HospitalInspections.org

Based on observation and staff interview the facility is not ensuring that doors to the corridor are sealed to prevent the passage of smoke. This deficient practice of not ensuring that doors to the corridor prevents passage of smoke products prevents the ability of the facility to properly confine fire and smoke products and to properly defend occupants in place, affecting approximately patients in one of four smoke zones. The facility has a capacity of 25 with a census of 2 at the time of survey.

Findings include:

During the survey on September 17, 2015 at 2:00 PM it is observed that a self-closing device was removed from the west laboratory door to corridor leaving four bolts holes approximately ¼ inch in diameter where self-closing device removed.

The Maintenance Director was present at the time of the observation and acknowledged the findings.

Review of the following NFPA Standard revealed: Doors in corridor walls of sprinklered buildings shall be constructed to resist the passage of smoke and shall be provided with suitable means of keeping the doors closed. Doors in non sprinklered buildings shall have doors constructed to resist the passage of smoke for at least twenty minutes and shall be provided with suitable means of keeping the doors closed. Doors should not be blocked open by furniture, doorstops, chocks, tiebacks, drop down or plunger type devices, or other devices that necessitate manual unlatching or releasing action. Friction latches or magnetic catches that release when the door is pushed or pulled are acceptable. Clearance between the bottom of the door and the floor covering shall not exceed 1 inch. 2000 NFPA 101, 19.3.6.3.1 and 19.3.6.3

Based on observation and staff interview the facility fails to maintain two of three smoke barriers to at least one half hour fire resistance and ensure continuation of the smoke barrier seal. This deficient practice would prevent containment of fire and smoke, affecting 25 patients in three of four smoke zones. The facility has a capacity of 25 and a census of 2 at the time of survey.

Findings include:

During the survey on September 18, 2015 the following is observed:

1. At 8:55AM the smoke barrier wall above the ceiling tile level in room 122 has a 3 inch diameter opening where the sprinkler piping penetrates the smoke barrier.

2. At 9:10 AM the smoke barrier wall above the ceiling tile level in the nurse rest room has a 3 inch diameter opening where the sprinkler piping penetrates the smoke barrier.

3. At 9:45 AM the smoke barrier wall above the ceiling tile level in room 106 does not extend to the roof decks. The incomplete portion of the west wall in this room is approximately 16 foot by 18 inches.

4. At 9:55 AM the smoke barrier wall above the ceiling tile level in room 117 has a ½ inch gap around two separate conduit runs passing through the barrier.

The Maintenance Director was present at the time of the observation and acknowledged the findings.

Review of the following NFPA Standard revealed: Requires smoke walls to have a fire resistance rating of at least a half hour and to be continuous from floor to roof deck and from outside wall to outside wall. 2000 NFPA 101, 19.3.7.3

Review of the following NFPA Standard revealed: Smoke barriers shall be continuous from an outside wall to an outside wall. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces per NFPA 101, 8.3.2. When pipes, conduits, cables, wires, air ducts and similar building service equipment pass through smoke barriers, the space between the penetrating item and the smoke barrier shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier or protected by an approved device that is designed for the specific purpose per 2000 NFPA 101, 8.3.6.1

Based on observation and staff interview, the facility failed to provide separation of hazardous areas from other spaces. The area of deficient practice would provide a path for smoke and fire to travel into adjoining areas, affecting patients in one of four smoke zones. This facility has a capacity of 25 and a census of 2at the time of the survey.

Findings include:

During the survey on September 17, 2015 at 1:45 PM it is observed that the east wall of the boiler room abutting the corridor is penetrated where a blue data sleeve passes through the wall leaving a ¼ inch gap around the data sleeve.

The Maintenance Director was present at the time of the observation and acknowledged the findings.

Review of the following NFPA Standard revealed: Hazardous areas shall be safeguarded by a fire barrier of one-hour fire resistance rating or provided with an automatic sprinkler system and doors shall have self-closing devices and positive latches. 2000 NFPA 101, 19.3.2.1 and 2000 NFPA 101, 8.4.1

Review of the following NFPA Standard revealed: Protection from any area having a degree of hazard greater than that normal to the general occupancy of the building or structure shall be provided by one of the following means:
(1) Enclose the area with a fire barrier without windows that has a 1 hour fire resistance rating in accordance with Section 8.2.
(2) Protect the area with automatic extinguishing systems in accordance with Section 9.7.
(3) Apply both 8.4.1.1(1) and (2) where the hazard is severe or where otherwise specified by Chapters 12 through 42. 2000 NFPA 101, 8.4.1

Based on observation and staff interview the facility fails to assure there is sufficient normal illumination for the exit discharge paths. This deficient practice fails to ensure that all areas of egress will not be left in total darkness, affecting all occupants in four of four smoke zones. The facility has a capacity of 25 with a census of 2 at the time of survey.

Findings include:

During the survey on September 17, 2015 at 2:10 PM it is observed that the normal lighting for all exit discharge paths except the former ambulance canopy on the northwest side of the hospital, rely on single bulb fixtures to supply lighting for these exit discharge paths.

The Maintenance Director was present at the time of the observation 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.

Exception: Automatic, motion sensor type lighting switches shall be permitted within the means of egress, provided that the switch controllers are equipped for fail safe operation, the illumination timers are set for a minimum15 minute duration, and the motion sensor is activated by any occupant movement in the area served by the lighting units. 2000 NFPA 101, Section 7.8.1.2

Review of the following NFPA Standard revealed: Required illumination shall be arranged so that the failure of any single bulb or unit does not result in less than .2 foot-candles of illumination in any designated area. 2000 NFPA 101, 7.8.1.4

Based on observation and staff interview the facility failed to provide emergency lighting as required for exit discharge paths. The deficient practice could leave the exit discharge paths without illumination during a disruption of normal power or in the event of an emergency. This deficiency affects all occupants in four of four smoke zones. The facility has a capacity of 25 and census of 2 at the time of the survey.

