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The facility failed to provide corridor doors that would close and resist the passage of smoke. Findings include: During the survey, the following are examples of what was observed:

1. Office door # 9 handle was loose allowing this surveyor to see into the room from the corridor.

2. Office door # 8 failed to latch.

3. Office door # 2 failed to latch.

4. Patient Room 205 door failed to latch.

5. Men's Restroom door failed to latch front Lobby.


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6. The following Third Floor corridor doors were not or did not have positive latching hardware:
a. Residential Classroom
b. Acute Adolescent Classroom
c. Refrigerator Room
d. Quiet Room (323)
e. Rooms 302, 305, 318, 322, 324, and 326


2000 NFPA 101, 19.3.6.3.2 Doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door. Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.2.
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The facility failed to maintain the elevator shafts per code. Findings include:

During the survey, the following is an example of what was observed:

Both elevators 1 and 2 had unsealed penetrations in the walls.



2000 NFPA 101, 19.3.1.1 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.
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The facility failed to maintain the smoke barrier per code. Findings include:
During the survey, the following is an example of what was observed:

The third floor smoke barrier at the smoke doors by the Patient Lounge/Room 320 had an unsealed penetration of a single blue wire.



2000 NFPA 101, 8.3.6.1 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.

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The facility failed to maintain the smoke barrier to restrict the passage of smoke. Findings include: During the survey, the following is an example of what was observed:

1. The left door in the smoke barrier by Office # 3 second floor, failed to close tight when doors were released, while testing the fire alarm.


27382


2. The right leaf of the Third Floor smoke doors at room 317 did not close under the fire alarm.


2000 NFPA 101, 19.2.2.2.6 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.
2000 NFPA 101, 8.3.4.3 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.
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The facility failed to provide readily accessible exits at all times. Findings include: During the survey, the following is an example of what was observed:


1. On the second floor the double set of doors, from the Lobby, were observed with magnetic locking devices on the doors. These locks were disabled at the time of the survey when this surveyor first entering the facility. Based on interview with the Maintanance Director, he advised that the locks did not function. A key pad was observed located by the doors to release doors in the event you had to exit through the doors. During the interview the Maintanance Director advised this surveyor that a key was not available for the magnetic locking device.


NFPA 101, 7.2.1.6.1(a) Doors having delayed egress locking arrangements shall unlock upon actuation of the fire detection system or sprinkler system.

Alabama Department of Public Health Memo "Exit Door Locking Arrangements in Health Care Facilities" revised 12/19/03, as authority having jurisdiction: a manual release switch shall be provided on both sides of each locked door (required only on the indoor side of exterior doors). An "emergency release switch" or "dead man" release switch shall be provided at the nearest nurses' station. There shall also be a sign at each door and nurses' station release switch indicating the door switch. The administration must furnish a written statement of justification (the "clinical needs of residents" make the locks necessary).


27382


1. The following doors per interview and observation were observed with either broken deadbolts that only worked from the outside - by staff or hasps with padlocks:

a. Patient Rooms throughout the facility
b. Toilet Rooms
c. Shower/Bathing Rooms


19.2.2.2.4 Doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side.

2000 NFPA 101, 7.1.10.1 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.
2000 NFPA 101, 7.2.1.5.1 Doors shall be arranged to be opened readily from the egress side whenever the building is occupied. Locks, if provided, shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side.

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The facility failed to provide a complete fire safety plan. Findings include: During the survey, the following is an example of what was observed:

Based upon documentation provided by the facility, the fire safety plan did not indicate the patients would be moved from the affected area to an un-affected area in the event of a fire. What this surveyor read when reviewing the fire safety plan, was (discouarge personnel from congregating at the location of the fire.) Report to the designated area for your department.



NFPA 101, 19.7.2.2 A written health care occupancy fire safety plan shall provide for the following: (1) Use of alarms, (2) Transmission of alarm to fire department, (3) Response to alarms, (4) Isolation of fire, (5) Evacuation of immediate area, (6) Evacuation of smoke compartment, (7) Preparation of floors and building for evacuation, and (8) Extinguishment of fire.

