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Based on observation and staff interview the facility fails to assure there is sufficient normal illumination for the exit north exit discharge paths. This deficient practice fails to ensure that all areas of egress will not be left in total darkness, affecting all Patients in 3 smoke zones. The facility has a capacity of 25 and a census of 1 at the time of survey.

Findings include:

During the survey on June 7, 2017, at 1:35 pm the following is observed: that the normal lighting provided for all exit discharges relies on single bulb fixtures to supply lighting for the exit discharge paths.

The Maintenance Director was present and acknowledged the findings

Review of the following NFPA Standard revealed: Illumination of means of egress shall be continuous during the time that the conditions of occupancy require that the means of egress be available for use. Artificial lighting shall be employed at such locations and for such periods of time as required to maintain the illumination to the minimum criteria values herein specified.
Illumination of means of egress shall be continuous during the time that the conditions of occupancy require that the means of egress be available for use, unless otherwise provided in 7.8.1.2.2.
NFPA 101 2012, 7.8.1.2
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 (2.2 lux) in any designated area.
NFPA 101 2012 7.8.1.2, 7.8.1.4*

Based on observation, record review and interview the facility does not assure a fire watch procedure and policy is written as required for implementation when the fire alarm more than 4 hours in a 24 hour period. This deficient practice would prevent proper notification of insurance carrier, the alarm company, property owner or designated representative, and other authorities having jurisdiction as required, affecting all patients and staff in in all smoke zones. The facility has a capacity of 25 and a census of 1 at the time of survey.

Findings include:

During record review on June 7, 2017, the following is observed: Between 10:30 am and 12:30 pm it is revealed that the facility did not have a written policy for implementing a fire watch for alarm systems impairment.
The Maintenance Director was present during the survey and acknowledged the findings.

Review of the following NFPA Standard revealed: Where a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated, or an approved fire watch shall be provided for all 2012 NFPA 1012 9.6.1.6*

Based on record review and staff interview, the facility failed to assure that the sprinkler system is tested in accordance with the 2011 edition of NFPA 25. This deficient practice fails to ensure that the sprinkler system will operate properly in the event of a fire, affecting all patients and staff in all 3 smoke zones. The facility has a capacity of 25 with a census of 1 at the time of survey.

Findings include:

During record review on June 7, 2017, between 10:30 am and 12:30pm it is observed when reviewing the facility's sprinkler inspection and testing records found no quarterly inspections in 2016 and 2017
The Maintenance Director was present during record review and acknowledged the findings.

Review of the following NFPA Standard revealed: 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.
2012 NFPA 101, 9.7.5

Based on observation, record review and interview the facility does not assure a fire watch procedure and policy is written as required for implementation when the fire sprinkler system is out of service for more than 10 hours in a 24 hour period and fire alarm more than 4 hours in a 24 hour period. This deficient practice would prevent proper notification of insurance carrier, the alarm company, property owner or designated representative, and other authorities having jurisdiction as required, affecting all patients and staff in in all smoke zones. The facility has a capacity of 25 and a census of 1 at the time of survey.

Findings include:

During record review on June 7, 2017, the following is observed: Between 10:30 am and 12:30 pm it is revealed that the facility does not have a written policy for implementing a fire watch for sprinkler system
The Maintenance Director was present during the survey and acknowledged the findings.

Review of the following NFPA Standard revealed: Sprinkler System Impairments. Sprinkler impairment procedures shall comply with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. 2012 NFPA 101, 9.7.6

Review of the following NFPA Standard revealed: All preplanned impairments shall be authorized by the impairment coordinator. 2011 NFPA 25, 15.5.1

Review of the following NFPA Standard revealed: Before authorization is given, the impairment coordinator shall be responsible for verifying that the following procedures have been implemented:
(1) The extent and expected duration of the impairment have been determined.
(2) The areas or buildings involved have been inspected and the increased risks determined.
(3) Recommendations have been submitted to management or the property owner or designated representative.
(4) Where a required fire protection system is out of service for more than 10 hours in a 24-hour period, the impairment coordinator shall arrange for one of the following:
(a) Evacuation of the building or portion of the building affected by the system out of service
(b) An approved fire watch
(c) Establishment of a temporary water supply
(d) Establishment and implementation of an approved program to eliminate potential ignition sources and limit the amount of fuel available to the fire
(5) The fire department has been notified.
(6) The insurance carrier, the alarm company, property owner or designated representative, and other authorities having jurisdiction have been notified.
(7) The supervisors in the areas to be affected have been notified.
(8) A tag impairment system has been implemented. (See Section 15.3.)
(9) All necessary tools and materials have been assembled on the impairment site. 2011 NFPA 25, 15.5.2

