HospitalInspections.org

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Based on the observation during the survey on 07/16/2015, the facility failed to maintain the corridor walls. Findings include:

Throughout the partially sprinklered single story building of this facility, corridor walls were observed that did not have a fire rating of at least 30 minutes and were not smoke resistive based on observation on the room side of these corridor walls. Examples:

1. The Blood Draw Room corridor wall had unsealed penetrations
2. The Meeting Room corridor wall did not extend above the original plaster ceiling (the original plaster ceiling had been severly compromised).
3. The Mechanical Room 3A corridor wall had two unsealed penetrations

This deficiency impacted 1 of 1 smoke compartments.
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Review of 2000 NFPA 101, 19.3.6.2.1 Corridor walls shall be continuous from the floor to the underside of the floor or roof deck above, through any concealed spaces, such as those above suspended ceilings, and through interstitial structural and mechanical spaces, and they shall have a fire resistance rating of not less than 1/2 hour.
Exception No. 1*: In smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.2, a corridor shall be permitted to be separated from all other areas by non-fire-rated partitions and shall be permitted to terminate at the ceiling where the ceiling is constructed to limit the transfer of smoke.
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Based on the observation on 7/16/2015, the facility failed to maintain corridor doors to resist the passage of smoke. Findings include:

The door to ICU/CCU failed to positive latch. This door opens into the corridor.

The deficiency impacted 1 of 2 smoke compartments.
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NFPA 101, 19.3.6.3.1

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Based on the observation on 7/15/2015, the facility failed to maintain smoke barriers to limit the spread of fire and restrict the movement of smoke. Findings include:

1. Unsealed penetrations at the end of a sleeve, in the smoke barrier, by the elevator, and around water lines on the side of barrier by the Third Floor stairwell.

2. Unsealed penetrations at the end of a sleeve, around two water lines, and in the smoke barrier by Patient Room 317.

The deficiency impacted 1 of 3 smoke compartments.
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NFPA 101, 19.3.7.3

NFPA 101, 8.3.2

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Based on the observation on 7/15/2015, the facility failed to provide separation of hazardous area. Findings include:

1. The door from the dish washing area failed to positive latch. This door opens from the Dining Room, which allows entrance into where customers leave their trays after eating. This area, and door is part of a two hour separation from kitchen and Dining Room.


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2. Room 207 (File Storage Room) was over 50 sq. ft. with combustibles in a smoke compartment with a complete automatic sprinkler system; the door to this room did not have a self-closing device.

The deficiency impacted 1 of 7 smoke compartments.
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Review of 2000 NFPA 101, 19.3.2.1 Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing.
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Based on the observation during the survey on 07/16/2015, the facility failed to provide separation of hazardous area. Findings include:

1. Storage Room in the Blood Bank was over 50 sq. ft. with combustibles in a smoke compartment with a partial automatic sprinkler system; this room did not have a 45 minute rated door (this room did not have a door at all).
2. X-ray Storage Room was over 50 sq. ft. with combustibles in a smoke compartment with a partial automatic sprinkler system; this room was not safeguarded by a fire barrier having a 1-hour fire resistance rating.

The deficiency impacted 1 of 1 smoke compartments.
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Review of 2000 NFPA 101, 8.4.1.3 Doors in barriers required to have a fire resistance rating shall have a 3/4-hour fire protection rating and shall be self-closing or automatic-closing in accordance with 7.2.1.8.

Review of 2000 NFPA 101, 19.3.2.1 Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing.
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Based on the observation on 7/15/2015, the facility failed to maintain stairways with at least 1 hour fire resistance. Findings include:

Unsealed opening approximately 1"x 1" in the wall of the stairwell by ICU/CCU entrance near Patient Room 311.

The deficiency impacted 1 of 2 smoke compartments.
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NFPA 101, 19.3.1.1, 8.2.3.2.4, and 7.1.3.2.1 requires a fire resistance rating.
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Based on the observation during the survey on 07/16/2015, the facility failed to maintain the stairs. Findings include:

The "Old Classroom Stairwell" was observed with twelve tubs, several barrels, and other items being stored at the bottom of this stairwell.

The deficiency impacted 1 of 1 smoke compartments.
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Review of 2000 NFPA 101, 7.2.2.5.3 There shall be no enclosed, usable space within an exit enclosure, including under stairs, nor shall any open space within the enclosure be used for any purpose that has the potential to interfere with egress.

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Based on the observation on 7/15/2015, the facility failed to maintain fire barriers to limit the spread of fire and restrict the movement of smoke from one side of the fire barrier to the other. Findings include:

Unsealed penetrations around 2 sections of conduit, in the fire barrier, by same day surgery waiting room.

The deficiency impacted 1 of 3 smoke compartments.
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NFPA 101, 19.2.2.5 and 7.2.4.3 Openings in fire barriers shall be constructed to limit the spread of fire and restrict the movement of smoke from one side of the fire barrier to the other.