The facility failed to conduct fire drills per code. Findings include:

During the survey, the following are examples of what was observed:

1. Per interview with the staff, the facility has an added eight hour shift from 3pm - 11pm (besides the two regular twelve hour shifts), this shift did not have one drill during the last 12 months.
2. Per interview with the staff, the facility have 1-2 employees that work weekends only, these staff members did not have a drill during the last 12 months.
3. Per interview with the staff and documentation from the facility, not all staff members are signing off / participating in the fire drills.
4. Per documentation from the facility, the 7pm - 7am shift had all fire drills in the last 12 months conducted between 6:00am and 6:40am.


2000 NFPA 101, 19.7.1.2 Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
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Facility failed to maintain the Digital Alarm Communicator Transmitter in the fire alarm system. Findings include: During the survey, the following is an example of what was observed:

When the Auto Dialer was tested for phone line 1, failure was not indicated at the protected premise within the allotted four (5) minute time frame.


1999 NFPA 72, Section 1-5.4.6, 5-5.3.2.1.5, and 5-5.3.2.1.6.2. Phone line and communication failure shall be indicated at the facility.

The facility failed to perform sensitivity testing of the smoke detectors. Findings include: During the survey, the following is an example of what was observed:

Documentation was not provided for the sensitivity testing of the smoke detectors.


Documentation, provided by the facility during the survey, did not indicate sensitivity testing of the smoke detectors. Detector sensitivity shall be checked with one year after installation and every alternate year thereafter per 72, 7-3.2.1. (Up to 5 years permitted under certain circumstances. See 7-3.2.1).

The facility failed to provide metal self-closing containers for disposing of cigarette butts and ashes from ashtrays. Findings include: During the survey, the following is an example of what was observed:

Metal self-closing containers, or noncombustible ashtrays were not provided at the two designated smoking areas. One area is located at the Northend of the facility and the other is located by the Main Entrance of the facility.


NFPA 101, 19.7.4 Ashtrays of noncombustible material and safe design, and metal self-closing containers for disposing of cigarette butts and ashes from ashtrays, shall be provided.

The facility failed to prohibit portable space heating devices. Findings include:
During the survey, the following is an example of what was observed:

A portable space heating device was observed in the "Dictation Room" in the Therapy Room on the Third Floor.


2000 NFPA 101, 19.7.8 Portable space-heating devices shall be prohibited in all health care occupancies.
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The facility failed to maintain exits free of all obstructions.; Findings include: During the survey, the following are examples of what was observed:

1. The Exit Discharge for the Exit Stairwell which discharges into the Employee parking lot, had a vehicle parked in the means of egress, obstructing access from the facility.


27382


2. On the Third Floor a table, copier, and desk were located in the corridor outside the Residential Classroom.

3. On the Third Floor a desk and a chair were located in the corridor outside room 323.

4. On the Third Floor seven chairs were located throughout the corridor in the girls side.

5. On the Third Floor at the Front Left Stairs was oberved blocked by a truck.


2000 NFPA 101, 7.1.10.1 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.
2000 NFPA 101, 7.1.10.2.1 No furnishings, decorations, or other objects shall obstruct exits, access thereto, egress therefrom, or visibility thereof.
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The facility failed to maintain the curtains/draperies per code. Findings include:
During the survey, the following is an example of what was observed:

The facility failed to provide flame resistant documentation on the curtains in room 301.


2000 NFPA 101, 10.3.1 Where required by the applicable provisions of this Code, draperies, curtains, and other similar loosely hanging furnishings and decorations shall be flame resistant as demonstrated by testing in accordance with NFPA 701, Standard Methods of Fire Tests for Flame Propagation of Textiles and Films.
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The facility failed to provide proper emergency lighting at the generator set and controls. Findings include: During the survey, the following is an example of what was observed:

Battery-powered light was not provided in the Generator Set Control Room.