Findings include:

During the survey on September 17, 2015 2:10 PM it is observed that all the exit discharge lighting is activated by a timing device. These are the same fixtures relied upon to provide the emergency lighting.

The Maintenance Director was present at the time of the observation and acknowledged the findings.

Review of the following NFPA Standard revealed: Emergency lighting for means of egress shall be provided in accordance with Section 7.9 for the following: buildings or structures where required by the occupancy chapters, underground and windowless structures as required by Section 11.7, high-rise buildings as required by other sections of this Code, doors equipped with delayed egress locks, and stair shaft and vestibules of smoke proof enclosures. For the purposes of this requirement, exit access shall include designated stairs, aisles, corridors, ramps, escalators, and passageways leading to an exit and exit discharge shall include designated stairs, ramps, aisles, walkways, and escalators leading to a public way. 2000 NFPA 101, 7.9.1.1

Review of the following NFPA Standard revealed: Emergency illumination shall be provided for not less than 11/2 hours in the event of failure of normal lighting. Emergency lighting facilities shall be arranged to provide initial illumination that is not less than an average of 1 foot-candle. 2000 NFPA 101, 7.9.2.1

Review of the following NFPA Standard revealed: The emergency lighting system shall be arranged to provide the required illumination automatically in the event of the interruption of normal lighting, opening of a circuit breaker, or a manual act, including accidental opening of a switch controlling normal lighting facilities. 2000 NFPA 101, 7.9.2.2

Based on record review and staff interview the facility failed to provide a written fire safety plan that addresses the transmission of the alarm to the fire department. The deficient practice may delay response of the fire department, affecting all occupants in four of four smoke zones. The facility has a capacity of 25 and census of 2 at the time of the survey.

Findings include:

During the record review on September 18, 2015at 12:40 PM it is observed that the written fire emergency plan does not indicate that the requirement for transmission of the alarm to the fire department.

The Maintenance Supervisor was present at the time of the observation and acknowledged the findings.

Review of the following NFPA Standard revealed: The administration of every health care occupancy shall have, in effect and available to all supervisory personnel, written copies of a plan for the protection of all persons in the event of fire, for their evacuation to areas of refuge, and for their evacuation from the building when necessary. All employees shall be periodically instructed and kept informed with respect to their duties under the plan. A copy of the plan shall be readily available at all times in the telephone operator ' s position or at the security center. The provisions of 19.7.1.2 through 19.7.2.3 shall apply. 2000 NFPA 101, Section 19.7.1.1

Review of the following NFPA Standard revealed: For health care occupancies, the proper protection of patients shall require the prompt and effective response of health care personnel. The basic response required of staff shall include the removal of all occupants directly involved with the fire emergency, transmission of an appropriate fire alarm signal to warn other building occupants and summon staff, confinement of the effects of the fire by closing doors to isolate the fire area, and the relocation of patients as detailed in the health care occupancy ' s fire safety plan. 2000 NFPA 101, Section 19.7.2.1

Review of the following NFPA Standard revealed: A written health care occupancy fire safety plan shall provide for the following:

(1) Use of alarms
(2) Transmission of alarm to fire department
(3) Response to alarms
(4) Isolation of fire
(5) Evacuation of immediate area
(6) Evacuation of smoke compartment
(7) Preparation of floors and building for evacuation
(8) Extinguishment of fire
2000 NFPA 101, Section 19.7.2.2

Based on record review and staff interview, the facility is not conducting fire drills as required and properly recording the results and facts relating to the fire drills. This deficient practice affects the ability of the staff to properly respond in the event of an actual emergency, affecting all occupants in all four smoke zones. The facility has a capacity of 25 with a census of 2 at the time of survey.

Findings include:

During record review on September 18, 2015 at 12:45 PM the following is observed:

1. Review of fire drill records for the last 6 quarters revealed that the drills conducted on August 28, 2014 at 10:45AM, November 28, 2014 at 7:30 AM and January 21, 2015 at 2:25 PM did not transmit an alarm to the monitoring company when compared to the monitoring company ' s receiving log.

2. Review of the facility's fire drill records for the last 6 quarters revealed that the drills conducted on September 12, 2014 at 3:30 AM, February 25, 2015 at 3:20 AM and April 28, 2015at 11:30PM indicated that these drills were audible type drills and did not transmit an alarm to the monitoring company when compared to the monitoring company ' s receiving log.

3. Review of the facility's fire drill records for the last 6 quarters revealed that no time of day was recorded on the drill record dated July 28, 2015.

4. Review of the facility's fire drill records for the last 6 quarters revealed that fire drills have not been conducted for each shift based on employee group and shift schedule. This facility employs a 12 hour employee schedule and each employee group is not being drilled quarterly.

The Maintenance Director was present at the time of the observation and acknowledged the findings.

Review of the following NFPA Standard revealed: 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. 2000 NFPA 101, 19.7.1.2

Based on observation and record review, the facility failed to provide and maintain the fire alarm system as required by NFPA 72. The failure to replace batteries in the fire alarm control panel as required fails to ensure reliability of the alarm system in the event of an emergency, affecting the entire facility. The facility has a capacity of 25 and census of 2 at the time of the survey.

