildup. Allowing grease laden material (a source of combustion) to accumulate on this screen increases the fuel load thus increasing the possibilities of a grease laden fire occurring.

Note: No kitchen Quick Check inspections were being performed. UL300 Listed fire protection system. Reference NFPA 17A: 'Standard for Wet Chemical Extinguishing Systems... 5-2.1': Inspection shall be conducted on a monthly basis with the manufacturer's listed installation and maintenance manual or the owner's manual. As a minimum, this " quick check " or inspection shall include verification of the following:

(a) The extinguishing system is in its proper location.
(b) The manual actuators are unobstructed.
(c) The tamper indicators and seals are intact.
(d) The maintenance tag or certificate is in place.
(e) No obvious physical damage or condition exists that might prevent operation.
(f) The pressure gauge(s), if provided, is in operable range.
(g) The nozzle blow-off caps are intact and undamaged.
(h) The hood, duct and protected cooking appliances have not been replaced, modified or relocated.

NFPA 17A 5-2.2: "If any deficiencies are found, appropriate corrective actions shall be taken immediately."

NFPA 17A 5.2.3: "Personnel making inspections shall keep records for those extinguishing systems that were found to require corrective actions."

NFPA 17A 5-3.4: "At least monthly, the date the inspection is performed and the initials of the person performing the inspection shall be recorded. The records shall be retained for the period between the semiannual maintenance inspections."

2. At 9:55 a.m., observed that the ansul fire protection system nozzles within the kitchen's exhaust hood (Welch Cafeteria's kitchen; K-1AW-GR-C-30-&) were positioned directly/centered over the six (6) burner stove (open flames) and the deep fat fryer unit located directly next to it. The fryer and this 6 burner stove were not properly separated (16 inches). Upon interview of the facility director, "They will be separated by a proper guard."

3. At 2:30 p.m., while on tour of the main campus kitchens observed the suppression systems for Hoods 2 & 3 which must meet the requirements of an Underwriters Laboratories 300 wet chemical installation. They do not. Both ansul system units/panels were missing indicator pins, therefore, could not determine whether they were both in the active/ready position.

These findings were confirmed during the exit conference with the manager of facilities, the administrative director of facilities, Orlando facilities director / assistant director, the system safety director and the director of environment accreditation at 5:25 p.m. on October 25, 2011.

The findings were re-confirmed with the Director of Environment Accreditation on October 28, 2011 at 3:45 PM.

59A-3.077/.078/.079, F.A.C.
NFPA 96, 8-2, 13-3.2.4, 13.3, 6.2.3.3, & 6.2.5. The design, installation, and use of commercial cooking equipment are in accordance with NFPA 101 Life Safety Code (2000) 9.2.3; 19.3.2.5, 4.6.12.1-.4 & 9.6; NFPA 96(98), 8-2, & 13-3.2.4; NFPA 17, 9-2 & NFPA 17A, 5-2
Correction Date: 11/28/2011

Based on observation and interview with the facility lab director, the facility did not comply with NFPA standards for the storage and use of combustible liquids that have been adopted to protect the staff, patients and the public from fire and the products of combustion. The facility failed to maintain features of fire protection and occupancy that are necessary to safely handle hazardous materials. NFPA 101 (2000), Chapter 19.3.2.2, "Quantities of flammable, combustible or hazardous materials that are considered as a hazard shall be protected in accordance with NFPA 99, Standard for Health Care Facilities." NFPA 99 Ch. 11 .7.2.1 requires that "Flammable and combustible liquids shall be used from and stored in approved containers in accordance with NFPA 30, Flammable and Combustible Liquids Code and NFPA 45, Standard on Fire Protection for Laboratories using Chemicals." Also, Ch. 11.8.1.2(4) requires that...'Shelf stocks and storage of flammable and combustible materials . . . .shall be reviewed at appropriate, regular intervals."
Findings include:
At 12:50 p.m. on October 26, 2011, in the company of the director of facilities a survey of the elevator mechanical room at the Winter Park campus was done. Observed five - 5 gallon containers of stored elevator oil. These containers were not capped/sealed. All were marked with 704 labels that indicated that the contents had a combustible rating. Also observed were numerous oil soaked rags that were not properly secured/contained. Interview of the director of facilities revealed that the outside vendor had not followed the proper protocol and allowed such a condition to exist. These items were improperly stored per policy. There was no indication of or a record of periodic inspections for this area.
These findings were confirmed during the exit conference with Nursing Administrator, the Manager of Engineering, the Administrative Director of Facilities, Facilities Educator/Safety, the Safety Coordinator and the Director of Facilities at 3:45 p.m. on October 26, 2011.

The findings were re-confirmed with the Director of Environment Accreditation on October 28, 2011 at 3:45 PM.

59A-3.077/.078/.079, F.A.C.
NFPA 101-2000, 19.3.2.2 & 4.6.12.1; NFPA 99 (1999), 11.7.2.1; NFPA 30; NFPA 45, 11.8.1.1.4, 11.8.1.2 (4)
Correction Date: 11/28/2011

Based on an observation and interviews with facility staff, the facility did not maintain the following per the National Electric Code (NEC); Article 517 and NFPA 99. The facility failed to maintain fire protection and occupancy features necessary to minimize hazards. Use of temporary wiring for a high amperage / motorized device did not demonstrate compliance with the code standard. Ten (10) out of 80 plus electrical devices sampled did not operate as required.

Findings include:

Observations and interviews staff during the life safety tour of the Florida Hospital-East campus on October 27, 2011 with engineering staff, revealed that the following electrical applications were not in accordance with NFPA 70, the National Electrical Code:

1. At 2:45 PM while on tour of the doctor's lounge, a steam table built in to the cabinetry was observed. The steam table was installed with clearances to the cabinetry less than required by the manufacturer as indicated on the installation warning label of the appliance. Utilization equipment shall be installed in accordance with manufacturer's instructions per NFPA 70(1999)
2. Multi-plug non hospital grade power strips (temporary wiring) and plain extension cord used as permanent cords used to power high amperage refrigerators, microwave, etc. in the following areas:

a. At 1:05 p.m. - 3rd floor nurse administration office- also found two power strips connected together;
b. At 2:15 p.m. - Nurses' station on the second floor. Also plugged multiple strips / extension cords together.
c. At 3:05 p.m. - Emergency Department; non-hospital grade power strips in patient care area.

Note: these power strips did not identify that they were rated for use with high amperage motorized devices / wet areas and also not for patient care devices.

These findings were confirmed during the exit conference with the manager of facilities, the administrative director of facilities and the facilities director at 4:25 p.m. on October 27, 2011.

The general findings were re-confirmed with the Director of Environment Accreditation on October 28, 2011 at 3:45 PM.

59A-3.077/.078/.079, F.A.C.
NFPA 70 , National Electric Code (NEC), 384-13 & NFPA 101-2000, 4.6.12.1-.4 NFPA 70, Article 517; NFPA 99 ,7-5.1.2.4, 9-2.1.2.1/.2 ,3-3.4.2.3,3-3.4.3
Correction Date: 11/28/2011