1999 NFPA 99, 3-6.1.1 and 3-4.1.1.4, and 1999 NFPA 110, 5-3.1. Emergency generator equipment locations.

A) The facility failed to provide receptacles for appliances. Findings include: During the survey, the following are examples of what was observed:

1. A Microwave was plugged into a surge protector Front Lobby Reception Office.

2. A three way electrical adapter was in use Office 305 Third Floor.


27382


B) The facility failed to maintain the electrical system per code. Findings include:
During the survey, the following are examples of what was observed:

1. The Acute Children's Classroom on the Third Floor had an electrical three way adapter plugged into the wall outlet in use.

2. Office/Room 321 had a refrigerator plugged into an extension cord, plugged into a surge protector.


1999 NFPA 70, 400-7 and 400-8, and HCFA Transmittal Notice 22-99 The 1984 edition of the National Electric Code restricts the use of extension cords to temporary short term uses. It is the policy of HCFA to prohibit non-circuit breaker protected extension cords in health care. The limited use of circuit breaker protected power strips is acceptable, provided the current is limited to 15 amps or less, and no major appliances such as air conditioners, refrigerators, or heating units are connected to the power strip.

2000 NFPA 101, 9.1.2 Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.
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The facility failed to provide an elevator recall system for the two elevators per code. Findings include:

During the survey, the following are examples of what was observed:

The two elevators were observed without an elevator recall system. The Second Floor of the four story building is the "designated level".

2000 NFPA 101, 19.5.3 Elevators, escalators, and conveyors shall comply with the provisions of Section 9.4.
2000 NFPA 101, 9.4.3.2 All existing elevators having a travel distance of 25 ft (7.6 m) or more above or below the level that best serves the needs of emergency personnel for fire fighting or rescue purposes shall conform to the Fire Fighters' Service Requirements of ASME/ANSI A17.3, Safety Code for Existing Elevators and Escalators.
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The facility failed to provide corridor doors that would close and resist the passage of smoke. Findings include: During the survey, the following are examples of what was observed:

1. Office door # 9 handle was loose allowing this surveyor to see into the room from the corridor.

2. Office door # 8 failed to latch.

3. Office door # 2 failed to latch.

4. Patient Room 205 door failed to latch.

5. Men's Restroom door failed to latch front Lobby.


27382


6. The following Third Floor corridor doors were not or did not have positive latching hardware:
a. Residential Classroom
b. Acute Adolescent Classroom
c. Refrigerator Room
d. Quiet Room (323)
e. Rooms 302, 305, 318, 322, 324, and 326


2000 NFPA 101, 19.3.6.3.2 Doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door. Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.2.
.

The facility failed to maintain the elevator shafts per code. Findings include:

During the survey, the following is an example of what was observed:

Both elevators 1 and 2 had unsealed penetrations in the walls.



2000 NFPA 101, 19.3.1.1 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.
.

The facility failed to maintain the smoke barrier per code. Findings include:
During the survey, the following is an example of what was observed:

The third floor smoke barrier at the smoke doors by the Patient Lounge/Room 320 had an unsealed penetration of a single blue wire.



2000 NFPA 101, 8.3.6.1 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.

.

The facility failed to maintain the smoke barrier to restrict the passage of smoke. Findings include: During the survey, the following is an example of what was observed:

1. The left door in the smoke barrier by Office # 3 second floor, failed to close tight when doors were released, while testing the fire alarm.


27382


2. The right leaf of the Third Floor smoke doors at room 317 did not close under the fire alarm.


2000 NFPA 101, 19.2.2.2.6 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.
2000 NFPA 101, 8.3.4.3 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.
.

The facility failed to provide readily accessible exits at all times. Findings include: During the survey, the following is an example of what was observed:


1. On the second floor the double set of doors, from the Lobby, were observed with magnetic locking devices on the doors. These locks were disabled at the time of the survey when this surveyor first entering the facility. Based on interview with the Maintanance Director, he advised that the locks did not function. A key pad was observed located by the doors to release doors in the event you had to exit through the doors. During the interview the Maintanance Director advised this surveyor that a key was not available for the magnetic locking device.