Findings include:

During the record review on September 18, 2015at 11:00 AM it is observed that the fire alarm vendor report dated February 4, 2015 indicated that the batteries in the fire alarm control panel failed the load test and there is no documentation indicating this deficiency has been remedied..

The Maintenance Director was present at the time of the observation and acknowledged the findings.

Review of the following NFPA Standard revealed: Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of the code, such device, equipment, system, condition, arrangement, level of protection, thereafter be maintained unless the Code exempts such maintenance. 2000 NFPA 101, 4.5.7

Review of the following NFPA Standard revealed: System defects and malfunctions shall be corrected. If a defect or malfunction is not corrected at the conclusion of system inspection, testing, or maintenance, the system owner representative shall be informed of the impairment in writing within 24 hours. 1999 NFPA 72, 7-1.1.2

Review of the following NFPA Standard revealed: Testing shall be performed in accordance with the schedules in Chapter 7 or more often if required by the authority having jurisdiction. If automatic testing is performed at least weekly be a remotely monitored fire alarm control unit specifically listed for the application, the manual testing frequency shall be permitted to be extended to annual. Table 7-3.2 shall apply.

Exception: Devices or equipment that are inaccessible for safety consideration (for example, continuous process operations, energized electrical equipment, radiation, and excessive height) shall be tested during scheduled shutdowns if approved by the authority having jurisdiction but shall not be tested more than every 18 months. 1999 NFPA 72, 7-3.2

Based on record review and staff interview, the facility failed to assure that the sprinkler system is tested in accordance with the 1998 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 occupants in all four smoke zones. The facility has a capacity of 25 with a census of 2 at the time of survey.

Findings include:

During record review on September 18, 2015 at 11:45 AM it is observed when reviewing the facility's sprinkler inspection and testing records for the last 6 quarters that quarterly testing was not performed utilizing the inspector ' s test valves located in two locations other than the sprinkler riser room.

The Maintenance Director was present during record review and acknowledged the findings.

Review of the following NFPA Standard revealed: Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction. 2000 NFPA 101, 4.6.12.1

Review of the following NFPA Standard revealed: 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. 2000 NFPA 101, 9.7.5

Review of the following NFPA Standard revealed: The owner or occupant shall provide ready accessibility to components of water based fire protection systems that require inspection, testing, or maintenance. 1998 NFPA 25, 14.1*

Review of the following NFPA Standard revealed: Alarm Devices. Waterflow alarm devices including, but not limited to, mechanical water motor gongs, vane-type waterflow devices, and pressure switches that provide audible or visual signals shall be tested quarterly. 1998 NFPA 25, 2-3.3.1

Review of the following NFPA Standard revealed: Testing the waterflow alarms on wet pipe systems shall be accomplished by opening the inspector ' s test connection. Fire pumps shall not be turned off during testing unless all impairment procedures contained in Chapter 11 are followed.

Exception: Where freezing weather conditions or other circumstances prohibit use of the inspector ' s test connection, the bypass connection shall be permitted to be used. 1998 NFPA 25, 2-3.3

Based on observation and record review, the facility fails to maintain fire dampers in heating, ventilation and air conditioning assemblies as required. This deficient practice of not identifying, testing and maintaining fire dampers as required, increases the risk fire affecting all occupants all four smoke zones. The facility has a capacity of 25 and census of 2 at the time of the survey.

Findings include:

During record review on September 18, 2015 at 11:15 AM it is observed that fusible link activated fire dampers in the heating and air conditioning system located throughout the facility have not been inspected and tested.

The Maintenance Director was present at the time of the observation and acknowledged the findings.

Review of the following NFPA Standard revealed: Air conditioning, heating, ventilating ductwork, and related equipment shall be in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, or NFPA 90B, Standard for the Installation of Warm Air Heating and Air-Conditioning Systems, as applicable, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction. 2000 NFPA 101, 9.2.1

Review of the following NFPA Standard revealed: At least every 4 years, fusible links 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. 1999 NFPA 90A, 3-4.7

Based on record review and staff interview the facility fails to provide for testing of the medical gas system. This deficient practice could adversely affect all persons using or receiving medical gases from the bulk medical gas system. The facility has a capacity of 25 and a census of 2 at the time of the survey.

Findings include:

During record review on September 18, 2015 at 11:45 AM it is observed that no documentation of medical gas system testing and inspection has been performed.

The Maintenance Director was present at the time of the observation and acknowledged the findings.

Review of the following NFPA Standard revealed: Medical gas storage and administration shall be protected in accordance with NFPA 99, Standard for Health Care Facilities. 2000 NFPA 101, 19.3.2.4

Review of the following NFPA Standard revealed: These systems should be checked daily to assure that proper pressure is maintained and that the changeover signal has not malfunctioned. Periodic retesting of the routine changeover signal is not required. Annual retesting of the operation of the reserve and activation of the reserve-in-use signal should be performed. 1999 NFPA 99, C-4.2.2 [4-3.1.1.6]

Review of the following NFPA Standard revealed: Piping system pressure gauges and other gauges designated alarms in 4-3.4.1.4(b)1 should be checked at least annually. 1999 NFPA 99, 4-3.1.2.1(b)6

Review of the following NFPA Standard revealed: Maintenance and periodic testing of the bulk system is the responsibility of the owner or the organization responsible for the operation and maintenance of that system. The staff of the facility should check the supply system daily to ensure that medical gas is ordered when the contents gauge drops to the reorder level designated by the supplier. Piping system pressure gauges and other gauges designated by the supplier should be checked regularly, and gradual variation, either increases or decreases, from the normal should be reported to the supplier. These variations might indicate the need for corrective action. Periodic testing of the master signal panel system, other than the routine changeover signal, should be performed. Request assistance from the supplier or detailed instruction readjustment of bulk supply controls is necessary to these tests.
1999 NFPA 99, C-4.2.4 [4-3.1.1.7]

Based on record review and staff interview the facility fails to ensure that anesthetizing locations have the capability of controlling the relative humidity at required levels. This deficient practice could adversely affect all occupants in anesthetizing locations. The facility has a capacity of 25 and a census of 2 at the time of the survey.