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Based on the observation on 7/15/2015, the facility failed to maintain the Digital Alarm Communicator. Findings include:

The remote annunciator screen was observed to be blank by this surveyor before the phone lines were unplugged.

1. When the Auto Dialer was tested for phone line 1, audible was indicated at the protected premise within the allotted 4 minute time frame, but the panel did not indicate visually for phone line 1.

2. When the Auto Dialer was tested for phone line 2, audible was indicated at the protected premise within the allotted 4 minute time frame, but panel did not indicate a visually for phone line 2.

3. When the Auto Dialer was tested for Communication Failure, an audible was indicated at the protected premise within the allotted 15 minute time frame (5 minimum to 10 maximum attempts for signal transmission), but the panel did not indicate a visually for auto dialer failure.


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4. At the main fire alarm control panel when both phone lines were disconnected, after 17 minutes the panel only showed a "line 2" trouble.

5. The fire alarm strobe at ER Admissions had a flash rate less than one flash every second.
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Review of 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.

Review of 1999 NFPA 72, 5-5.3.2.1.6.2
The following requirements shall apply to all combinations in 5-5.3.2.1.6.1:
(1) Both channels shall be supervised in a manner approved for the means of transmission employed.
(2) Both channels shall be tested at intervals not exceeding 24 hours.
Exception No. 1: For public cellular telephone service, a verification (test) signal shall be transmitted at least monthly.
Exception No. 2: Where two telephone lines (numbers) are used, it shall be permitted to test each telephone line (number) at alternating 24-hour intervals.
(3) The failure of either channel shall send a trouble signal on the other channel within 4 minutes.
(4) When one transmission channel has failed, all status change signals shall be sent over the other channel.
Exception: Where used in combination with a DACT, a derived local channel shall not be required to send status change signals other than those indicating that adverse conditions exist on the telephone line (number).
(5) The primary channel shall be capable of delivering an indication to the DACT that the message has been received by the supervising station.
(6) The first attempt to send a status change signal shall use the primary channel.
Exception: Where the primary channel is known to have failed.
(7) Simultaneous transmission over both channels shall be permitted.
(8) Failure of telephone lines (numbers) or cellular service shall be annunciated locally.

1999 NFPA 72, 4-4.2 Light Pulse Characteristics.
The flash rate shall not exceed two flashes per second (2 Hz) nor be less than one flash every second (1 Hz) throughout the listed voltage range of the appliance.
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Based on the observation on 7/16/2015, the facility failed to maintain the Digital Alarm Communicator. Findings include:

The remote annunciator screen was observed by this surveyor to be blank, before the phone lines were unplugged.

1. When the Auto Dialer was tested for phone line 1, audible was indicated at the protected premise within the allotted 4 minute time frame, but the panel did not indicate visually for phone line 1.

2. When the Auto Dialer was tested for phone line 2, audible was indicated at the protected premise within the allotted 4 minute time frame, but panel did not indicate visually for phone line 2.

3. When the Auto Dialer was tested for Communication Failure, audible was indicated at the protected premise within the allotted 15 minute time frame (5 minimum to 10 maximum attempts for signal transmission), but panel did not indicate visually for auto dialer failure.
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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.


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4. At the main fire alarm control panel when both phone lines were disconnected after 17 minutes the panel only showed a "line 2" trouble.

The deficiency impacted 7 of 7 smoke compartments.
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Review of 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.

Review of 1999 NFPA 72, 5-5.3.2.1.6.2
The following requirements shall apply to all combinations in 5-5.3.2.1.6.1:
(1) Both channels shall be supervised in a manner approved for the means of transmission employed.
(2) Both channels shall be tested at intervals not exceeding 24 hours.
Exception No. 1: For public cellular telephone service, a verification (test) signal shall be transmitted at least monthly.
Exception No. 2: Where two telephone lines (numbers) are used, it shall be permitted to test each telephone line (number) at alternating 24-hour intervals.
(3) The failure of either channel shall send a trouble signal on the other channel within 4 minutes.
(4) When one transmission channel has failed, all status change signals shall be sent over the other channel.
Exception: Where used in combination with a DACT, a derived local channel shall not be required to send status change signals other than those indicating that adverse conditions exist on the telephone line (number).
(5) The primary channel shall be capable of delivering an indication to the DACT that the message has been received by the supervising station.
(6) The first attempt to send a status change signal shall use the primary channel.
Exception: Where the primary channel is known to have failed.
(7) Simultaneous transmission over both channels shall be permitted.
(8) Failure of telephone lines (numbers) or cellular service shall be annunciated locally.

