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Based on document review and staff interview, it was determined that the hospital did not ensure that the sprinkler system is maintained in accordance with NFPA 25 1998 Table 2-1 and Table 9-1.

Findings include:

1. On 09/30/14 at 11:00 AM, the facility was requested to provide reports and details of follow up related to the survey of 01/13/2014, particularly information regarding the tests and maintenance of the sprinkler system.

On 10/01/14 at 11:30 AM, the Director of Engineering acknowledged that currently the facility did not have any documentation or report available to show that the five (5) year internal inspections for obstructions on the sprinkler piping, alarm valves, and associated trim and check valves, and verification for the recalibration and replacement of the gauges were conducted.

Furthermore, the facility did not have a current main drain test that may compare and evaluate the residual and static pressures from the previous years.

THESE ARE REPEAT CITATIONS FROM THE FULL FEDERAL SURVEY OF THE FACILITY DATED 01/13/14. The facility was cited for the same issue and had responded in its Plan of Correction that "The Associate Executive Director has secured the services of a Fire Suppression Engineering Company to determine the inspection and test points required to safely perform the sprinkler obstruction test for all sprinkler areas. The consulting firm has been contacted to evaluate the current maintenance program to ensure all the NFPA protocols are followed; to develop the scope of work to resolve the Life Safety Code Standards identified in tag K062. Testing will commence on 04/01/14 and will be completed by 06/30/14." Completion date 04/01/14-06/30/14.

The Plan of Correction further states "Access points to be installed into the sprinkler mains, to facilitate future testing and frequencies will follow NFPA protocols. The Director of Facilities will report to the Environment of Care (EOC) PI Committee monthly. Any significant Life Safety deficiencies will be escalated to the Executive QA/PI." Completion date 02/04/14-06/30/14 and On-going Monitoring.

For the issues of gauges and valves the Plan Of Correction states that "All gauges and valves are scheduled to be evaluated, repaired or replaced as needed as part of the scope of work from the consulting engineer." Completion date 04/01/14-06/30/14.

For the issue of Main Drain test the Plan of Correction states that "Associate Executive Director secured services of a Fire Suppression Engineering Company to determine inspection and test points required to perform the NFPA Main drain tests static and residual pressure from the previous reports." Completion date 04/01/14-06/30/14.

Facility at the time of this survey could not provide evidence of the completion of the work by 06/30/14 as promised in their Plan of Correction (POC). Also the completion date of 06/30/14 was indicated in a waiver request which was subsequently approved by the Centers for Medicare and Medicaid Services.

The facility did not complete the work, and therefore, has not provided any documentation or reports indicated in the waiver request. Also, the facility did not notify the Department of Health of any deviation from the proposed waiver request completion date.

All above findings were verified with the Associate Executive Director and Director of Engineering.

Based on observation and document review, the facility did not ensure that the penetrations of fire/smoke barrier walls were maintained for its full integrity by being protected/sealed with a material capable of maintaining the fire and smoke resistance of the barrier as per NFPA 101, 2000, 8.3.6.

Findings include:

1. On 09/30/14 at 11:00 AM, facility was requested to provide plans, evidence and progress regarding the resolution of the issue of penetrations of the fire/smoke barrier walls that were noted during the Federal survey of 01/13/14.

The Associate Executive Director (AED) stated that the patient care buildings and floors were being taken care first and that the Mural Pavilion (MP) building was evaluated and all penetrations were appropriately sealed. However, later in the afternoon of 09/30/14, he stated that he is not sure if the whole MP building was completely patched for all penetrations.

The AED provided a document titled 'Above Ceiling Inspections' indicating the schedule the facility is utilizing for tracking the work of penetrations and fire spray of I-beams.

In the first column for 'location' this schedule had floor numbers. There was no other information in the schedule as to how many barriers and areas of concern in need of being fixed / patched were identified during the facility's floor by floor inspections. In the second column the 'priority levels' were designated. No supporting document was available to identify the criteria used to determine the priority levels, so the appropriateness of the assigned priority levels could not be evaluated nor could it be determined if the needs of the patient care floors were being adequately addressed.

For the Mural Pavilion building only Floor #6 was documented in the schedule as high priority and all other floors were rated as medium and low. The schedule indicated only floor #6 of MP building was completed by 06/27/14.

The Associate Executive Director stated that in the MP building floors #3 and #4 are the Surgical Suites/Operating Rooms floors. No explanation was provided as to why the Operating Room floors were not identified as high priority. Per the facility's schedule the completion date for floor #3 and #4 is 08/15 and 07/15 respectively.

As per the waiver request that was submitted by the facility and subsequently approved by the Centers For Medicare and Medicaid Services, the facility ensured that "All direct patient care areas will be completed by 01/31/2015".

The facility did not ensure that the evaluation and assignment of the priority levels was done in a way to ensure that needed work in the patient care areas would be completed within the stated time frames.

2. During the tour of the facility from 09/30/14 to 10/01/14 between 11:00 AM to 3:00 PM, the fire/smoke barriers above the drop ceiling by the double doors were inspected for the integrity of smoke barriers. The inspection included the areas that were identified as being fixed by the facility as per the schedule/document "Above Ceiling Inspection". The following issues were observed:

i. Mural Pavilion (MP)-Floor #6 - Completion date 06/27/14:
A conduit with many wires measuring approximately 3 inch in diameter was noted penetrating the above door barrier by room #6193. This conduit did not have any fire stopping material fill stuffed inside it to avoid transfer of smoke/fire.

ii. Martin Luther King Building (MLK) - Floor #4 - Completion date 03/27/14:
Inspection of the space above the double doors in the Labor and Delivery unit revealed that there were holes with gray wires passing through the barrier that were not sealed. As per facility staff these holes appeared to have been made after the barrier was fixed / patched.

