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NFPA 101, 7.10.1.2 Exits. Exits other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign readily visible from any direction of exit access.

This STANDARD was not met as evidenced by:

Based on observation and staff interview, the facility failed to assure that all exits were obvious and clearly identifiable as exits.

Findings include:

On 2/23/2012, during a tour of the facility with the Chief Operating Officer and Director of Plant Operations, it was revealed that the Materials Management space (>1,000 ft2) did not have their primary exit (near the loading dock) marked with an exit sign. Also, the evacuation floorplan for this suite showed the primary exit door in the wrong location.

These findings were shared with the executive staff during the exit interview on 2/29/12.

NFPA 10 (2002 ed.) 5.1.2.2 Occupancy hazard protection shall be provided by fire extinguishers suitable for such Class A, B, C, D, or K fire potentials as might be present.
Table 5.2.1 Fire Extinguisher Size and Placement for: Class A Hazards: Maximum floor area per unit of A-3,000 square feet; Maximum travel distance to extinguisher-75 ft.
Table 5.3.1 Fire Extinguisher Size and Placement for: Class B Hazards: Maximum travel distance to extinguisher-30 ft.
5.5 Fire Extinguisher Size and Placement for Class C Hazards. Fire extinguishers with Class C ratings shall be required where energized electrical equipment can be encountered. This requirement includes situations where fire either directly involves or surrounds electrical equipment. Since the fire itself is a Class A or Class B hazard, the fire extinguishers shall be sized and located on the basis of the anticipated Class A or Class B hazard.
This STANDARD was not met as evidenced by:
Based on observation, the facility failed to assure adequate placement of "ABC" fire extinguishers within the food preparation and food storage areas. ABC extinguishers are effective in putting out small fires involving ordinary materials, flammable liquids, and fires caused by energized equipment.
Findings include:
During a tour of the facility on 2/23/12, it was observed that the kitchen area had two, "K" type extinguishers and no "ABC" type extinguishers. Type "K" extinguishers are designed to extinguish combustible cooking substances greater than 1/4" in thickness. An "ABC" type extinguisher is also required in the kitchen.
These findings were shared with the executive staff during the exit interview on 2/29/12.

NFPA 70, 517-42 Automatic Connection to the Life Safety Branch. ......The Life Safety Branch shall provide power for the following lighting, receptacles, and equipment. (f) Generator Set Location. Task illumination and selected receptacles in the generator set location.

This STANDARD is not met as evidenced by:

Based on observation and staff interview the facility failed to provide task illumination for the two, 1.25 Mega Watt (MW) generators.

Findings include:

During a tour of the facility on 2/23/12 at 3:00 PM with the Director of Plant Operations and the Maintenance Specialist, it was revealed that there was no task illumination provided at the site of the two generators, exterior to the building. The Maintenance Specialist indicated during an interview at this time, that after sunset and before sunrise, that he would open an access door to the generator and perform his duties using only a hand-held flashlight.

On 2/24/12, the off-site Occupational Medicine facility was surveyed using Chapter 39, EXISTING Business Occupancies, of the 2000 Edition of the National Fire Protection Association's (NFPA) 101, Life Safety Code.

The following regulatory deficiencies were identified:

1) (K038) Exit access is so arranged that exits are readily accessible at all times in accordance with 7.1.

NFPA 101, 7.2.1.4.4 During its swing, any door in a means of egress shall not leave not less than one-half of the required width of an aisle, corridor, passageway, or landing unobstructed and shall not project more than 7 inches into the required width of an aisle, corridor, passageway or landing when fully open.

This STANDARD was not met as evidenced by:

Based on observation, the facility failed to assure that exits were not obstructed by door swing.

Findings include:

On 2/24/12 during a tour of the facility, it was revealed that the door to the laboratory room was three feet wide and swung into an exit egress corridor five feet wide.

2) (K064) Portable fire extinguishers shall be provided in all health care occupancies in accordance with 9.7.4.1, NFPA 10.

This STANDARD was not met as evidenced by:

The facility failed to assure that all extinguishers were maintained in good working condition.

Findings include:

On 2/24/12 the facility's only portable fire extinguisher had a pressure gauge in which the indicator needle was below the green area of the dial.

3) (K070) Portable space heating devices shall be prohibited in all health care occupancies.

This STANDARD was not met as evidenced by:

The facility failed to assure that a portable space heater was not allowed on the premises.

Findings include:

On 2/24/12 a portable space heater with exposed elements (which would have exceeded 212 degrees Fahrenheit) was found on a counter in Exam Room #4.

4) (K075) Soiled linen or trash collection receptacles shall not exceed 32 gallons in capacity.

This STANDARD was not met as evidenced by:

Based on observation, the facility failed to assure that trash collection receptacles greater than 32 gallons were located in a room protected as a hazardous area.

Findings include:

On 2/24/12 the "Workroom" (a non-hazard area) contained one, 45-gallon biohazard container plus one five-gallon, biohazard container.

5) (K211) Alcohol Based Hand Rubs (ABHR) dispensers are not installed over or adjacent to an ignition source.

This STANDARD is not met as evidenced by:

The facility failed to assure that ABHRs were not installed over electrical devices.

Findings include:

On 2/24/12 an ABHR was observed to be installed over a duplex, electrical outlet in a corridor, in the Occupational Medicine facility.

Based on observation, the facility failed to assure that wall-mounted, Alcohol Based Hand Rub (ABHR) dispensers were not installed over ignition sources.

