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Based on observations and interview, it was determined the facility failed to maintain smoke barriers that would resist the passage of smoke between smoke compartments in accordance with National Fire Protection Association (NFPA) standards. The deficient practice has the potential to affect two (2) of three (3) smoke compartments, all residents, staff and visitors. The facility has the capacity for twenty-eight (28) beds and at the time of the survey, the census was twenty (20).

The findings include:

Observation, on 04/09/14 at 12:45 PM with the Vice President of Facilities Management, revealed the smoke partition, extending above the ceiling for Commonwealth Regional Specialty Hospital (CRSH) was penetrated by large holes across the back of the bathrooms and around a pipe in the storage room.

Interview, on 04/09/14 at 12:46 PM with the Vice President of Facilities Management, revealed he was unaware of the penetrations in the smoke barrier of the facility.

The census of twenty (20) was verified by the Administrator on 04/09/14. The findings were acknowledged by the Administrator and verified by the Vice President of Facilities Management at the exit interview on 04/09/14.

Actual NFPA Standard:

NFPA 101 (2000 Edition). 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:
(a) The space between the penetrating item and the smoke barrier shall
1. Be filled with a material capable of maintaining the smoke resistance of the smoke barrier, or
2. Be protected by an approved device designed for the specific purpose.
(b) 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
1. Be filled with a material capable of maintaining the smoke resistance of the smoke barrier, or
2. Be protected by an approved device designed for the specific purpose.
(c) Where designs take transmission of vibration into consideration, any vibration isolation shall
1. Be made on either side of the smoke barrier, or
2. Be made by an approved device designed for the specific purpose.

8.3.6.2 Openings occurring at points where floors or smoke
barriers meet the outside walls, other smoke barriers, or fire
barriers of a building shall meet one of the following conditions:
(1) It shall be filled with a material that is capable of maintaining
the smoke resistance of the floor or smoke barrier.
(2) It shall be protected by an approved device that is
designed for the specific purpose.

Based on observation and interview, it was determined the facility failed to ensure egress was maintained at all exit doors in accordance with National Fire Protection Protection Association (NFPA) standards. The deficient practice has the potential to affect two (2) of three (3) smoke compartments, residents, staff and visitors. The facility has the capacity for twenty-eight (28) beds and at the time of the survey, the census was twenty (20).

The findings include:

Observation, on 04/09/14 at 12:15 PM with the Vice President of Facilities Management, revealed the two (2) exit doors at the end of the hospital next to behavioral health were set for lockdown (delayed egress at the lock position) with all staff not being able to use the doors in an emergency unless the fire alarm was pulled. Further observation revealed the doors were equipped with exit signs and one set of doors did have a code pad to use the doors but the other set did not.

Interview, on 04/09/14 at 12:16 PM with the Vice President of Facilities Management, revealed he was unaware the doors couldn't be locked since they separated occupancies in the building. Further interview revealed the fire marshal stated the exits need to go through the doors to have proper egress from the facility.

The census of twenty (20) was verified by the Administrator on 04/09/14. The findings were acknowledged by the Administrator and verified by the Vice President of Facilities Management at the exit interview on 04/09/14.

Actual NFPA Standard:

NFPA 101 (2000 Edition) 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.
Exception No. 1: Door-locking arrangements without delayed egress shall be permitted in health care occupancies, or portions of health care occupancies, where the clinical needs of the patients require specialized security measures for their safety, provided that staff can readily unlock such doors at all times. (See 19.1.1.1.5 and 19.2.2.2.5.)
Exception No. 2*: Delayed-egress locks complying with 7.2.1.6.1 shall be permitted, provided that not more than one such device is located in any egress path.
Exception No. 3: Access-controlled egress doors complying with 7.2.1.6.2 shall be permitted.

Based on observation and interview, it was determined the facility failed to ensure exits were equipped with lighting in accordance with National Fire Protection Association (NFPA) standards. The deficient practice has the potential to affect two (2) of three (3) smoke compartments, residents, staff and visitors. The facility has the capacity for twenty-eight (28) beds and at the time of the survey, the census was twenty (20).

The findings include:

Observation, on 04/09/14 at 1:45 PM with the Vice President of Facilities Management, revealed the exterior exit at the bottom of stairwell #3 was not equipped with exterior lighting.