Review of the following NFPA Standard revealed: Emergency impairments shall include, but are not limited to, system leakage, interruption of water supply, frozen or ruptured piping, and equipment failure. When emergency impairments occur, emergency action shall be taken to minimize potential injury and damage.
The coordinator shall implement the steps outlined in Section 15.5. 2011 NFPA 25, 15.6.1, 15.6.2 & 15.6.3

Review of the following NFPA Standard revealed: Restoring Systems to Service. When all impaired equipment is restored to normal working order, the impairment coordinator shall verify that the following procedures have been implemented:
(1) Any necessary inspections and tests have been conducted to verify that affected systems are operational. The appropriate chapter of this standard shall be consulted for guidance on the type of inspection and test required.
(2) Supervisors have been advised that protection is restored.
(3) The fire department has been advised that protection is restored.
(4) The property owner or designated representative, insurance carrier, Alarm Company, and other authorities having jurisdiction have been advised that protection is restored.
(5) The impairment tag has been removed 2011 NFPA 25, 15.7

Based on observation and staff interview the facility fails to maintain smoke barriers to at least one hour fire resistance. This deficient practice would prevent containment of fire and smoke, affecting patients and staff in 2 of 3 smoke zones. The facility has a capacity of 25 with a census of 1 at the time of survey.
Findings include:
During the survey on June, 7 2017 the following is observed:
1. At 3:35 PM it is observed that the corridor smoke barrier wall opposite of room 232 has penetration from cables above suspended ceiling.

2. At 3:45 PM it is observed that corridor barrier wall in front lobby to common entry and clinic wing has penetration from cables above suspended ceiling,
The Maintenance Director was present and acknowledged the findings
Review of the following NFPA Standard revealed: 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) (c).
(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.
19.3.7.4 Reserved.
NFPA 101 2012 19.3.7.3, 19.3.7.5 Accumulation space shall be provided in accordance

Based on record review and staff interviews, the facility does not have a written evacuation and relocation plan that addresses each smoke zone in the event of an actual emergency, affecting all patients in all 3 smoke zones. The facility has a capacity of 25 with a census of 1 at the time of survey.
Findings include:
During record review on June 7, 2017, the following is observed: Between 10:30 am and 12:30 pm it is revealed that the facility does not have a written policy for the evacuation and relocation of staff and patients. The policy must include a detail of how each smoke zone will relocate and or evacuate staff and patients.
The Director was present during the survey and acknowledged the findings.
Review of the following NFPA Standard revealed: 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

NFPA 101 2012, 19.7.2.2

Based on record review and staff interview, the facility is not conducting fire drills at unexpected times as not establish a routine for each shift as required quarterly .This deficient practice affects the ability of the staff to properly respond in the event of an actual emergency and affects all Patients in 3 smoke zones. The facility has a capacity of 25 and a census of 1 at the time of survey.
Findings include:
During record review on June 7, 2017, between 10:30 am and 12:30pm, the following is observed:

1. Review of the facility's fire drill records for the previous 12 months revealed that fire drills conducted on the 1st shift during the last four quarters revealed that 2 of the 4 occurred within an hour of each other between 11:45 AM and 11:20 AM.

2. Review of the facility's fire drill records for the previous 12 months revealed that fire drills conducted on the 2nd shift during the last four quarters, revealed that 2 of the 4 occurred within an hour of each other between 4:00 PM and 4:45 PM

The Maintenance Director was present and acknowledged the findings

Review of the following NFPA Standard revealed: 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.
NFPA 101 2012, 19.7.1.6

Based on record review and staff interview the facility failed to assure that portable space heaters are not being used within the facility. This deficient practice could cause a fire due to excessive heat, affecting 1 of 3 smoke zones. This facility has a capacity of 25 beds with a census of 1 patient at the time of the survey.