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Based on the observation during the survey on 07/16/2015, the facility failed to provide a working fire alarm system. Findings include:

The fire alarm system was observed not working. The fire alarm panel and remote annunciator screens both were blank. When a pull station was activated nothing happened. Per interview with maintenance staff, lighting had hit the fire alarm panel earlier in the week.

The deficiency impacted 1 of 1 smoke compartments.
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Review of 2000 NFPA 101, 4.6.12.2*
Existing life safety features obvious to the public, if not required by the Code, shall be either maintained or removed.

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Based on the observation during the survey on 07/16/2015, the facility failed to maintain the automatic sprinkler system. Findings include:

1. Second Floor Geri-Psych. Ward - Laundry chute sprinkler head was observed with foreign material
2. The following rooms were missing ceiling tile:
a. 205
b. 222
3. The sprinkler pipe in the Maintenance Shop in the Basement was observed with a garden hose taped to this pipe.
4. The maintenance sprinkler line in Central Supply in the Basement was observed with a cable attached to this pipe.

The deficiency impacted 2 of 7 smoke compartments.
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Review of 1998 NFPA 25, 2-2.1.1 Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.

Review of 1999 NFPA 13, 5-8.4.2 Deflectors of sprinklers shall be aligned parallel to ceilings or roofs.

Review of 1998 NFPA 25, 2-2.2 Sprinkler pipe and fittings shall be inspected annually from the floor level. Pipe and fittings shall be in good condition and free of mechanical damage, leakage, corrosion, and misalignment. Sprinkler piping shall not be subjected to external loads by materials either resting on the pipe or hung from the pipe.
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Based on the observation during the survey on 07/16/2015, the facility failed to maintain the automatic sprinkler system. Findings include:

1. The automatic sprinkler riser gauges were observed to have a 2007 date. Per maintenance staff, the gauges have not been replaced or calibrated in the past five years.
2. The automatic sprinkler riser cabinet did not contain a special sprinkler wrench.

The deficiency impacted 1 of 1 smoke compartments.
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Review of 1998 NFPA 25, 2-3.2 Gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge. Gauges not accurate to within 3 percent of the full scale shall be recalibrated or replaced.

Review of 1998 NFPA 25, 2-4.1.6 A special sprinkler wrench shall be provided and kept in the cabinet to be used in the removal and installation of sprinklers. One sprinkler wrench shall be provided for each type of sprinkler installed.

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Based on the observation during the survey on 07/16/2015, the facility failed to prohibit smoking on the campus per the facility's smoking policy. Findings include:

Per documentation from the facility, the facility's campus is smoke free. Excessive smoking materials were observed outside the exit door from the "Old Classroom Stairwell".
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Review of 2000 NFPA 101, 19.7.4
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Based on the observation on 7/16/2015, the facility to maintain the dietary hood. Findings include:

A gap approximately half of an inch between one set of filters.
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NFPA 96, 3-2.3 Grease filters shall be listed and constructed of steel or listed equivalent material and shall be of rigid construction that will not distort or crush under normal operation, handling, and cleaning conditions. Filters shall be tight fitting and firmly held in place.

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Based on the observation on 7/16/2015, the facility failed to provide adequate sprinkler coverage. Findings include:

Sprinkler coverage was not provided for the Laundry chute. This was observed by this surveyor on the third floor at the top of the chute. Chute is located in a room across the corridor from Patient Room 343.
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Review of 2000 NFPA 101, 9.7.

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Based on the observation on 7/16/2015, the facility failed to maintain the dampers in barriers. Findings include:

While testing the fire alarm system, this surveyor observed the damper to be in the closed position prior to the first activation of the fire alarm system. This was confirmed by one of the maintenance personal during the testing.

The deficiency impacted 1 of smoke compartments.
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Review of 1999 NFPA 90 A, 3-4.7 At least every 4 years, fusible links (where applicable) shall be removed; all dampers shall be operated to verify that they fully close; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary.

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Based on the observation during the survey on 07/16/2015, the facility failed to maintain the following systems. Findings include:

1. The battery-powered emergency light fixture in the Life Safety and Critical Transfer Switch Room did not illminate when tested.
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Review of 1999 NFPA 110, 5-3.1 The Level 1 or Level 2 EPS equipment location shall be provided with battery-powered emergency lighting. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch.
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2. The two smoke dampers located above the smoke doors going into the sleep lab on the Second Floor were observed without motors.
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Review of 1999 NFPA 90A, 3-4.5.4 Dampers shall close against the maximum calculated airflow of that portion of the air duct system in which they are installed. Fire dampers shall be tested in accordance with UL 555, Standard for Safety Fire Dampers. Smoke dampers shall be tested in accordance with UL 555S, Standard for Safety Smoke Dampers.
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3. Per documentation and interview the facility had not corrected the comments and recommendations from the Medical Gas Report dated 05/28/2015.

