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Based on document review and interview, the facility failed to maintain an emergency preparedness plan. This was evidenced by the failure to provide document with date and signature to when the emergency preparedness plan was last reviewed and updated. This affected all two of two buildings, and could result in a delay in adequate response in the event of an emergency.

Findings:

During document review and interview with the staff on 12/10/19, the emergency preparedness manual was reviewed.

1. At 8:57 a.m., the facility's emergency plan failed to indicate when the emergency preparedness plan was last reviewed and updated. There was no annual review sheet with approval date and signature in the emergency preparedness plan. When interviewed, the Director of Ancillary & Support Services confirmed the finding and stated that it was last updated sometime in September/October of 2019.

Based on document review and interview, the facility failed to maintain a complete written emergency preparedness plan. This was evidenced by the failure to provide policy and procedure that included a system to track the location of on-duty staff during and after an emergency. This could result in the failure to protect two of two buildings during a disaster.

Findings:

During document review and interview with staff on 12/10/19, the emergency plan was reviewed.

1. At 10:35 a.m., the facility failed to provide policy and procedures that included a system to track the location of on-duty staff during and after an emergency. When interviewed, the Director of Ancillary & Support Services and the Director of Safety Bay Area confirmed the finding.

Based on document review and interview, the facility failed to maintain the emergency communication plan. This was evidenced by the failure to update the communication plan. This affected two of two buildings and could result in a delayed response to an emergency situation.

Findings:

During document review and interview with staff on 12/10/19, the emergency communication plan was reviewed.

1. At 9:55 a.m., the facility failed to update the primary and alternate means for communication in their communication plan. The communication plan indicated that one of the alternate communications was a satellite phone. When interviewed, the Director of Ancillary & Support Services confirmed the finding and stated that the facility does not have a satellite phone.

Based on observation, document review, and interview, the facility failed to maintain the exit signs. This was evidenced by the failure to perform the required monthly and annual functional test of the battery-powered emergency exit signs. This affected one of two buildings, and could result in potentially delay evacuation.


NFPA 101, Life Safety Code, 2012 Edition
19.2.10 Marking of Means of Egress.
19.2.10.1 Means of egress shall have signs in accordance with Section 7.10, unless otherwise permitted by 19.2.10.2, 19.2.10.3, or 19.2.10.4.

7.10.9.2 Testing. Exit signs connected to, or provided with, a battery-operated emergency illumination source, where required in 7.10.4, shall be tested and maintained in accordance with 7.9.3.

7.9.3 Periodic Testing of Emergency Lighting Equipment.
7.9.3.1 Required emergency lighting systems shall be tested in accordance with one of the three options offered by 7.9.3.1.1, 7.9.3.1.2, or 7.9.3.1.3.

7.9.3.1.1 Testing of required emergency lighting systems shall be permitted to be conducted as follows:
(1) Functional testing shall be conducted monthly, with a minimum of 3 weeks and a maximum of 5 weeks between tests, for not less than 30 seconds, except as otherwise permitted by 7.9.3.1.1(2).
(2)*The test interval shall be permitted to be extended beyond 30 days with the approval of the authority having jurisdiction.
(3) Functional testing shall be conducted annually for a minimum of 1 1/2 hours if the emergency lighting system is battery powered.
(4) The emergency lighting equipment shall be fully operational for the duration of the tests required by 7.9.3.1.1(1) and (3).
(5) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.


Findings:

During a tour of the facility, document review, and interview with staff on 12/11/19, the exit signs were observed and document requested.

Main Hospital

1. At 9:00 a.m., the facility failed to perform the required monthly and annual functional test of the battery-powered emergency exit signs. There were no testing records provided at time of survey.

The exit signs with battery-back up were observed in the Emergency Department. The exit signs were equipped with nickel cadmium battery.

When interviewed, the DPO stated that the exit signs were not tested because he did no not know that the exit signs were equipped with battery back-up.

The Engineering Staff opened the exit sign unit and verified the battery. The finding was confirmed by the DPO.

Based on observation and interview, the facility failed to maintain the electrical equipment. This was evidenced by the circuit breaker for the fire alarm system that was not identified with a red marking. This affected one of two buildings, and could result in staff inability to identify the circuit breaker in the event of an emergency.

