HospitalInspections.org

While surveying the facility with the safety director, the inspector observed that the cross corridor doors serving as opening protectives for the underground access corridor to 100 Campus Avenue (hospital side by the morgue) failed to latch in the closed position as required by the standard. This condition was also observed by the safety director.

K 12 Not Met:

1. While surveying the facility with the plant engineer, the inspector observed an unprotected structural steel beam present in the new electrical room outside the new administration suite on the first floor of building G. A fire spray was observed on other structural members and was found to have been scraped off and was not replaced after the work was completed. This does not meet for either a Type II standard.

2. While surveying the facility with the plant engineer, the inspector observed above the drop ceiling tile (tile marked Elevator 8 Sprinkler Value (ground floor H wing) an unprotected structural steel beam. A fire spray was observed on other structural members and was found to have been scraped off and was not replaced after the work was completed. This does not meet for either a Type I standard.



25654

While surveying the facility with the physical plant manager the inspector observed the following deficiencies pertaining to the required construction type of the areas inspected:
1. The door opening into the attic space identified as A442(A) was observed to be a 20 minute rated door that is not provided with a means to self-close the door. The door assembly must carry a minimum rating of at least one-hour and must be provided with a means to self-close and positively latch the door. (Referenced by facility FSES from 1982 stating an equivalent construction type of Type III(211).
2. The wall assembly in the " B " Wing to 4th floor stairwell was observed to have missing or damaged drywall on the attic side of the stairwell. The stairwell must be provided with a complete assembly having a rating of not less than one-hour. (Referenced by facility FSES from 1982 stating an equivalent construction type of Type III(211).
3. The standpipe located across from room A435 penetrates the floor/ceiling assembly and was not adequately sealed around the penetration. (Referenced by facility FSES from 1982 stating an equivalent construction type of Type III(211).
4. Penetrations into the attic space from the 4th floor levels of " A " Wing and " B " Wing were observed around openings where fire dampers had recently been installed. The openings must be sealed with assemblies having a fire resistance rating of not less than one-hour. (Referenced by facility FSES from 1982 stating an equivalent construction type of Type III(211).
5. The structural beams located above the chiller room mezzanine area in the plant engineering section of the building were found to have sections of the beam missing fireproofing material. The designed construction type of the plant engineering section of the building is Type I (332).
6. In room F152 (mechanical) an unprotected steel column was observed that appeared to have a structural function. The designed construction type of the " F " wing of the building is Type II(222).

K 17 Not Met:

1. While surveying the facility with the plant engineer, this inspector observed that the corridor wall at door location D 203, was not sealed to prevent the passage of smoke from the corridor to the Wound Care room. During the survey, the staff said the hole above and to the left of the doorframe was only recently created to allow for the installation of an automatic push pad and its mechanism which allows the room door to be easier for staff and patients to open it.

2. This inspector observed in the presence of the plant engineer, an open pipe which was located above the drop ceiling in the new Electrical closet in the new Administrative Suite. This wall is required to be smoke tight.

3. This inspector observed in the presence of the plant engineer, ductwork from the janitor's closet to the corridor (marked D 332) which had not been properly sealed around.

While surveying the facility with the safety director the inspector observed the following deficiencies in doors opening into the corridor enclosure from adjacent spaces:
1. The doors opening from patient sleeping rooms identified as B211, A222, and A235 were found to have malfunctioning door latching hardware that was not capable of provide a positive stop for the purpose of latching the door in the closed position.
2. The undercut on the door identified as A115 opening into the corridor from the adjacent office spaces was found to measure approximately 1.5 inches as measured from the finished floor level when the door was closed.




05910

K 18 Not Met:

1. While surveying the facility with the plant engineer, this inspector observed that the corridor door marked D 203, had positive latching hardware which had been taped over and the latch would not engage to keep the door closed in resisting the passage of smoke. During the survey, the staff said the installation of an automatic push pad and its mechanism would allow the room door to open easier for staff and patients. The doorframe had what appeared to be an electric striker plate installed which was not operational.

2. While surveying the facility with the plant engineer, this inspector observed corridor doors marked C 256 and C 257 which were damaged due to hitting and kicking. As a result the lower half of each door had been sprung which would prevent the door from resisting the passage of smoke.