Findings include:

During record review on September 18, 2015 at 10:45 AM it is observed that no documentation of relative humidity conditions in anesthetizing locations has been performed.

The Maintenance Director was present at the time of the observation and acknowledged the findings.

Review of the following NFPA Standard revealed: Medical gas storage and administration shall be protected in accordance with NFPA 99, Standard for Health Care Facilities. 2000 NFPA 101, 19.3.2.4

Review of the following NFPA Standard revealed: The mechanical ventilation system supplying anesthetizing locations shall have the capability of controlling the relative humidity at a level of 35 percent or greater. 1999 NFPA 99, 5-4.1.1

Based on observation and staff interview the facility failed to provide a remote stop for the emergency generator power supply as required. The deficient practice may prevent the emergency power supply from being stopped at the time of a power loss, affecting all occupants in all smoke zones. The facility has a capacity of 25 and census of 2 at the time of the survey.

Findings include:

During the observation on September 17, 2015at 1:30 PM it is observed that there is no remote stop for the generator located external to the weatherproof exterior generator enclosure.

Review of the following NFPA Standard revealed: Emergency generators providing power to emergency lighting systems shall be installed, tested, and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. Stored electrical energy systems, where required in this Code, shall be installed and tested in accordance with NFPA 111, Standard on Stored Electrical Energy Emergency and Standby Power Systems. 2000 NFPA 101, 7.9.2.3

Review of the following NFPA Standard revealed: Emergency generators, where required for compliance with this Code, shall be tested and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. 2000 NFPA 101, 9.1.3

Review of the following NFPA Standard revealed: All Level 1 and Level 2 installations shall have a remote manual stop station of a type similar to a break-glass station located outside the room housing the prime mover, where so installed, or located elsewhere on the premises where the prime mover is located outside the building. 1999 NFPA 110, 3-5.5.6

Based on observation, record review and interview the facility does not assure a fire watch procedure and policy is written and available for implementation when the fire sprinkler system is out of service for more than 4 hours in a 24 hour period. This deficient practice would allow facility exposure to undetected smoke and/or fire without an automatic sprinkler compensatory provision when it occurred, and without appropriately prepared staff response, affecting 25 occupants in all smoke zones. The facility has a capacity of 25 and a census of 2 at the time of survey.

Findings include:

During record review on September 18, 2015 at 12:45 PM it is observed that the facility's written policy for implementing a fire watch does not indicate that a fire watch will begin when the fire sprinkler system is out of service for more than 4 hours in a 24 hour period.

The Maintenance Director was present at the time of the observation and acknowledged the findings.

Review of the following NFPA Standard revealed: Where a required automatic sprinkler system is out of service for more than 4 hours in a 24 hour period, the AHJ shall be notified, and the building shall be evacuated or an approved fire watch shall be provided until the sprinkler system has been returned to service. 2000 NFPA 101, 9.7.6.1

Review of the following NFPA Standard revealed: The following procedures shall be implemented: the extent and expected duration of the impairment shall be determined; the area or buildings involved shall be inspected and the increased risks determined; and recommendations submitted to management or building owner/manager. Where a required fire protection system is out of service for more than 4 hours in a 24 hour period, the impairment coordinator shall arrange for one of the following: evacuation of the building affected by the system out of service; an approved fire watch; establishment of a temporary water supply; implementation of a program to eliminate potential ignition sources and limit the amount of fuel available; notification of the fire department; the insurance carrier, the alarm company, building owner/manager, and other AHJ ' s; notification of the supervisors in the affected areas; a tag impairment system has been implemented; all necessary tools and materials have been assembled on the site for preplanned impairments. A fire watch should consist of trained personnel who continuously patrol the effected area, with ready access to fire extinguishers and the ability to promptly notify the fire department. During the patrol of the area, the person should be looking for fire, and other fire protection features of the building such as egress routes and alarm systems are available and functioning properly. 1998 NFPA 25, 11-5

Based on observation, record review and interview the facility does not assure a fire watch procedure and policy is written and available for implementation when fire alarm system is out of service for more than 4 hours in a 24 hour period. This deficient practice would allow facility exposure to undetected smoke and/or fire without an automatic detection compensatory provision when it occurred, and without appropriately prepared staff response, affecting 25 occupants in all smoke zones. The facility has a capacity of 25 and a census of 2 at the time of survey.

Findings include:

During record review on September 18, 2015 at 12:45 PM it is observed that the facility's written policy for implementing a fire watch does not indicate that a fire watch will begin when the fire alarm system is out of service for more than 4 hours in a 24 hour period.

The Maintenance Director was present at the time of the observation and acknowledged the findings.

Review of the following NFPA Standard revealed: When a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the AHJ shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties until the fire alarm system has been returned to service. A fire watch should consist of trained personnel who continuously patrol the effected area, with ready access to fire extinguishers and the ability to promptly notify the fire department. During the patrol of the area, the person should look for fire, and that other fire protection features of the building such as egress routes and alarm systems are available and functioning properly. 2000 NFPA 101, 9.6.1.8

Based on observation and staff interview the facility is not ensuring that doors to the corridor are sealed to prevent the passage of smoke. This deficient practice of not ensuring that doors to the corridor prevents passage of smoke products prevents the ability of the facility to properly confine fire and smoke products and to properly defend occupants in place, affecting approximately patients in one of four smoke zones. The facility has a capacity of 25 with a census of 2 at the time of survey.