NFPA 101, Life Safety Code, 2012 Edition
39.5 Building Services.
39.5.1 Utilities. Utilities shall comply with the provisions of Section 9.1.

9.1.2 Electrical Systems. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless such installations are approved existing installations, which shall be permitted to be continued in service.
9.6.1.3 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use.

NFPA 72, National Fire Alarm and Signaling Code, 2010 Edition
10.5.5.2 Circuit Identification and Accessibility.

10.5.5.2.1 The location of the dedicated branch circuit disconnecting means shall be permanently identified at the control unit.

10.5.5.2.2 For fire alarm systems the circuit disconnecting means shall be identified as "FIRE ALARM CIRCUIT."

10.5.5.2.3 For fire alarm systems the circuit disconnecting means shall have a red marking.

10.5.5.2.4 The circuit disconnecting means shall be accessible only to authorized personnel.


Findings:

During a tour of the facility and interview with staff on 12/10/19, the electrical equipment was observed.

Sutter Lakeside Medical Practice

1. At 2:48 p.m., the electrical "Panel A Sec 2" that housed the fire alarm circuit breaker number 48, did not have red marking on the circuit breaker that identified as fire alarm. The electrical panel was located in the I.T. Room. When interviewed, the DPO confirmed the finding.

Based on document review and interview, the facility failed to maintain the fire alarm system (FAS). This was evidenced by the failure to provide documentation for the semi-annual fire alarm system inspection, by the failure to provide documentation for the semi-annual load voltage test for the sealed lead-acid batteries, by the failure to provide the annual maintenance and testing record of the FAS, and by batteries to the fire alarm control panel (FACP) system that were not marked with the month and year of manufacture. This could result in the ineffective operation of the FAS in the event of an emergency or fire, and affected one of two buildings.


NFPA 101, Life Safety Code, 2012 Edition
39.3.4 Detection, Alarm, and Communications Systems.
39.3.4.1 General. A fire alarm system in accordance with Section 9.6 shall be provided in all business occupancies where any one of the following conditions exists:
(1) The building is three or more stories in height.
(2) The occupancy is subject to 100 or more occupants above or below the level of exit discharge.
(3) The occupancy is subject to 1000 or more total occupants.

9.6 Fire Detection, Alarm, and Communications Systems.
9.6.1.3 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use.
9.6.1.5* To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code.


NFPA 72, National Fire Alarm and Signaling Code, 2010 Edition

10.5.9.1.1 Batteries shall be marked with the month and year of manufacture using the month/year format.

10.5.9.1.2 Where the battery is not marked with the month/ year by the manufacturer, the installer shall obtain the datecode and mark the battery with the month/year of battery manufacture.

14 Inspection, Testing, and Maintenance
14.4 Testing
Table 14.4.5 Testing Frequencies
6. Batteries - fire alarm systems
(d) Sealed lead-acid type
(1) Charger test (replace battery within 5 years after manufacturer or more frequently as needed.) - Annually
(2) Discharge test (30 minutes) - Annually
(3) Load voltage test - Semiannually

INSPECTION, TESTING, AND MAINTENANCE, Table 14.3.1

14.6.2.4* A record of all inspections, testing, and maintenance shall be provided that includes the following information regarding tests and all the applicable information requested in Figure 14.6.2.4:
(1) Date
(2) Test frequency
(3) Name of property
(4) Address
(5) Name of person performing inspection, maintenance, tests, or combination thereof, and affiliation, business address, and telephone number
(6) Name, address, and representative of approving agency(ies)
(7) Designation of the detector(s) tested
(8) Functional test of detectors
(9)*Functional test of required sequence of operations
(10) Check of all smoke detectors
(11) Loop resistance for all fixed-temperature, line-type heat detectors
(12) Functional test of mass notification system control units
(13) Functional test of signal transmission to mass notification systems
(14) Functional test of ability of mass notification system to silence fire alarm notification appliances
(15) Tests of intelligibility of mass notification system speakers
(16) Other tests as required by the equipment manufacturer's published instructions
(17) Other tests as required by the authority having jurisdiction
(18) Signatures of tester and approved authority representative
(19) Disposition of problems identified during test (e.g., system owner notified, problem corrected/successfully retested, device abandoned in place)


Findings:

During document review and interview with staff on 12/10/19, documents were requested.