3. While surveying the facility with the plant engineer, this inspector observed a corridor door marked TCO 2554 where the latching and/or closing mechanism failed to engage to maintain the door closed in it's frame.

While surveying the facility with the safety director the inspector observed the following deficiencies in fire resistive vertical opening protection required by the standard:
1. The door opening into the chapel across from room A352 was found to be a wood door with no recognized fire resistance rating measuring 1 3/8 inches thick. The door was also not capable of closing or latching in the closed position as the door lacked any closing or latching device. A glass transom was also located above the door. The opening must be provided with a fire door assembly having a minimum fire resistance rating of not less than one-hour and the transom opening must be protected with fire resistant construction having a rating of not less than one-hour in accordance with NFPA 101 Life Safety Code, sections 19.3.1.1 and 8.2.5 (2000 edition) as adopted by the Code of Federal Regulations.
2. The common wall between the chapel and the adjacent custodial storage room on the 3rd floor of the building was found to be incomplete above the suspended ceiling level as observed from the custodial storage room. The wall must be complete on the storage room side of the common wall.
3. The custodial storage door opening into the " A " Wing stairwell by the chapel was found to have an initial 45 minute rating and appears to have been substantially modified from its original configuration. A fire resistive assembly having a rating at least that of the stairwell enclosure (2 hours) must be provided.
4. The door opening from F152 (mechanical) into the convenience stairwell on " F " Wing was found to be incapable of fully closing and latching with the force applied by the self-closing device on the door.





05910

K 20 Not Met:

1. During the walk-through inspection, this inspector observed in the presence of the facility plant engineer, the wall above the drop ceiling tiles entering the elevator shaft closest to the Womens' Pavillion OR was not sealed tight to the underside of the roof above.

2. During the walk-through inspection, this inspector observed in the presence of the facility plant engineer, the wall above the drop ceiling tiles entering the elevator shaft 1 was not sealed tight to the underside of the floor pan above.

3. During the walk-through inspection, this inspector observed in the presence of the plant engineer, three open electrical conduits passed through the corridor wall into the elevator shafts, at the elevators outside the new registration area.

4. During the walk-through inspection, this inspector observed in the presence of the facility plant engineer, the wall above the drop ceiling tiles entering the elevator shaft (ground floor level Womens' Pavillion, elevator closest to stair WS 1-0) 1 was not sealed tight to the underside of the floor pan above.

5. During the walk-through inspection, this inspector observed in the presence of the facility's plant engineer, a large open conduit in the floor in the Room used as a Cath Lab at the "Monitoring Area." This allows for an unprotected vertical opening between floors and fails to maintain the required one hour separation.

While surveying the facility with the safety director the inspector observed the following deficiencies in the facility smoke barriers sampled for inspection:
1. Openings in the smoke barrier at the attic level between " A " Wing and " B " Wing. Small utility penetrations in the smoke barrier were observed and the seams between the smoke barrier wall assembly and the ceiling were not properly sealed. (Referenced by facility FSES from 1982).
2. Expanding foam insulation was observed to have been utilized to partially fill an opening in the smoke barrier wall assembly above the suspended ceiling on " B " Wing adjacent to the smoke barrier doors identified as AB1-3 (across the corridor from purchasing). The expanding foam insulation does not carry any recognized fire resistive rating.




05910

K 25 Not Met:

1. This inspector observed in the presence of the plant engineer, an open electrical conduit which was located above the drop ceiling by D431 through a required fire wall. This wall is required to be at least one-hour fire rated.

2. This inspector observed in the presence of the plant engineer, an open electrical conduit which was located above the drop ceiling by E231 B through a required fire wall. This wall is required to be at least one-hour fire rated.

3. This inspector observed in the presence of the plant engineer, an open electrical conduit which was located above the drop ceiling G 1019 through a required fire wall. This wall is required to be at least one-hour fire rated.

4. While surveying the facility with the plant engineer, this inspector observed that the fire/smoke barrier between " C " and " D " wings (above the ceiling tiles), at the cross corridor door location, had walls that were not fully sealed wall to wall and had an open electrical conduit passing through it.