Findings include:

During the survey on September 17, 2015 at 2:00 PM it is observed that a self-closing device was removed from the west laboratory door to corridor leaving four bolts holes approximately ¼ inch in diameter where self-closing device removed.

The Maintenance Director was present at the time of the observation and acknowledged the findings.

Review of the following NFPA Standard revealed: Doors in corridor walls of sprinklered buildings shall be constructed to resist the passage of smoke and shall be provided with suitable means of keeping the doors closed. Doors in non sprinklered buildings shall have doors constructed to resist the passage of smoke for at least twenty minutes and shall be provided with suitable means of keeping the doors closed. Doors should not be blocked open by furniture, doorstops, chocks, tiebacks, drop down or plunger type devices, or other devices that necessitate manual unlatching or releasing action. Friction latches or magnetic catches that release when the door is pushed or pulled are acceptable. Clearance between the bottom of the door and the floor covering shall not exceed 1 inch. 2000 NFPA 101, 19.3.6.3.1 and 19.3.6.3

Based on observation and staff interview the facility fails to maintain two of three smoke barriers to at least one half hour fire resistance and ensure continuation of the smoke barrier seal. This deficient practice would prevent containment of fire and smoke, affecting 25 patients in three of four smoke zones. The facility has a capacity of 25 and a census of 2 at the time of survey.

Findings include:

During the survey on September 18, 2015 the following is observed:

1. At 8:55AM the smoke barrier wall above the ceiling tile level in room 122 has a 3 inch diameter opening where the sprinkler piping penetrates the smoke barrier.

2. At 9:10 AM the smoke barrier wall above the ceiling tile level in the nurse rest room has a 3 inch diameter opening where the sprinkler piping penetrates the smoke barrier.

3. At 9:45 AM the smoke barrier wall above the ceiling tile level in room 106 does not extend to the roof decks. The incomplete portion of the west wall in this room is approximately 16 foot by 18 inches.

4. At 9:55 AM the smoke barrier wall above the ceiling tile level in room 117 has a ½ inch gap around two separate conduit runs passing through the barrier.

The Maintenance Director was present at the time of the observation and acknowledged the findings.

Review of the following NFPA Standard revealed: Requires smoke walls to have a fire resistance rating of at least a half hour and to be continuous from floor to roof deck and from outside wall to outside wall. 2000 NFPA 101, 19.3.7.3

Review of the following NFPA Standard revealed: Smoke barriers shall be continuous from an outside wall to an outside wall. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces per NFPA 101, 8.3.2. When pipes, conduits, cables, wires, air ducts and similar building service equipment pass through smoke barriers, the space between the penetrating item and the smoke barrier shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier or protected by an approved device that is designed for the specific purpose per 2000 NFPA 101, 8.3.6.1

Based on observation and staff interview, the facility failed to provide separation of hazardous areas from other spaces. The area of deficient practice would provide a path for smoke and fire to travel into adjoining areas, affecting patients in one of four smoke zones. This facility has a capacity of 25 and a census of 2at the time of the survey.

Findings include:

During the survey on September 17, 2015 at 1:45 PM it is observed that the east wall of the boiler room abutting the corridor is penetrated where a blue data sleeve passes through the wall leaving a ¼ inch gap around the data sleeve.

The Maintenance Director was present at the time of the observation and acknowledged the findings.

Review of the following NFPA Standard revealed: Hazardous areas shall be safeguarded by a fire barrier of one-hour fire resistance rating or provided with an automatic sprinkler system and doors shall have self-closing devices and positive latches. 2000 NFPA 101, 19.3.2.1 and 2000 NFPA 101, 8.4.1

Review of the following NFPA Standard revealed: Protection from any area having a degree of hazard greater than that normal to the general occupancy of the building or structure shall be provided by one of the following means:
(1) Enclose the area with a fire barrier without windows that has a 1 hour fire resistance rating in accordance with Section 8.2.
(2) Protect the area with automatic extinguishing systems in accordance with Section 9.7.
(3) Apply both 8.4.1.1(1) and (2) where the hazard is severe or where otherwise specified by Chapters 12 through 42. 2000 NFPA 101, 8.4.1

Based on observation and staff interview the facility fails to assure there is sufficient normal illumination for the exit discharge paths. This deficient practice fails to ensure that all areas of egress will not be left in total darkness, affecting all occupants in four of four smoke zones. The facility has a capacity of 25 with a census of 2 at the time of survey.

Findings include:

During the survey on September 17, 2015 at 2:10 PM it is observed that the normal lighting for all exit discharge paths except the former ambulance canopy on the northwest side of the hospital, rely on single bulb fixtures to supply lighting for these exit discharge paths.

The Maintenance Director was present at the time of the observation 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.

Exception: Automatic, motion sensor type lighting switches shall be permitted within the means of egress, provided that the switch controllers are equipped for fail safe operation, the illumination timers are set for a minimum15 minute duration, and the motion sensor is activated by any occupant movement in the area served by the lighting units. 2000 NFPA 101, Section 7.8.1.2

Review of the following NFPA Standard revealed: Required illumination shall be arranged so that the failure of any single bulb or unit does not result in less than .2 foot-candles of illumination in any designated area. 2000 NFPA 101, 7.8.1.4

Based on observation and staff interview the facility failed to provide emergency lighting as required for exit discharge paths. The deficient practice could leave the exit discharge paths without illumination during a disruption of normal power or in the event of an emergency. This deficiency affects all occupants in four of four smoke zones. The facility has a capacity of 25 and census of 2 at the time of the survey.