NFPA 101, 7.2.1.6.1(a) Doors having delayed egress locking arrangements shall unlock upon actuation of the fire detection system or sprinkler system.

Alabama Department of Public Health Memo "Exit Door Locking Arrangements in Health Care Facilities" revised 12/19/03, as authority having jurisdiction: a manual release switch shall be provided on both sides of each locked door (required only on the indoor side of exterior doors). An "emergency release switch" or "dead man" release switch shall be provided at the nearest nurses' station. There shall also be a sign at each door and nurses' station release switch indicating the door switch. The administration must furnish a written statement of justification (the "clinical needs of residents" make the locks necessary).


27382


1. The following doors per interview and observation were observed with either broken deadbolts that only worked from the outside - by staff or hasps with padlocks:

a. Patient Rooms throughout the facility
b. Toilet Rooms
c. Shower/Bathing Rooms


19.2.2.2.4 Doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side.

2000 NFPA 101, 7.1.10.1 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.
2000 NFPA 101, 7.2.1.5.1 Doors shall be arranged to be opened readily from the egress side whenever the building is occupied. Locks, if provided, shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side.

.

The facility failed to provide a complete fire safety plan. Findings include: During the survey, the following is an example of what was observed:

Based upon documentation provided by the facility, the fire safety plan did not indicate the patients would be moved from the affected area to an un-affected area in the event of a fire. What this surveyor read when reviewing the fire safety plan, was (discouarge personnel from congregating at the location of the fire.) Report to the designated area for your department.



NFPA 101, 19.7.2.2 A written health care occupancy fire safety plan shall provide for the following: (1) Use of alarms, (2) Transmission of alarm to fire department, (3) Response to alarms, (4) Isolation of fire, (5) Evacuation of immediate area, (6) Evacuation of smoke compartment, (7) Preparation of floors and building for evacuation, and (8) Extinguishment of fire.

The facility failed to conduct fire drills per code. Findings include:

During the survey, the following are examples of what was observed:

1. Per interview with the staff, the facility has an added eight hour shift from 3pm - 11pm (besides the two regular twelve hour shifts), this shift did not have one drill during the last 12 months.
2. Per interview with the staff, the facility have 1-2 employees that work weekends only, these staff members did not have a drill during the last 12 months.
3. Per interview with the staff and documentation from the facility, not all staff members are signing off / participating in the fire drills.
4. Per documentation from the facility, the 7pm - 7am shift had all fire drills in the last 12 months conducted between 6:00am and 6:40am.


2000 NFPA 101, 19.7.1.2 Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
.

Facility failed to maintain the Digital Alarm Communicator Transmitter in the fire alarm system. Findings include: During the survey, the following is an example of what was observed:

When the Auto Dialer was tested for phone line 1, failure was not indicated at the protected premise within the allotted four (5) minute time frame.


1999 NFPA 72, Section 1-5.4.6, 5-5.3.2.1.5, and 5-5.3.2.1.6.2. Phone line and communication failure shall be indicated at the facility.

The facility failed to perform sensitivity testing of the smoke detectors. Findings include: During the survey, the following is an example of what was observed:

Documentation was not provided for the sensitivity testing of the smoke detectors.


Documentation, provided by the facility during the survey, did not indicate sensitivity testing of the smoke detectors. Detector sensitivity shall be checked with one year after installation and every alternate year thereafter per 72, 7-3.2.1. (Up to 5 years permitted under certain circumstances. See 7-3.2.1).

The facility failed to provide metal self-closing containers for disposing of cigarette butts and ashes from ashtrays. Findings include: During the survey, the following is an example of what was observed:

Metal self-closing containers, or noncombustible ashtrays were not provided at the two designated smoking areas. One area is located at the Northend of the facility and the other is located by the Main Entrance of the facility.