The deficiency impacted 7 of 7 smoke compartments.
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Review of 1999 NFPA 99, 4-3.5.2.3 Patient Gas Systems - Level 1.
(a) * Piping systems shall not be used for the distribution of flammable anesthetic gases.
(b) Nonflammable medical gas systems used to supply gases for respiratory therapy shall be installed in accordance with 4-3.1 of this chapter.
(c) Maintenance programs in accordance with the manufacturers ' recommendations shall be established for the medical air compressor supply system as connected in each individual installation.
(d) * The responsible authority of the facility shall establish procedures to ensure that all signal warnings are promptly evaluated and that all necessary measures are taken to reestablish the proper functions of the medical gas system.
(e) Piping systems for gases shall not be used as a grounding electrode.
(f) The facility shall have the capability and organization to implement a plan to cope with a complete loss of any medical gas system.
(g) A periodic testing procedure for nonflammable medical gas and related alarm systems shall be implemented.
(h) The test specified in 4-3.4.1.3(i) shall be conducted on the downstream portions of the medical gas piping system whenever a system is breached or whenever modifications are made or maintenance performed.
(i) * Periodic retesting of audible and visual alarm indicators shall be performed to determine that they are functioning properly, and records of the test shall be maintained until the next test.

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Based on the observation during the survey on 07/16/2015, the facility failed to maintain the following systems. Findings include:

1. OR #1's smoke detector did not activate
a. The fire alarm system
b. The smoke venting system
2. OR #2's smoke detector did not activate the fire alarm system
3. Per documentation and interview the facility had not corrected the comments and recommendations from the Medical Gas Report dated 05/28/2015.
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Review of 1999 NFPA 99, 5-4.1.2 Supply and exhaust systems for windowless anesthetizing locations shall be arranged to automatically vent smoke and products of combustion.

Review of 2000 NFPA 101, 19.3.4.2 Initiation of the required fire alarm systems shall be by manual means in accordance with 9.6.2 and by means of any required sprinkler system waterflow alarms, detection devices, or detection systems.

Review of 1999 NFPA 99, 4-3.5.2.3 Patient Gas Systems - Level 1.
(a) * Piping systems shall not be used for the distribution of flammable anesthetic gases.
(b) Nonflammable medical gas systems used to supply gases for respiratory therapy shall be installed in accordance with 4-3.1 of this chapter.
(c) Maintenance programs in accordance with the manufacturers ' recommendations shall be established for the medical air compressor supply system as connected in each individual installation.
(d) * The responsible authority of the facility shall establish procedures to ensure that all signal warnings are promptly evaluated and that all necessary measures are taken to reestablish the proper functions of the medical gas system.
(e) Piping systems for gases shall not be used as a grounding electrode.
(f) The facility shall have the capability and organization to implement a plan to cope with a complete loss of any medical gas system.
(g) A periodic testing procedure for nonflammable medical gas and related alarm systems shall be implemented.
(h) The test specified in 4-3.4.1.3(i) shall be conducted on the downstream portions of the medical gas piping system whenever a system is breached or whenever modifications are made or maintenance performed.
(i) * Periodic retesting of audible and visual alarm indicators shall be performed to determine that they are functioning properly, and records of the test shall be maintained until the next test.

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Based on the observation on 7/16/2015, the facility failed to maintain the electrical system. Findings include:

1. Two junction box covers were missing above the ceiling at the two hour barrier between the Kitchen and Dining Room.
2. Cover was missing on 1 electrical outlet in same day surgery equipment storage room.
3. A shop light was powered by the use of a extension cord without overcurrent protection in the interstitial space. Access to the interstitial space is located in the mechanical room by the kitchen.


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4. Room 206 had an extension cord plugged into a surge protector (extension cord) plugged into a surge protector (extension cord).
5. Room 207 had a refrigerator plugged into a surge protector (extension cord).
6. The Maintenance Office in the Maintenance Shop in the Basement had a surge protector (extension cord) plugged into a surge protector (extension cord).

The deficiency impacted 2 of 7 smoke compartments.
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Review of 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.

Review of 1999 NFPA 70, 400-7 (b) Attachment Plugs. Where used as permitted in subsections (a)(3), (a)(6), and (a)(8), each flexible cord shall be equipped with an attachment plug and shall be energized from a receptacle outlet.