Findings include:

During a tour of the facility on the afternoon of 2/22/12, ABHR dispensers were observed over points of ignition in Room 820 (night light) and Room 516 (duplex electrical outlet).

These findings were shared with the executive staff during the exit interview on 2/29/12.

NFPA 101, 7.10.1.2 Exits. Exits other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign readily visible from any direction of exit access.

This STANDARD was not met as evidenced by:

Based on observation and staff interview, the facility failed to assure that all exits were obvious and clearly identifiable as exits.

Findings include:

On 2/23/2012, during a tour of the facility with the Chief Operating Officer and Director of Plant Operations, it was revealed that the Materials Management space (>1,000 ft2) did not have their primary exit (near the loading dock) marked with an exit sign. Also, the evacuation floorplan for this suite showed the primary exit door in the wrong location.

These findings were shared with the executive staff during the exit interview on 2/29/12.

NFPA 10 (2002 ed.) 5.1.2.2 Occupancy hazard protection shall be provided by fire extinguishers suitable for such Class A, B, C, D, or K fire potentials as might be present.
Table 5.2.1 Fire Extinguisher Size and Placement for: Class A Hazards: Maximum floor area per unit of A-3,000 square feet; Maximum travel distance to extinguisher-75 ft.
Table 5.3.1 Fire Extinguisher Size and Placement for: Class B Hazards: Maximum travel distance to extinguisher-30 ft.
5.5 Fire Extinguisher Size and Placement for Class C Hazards. Fire extinguishers with Class C ratings shall be required where energized electrical equipment can be encountered. This requirement includes situations where fire either directly involves or surrounds electrical equipment. Since the fire itself is a Class A or Class B hazard, the fire extinguishers shall be sized and located on the basis of the anticipated Class A or Class B hazard.
This STANDARD was not met as evidenced by:
Based on observation, the facility failed to assure adequate placement of "ABC" fire extinguishers within the food preparation and food storage areas. ABC extinguishers are effective in putting out small fires involving ordinary materials, flammable liquids, and fires caused by energized equipment.
Findings include:
During a tour of the facility on 2/23/12, it was observed that the kitchen area had two, "K" type extinguishers and no "ABC" type extinguishers. Type "K" extinguishers are designed to extinguish combustible cooking substances greater than 1/4" in thickness. An "ABC" type extinguisher is also required in the kitchen.
These findings were shared with the executive staff during the exit interview on 2/29/12.

NFPA 70, 517-42 Automatic Connection to the Life Safety Branch. ......The Life Safety Branch shall provide power for the following lighting, receptacles, and equipment. (f) Generator Set Location. Task illumination and selected receptacles in the generator set location.

This STANDARD is not met as evidenced by:

Based on observation and staff interview the facility failed to provide task illumination for the two, 1.25 Mega Watt (MW) generators.

Findings include:

During a tour of the facility on 2/23/12 at 3:00 PM with the Director of Plant Operations and the Maintenance Specialist, it was revealed that there was no task illumination provided at the site of the two generators, exterior to the building. The Maintenance Specialist indicated during an interview at this time, that after sunset and before sunrise, that he would open an access door to the generator and perform his duties using only a hand-held flashlight.

On 2/24/12, the off-site Occupational Medicine facility was surveyed using Chapter 39, EXISTING Business Occupancies, of the 2000 Edition of the National Fire Protection Association's (NFPA) 101, Life Safety Code.

The following regulatory deficiencies were identified:

1) (K038) Exit access is so arranged that exits are readily accessible at all times in accordance with 7.1.

NFPA 101, 7.2.1.4.4 During its swing, any door in a means of egress shall not leave not less than one-half of the required width of an aisle, corridor, passageway, or landing unobstructed and shall not project more than 7 inches into the required width of an aisle, corridor, passageway or landing when fully open.

This STANDARD was not met as evidenced by:

Based on observation, the facility failed to assure that exits were not obstructed by door swing.

Findings include:

On 2/24/12 during a tour of the facility, it was revealed that the door to the laboratory room was three feet wide and swung into an exit egress corridor five feet wide.

2) (K064) Portable fire extinguishers shall be provided in all health care occupancies in accordance with 9.7.4.1, NFPA 10.

This STANDARD was not met as evidenced by:

The facility failed to assure that all extinguishers were maintained in good working condition.

Findings include:

On 2/24/12 the facility's only portable fire extinguisher had a pressure gauge in which the indicator needle was below the green area of the dial.

3) (K070) Portable space heating devices shall be prohibited in all health care occupancies.

This STANDARD was not met as evidenced by:

The facility failed to assure that a portable space heater was not allowed on the premises.

Findings include:

On 2/24/12 a portable space heater with exposed elements (which would have exceeded 212 degrees Fahrenheit) was found on a counter in Exam Room #4.

4) (K075) Soiled linen or trash collection receptacles shall not exceed 32 gallons in capacity.

This STANDARD was not met as evidenced by:

Based on observation, the facility failed to assure that trash collection receptacles greater than 32 gallons were located in a room protected as a hazardous area.

Findings include:

On 2/24/12 the "Workroom" (a non-hazard area) contained one, 45-gallon biohazard container plus one five-gallon, biohazard container.

5) (K211) Alcohol Based Hand Rubs (ABHR) dispensers are not installed over or adjacent to an ignition source.

This STANDARD is not met as evidenced by:

The facility failed to assure that ABHRs were not installed over electrical devices.

Findings include:

On 2/24/12 an ABHR was observed to be installed over a duplex, electrical outlet in a corridor, in the Occupational Medicine facility.