Interview, on 04/09/14 at 1:46 PM with the Vice President of Facilities Management, revealed he was unaware the exterior exit at the bottom of stairwell #3 was not equipped with exterior lighting.

Observation, on 04/09/14 at 1:47 PM with the Vice President of Facilities Management, revealed the exterior exit at bottom of stairwell #2 was equipped with a one bulb light fixture.

Interview, on 04/09/14 at 1:48 PM with the Vice President of Facilities Management, revealed he was unaware the exterior exit was only equipped with one light.

The census of twenty (20) was verified by the Administrator on 04/09/14. The findings were acknowledged by the Administrator and verified by the Vice President of Facilities Management at the exit interview on 04/09/14.

Actual NFPA Standard:

NFPA 101 (2000 edition) 7.8.1.4* Required illumination shall be arranged so that the
failure of any single lighting unit does not result in an illumination
level of less than 0.2 ft-candle (2 lux) in any designated
area.

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted quarterly on each shift at random times, in accordance with National Fire Protection Association (NFPA) standards. The deficient practice has the potential to affect three (3) of three (3) smoke compartments, residents, staff and visitors. The facility has the capacity for twenty-eight (28) beds and at the time of the survey, the census was twenty (20).

The findings include:

Fire Drill review, on 04/09/14 at 9:08 AM with the Vice President of Facilities Management, revealed the fire drills were not being conducted at random times on all shifts. Fire drills on second shift were conducted routinely at 3:00 AM for the last four (4) quarters.

Interview, on 04/09/14 at 9:09 AM with the Vice President of Facilities Management, revealed he was unaware the fire drills were not being conducted as required. The Vice President of Facilities Management was unaware of the time separation on each shift to consider the times unexpected.

The census of twenty (20) was verified by the Administrator on 04/09/14. The findings were acknowledged by the Administrator and verified by the Vice President of Facilities Management at the exit interview on 04/09/14.

Actual NFPA Standard:

Reference: NFPA 101 (2000 edition) 19.7.1.2. Fire drills shall be conducted at least quarterly on each shift and at unexpected times under varied conditions on all shifts.

Based on observation and interview, it was determined the facility failed to ensure electrical wiring was maintained in accordance with National Fire Protection Association (NFPA) standards. The deficient practice has the potential to affect two (2) of three (3) smoke compartments, residents, staff and visitors. The facility has the capacity for twenty-eight (28) beds and at the time of the survey, the census was twenty (20).

The findings include:

Observations, on 04/09/14 at 12:30 PM with the Vice President of Facilities Management, revealed the electrical panel in the clean linen room for CRSH had storage within three (3) feet of the electrical panels. The panel was blocked by linen carts.

Interview, on 04/09/14 at 12:31 PM with the Vice President of Facilities Management, revealed he was under the impression if the storage was on wheels then the items could be stored within three (3) feet of an electrical panel.

Observations, on 04/09/14 at 1:15 PM with the Vice President of Facilities Management, revealed the electrical panel in the clean linen room for 6b had storage within three (3) feet of the electrical panels. The panel was blocked by linen carts.

Interview, on 04/09/14 at 1:16 PM with the Vice President of Facilities Management, revealed he was under the impression if the storage was on wheels then the items could be stored within three (3) feet of an electrical panel.

The census of twenty (20) was verified by the Administrator on 04/09/14. The findings were acknowledged by the Administrator and verified by the Vice President of Facilities Management at the exit interview on 04/09/14.

Actual NFPA Standard:

Reference: NFPA 70 (1999 edition) 110-26. Spaces 10.26 Spaces About Electrical Equipment.
Sufficient access and working space shall be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment. Enclosures housing electrical apparatus that are controlled by lock and key shall be considered accessible to qualified persons.
(A) Working Space. Working space for equipment operating at 600 volts, nominal, or less to ground and likely to require examination, adjustment, servicing, or maintenance while energized shall comply with the dimensions of 110.26(A)(1), (2), and (3) or as required or permitted elsewhere in this Code.
(1) Depth of Working Space. The depth of the working space in the direction of live parts shall not be less than that specified in Table 110.26(A)(1) unless the requirements of 110.26(A)(1)(a), (b), or (c) are met. Distances shall be measured from the exposed live parts or from the enclosure or opening if the live parts are enclosed.
Table 110.26(A)(1) Working Spaces