While surveying the facility with the safety director, the inspector observed that the smoke partition doors adjacent to B114 did not fully close as required by the standard due to a mechanical defect. This condition was also observed by the safety director and the physical plant manager.

While surveying the facility with the safety director the inspector observed the following deficiencies relating to hazard area protection in accordance with the standard:
1. The door to room B220 (gift shop storage room) lacks a self-closing device. In addition the door is provided with a mail slot that fully penetrates the door slab. The quantity of combustible storage observed in the room warrants classification as a hazard area in accordance with the standard.
2. Penetrations through the required fire barrier at the wall and ceiling level in A111 (elevator machinery room) were observed.
3. The hazardous stores room (E036) door opening into the corridor is currently a door with no recognized fire resistive rating or self-closing capability. The door assembly must be a rated assembly with a minimum 45 minute fire resistive rating that is capable of self-closing and positively latching in the closed position in accordance with NFPA 101 Life Safety Code, sections 19.3.2.1 and 8.4.1.1(3) as adopted by the Code of Federal Regulations.
4. A single unprotected conduit penetration was observed between E036 storage and the adjacent corridor near the door opening to the space from the corridor.
5. The door accessing room E014 (storage) is not equipped with a self-closing device as required by the standard.
6. The door accessing room W016 (medical records and lab storage) from the corridor was not capable of fully closing and latching at the time of inspection due to a mechanical defect.





05910

K 29 Not Met:

1. During the survey of the facility this inspector, in the presence of the plant engineer observed the elevator machine room marked W 042 (ground floor Womens' Pavillion) had walls which were not tight to the underside of the floor deck above. These had not been sealed as required to maintain the required one hour fire rated separation.

2. During the survey of the facility this inspector in the presence of the plant engineer observed above the drop ceiling tile, the soiled utility room (room W 211) had walls between the A) corridor and the room, B) the room to the Womens' Pavillion OR Scrub space which were not tight to the underside of the roof deck above. These had not been sealed as required to maintain the required one hour fire rated separation.

3. During the survey of the facility this inspector, in the presence of the plant engineer observed above the drop ceiling tile, the large ICU (suite) storage room had walls between the A) corridor and the room, B) the clean and soiled utility spaces, which were not tight to the underside of the roof deck above and had open electrical conduit passing through from the storage room to the suite. These had not been sealed as required to maintain the required one hour fire rated separation.

4. During the survey of the facility with the plant engineer, this inspector observed an open electrical conduit from the soiled utility room (C 348) into the corridor which was not sealed as required.

5. During the survey of the facility with the plant engineer, this inspector observed open electrical conduits in the electrical closet containing the panel marked 3 C 1 and across from room C 334 which was not sealed as required.

K 33 Not Met:

1. This inspector observed in the presence of the plant engineer, an open electrical conduit which was located above the drop ceiling at door D2-1FD through a required fire wall. This wall is required to be at least one-hour fire rated.

2. This inspector observed in the presence of the plat engineer, missing gypsum wallboard above the drop ceiling till at the door marked D3-2FD. Additionally possible fire rated mineral wool batting which in some location was installed had not been sealed over with a rated compound to finish the listed assembly to maintain the one-hour or greater rating.

3. This inspector observed in the presence of the plant engineer, penetrations from the corridor into WC-1 stair on the 1st floor level of the Women ' s center, through a required fire wall. This wall is required to be at least one-hour fire rated.

4. This inspector observed in the presence of the plant engineer, an open electrical conduit above the drop ceiling tiles, from the corridor into WC-2 stair on the 1st floor level of the Womens' center, through a required fire wall. Additionally the wall was not properly sealed to the underside of the floor pan above. This wall is required to be at least one-hour fire rated.

5. This inspector observed in the presence of the plant engineer, penetrations above the drop ceiling tiles, from the corridor into WC-3 stair on the 1st floor level, through a required fire wall. Additionally the wall was not properly sealed to the underside of the floor pan above. This wall is required to be at least one-hour fire rated.

6. This inspector observed in the presence of the plant engineer, at stair WS 1-0, possible fire rated mineral wool batting which in some location was installed had not been sealed over with a rated compound to finish the listed assembly to maintain the one-hour or greater rating.