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Based on the observation during the survey on 07/16/2015, the facility failed to maintain the corridor walls. Findings include:

Throughout the partially sprinklered single story building of this facility, corridor walls were observed that did not have a fire rating of at least 30 minutes and were not smoke resistive based on observation on the room side of these corridor walls. Examples:

1. The Blood Draw Room corridor wall had unsealed penetrations
2. The Meeting Room corridor wall did not extend above the original plaster ceiling (the original plaster ceiling had been severly compromised).
3. The Mechanical Room 3A corridor wall had two unsealed penetrations

This deficiency impacted 1 of 1 smoke compartments.
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Review of 2000 NFPA 101, 19.3.6.2.1 Corridor walls shall be continuous from the floor to the underside of the floor or roof deck above, through any concealed spaces, such as those above suspended ceilings, and through interstitial structural and mechanical spaces, and they shall have a fire resistance rating of not less than 1/2 hour.
Exception No. 1*: In smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.2, a corridor shall be permitted to be separated from all other areas by non-fire-rated partitions and shall be permitted to terminate at the ceiling where the ceiling is constructed to limit the transfer of smoke.
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Based on the observation on 7/16/2015, the facility failed to maintain corridor doors to resist the passage of smoke. Findings include:

The door to ICU/CCU failed to positive latch. This door opens into the corridor.

The deficiency impacted 1 of 2 smoke compartments.
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NFPA 101, 19.3.6.3.1

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Based on the observation on 7/15/2015, the facility failed to maintain smoke barriers to limit the spread of fire and restrict the movement of smoke. Findings include:

1. Unsealed penetrations at the end of a sleeve, in the smoke barrier, by the elevator, and around water lines on the side of barrier by the Third Floor stairwell.

2. Unsealed penetrations at the end of a sleeve, around two water lines, and in the smoke barrier by Patient Room 317.

The deficiency impacted 1 of 3 smoke compartments.
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NFPA 101, 19.3.7.3

NFPA 101, 8.3.2

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Based on the observation on 7/15/2015, the facility failed to provide separation of hazardous area. Findings include:

1. The door from the dish washing area failed to positive latch. This door opens from the Dining Room, which allows entrance into where customers leave their trays after eating. This area, and door is part of a two hour separation from kitchen and Dining Room.


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2. Room 207 (File Storage Room) was over 50 sq. ft. with combustibles in a smoke compartment with a complete automatic sprinkler system; the door to this room did not have a self-closing device.

The deficiency impacted 1 of 7 smoke compartments.
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Review of 2000 NFPA 101, 19.3.2.1 Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing.
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Based on the observation during the survey on 07/16/2015, the facility failed to provide separation of hazardous area. Findings include:

1. Storage Room in the Blood Bank was over 50 sq. ft. with combustibles in a smoke compartment with a partial automatic sprinkler system; this room did not have a 45 minute rated door (this room did not have a door at all).
2. X-ray Storage Room was over 50 sq. ft. with combustibles in a smoke compartment with a partial automatic sprinkler system; this room was not safeguarded by a fire barrier having a 1-hour fire resistance rating.

The deficiency impacted 1 of 1 smoke compartments.
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Review of 2000 NFPA 101, 8.4.1.3 Doors in barriers required to have a fire resistance rating shall have a 3/4-hour fire protection rating and shall be self-closing or automatic-closing in accordance with 7.2.1.8.

Review of 2000 NFPA 101, 19.3.2.1 Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing.
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Based on the observation on 7/15/2015, the facility failed to maintain stairways with at least 1 hour fire resistance. Findings include:

Unsealed opening approximately 1"x 1" in the wall of the stairwell by ICU/CCU entrance near Patient Room 311.

The deficiency impacted 1 of 2 smoke compartments.
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NFPA 101, 19.3.1.1, 8.2.3.2.4, and 7.1.3.2.1 requires a fire resistance rating.
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Based on the observation during the survey on 07/16/2015, the facility failed to maintain the stairs. Findings include:

The "Old Classroom Stairwell" was observed with twelve tubs, several barrels, and other items being stored at the bottom of this stairwell.

The deficiency impacted 1 of 1 smoke compartments.
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Review of 2000 NFPA 101, 7.2.2.5.3 There shall be no enclosed, usable space within an exit enclosure, including under stairs, nor shall any open space within the enclosure be used for any purpose that has the potential to interfere with egress.

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Based on the observation on 7/15/2015, the facility failed to maintain fire barriers to limit the spread of fire and restrict the movement of smoke from one side of the fire barrier to the other. Findings include:

Unsealed penetrations around 2 sections of conduit, in the fire barrier, by same day surgery waiting room.

The deficiency impacted 1 of 3 smoke compartments.
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NFPA 101, 19.2.2.5 and 7.2.4.3 Openings in fire barriers shall be constructed to limit the spread of fire and restrict the movement of smoke from one side of the fire barrier to the other.

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Based on the review of facility documentation on 07/16/2015, the facility failed to conduct fire drills, maintain the documentation for fire drills, and to provide proof of participation of all on duty staff at the time of the drill(s).

First Shift
04/14/2015 - 10:30 am
01/21/2015 - 10:00 am
12/23/2014 - 10:30 am
08/13/2014 - 8:30 am

Second Shift
06/25/2015 - 2:45 pm
02/26/2015 - 3:00 pm
10/20/2014 - 3:13 pm
07/25/2014 - 3:00 pm

Third Shift
05/18/2015 - 11:15 pm
03/26/2015 - 11:15 pm
11/27/2014 - 11:15 pm
09/16/2014 - No Time

The deficiency impacted 7 of 7 smoke compartments.
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Review of 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.
Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building.