Findings include:

During the survey on September 17, 2015 2:10 PM it is observed that all the exit discharge lighting is activated by a timing device. These are the same fixtures relied upon to provide the emergency lighting.

The Maintenance Director was present at the time of the observation and acknowledged the findings.

Review of the following NFPA Standard revealed: Emergency lighting for means of egress shall be provided in accordance with Section 7.9 for the following: buildings or structures where required by the occupancy chapters, underground and windowless structures as required by Section 11.7, high-rise buildings as required by other sections of this Code, doors equipped with delayed egress locks, and stair shaft and vestibules of smoke proof enclosures. For the purposes of this requirement, exit access shall include designated stairs, aisles, corridors, ramps, escalators, and passageways leading to an exit and exit discharge shall include designated stairs, ramps, aisles, walkways, and escalators leading to a public way. 2000 NFPA 101, 7.9.1.1

Review of the following NFPA Standard revealed: Emergency illumination shall be provided for not less than 11/2 hours in the event of failure of normal lighting. Emergency lighting facilities shall be arranged to provide initial illumination that is not less than an average of 1 foot-candle. 2000 NFPA 101, 7.9.2.1

Review of the following NFPA Standard revealed: The emergency lighting system shall be arranged to provide the required illumination automatically in the event of the interruption of normal lighting, opening of a circuit breaker, or a manual act, including accidental opening of a switch controlling normal lighting facilities. 2000 NFPA 101, 7.9.2.2

Based on record review and staff interview the facility failed to provide a written fire safety plan that addresses the transmission of the alarm to the fire department. The deficient practice may delay response of the fire department, affecting all occupants in four of four smoke zones. The facility has a capacity of 25 and census of 2 at the time of the survey.

Findings include:

During the record review on September 18, 2015at 12:40 PM it is observed that the written fire emergency plan does not indicate that the requirement for transmission of the alarm to the fire department.

The Maintenance Supervisor was present at the time of the observation and acknowledged the findings.

Review of the following NFPA Standard revealed: The administration of every health care occupancy shall have, in effect and available to all supervisory personnel, written copies of a plan for the protection of all persons in the event of fire, for their evacuation to areas of refuge, and for their evacuation from the building when necessary. All employees shall be periodically instructed and kept informed with respect to their duties under the plan. A copy of the plan shall be readily available at all times in the telephone operator ' s position or at the security center. The provisions of 19.7.1.2 through 19.7.2.3 shall apply. 2000 NFPA 101, Section 19.7.1.1

Review of the following NFPA Standard revealed: For health care occupancies, the proper protection of patients shall require the prompt and effective response of health care personnel. The basic response required of staff shall include the removal of all occupants directly involved with the fire emergency, transmission of an appropriate fire alarm signal to warn other building occupants and summon staff, confinement of the effects of the fire by closing doors to isolate the fire area, and the relocation of patients as detailed in the health care occupancy ' s fire safety plan. 2000 NFPA 101, Section 19.7.2.1

Review of the following NFPA Standard revealed: A written health care occupancy fire safety plan shall provide for the following:

(1) Use of alarms
(2) Transmission of alarm to fire department
(3) Response to alarms
(4) Isolation of fire
(5) Evacuation of immediate area
(6) Evacuation of smoke compartment
(7) Preparation of floors and building for evacuation
(8) Extinguishment of fire
2000 NFPA 101, Section 19.7.2.2

Based on record review and staff interview, the facility is not conducting fire drills as required and properly recording the results and facts relating to the fire drills. This deficient practice affects the ability of the staff to properly respond in the event of an actual emergency, affecting all occupants in all four smoke zones. The facility has a capacity of 25 with a census of 2 at the time of survey.

Findings include:

During record review on September 18, 2015 at 12:45 PM the following is observed:

1. Review of fire drill records for the last 6 quarters revealed that the drills conducted on August 28, 2014 at 10:45AM, November 28, 2014 at 7:30 AM and January 21, 2015 at 2:25 PM did not transmit an alarm to the monitoring company when compared to the monitoring company ' s receiving log.

2. Review of the facility's fire drill records for the last 6 quarters revealed that the drills conducted on September 12, 2014 at 3:30 AM, February 25, 2015 at 3:20 AM and April 28, 2015at 11:30PM indicated that these drills were audible type drills and did not transmit an alarm to the monitoring company when compared to the monitoring company ' s receiving log.

3. Review of the facility's fire drill records for the last 6 quarters revealed that no time of day was recorded on the drill record dated July 28, 2015.

4. Review of the facility's fire drill records for the last 6 quarters revealed that fire drills have not been conducted for each shift based on employee group and shift schedule. This facility employs a 12 hour employee schedule and each employee group is not being drilled quarterly.

The Maintenance Director was present at the time of the observation and acknowledged the findings.

Review of the following NFPA Standard revealed: 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. 2000 NFPA 101, 19.7.1.2

Based on observation and record review, the facility failed to provide and maintain the fire alarm system as required by NFPA 72. The failure to replace batteries in the fire alarm control panel as required fails to ensure reliability of the alarm system in the event of an emergency, affecting the entire facility. The facility has a capacity of 25 and census of 2 at the time of the survey.