Sutter Lakeside Medical Practice

1. At 2:26 p.m., two of two sealed-lead acid batteries in the FACP were not marked with the month and year of manufacture. When interviewed, the DPO confirmed the finding and stated that the batteries have no date.

2. At 2:55 p.m., there was no FAS annual inspection and testing report provided at time of survey. When interviewed, the DPO confirmed the finding and stated that he called the building management to obtain records.

3. At 2:57 p.m., the facility failed to provide documentation for the semi-annual fire alarm system inspection at time of survey. When interviewed, the DPO confirmed the finding and stated that he called the building management to obtain records.

4. At 2:58 p.m., the facility failed to provide documentation the semi-annual load voltage test for the sealed lead-acid batteries at time of survey. When interviewed, the DPO confirmed the finding and stated that he called the building management to obtain records.

Based on document review and interview, the facility failed to maintain the automatic sprinkler system. This was evidenced by the failure to provide documentation for the required test and inspections. This affected two of two buildings and could result in an ineffective operation of the automatic sprinkler system in the event of a fire.

NFPA 101, Life Safety Code, 2012 Edition
4.6.12.4 Any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature requiring periodic testing, inspection, or operation to ensure its maintenance shall be tested, inspected, or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction.

19.3.5.1 Buildings containing nursing homes shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 19.3.5.5.

9.7 Automatic Sprinklers and Other Extinguishing Equipment.
9.7.1 Automatic Sprinklers.

9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

9.7.7 Documentation. All required documentation regarding the design of the fire protection system and the procedures for maintenance, inspection, and testing of the fire protection system shall be maintained at an approved, secured location for the life of the fire protection system.

9.7.8 Record Keeping. Testing and maintenance records required by NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, shall be maintained at an approved, secured location.


NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition

Table 2-1 Summary of Sprinkler System Inspection, Testing, and Maintenance
Gauges (dry, preaction deluge systems) Inspection Weekly/monthly 2-2.4.2
Control valves Inspection Weekly/monthly Table 9-1
Alarm devices Inspection Quarterly 2-2.6
Gauges (wet pipe systems) Inspection Monthly 2-2.4.1
Hydraulic nameplate Inspection Quarterly 2-2.7
Buildings Inspection Annually (prior to freezing weather) 2-2.5
Hanger/seismic bracing Inspection Annually 2-2.3
Pipe and fittings Inspection Annually 2-2.2
Sprinklers Inspection Annually 2-2.1.1
Spare sprinklers Inspection Annually 2-2.1.3
Fire department connections Inspection Table 9-1
Valves (all types) Inspection Table 9-1
Alarm devices Test Quarterly 2-3.3
Main drain Test Annually Table 9-1
Antifreeze solution Test Annually 2-3.4
Gauges Test 5 years 2-3.2
Sprinklers - extra-high temp. Test 5 years 2-3.1.1 Exception No. 3
Sprinklers - fast response Test At 20 years and every 10 years thereafter 2-3.1.1 Exception No. 2
Sprinklers Test At 50 years and every 10 years thereafter 2-3.1.1
Valves (all types) Maintenance Annually or as needed Table 9-1
Obstruction investigation Maintenance 5 years or as needed Chapter 10

5.2.4.1* Gauges on wet pipe sprinkler systems shall be inspected monthly to ensure that they are in good condition and that normal water supply pressure is being maintained.

13.4.1.1* Alarm valves and system riser check valves shall be externally inspected monthly and shall verify the following:
(1) The gauges indicate normal supply water pressure is being maintained.
(2) The valve is free of physical damage.
(3) All valves are in the appropriate open or closed position.
(4) The retarding chamber or alarm drains are not leaking.


Findings:

During document review and interview with staff, documents were requested.

12/9/19 - Main Hospital

1. At 12:50 p.m., the facility failed to provide complete records of the monthly inspection of the sprinkler gauges and valves. The facility conducts quarterly inspections and were conducted on 1/4/19, 4/22/19, 7/17/19, and 10/25/19. The facility did not provide monthly inspections for the months of February, March, May, June, August, September, November, of 2019, and December of 2018/2019. When interviewed, the DPO stated that he did not know of the monthly inspection requirement.