Review of 2000 NFPA 101, 4.7.2* Emergency egress and relocation drills, where required by Chapters 11 through 42 or the authority having jurisdiction, shall be held with sufficient frequency to familiarize occupants with the drill procedure and to establish conduct of the drill as a matter of routine. Drills shall include suitable procedures to ensure that all persons subject to the drill participate.

Review of 2000 NFPA 101, 4.7.5* Drills shall be held at expected and unexpected times and under varying conditions to simulate the unusual conditions that can occur in an actual emergency.

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Based on the observation on 7/15/2015, the facility failed to maintain the Digital Alarm Communicator. Findings include:

The remote annunciator screen was observed to be blank by this surveyor before the phone lines were unplugged.

1. When the Auto Dialer was tested for phone line 1, audible was indicated at the protected premise within the allotted 4 minute time frame, but the panel did not indicate visually for phone line 1.

2. When the Auto Dialer was tested for phone line 2, audible was indicated at the protected premise within the allotted 4 minute time frame, but panel did not indicate a visually for phone line 2.

3. When the Auto Dialer was tested for Communication Failure, an audible was indicated at the protected premise within the allotted 15 minute time frame (5 minimum to 10 maximum attempts for signal transmission), but the panel did not indicate a visually for auto dialer failure.


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4. At the main fire alarm control panel when both phone lines were disconnected, after 17 minutes the panel only showed a "line 2" trouble.

5. The fire alarm strobe at ER Admissions had a flash rate less than one flash every second.
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Review of 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.

Review of 1999 NFPA 72, 5-5.3.2.1.6.2
The following requirements shall apply to all combinations in 5-5.3.2.1.6.1:
(1) Both channels shall be supervised in a manner approved for the means of transmission employed.
(2) Both channels shall be tested at intervals not exceeding 24 hours.
Exception No. 1: For public cellular telephone service, a verification (test) signal shall be transmitted at least monthly.
Exception No. 2: Where two telephone lines (numbers) are used, it shall be permitted to test each telephone line (number) at alternating 24-hour intervals.
(3) The failure of either channel shall send a trouble signal on the other channel within 4 minutes.
(4) When one transmission channel has failed, all status change signals shall be sent over the other channel.
Exception: Where used in combination with a DACT, a derived local channel shall not be required to send status change signals other than those indicating that adverse conditions exist on the telephone line (number).
(5) The primary channel shall be capable of delivering an indication to the DACT that the message has been received by the supervising station.
(6) The first attempt to send a status change signal shall use the primary channel.
Exception: Where the primary channel is known to have failed.
(7) Simultaneous transmission over both channels shall be permitted.
(8) Failure of telephone lines (numbers) or cellular service shall be annunciated locally.

1999 NFPA 72, 4-4.2 Light Pulse Characteristics.
The flash rate shall not exceed two flashes per second (2 Hz) nor be less than one flash every second (1 Hz) throughout the listed voltage range of the appliance.
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Based on the observation on 7/16/2015, the facility failed to maintain the Digital Alarm Communicator. Findings include:

The remote annunciator screen was observed by this surveyor to be blank, before the phone lines were unplugged.

1. When the Auto Dialer was tested for phone line 1, audible was indicated at the protected premise within the allotted 4 minute time frame, but the panel did not indicate visually for phone line 1.

2. When the Auto Dialer was tested for phone line 2, audible was indicated at the protected premise within the allotted 4 minute time frame, but panel did not indicate visually for phone line 2.

3. When the Auto Dialer was tested for Communication Failure, audible was indicated at the protected premise within the allotted 15 minute time frame (5 minimum to 10 maximum attempts for signal transmission), but panel did not indicate visually for auto dialer failure.
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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.


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4. At the main fire alarm control panel when both phone lines were disconnected after 17 minutes the panel only showed a "line 2" trouble.

The deficiency impacted 7 of 7 smoke compartments.
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Review of 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.

Review of 1999 NFPA 72, 5-5.3.2.1.6.2
The following requirements shall apply to all combinations in 5-5.3.2.1.6.1:
(1) Both channels shall be supervised in a manner approved for the means of transmission employed.
(2) Both channels shall be tested at intervals not exceeding 24 hours.
Exception No. 1: For public cellular telephone service, a verification (test) signal shall be transmitted at least monthly.
Exception No. 2: Where two telephone lines (numbers) are used, it shall be permitted to test each telephone line (number) at alternating 24-hour intervals.
(3) The failure of either channel shall send a trouble signal on the other channel within 4 minutes.
(4) When one transmission channel has failed, all status change signals shall be sent over the other channel.
Exception: Where used in combination with a DACT, a derived local channel shall not be required to send status change signals other than those indicating that adverse conditions exist on the telephone line (number).
(5) The primary channel shall be capable of delivering an indication to the DACT that the message has been received by the supervising station.
(6) The first attempt to send a status change signal shall use the primary channel.
Exception: Where the primary channel is known to have failed.
(7) Simultaneous transmission over both channels shall be permitted.
(8) Failure of telephone lines (numbers) or cellular service shall be annunciated locally.