Findings include:

During the record review on September 18, 2015at 11:00 AM it is observed that the fire alarm vendor report dated February 4, 2015 indicated that the batteries in the fire alarm control panel failed the load test and there is no documentation indicating this deficiency has been remedied..

The Maintenance Director was present at the time of the observation and acknowledged the findings.

Review of the following NFPA Standard revealed: Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of the code, such device, equipment, system, condition, arrangement, level of protection, thereafter be maintained unless the Code exempts such maintenance. 2000 NFPA 101, 4.5.7

Review of the following NFPA Standard revealed: System defects and malfunctions shall be corrected. If a defect or malfunction is not corrected at the conclusion of system inspection, testing, or maintenance, the system owner representative shall be informed of the impairment in writing within 24 hours. 1999 NFPA 72, 7-1.1.2

Review of the following NFPA Standard revealed: Testing shall be performed in accordance with the schedules in Chapter 7 or more often if required by the authority having jurisdiction. If automatic testing is performed at least weekly be a remotely monitored fire alarm control unit specifically listed for the application, the manual testing frequency shall be permitted to be extended to annual. Table 7-3.2 shall apply.

Exception: Devices or equipment that are inaccessible for safety consideration (for example, continuous process operations, energized electrical equipment, radiation, and excessive height) shall be tested during scheduled shutdowns if approved by the authority having jurisdiction but shall not be tested more than every 18 months. 1999 NFPA 72, 7-3.2

Based on record review and staff interview, the facility failed to assure that the sprinkler system is tested in accordance with the 1998 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 occupants in all four smoke zones. The facility has a capacity of 25 with a census of 2 at the time of survey.

Findings include:

During record review on September 18, 2015 at 11:45 AM it is observed when reviewing the facility's sprinkler inspection and testing records for the last 6 quarters that quarterly testing was not performed utilizing the inspector ' s test valves located in two locations other than the sprinkler riser room.

The Maintenance Director was present during record review and acknowledged the findings.

Review of the following NFPA Standard revealed: Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction. 2000 NFPA 101, 4.6.12.1

Review of the following NFPA Standard revealed: 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. 2000 NFPA 101, 9.7.5

Review of the following NFPA Standard revealed: The owner or occupant shall provide ready accessibility to components of water based fire protection systems that require inspection, testing, or maintenance. 1998 NFPA 25, 14.1*

Review of the following NFPA Standard revealed: Alarm Devices. Waterflow alarm devices including, but not limited to, mechanical water motor gongs, vane-type waterflow devices, and pressure switches that provide audible or visual signals shall be tested quarterly. 1998 NFPA 25, 2-3.3.1

Review of the following NFPA Standard revealed: Testing the waterflow alarms on wet pipe systems shall be accomplished by opening the inspector ' s test connection. Fire pumps shall not be turned off during testing unless all impairment procedures contained in Chapter 11 are followed.

Exception: Where freezing weather conditions or other circumstances prohibit use of the inspector ' s test connection, the bypass connection shall be permitted to be used. 1998 NFPA 25, 2-3.3

Based on observation and record review, the facility fails to maintain fire dampers in heating, ventilation and air conditioning assemblies as required. This deficient practice of not identifying, testing and maintaining fire dampers as required, increases the risk fire affecting all occupants all four smoke zones. The facility has a capacity of 25 and census of 2 at the time of the survey.

Findings include:

During record review on September 18, 2015 at 11:15 AM it is observed that fusible link activated fire dampers in the heating and air conditioning system located throughout the facility have not been inspected and tested.

The Maintenance Director was present at the time of the observation and acknowledged the findings.

Review of the following NFPA Standard revealed: Air conditioning, heating, ventilating ductwork, and related equipment shall be in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, or NFPA 90B, Standard for the Installation of Warm Air Heating and Air-Conditioning Systems, as applicable, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction. 2000 NFPA 101, 9.2.1

Review of the following NFPA Standard revealed: At least every 4 years, fusible links 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. 1999 NFPA 90A, 3-4.7

Based on record review and staff interview the facility fails to provide for testing of the medical gas system. This deficient practice could adversely affect all persons using or receiving medical gases from the bulk medical gas system. The facility has a capacity of 25 and a census of 2 at the time of the survey.

Findings include:

During record review on September 18, 2015 at 11:45 AM it is observed that no documentation of medical gas system testing and inspection has been performed.

The Maintenance Director was present at the time of the observation and acknowledged the findings.

Review of the following NFPA Standard revealed: Medical gas storage and administration shall be protected in accordance with NFPA 99, Standard for Health Care Facilities. 2000 NFPA 101, 19.3.2.4

Review of the following NFPA Standard revealed: These systems should be checked daily to assure that proper pressure is maintained and that the changeover signal has not malfunctioned. Periodic retesting of the routine changeover signal is not required. Annual retesting of the operation of the reserve and activation of the reserve-in-use signal should be performed. 1999 NFPA 99, C-4.2.2 [4-3.1.1.6]

Review of the following NFPA Standard revealed: Piping system pressure gauges and other gauges designated alarms in 4-3.4.1.4(b)1 should be checked at least annually. 1999 NFPA 99, 4-3.1.2.1(b)6

Review of the following NFPA Standard revealed: Maintenance and periodic testing of the bulk system is the responsibility of the owner or the organization responsible for the operation and maintenance of that system. The staff of the facility should check the supply system daily to ensure that medical gas is ordered when the contents gauge drops to the reorder level designated by the supplier. Piping system pressure gauges and other gauges designated by the supplier should be checked regularly, and gradual variation, either increases or decreases, from the normal should be reported to the supplier. These variations might indicate the need for corrective action. Periodic testing of the master signal panel system, other than the routine changeover signal, should be performed. Request assistance from the supplier or detailed instruction readjustment of bulk supply controls is necessary to these tests.
1999 NFPA 99, C-4.2.4 [4-3.1.1.7]

Based on record review and staff interview the facility fails to ensure that anesthetizing locations have the capability of controlling the relative humidity at required levels. This deficient practice could adversely affect all occupants in anesthetizing locations. The facility has a capacity of 25 and a census of 2 at the time of the survey.