While surveying the facility with the physical plant manager, the inspector observed that the doors from the following patient rooms opening into the corridor do not comply with NFPA 101 Life Safety Code, section 7.2.1.4.4:
During its swing, any door leaf in a means of egress shall leave not less than one-half of the required width of an aisle, a corridor, a passageway, or a landing unobstructed and shall project not more than 7 in. into the required width of an aisle, a corridor, a passageway, or a landing, when fully open.
1. " A " Wing patient exam room A344.
2. " A " Wing patient room A346
3. " A " Wing patient room A347
4. " A " Wing patient room A348
The doors noted open into the required 8 foot clear corridor width at least half the required clear width of the corridor and project more than 7 inches into the corridor when fully opened.

While surveying the facility with the physical plant manager, the inspector observed that the attic space lacks sufficient manual fire alarm pull stations and notification appliances in accordance with NFPA 72 National Fire Alarm Code (1999 edition) as referenced by NFPA 101 Life Safety Code, sections 19.3.4 and 9.6 (2000 edition). The following deficiencies were observed and were referenced by the FSES validation study that was commissioned voluntarily by the facility for the 1982 FSES for the " A " and " B " Wings of the facility in July of 2012:
1. Manual fire alarm pull stations must be provided within five feet of every exit from the attic level of the building in accordance with NFPA 72 National Fire Alarm Code, section 2-8 (1999 edition).
2. Notification appliances must be provided in accordance with NFPA 72 National Fire Alarm Code, Chapter 4 (1999 edition).

While surveying the facility with the physical plant manager and safety director, the inspector observed the following deficiencies relating to the building fire sprinkler system:
1. No fire sprinkler coverage was observed in the storage closet located adjacent to room B301.
2. Room B210 (telecommunications closet) was observed to lack fire sprinkler coverage below the suspended ceiling grid in the room.
3. The elevator # 5 entrance vestibule lacks fire sprinkler coverage below the suspended ceiling grid.
4. Duct work was observed to be supported by fire sprinkler piping in the " B " Wing attic adjacent to air handling unit B4 MAU.





05910

K 56 Not Met:

During the walk-through inspection of the facility, in the presence of the plant engineer a dirty sprinkler head by air handler unit AHU-H1 (H wing) was observed covered with what appeared to be fire spray from when the spray was applied to the structural beams above. Additionally due to duct work in that same general area (above the chemical shot feeder) a section of sprinkler pipe was found to be missing a sprinkler head in order to provide proper sprinkler coverage of the area due to the obstruction caused by the section of duct.

K 71 Not Met:

1. This inspector observed in the presence of the plant engineer, penetrations around various pipes, above the drop ceiling tiles, from the corridor into the space containing the opening for the laundry and dust (dirt) chutes, through a required fire wall (by door mark D2- 2FD). Additionally above the dropping ceiling the wall was missing gypsum wallboard and penetrates were observed at the location marked C 226. These walls are required to be at least one-hour fire rated.

2. This inspector observed in the presence of the plant engineer, possible fire rated mineral wool batting which in some location was installed but had not been sealed over with a rated compound to finish the listed assembly to maintain the one-hour or greater fire rating, from the janitor's closet into the space containing the opening for the laundry and dust (dirt) chutes, through a required fire wall (space marked D 332).

K 72 Not Met:

While surveying the facility with the plant engineer, this inspector observed that a rolling cart shelf(s) (used to restock the changing rooms) containing clean changing gowns (extras after restocking) was stored in the hallway outside the cardiac stress testing area along with a movable exam table from the cardiac stress testing room. In discussing this with a radiology person, it was determined the movable exam table moves in and out of the room based on the needs of the patient (if they are arrive by wheelchair, walk-in or another department) and no plan for moving it out of the hallway if an emergency had been established. However the radiology person did state that this area is due to be remodeled in the near future and space needs to be established to prevent this from happening.

While surveying the facility with the physical plant manager, the inspector observed an unsecured " E " size oxygen cylinder that was not adequately secured from falling or being knocked over in room A331A (Behavioral Unit). The cylinder was properly secured by nursing staff at the time of observation.