12/10/19 - Sutter Lakeside Medical Practice

2. At 2:43 p.m., the facility failed to provide records for the monthly inspection of the sprinkler gauges and valves during the survey. When interviewed, the DPO confirmed the finding.

3. At 2:44 p.m., there were no records provided for four of four quarterly inspection of the sprinkler system upon request. When interviewed, the DPO confirmed the finding and stated that he called the building management to obtain records.

4. At 2:45 p.m., there were no records provided for two of two semi-annual waterflow test report upon request. When interviewed, the DPO confirmed the finding and stated that he called the building management to obtain records.

5. At 2:46 p.m., there was no annual inspection and testing report provided for the sprinkler system at time of survey. When interviewed, the DPO confirmed the finding and stated that he called the building management to obtain records.

6. At 2:47 p.m., there was no five year certification report for the sprinkler system provided at time of survey. There was no certification sticker observed on the sprinkler riser. The sprinkler riser was located at side of the building. When interviewed, the DPO confirmed the finding and stated that he called the building management to obtain records.

Based on observation and interview, the facility failed to maintain the integrity of the smoke barrier walls. This was evidenced by an unsealed penetration in the smoke barrier wall. This could result in the spread of smoke and fire and increase the risk of injury to residents and staff in the event of a fire, and affected one of two buildings.


NAPA 101, Life Safety Code, 2012 Edition
19.3.7.3 Any required smoke barrier shall be constructed in accordance with Section 8.5 and shall have a minimum 1/2-hour fire resistance rating, unless otherwise permitted by one of the following:
(1) This requirement shall not apply where an atrium is used, and both of the following criteria also shall apply:
(a) Smoke barriers shall be permitted to terminate at an atrium wall constructed in accordance with 8.6.7(1)(ac).
(B) Not less than two separate smoke compartments shall be provided on each floor.
(2) Smoke dampers shall not be required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air-conditioning systems where an approved, supervised automatic sprinkler system in accordance with 19.3.5.8 has been provided for smoke compartments adjacent to the smoke barrier.

8.5.6.2 Penetrations for cables, cable trays, conduits, pipes, tubes, vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a smoke barrier, or through the ceiling membrane of the roof/ceiling of a smoke barrier assembly, shall be protected by a system or material capable of restricting the transfer of smoke.

8.5.6.3 Where a smoke barrier is also constructed as a fire barrier, the penetrations shall be protected in accordance with the requirements of 8.3.5 to limit the spread of fire for a time period equal to the fire resistance rating of the assembly and 8.5.6 to restrict the transfer of smoke, unless the requirements of 8.5.6.4 are met.


Findings:

During a tour of the facility and interview with staff on 12/10/19, the smoke barrier wall was observed.

Main Hospital

Based on document review and interview, the facility failed to ensure that all staff were familiar with procedures during fire drills. This was evidenced by failure to provide documentation to show that all staff participated during fire drills at least quarterly on each shift. This affected all patients and staff in one of two buildings, and could result in potential harm, should staff members be untrained and unaware of their roles and responsibilities during a fire.


NFPA 101, Life Safety Code, 2012 Edition
19.7* Operating Features.
19.7.1 Evacuation and Relocation Plan and Fire Drills.

19.7.1.1 The administration of every health care occupancy shall have, in effect and available to all supervisory personnel, written copies of a plan for the protection of all persons in the event of fire, for their evacuation to areas of refuge, and for their evacuation from the building when necessary.

19.7.1.2 All employees shall be periodically instructed and kept informed with respect to their duties under the plan required by 19.7.1.1.

19.7.1.3 A copy of the plan required by 19.7.1.1 shall be readily available at all times in the telephone operator ' s location or at the security center.

19.7.1.4* Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions.

19.7.1.5 Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building.

19.7.1.6 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.

19.7.1.7 When drills are conducted between 9:00 p.m. and 6:00 a.m. (2100 hours and 0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.

19.7.1.8 Employees of health care occupancies shall be instructed in life safety procedures and devices

19.7.2 Procedure in case of fire.

19.7.2.1* Protection of Patients.

19.7.2.1.1 For health care occupancies, the proper protection of patients shall require the prompt and effective response of health care personnel.