Nominal Voltage to Ground Minimum Clear Distance
Condition 1 Condition 2 Condition 3
0-150 900 mm (3 ft) 900 mm (3 ft) 900 mm (3 ft)
151-600 900 mm (3 ft) 1 m (3? ft) 1.2 m (4 ft)
Note: Where the conditions are as follows:
Condition 1 - Exposed live parts on one side and no live or grounded parts on the other side of the working space, or exposed live parts on both sides effectively guarded by suitable wood or other insulating materials. Insulated wire or insulated busbars operating at not over 300 volts to ground shall not be considered live parts.
Condition 2 - Exposed live parts on one side and grounded parts on the other side. Concrete, brick, or tile walls shall be considered as grounded.
Condition 3 - Exposed live parts on both sides of the work space (not guarded as provided in Condition 1) with the operator between.

(a) Dead-Front Assemblies. Working space shall not be required in the back or sides of assemblies, such as dead-front switchboards or motor control centers, where all connections and all renewable or adjustable parts, such as fuses or switches, are accessible from locations other than the back or sides. Where rear access is required to work on nonelectrical parts on the back of enclosed equipment, a minimum horizontal working space of 762 mm (30 in.) shall be provided.
(b) Low Voltage. By special permission, smaller working spaces shall be permitted where all uninsulated parts operate at not greater than 30 volts rms, 42 volts peak, or 60 volts dc.
(c) Existing Buildings. In existing buildings where electrical equipment is being replaced, Condition 2 working clearance shall be permitted between dead-front switchboards, panelboards, or motor control centers located across the aisle from each other where conditions of maintenance and supervision ensure that written procedures have been adopted to prohibit equipment on both sides of the aisle from being open at the same time and qualified persons who are authorized will service the installation.
(2) Width of Working Space. The width of the working space in front of the electric equipment shall be the width of the equipment or 750 mm (30 in.), whichever is greater. In all cases, the work space shall permit at least a 90 degree opening of equipment doors or hinged panels.
(3) Height of Working Space. The work space shall be clear and extend from the grade, floor, or platform to the height required by 110.26(E). Within the height requirements of this section, other equipment that is associated with the electrical installation and is located above or below the electrical equipment shall be permitted to extend not more than 150 mm (6 in.) beyond the front of the electrical equipment.
(B) Clear Spaces. Working space required by this section shall not be used for storage. When normally enclosed live parts are exposed for inspection or servicing, the working space, if in a passageway or general open space, shall be suitably guarded.
(C) Entrance to Working Space.
(1) Minimum Required. At least one entrance of sufficient area shall be provided to give access to working space about electrical equipment.
(2) Large Equipment. For equipment rated 1200 amperes or more and over 1.8 m (6 ft) wide that contains overcurrent devices, switching devices, or control devices, there shall be one entrance to the required working space not less than 610 mm (24 in.) wide and 2.0 m (6? ft) high at each end of the working space. Where the entrance has a personnel door(s), the door(s) shall open in the direction of egress and be equipped with panic bars, pressure plates, or other devices that are normally latched but open under simple pressure.
A single entrance to the required working space shall be permitted where either of the conditions in 110.26(C)(2)(a) or (b) is met.
(a) Unobstructed Exit. Where the location permits a continuous and unobstructed way of exit travel, a single entrance to the working space shall be permitted.
(b) Extra Working Space. Where the depth of the working space is twice that required by 110.26(A)(1), a single entrance shall be permitted. It shall be located so that the distance from the equipment to the nearest edge of the entrance is not less than the minimum clear distance specified in Table 110.26(A)(1) for equipment operating at that voltage and in that condition.
(D) Illumination. Illumination shall be provided for all working spaces about service equipment, switchboards, panelboards, or motor control centers installed indoors. Additional lighting outlets shall not be required where the work space is illuminated by an adjacent light source or as permitted by 210.70(A)(1), Exception No. 1, for switched receptacles. In electrical equipment rooms, the illumination shall not be controlled by automatic means only.