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Based on the observation during the survey on 07/16/2015, the facility failed to provide a working fire alarm system. Findings include:

The fire alarm system was observed not working. The fire alarm panel and remote annunciator screens both were blank. When a pull station was activated nothing happened. Per interview with maintenance staff, lighting had hit the fire alarm panel earlier in the week.

The deficiency impacted 1 of 1 smoke compartments.
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Review of 2000 NFPA 101, 4.6.12.2*
Existing life safety features obvious to the public, if not required by the Code, shall be either maintained or removed.

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Based on the observation during the survey on 07/16/2015, the facility failed to maintain the automatic sprinkler system. Findings include:

1. Second Floor Geri-Psych. Ward - Laundry chute sprinkler head was observed with foreign material
2. The following rooms were missing ceiling tile:
a. 205
b. 222
3. The sprinkler pipe in the Maintenance Shop in the Basement was observed with a garden hose taped to this pipe.
4. The maintenance sprinkler line in Central Supply in the Basement was observed with a cable attached to this pipe.

The deficiency impacted 2 of 7 smoke compartments.
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Review of 1998 NFPA 25, 2-2.1.1 Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.

Review of 1999 NFPA 13, 5-8.4.2 Deflectors of sprinklers shall be aligned parallel to ceilings or roofs.

Review of 1998 NFPA 25, 2-2.2 Sprinkler pipe and fittings shall be inspected annually from the floor level. Pipe and fittings shall be in good condition and free of mechanical damage, leakage, corrosion, and misalignment. Sprinkler piping shall not be subjected to external loads by materials either resting on the pipe or hung from the pipe.
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Based on the observation during the survey on 07/16/2015, the facility failed to maintain the automatic sprinkler system. Findings include:

1. The automatic sprinkler riser gauges were observed to have a 2007 date. Per maintenance staff, the gauges have not been replaced or calibrated in the past five years.
2. The automatic sprinkler riser cabinet did not contain a special sprinkler wrench.

The deficiency impacted 1 of 1 smoke compartments.
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Review of 1998 NFPA 25, 2-3.2 Gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge. Gauges not accurate to within 3 percent of the full scale shall be recalibrated or replaced.

Review of 1998 NFPA 25, 2-4.1.6 A special sprinkler wrench shall be provided and kept in the cabinet to be used in the removal and installation of sprinklers. One sprinkler wrench shall be provided for each type of sprinkler installed.

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Based on the observation during the survey on 07/16/2015, the facility failed to prohibit smoking on the campus per the facility's smoking policy. Findings include:

Per documentation from the facility, the facility's campus is smoke free. Excessive smoking materials were observed outside the exit door from the "Old Classroom Stairwell".
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Review of 2000 NFPA 101, 19.7.4
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Based on the observation on 7/16/2015, the facility to maintain the dietary hood. Findings include:

A gap approximately half of an inch between one set of filters.
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NFPA 96, 3-2.3 Grease filters shall be listed and constructed of steel or listed equivalent material and shall be of rigid construction that will not distort or crush under normal operation, handling, and cleaning conditions. Filters shall be tight fitting and firmly held in place.

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Based on the observation on 7/16/2015, the facility failed to provide adequate sprinkler coverage. Findings include:

Sprinkler coverage was not provided for the Laundry chute. This was observed by this surveyor on the third floor at the top of the chute. Chute is located in a room across the corridor from Patient Room 343.
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Review of 2000 NFPA 101, 9.7.

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Based on the observation on 7/16/2015, the facility failed to maintain the dampers in barriers. Findings include:

While testing the fire alarm system, this surveyor observed the damper to be in the closed position prior to the first activation of the fire alarm system. This was confirmed by one of the maintenance personal during the testing.

The deficiency impacted 1 of smoke compartments.
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Review of 1999 NFPA 90 A, 3-4.7 At least every 4 years, fusible links (where applicable) shall be removed; all dampers shall be operated to verify that they fully close; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary.