NFPA 101, 19.7.4 Ashtrays of noncombustible material and safe design, and metal self-closing containers for disposing of cigarette butts and ashes from ashtrays, shall be provided.

The facility failed to prohibit portable space heating devices. Findings include:
During the survey, the following is an example of what was observed:

A portable space heating device was observed in the "Dictation Room" in the Therapy Room on the Third Floor.


2000 NFPA 101, 19.7.8 Portable space-heating devices shall be prohibited in all health care occupancies.
.

The facility failed to maintain exits free of all obstructions.; Findings include: During the survey, the following are examples of what was observed:

1. The Exit Discharge for the Exit Stairwell which discharges into the Employee parking lot, had a vehicle parked in the means of egress, obstructing access from the facility.


27382


2. On the Third Floor a table, copier, and desk were located in the corridor outside the Residential Classroom.

3. On the Third Floor a desk and a chair were located in the corridor outside room 323.

4. On the Third Floor seven chairs were located throughout the corridor in the girls side.

5. On the Third Floor at the Front Left Stairs was oberved blocked by a truck.


2000 NFPA 101, 7.1.10.1 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.
2000 NFPA 101, 7.1.10.2.1 No furnishings, decorations, or other objects shall obstruct exits, access thereto, egress therefrom, or visibility thereof.
.

The facility failed to maintain the curtains/draperies per code. Findings include:
During the survey, the following is an example of what was observed:

The facility failed to provide flame resistant documentation on the curtains in room 301.


2000 NFPA 101, 10.3.1 Where required by the applicable provisions of this Code, draperies, curtains, and other similar loosely hanging furnishings and decorations shall be flame resistant as demonstrated by testing in accordance with NFPA 701, Standard Methods of Fire Tests for Flame Propagation of Textiles and Films.
.

The facility failed to provide proper emergency lighting at the generator set and controls. Findings include: During the survey, the following is an example of what was observed:

Battery-powered light was not provided in the Generator Set Control Room.



1999 NFPA 99, 3-6.1.1 and 3-4.1.1.4, and 1999 NFPA 110, 5-3.1. Emergency generator equipment locations.

A) The facility failed to provide receptacles for appliances. Findings include: During the survey, the following are examples of what was observed:

1. A Microwave was plugged into a surge protector Front Lobby Reception Office.

2. A three way electrical adapter was in use Office 305 Third Floor.


27382


B) The facility failed to maintain the electrical system per code. Findings include:
During the survey, the following are examples of what was observed:

1. The Acute Children's Classroom on the Third Floor had an electrical three way adapter plugged into the wall outlet in use.

2. Office/Room 321 had a refrigerator plugged into an extension cord, plugged into a surge protector.


1999 NFPA 70, 400-7 and 400-8, and HCFA Transmittal Notice 22-99 The 1984 edition of the National Electric Code restricts the use of extension cords to temporary short term uses. It is the policy of HCFA to prohibit non-circuit breaker protected extension cords in health care. The limited use of circuit breaker protected power strips is acceptable, provided the current is limited to 15 amps or less, and no major appliances such as air conditioners, refrigerators, or heating units are connected to the power strip.

2000 NFPA 101, 9.1.2 Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.
.

The facility failed to provide an elevator recall system for the two elevators per code. Findings include:

During the survey, the following are examples of what was observed:

The two elevators were observed without an elevator recall system. The Second Floor of the four story building is the "designated level".

2000 NFPA 101, 19.5.3 Elevators, escalators, and conveyors shall comply with the provisions of Section 9.4.
2000 NFPA 101, 9.4.3.2 All existing elevators having a travel distance of 25 ft (7.6 m) or more above or below the level that best serves the needs of emergency personnel for fire fighting or rescue purposes shall conform to the Fire Fighters' Service Requirements of ASME/ANSI A17.3, Safety Code for Existing Elevators and Escalators.
.