Findings include:

During the survey on June 7, 2017, at 2:43 pm. the following is observed: a portable space heater is found under a desk in room 232.
The Maintenance Director was present and acknowledged the findings

Review of the following NFPA Standard revealed: Portable Space-Heating Devices. Portable space heating devices shall be prohibited in all health care occupancies, unless both of the following criteria are met:
(1) Such devices are used only in nonsleeping staff and employee areas.
(2) The heating elements of such devices do not exceed 212°F (100°C).
NFPA 101 2012, 19.7.8

Based on record review and staff interview , the facility failed to assure that medical gas piping system are maintained and Labels are attached to medical gas piping systems. This deficient practice fails to ensure that meters, valves and regulators are clearly and permanently labeled for the medical gas piping system. The facility has a capacity of 25 and a census of 1 at the time of the survey.
Findings include:


During record review on June 7, 2017, between 10:30 am and 12:30pm, the following is observed: documentation from the last testing and maintenance inspection reviled that compressors, vacuum systems and source valves have deficiencies. No documentation is provided that the deficiencies have been corrected,



1. Air compressor has no local lag alarm tag installed and tied into master alarm panel.

2. Air compressor receiver does not have a sight glass.

4. Air compressor receiver does not have a 3-valve bypass.

5. Air compressor dryers cannot be isolated for service.

6. Air compressor does not have an auto drain on per-filters.

7. Air compressor filter cannot be isolated for service

8. Each air compressor regulator does not have its own pressure gauge.

9. Air compressor regulators cannot be isolated for service.

10. No air compressor dew point monitor is present and powered.

11. Air compressor does not have a carbon monoxide present and powered and has a non-expired calibration.

12. Air compressor has no sample port installed.

13. Air compressor intake is galvanized.

14. Vacuum does not have an isolation valve for service.

15. Vacuum does not have a local lag alarm installed and tied into master alarm panel.

16. Vacuum receiver cannot be isolated from the system

17. Bulk source valve is not properly labeled.

18. 1st floor ICU/recovery room 226-229 zone valve box is located behind normally open door.

19. 1st floor ICU/recovery room 226-229 no area alarm.


The Maintenance Director was present and acknowledged the findings



Equipment listed for use in oxygen-enriched atmospheres shall be so labeled.
NFPA 99 2012, 11.5.3.1.1

Oxygen-metering equipment and pressure reducing regulators shall be conspicuously labeled as follows: OXYGEN - USE NO OIL 11.5.3.1.3 Flowmeters, pressure reducing regulators, and oxygen-dispensing apparatus shall be clearly and permanently labeled, designating the gas or mixture of gases for which they are intended.
NFPA 99 2012, 11.5.3.1.2

Apparatus whose calibration or function is dependent on gas density shall be labeled as to the proper supply gas gauge pressure (kPa/psi) for which it is intended.
NFPA 99 2012, 11.5.3.1.4

Oxygen-metering equipment, pressure reducing regulators, humidifiers, and nebulizers shall be labeled with the name of the manufacturer or supplier
NFPA 99 2012, 11.5.3.1.5

Medical Air Compressor Systems

(A) Tests of the medical air compressor system shall include
the purity test for air quality, and the test of the alarm sensors
after calibration and setup per the manufacturer's instructions,
as well as lead-lag controls.
(B) Tests shall be conducted at the sample port of the medical
air system.
(C) The operation of the system control sensors, such as dew
point, air temperature, and all other air quality monitoring sensors
and controls, shall be checked for proper operation and
function before the system is put into service.
(D) The quality of medical air as delivered by the compressor air
supply shall be verified after installation of new components
prior to use by patients.
(E) The air quality tests in 5.1.12.3.14.3(D) shall be conducted
after the medical air source system, has been operating
normally but with the source valve closed under a simulated
load for an elapsed time of at least 12 hours.
(F) The aggregate run time on the compressors shall not be
used to determine the elapsed time.
(G) Loading shall be simulated by continuously venting air atapproximately 25 percent of the rated system capacity.
(H) Ademand of approximately 25 percent of the rated compressor
capacity shall be created to cause the compressors to
cycle on and off continuously and the dryers to operate for the
24-hour period.
NFPA 99 2012 5.1.12.3.14.3, 5.1.12.3.14.3


Maintenance of Medical Gas, Vacuum, WAGD, andMedical Support Gas Systems.

Scheduled maintenance

for equipment and procedures shall be established through
the risk assessment of the facility and developed with consideration
of the original equipment manufacturer recommendations
and other recommendations as required by the authority
having jurisdiction
NFPA 99 20125. 1.14.2 ,5.1.14.2.2.4.