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Based on the observation during the survey on 07/16/2015, the facility failed to maintain the following systems. Findings include:

1. The battery-powered emergency light fixture in the Life Safety and Critical Transfer Switch Room did not illminate when tested.
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Review of 1999 NFPA 110, 5-3.1 The Level 1 or Level 2 EPS equipment location shall be provided with battery-powered emergency lighting. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch.
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2. The two smoke dampers located above the smoke doors going into the sleep lab on the Second Floor were observed without motors.
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Review of 1999 NFPA 90A, 3-4.5.4 Dampers shall close against the maximum calculated airflow of that portion of the air duct system in which they are installed. Fire dampers shall be tested in accordance with UL 555, Standard for Safety Fire Dampers. Smoke dampers shall be tested in accordance with UL 555S, Standard for Safety Smoke Dampers.
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3. Per documentation and interview the facility had not corrected the comments and recommendations from the Medical Gas Report dated 05/28/2015.

The deficiency impacted 7 of 7 smoke compartments.
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Review of 1999 NFPA 99, 4-3.5.2.3 Patient Gas Systems - Level 1.
(a) * Piping systems shall not be used for the distribution of flammable anesthetic gases.
(b) Nonflammable medical gas systems used to supply gases for respiratory therapy shall be installed in accordance with 4-3.1 of this chapter.
(c) Maintenance programs in accordance with the manufacturers ' recommendations shall be established for the medical air compressor supply system as connected in each individual installation.
(d) * The responsible authority of the facility shall establish procedures to ensure that all signal warnings are promptly evaluated and that all necessary measures are taken to reestablish the proper functions of the medical gas system.
(e) Piping systems for gases shall not be used as a grounding electrode.
(f) The facility shall have the capability and organization to implement a plan to cope with a complete loss of any medical gas system.
(g) A periodic testing procedure for nonflammable medical gas and related alarm systems shall be implemented.
(h) The test specified in 4-3.4.1.3(i) shall be conducted on the downstream portions of the medical gas piping system whenever a system is breached or whenever modifications are made or maintenance performed.
(i) * Periodic retesting of audible and visual alarm indicators shall be performed to determine that they are functioning properly, and records of the test shall be maintained until the next test.

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Based on the observation during the survey on 07/16/2015, the facility failed to maintain the following systems. Findings include:

1. OR #1's smoke detector did not activate
a. The fire alarm system
b. The smoke venting system
2. OR #2's smoke detector did not activate the fire alarm system
3. Per documentation and interview the facility had not corrected the comments and recommendations from the Medical Gas Report dated 05/28/2015.
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Review of 1999 NFPA 99, 5-4.1.2 Supply and exhaust systems for windowless anesthetizing locations shall be arranged to automatically vent smoke and products of combustion.

Review of 2000 NFPA 101, 19.3.4.2 Initiation of the required fire alarm systems shall be by manual means in accordance with 9.6.2 and by means of any required sprinkler system waterflow alarms, detection devices, or detection systems.

Review of 1999 NFPA 99, 4-3.5.2.3 Patient Gas Systems - Level 1.
(a) * Piping systems shall not be used for the distribution of flammable anesthetic gases.
(b) Nonflammable medical gas systems used to supply gases for respiratory therapy shall be installed in accordance with 4-3.1 of this chapter.
(c) Maintenance programs in accordance with the manufacturers ' recommendations shall be established for the medical air compressor supply system as connected in each individual installation.
(d) * The responsible authority of the facility shall establish procedures to ensure that all signal warnings are promptly evaluated and that all necessary measures are taken to reestablish the proper functions of the medical gas system.
(e) Piping systems for gases shall not be used as a grounding electrode.
(f) The facility shall have the capability and organization to implement a plan to cope with a complete loss of any medical gas system.
(g) A periodic testing procedure for nonflammable medical gas and related alarm systems shall be implemented.
(h) The test specified in 4-3.4.1.3(i) shall be conducted on the downstream portions of the medical gas piping system whenever a system is breached or whenever modifications are made or maintenance performed.
(i) * Periodic retesting of audible and visual alarm indicators shall be performed to determine that they are functioning properly, and records of the test shall be maintained until the next test.

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Based on the observation on 7/16/2015, the facility failed to maintain the electrical system. Findings include:

1. Two junction box covers were missing above the ceiling at the two hour barrier between the Kitchen and Dining Room.
2. Cover was missing on 1 electrical outlet in same day surgery equipment storage room.
3. A shop light was powered by the use of a extension cord without overcurrent protection in the interstitial space. Access to the interstitial space is located in the mechanical room by the kitchen.


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4. Room 206 had an extension cord plugged into a surge protector (extension cord) plugged into a surge protector (extension cord).
5. Room 207 had a refrigerator plugged into a surge protector (extension cord).
6. The Maintenance Office in the Maintenance Shop in the Basement had a surge protector (extension cord) plugged into a surge protector (extension cord).

The deficiency impacted 2 of 7 smoke compartments.
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Review of 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.

Review of 1999 NFPA 70, 400-7 (b) Attachment Plugs. Where used as permitted in subsections (a)(3), (a)(6), and (a)(8), each flexible cord shall be equipped with an attachment plug and shall be energized from a receptacle outlet.