19.7.2.1.2 The basic response required of staff shall include the following:
(1) Removal of all occupants directly involved with the fire emergency
(2) Transmission of an appropriate fire alarm signal to warn other building occupants and summon staff
(3) Confinement of the effects of the fire by closing doors to isolate the fire area
(4) Relocation of patients as detailed in the health care occupancy ' s fire safety plan

19.7.2.2 Fire Safety Plan. A written health care occupancy fire safety plan shall provide for all of the following:
(1) Use of alarms
(2) Transmission of alarms to fire department
(3) Emergency phone call to fire department
(4) Response to alarms
(5) Isolation of fire
(6) Evacuation of immediate area
(7) Evacuation of smoke compartment
(8) Preparation of floors and building for evacuation
(9) Extinguishment of fire

19.7.2.3 Staff Response.
19.7.2.3.1 All health care occupancy personnel shall be instructed in the use of and response to fire alarms.
19.7.2.3.2 All health care occupancy personnel shall be instructed in the use of the code phrase to ensure transmission of an alarm under any of the following conditions:
(1) When the individual who discovers a fire must immediately go to the aid of an endangered person
(2) During a malfunction of the building fire alarm system 19.7.2.3.3 Personnel hearing the code announced shall first activate the building fire alarm using the nearest manual fire alarm box and then shall execute immediately their duties as outlined in the fire safety plan.


Findings:

During document review and interview with staff on 12/9/19, the fire drill document was reviewed.

Main Hospital

1. At 8:40 a.m., the facility failed to provide documentation to show that all staff participated during fire drills at least quarterly on each shift. There were no all staff participation sign-in sheet provided at time of survey. When interviewed, the DPO stated that there is no all staff participation sign-in sheet. The DPO further stated that only the department hosting the fire drills provided staff sign-in sheet.

Based on observation, document review, and interview, the facility failed to maintain the electrical system and its components. This was evidenced by the failure to provide complete electrical receptacle testing records for the wet procedure locations. This affected one of two buildings, and could result in an electrical fire.


NFPA 99, Health Care Facilities Code, 2012 Edition
6.3.2.2.8.1* Wet procedure locations shall be provided with special protection against electric shock.

6.3.2.2.8.5 In existing construction, the requirements of 6.3.2.2.8.1 shall not be required when a written inspection procedure, acceptable to the authority having jurisdiction, is continuously enforced by a designated individual at the hospital to indicate that equipment grounding conductors for 120-V, single phase, 15-A and 20-A receptacles; equipment connected by cord and plug; and fixed electrical equipment are installed and maintained in accordance with NFPA 70, National Electrical Code, and the applicable performance requirements of this chapter.

(B) Fixed receptacles, equipment connected by cord and plug, and fixed electrical equipment shall be tested as follows:
(1) When first installed
(2) Where there is evidence of damage
(3) After any repairs
(4) At intervals not exceeding 6 months

6.3.4.1.3 Receptacles not listed as hospital-grade, at patient bed locations and in locations where deep sedation or general anesthesia is administered, shall be tested at intervals not exceeding 12 months.

6.3.4.2 Record Keeping.
6.3.4.2.1* General.
6.3.4.2.1.1 A record shall be maintained of the tests required by this chapter and associated repairs or modification.
6.3.4.2.1.2 At a minimum, the record shall contain the date, the rooms or areas tested, and an indication of which items have met, or have failed to meet, the performance requirements of this chapter.


Findings:

During a tour of the facility, document review, and interview with staff on 12/9/19, the records were reviewed.

Main Hospital

1. At 2:35 p.m., there were no records provided for the testing of the electrical outlets in the Operating Rooms. The receptacle testing record provided had a date of 6/2019. There were no previous records provided for the receptacle testing in the Operating Rooms.

The DPO provided a letter to all general acute care hospitals (GACH) dated May 26, 1999 from Department of Health Services Licensing and Certification. The letter was in response to request for clarification of California Code of Regulations (CCR), Chapter 1, Division 5, Title 22 Sections 70837 and 70853 that pertain to polarity and tension tests of electrical outlets in electrically sensitive areas pursuant to Section 1276(b) of the Health and Safety Code (H7S) that would allow tests to be done annually.

The Life Safety Code utilizes NFPA 99, 2012 Edition. The letter provided to all GACH utilized CCR Title 22 code.