Findings include:

During record review on September 18, 2015 at 10:45 AM it is observed that no documentation of relative humidity conditions in anesthetizing locations has been performed.

The Maintenance Director was present at the time of the observation and acknowledged the findings.

Review of the following NFPA Standard revealed: Medical gas storage and administration shall be protected in accordance with NFPA 99, Standard for Health Care Facilities. 2000 NFPA 101, 19.3.2.4

Review of the following NFPA Standard revealed: The mechanical ventilation system supplying anesthetizing locations shall have the capability of controlling the relative humidity at a level of 35 percent or greater. 1999 NFPA 99, 5-4.1.1

Based on observation and staff interview the facility failed to provide a remote stop for the emergency generator power supply as required. The deficient practice may prevent the emergency power supply from being stopped at the time of a power loss, affecting all occupants in all smoke zones. The facility has a capacity of 25 and census of 2 at the time of the survey.

Findings include:

During the observation on September 17, 2015at 1:30 PM it is observed that there is no remote stop for the generator located external to the weatherproof exterior generator enclosure.

Review of the following NFPA Standard revealed: Emergency generators providing power to emergency lighting systems shall be installed, tested, and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. Stored electrical energy systems, where required in this Code, shall be installed and tested in accordance with NFPA 111, Standard on Stored Electrical Energy Emergency and Standby Power Systems. 2000 NFPA 101, 7.9.2.3

Review of the following NFPA Standard revealed: Emergency generators, where required for compliance with this Code, shall be tested and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. 2000 NFPA 101, 9.1.3

Review of the following NFPA Standard revealed: All Level 1 and Level 2 installations shall have a remote manual stop station of a type similar to a break-glass station located outside the room housing the prime mover, where so installed, or located elsewhere on the premises where the prime mover is located outside the building. 1999 NFPA 110, 3-5.5.6

Based on observation, record review and interview the facility does not assure a fire watch procedure and policy is written and available for implementation when the fire sprinkler system is out of service for more than 4 hours in a 24 hour period. This deficient practice would allow facility exposure to undetected smoke and/or fire without an automatic sprinkler compensatory provision when it occurred, and without appropriately prepared staff response, affecting 25 occupants in all smoke zones. The facility has a capacity of 25 and a census of 2 at the time of survey.

Findings include:

During record review on September 18, 2015 at 12:45 PM it is observed that the facility's written policy for implementing a fire watch does not indicate that a fire watch will begin when the fire sprinkler system is out of service for more than 4 hours in a 24 hour period.

The Maintenance Director was present at the time of the observation and acknowledged the findings.

Review of the following NFPA Standard revealed: Where a required automatic sprinkler system is out of service for more than 4 hours in a 24 hour period, the AHJ shall be notified, and the building shall be evacuated or an approved fire watch shall be provided until the sprinkler system has been returned to service. 2000 NFPA 101, 9.7.6.1

Review of the following NFPA Standard revealed: The following procedures shall be implemented: the extent and expected duration of the impairment shall be determined; the area or buildings involved shall be inspected and the increased risks determined; and recommendations submitted to management or building owner/manager. Where a required fire protection system is out of service for more than 4 hours in a 24 hour period, the impairment coordinator shall arrange for one of the following: evacuation of the building affected by the system out of service; an approved fire watch; establishment of a temporary water supply; implementation of a program to eliminate potential ignition sources and limit the amount of fuel available; notification of the fire department; the insurance carrier, the alarm company, building owner/manager, and other AHJ ' s; notification of the supervisors in the affected areas; a tag impairment system has been implemented; all necessary tools and materials have been assembled on the site for preplanned impairments. A fire watch should consist of trained personnel who continuously patrol the effected area, with ready access to fire extinguishers and the ability to promptly notify the fire department. During the patrol of the area, the person should be looking for fire, and other fire protection features of the building such as egress routes and alarm systems are available and functioning properly. 1998 NFPA 25, 11-5

Based on observation, record review and interview the facility does not assure a fire watch procedure and policy is written and available for implementation when fire alarm system is out of service for more than 4 hours in a 24 hour period. This deficient practice would allow facility exposure to undetected smoke and/or fire without an automatic detection compensatory provision when it occurred, and without appropriately prepared staff response, affecting 25 occupants in all smoke zones. The facility has a capacity of 25 and a census of 2 at the time of survey.

Findings include:

During record review on September 18, 2015 at 12:45 PM it is observed that the facility's written policy for implementing a fire watch does not indicate that a fire watch will begin when the fire alarm system is out of service for more than 4 hours in a 24 hour period.

The Maintenance Director was present at the time of the observation and acknowledged the findings.

Review of the following NFPA Standard revealed: When a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the AHJ shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties until the fire alarm system has been returned to service. A fire watch should consist of trained personnel who continuously patrol the effected area, with ready access to fire extinguishers and the ability to promptly notify the fire department. During the patrol of the area, the person should look for fire, and that other fire protection features of the building such as egress routes and alarm systems are available and functioning properly. 2000 NFPA 101, 9.6.1.8