Furthermore in the above ceiling inspection of the waiting room two big gaps/penetrations measuring approximately 12 inches in diameter were observed made by sprinkler pipes. These gaps/penetrations were not sealed with anything.

iii. Martin Luther King Building (MLK) - Floor #3 - Completion date 04/29/14:
Above ceiling inspection revealed many gaps and holes in the barrier wall of the Out-patient Pain Management clinic.

iv. Martin Luther King Building (MLK) - Floor #15 - Completion date 09/04/14:
Above ceiling inspection by the storage areas reveled that the barrier was not going from slab to slab. There were penetrations made by cooper colored pipes that were not sealed with appropriate fire retardant material. Furthermore, there was many gaps noted in the barrier.


The facility's schedule for repairing the barrier walls in these areas indicated that they were completely fixed. However, during the check of the progress of the repairs it was revealed that the barrier walls were not completely repaired. Since the facility did not have any documentation regarding how many, where and when penetrations were noted, the conditions observed during the survey could not be determined as being either pre-existing conditions that were not yet addressed or new conditions that developed after the inspections and or repairs were completed.

All above findings were verified with the Associate Executive Director and the maintenance staff escorting the surveyor during survey.

Based on the review of facility's emergency generator monthly load test logs and staff interview it could not be determined if the generators meet the guidelines of NFPA 99, 3.4.2.2, 3.4.2.1.4 and NFPA 110, since there was no transfer time or load pick up time indicated in the logs for the transfer from normal power to emergency power. This transfer must occur in 10 seconds or less.

Findings include:

On 09/30/14 at 11:00 AM facility was requested to provide the monthly load test logs for the emergency generators to show the transfer time from normal power to emergency power. On 10/01/14 at 2:00 PM, the Director or Facilities stated that the annual test of the automatic transfer switches (ATS) was done in 04/14 and that their is no requirement to test the ATS switch every month to assure that the transfer from normal power to emergency power occurs in 10 seconds or less.

THIS IS A REPEAT CITATION FROM THE FEDERAL SURVEY OF 01/13/14 FOR THE SAME ISSUE OF NO INFORMATION ON TRANSFER TIME DURING MONTHLY LOAD TEST. Facility in its Plan of Correction stated that "On a rotating basis, one ATS switch (critical) per month will be tested to ensure appropriate transfer time". Completion date 02/28/14.

The Associate Executive Director stated that when the facility started the testing of the emergency generators at the beginning of the year the transfer time was within the required 10 seconds. However, in the month of August 2014, the electrician pointed out that the transfer time was more than 10 seconds - about 11 to 12 seconds. When the issue was identified in August, the facility contacted an engineering company and requested a proposal repair / adjust the transfer time to be within 10 seconds. A copy of the proposal from the selected engineering contractor dated 08/21/14 was provided to the surveyor. It indicated that the facility notified the engineering company that the ATS does not transfer within 10 seconds as required by NFPA codes and that a thorough evaluation is required.

During review of the emergency generator monthly load test reports on 10/01/14 at 2:30 PM, there was no documentation of transfer time found in the previous load test reports / logs. Facility provided another log in conjunction with the monthly load tests which was titled "Automatic Transfer Switches (ATS) Testing". This ATS testing log only indicated which ATS switch was utilized for start-up of the generator, but did not have any transfer time documented.

The facility has been unable to demonstrate, since the date of the prior Federal Survey, for any month, that transfer from normal power to emergency power has occurred in 10 seconds or less, as is required under NFPA 99, 3.4.2.2, 3.4.2.1.4 and NFPA 110. Therefore, the completion date of 02/28/14 has not been met.

Findings were verified with Director of Facilities and Associate Executive Director.

Based on staff interview and document review, all electrical receptacles in patient care areas were not tested and maintained as per the codes of NFPA 1999 (99 ed).

Findings include:

On 09/30/14 at 11:30 AM, facility was requested to provide evidence/report and progress regarding the resolution of the issue of electrical receptacle testing in the facility that was noted lacking during the Federal survey of 01/13/14.

The Associate Executive Director provided a document /schedule titled "Receptacles Testing". The document indicated that the Martin Luther King (MLK) building was almost complete with receptacle testing, however, the Mural Pavilion (MP) building did not start the testing work on any of the floors.

It is to be noted and was told to the surveyor that floors #3 & #4 are the Surgical Suites/Operating Rooms floors in the MP building. The electrical testing on these floors was to be completed by 03/31/2014. No explanation was provided regarding why the electrical receptacles testing was not conducted on the above floors by the anticipated date of completion.

During the Federal Survey of 01/13/14 , the issue of electrical receptacles not being tested was identified. The facility in its Plan of Correction had stated that "All facility electrical receptacles testing has commenced on 03/01/14, testing throughout the Hospital. Patient Care Areas will be given priority". Completion date 03/01/14-06/30/15.

In the 'Receptacles Testing' schedule provided it was noted that in the second column of the form the 'priority level' designated to the Surgical/Operating Room floors was identified as 'Medium'. Since it was defined as medium, no work was started on the floor. No supporting document was available to identify the criteria used to determine the priority levels, so the appropriateness of the assigned priority levels could not be evaluated nor could it be determined if the needs of the patient care floors were being adequately addressed. Furthermore, it is unclear why the Operating Rooms were not considered patient care areas and afforded a higher priority level.

All above findings were verified with the Associate Executive Director and Director of Engineering.