While surveying the facility with the physical plant manager and safety director, the inspector observed an unsecured acetylene cylinder located the storage/maintenance area designated as E014. In accordance with NFPA 1 Uniform Fire Code, section 63.2.3.1.3.1 (2006 edition) adopted pursuant to Maine Law (Title 25 MRSA, Section 2452) the storage (or use) of flammable gases is prohibited in other than storage or industrial occupancies.





00466

K-130 Not Met. 99 Campus Ave.
While surveying the business office, Inspector observed that pieces of sheetrock had been removed from the ceiling of the boiler room to accommodate pipe hangers. Safety person was made aware of the condition.

K-130 Not Met 99 Campus Ave.
While surveying the facility with Safety person, this inspector observed that the elevator firefighters recall test form was not completed for Years 2011 and 2012 to date

K-130 Not Met 99 Campus.
While evaluating the sprinkler services tags and speaking with Hospital Engineer, it was noted that the required 5 year obstruction/internal examination testing had not been performed for this system
Ref NFPA 25 Chapter 14 section 14.2 .1 2011 Edition

K-130 Not Met. St Mary's Renaissance School.
While surveying this facility with the Safety person, this inspector observed the following deficiencies:
a. Required hand rails and guards were not provided for the interior and exterior stairs on south side of
first floor.
b. The southwest exit double doors do not open easily when activating the panic hardware.
c. Inspection observed combustible storage underneath an interior exit stair.
d. Records for testing of all emergency systems and egress drills were not available onsite for review.

.

K 143 Not Met:

While surveying the facility with the plant engineer, this inspector observed liquid oxygen being stored in an oxygen room (D220) set up with mechanical ventilation. But no signs could be found for when transferring was occurring, which could be posted to indicate when the operation was taking place.

K147 Not Met:

While surveying the facility with the plant engineer, this inspector observed numerous relocatable power taps providing power to a variety of items located both in general patient care areas and in critical care areas.

NFPA 99 Standard for Healthcare Facilities, defines general care areas as patient bedrooms, examining rooms, treatment rooms, clinics, and similar areas in which it is intended that the patient will come in contact with ordinary appliances such as a nurse-call system, electric beds, examining lamps, telephones, and entertainment devices. Critical Care Areas are defined as those special care units, intensive care units, coronary care units, angiography laboratories, cardiac catheterization laboratories, delivery rooms, operating rooms, postanesthesia recovery rooms, emergency departments, and similar areas in which patients are intended to be subjected to invasive procedures and connected to line-operated, patient-care-related electrical appliances.

Relocatable power taps must be used in accordance with their listing and electrical installations must be in accordance with NFPA 99 Standard for Healthcare Facilities and NFPA 70 National Electrical Code. The installation of relocatable power taps in patient (resident) care areas is prohibited according the following:
UL White Book (2009 Edition):
"Relocatable power taps are not intended to be permanently secured to
building structures, tables, work benches or similar structures, nor are they
intended to be used as a substitute for fixed wiring.
" Relocatable power taps have not been investigated and are not intended for use with general patient care areas or critical patient care areas of health care facilities as defined in Article 517 of ANSI/NFPA 70, ' 'National Electrical Code.' '

NFPA 70 National Electrical Code: ARTICLE 517 Health Care Facilities:
I. General
517.1 Scope.
The provisions of this article shall apply to electrical construction and installation criteria in health care facilities that provide services to human beings.

1. While surveying the facility with the physical plant director the inspector observed many relocatable power taps being used in lieu of fixed wiring, in violation of the standard located in the following patient care areas: Rooms D416, D418 (Detox), D409 B, D405 D (Case Manager ' s office where patients are seen), Detox Nurse ' s station open to corridor, D431, D430 (Detox), C 445, C 464, C 346, Open Nurse ' s station " C " Wing 3rd floor (open to corridor), room across from D 200A, D219A, ICU Family Conference Room, ICU Open Nurse ' s station, Open Nurse ' s station 2nd floor " C " wing (open to corridor), Women ' s Center Exam rooms 1, 2, 3, 4, 6, 7, 8, 9, 10, Pod 1 Nurse ' s station, Pod 2 Nurse ' s station, room W123, W117, W113 (doctors ' offices where patients are seen), Reception for Womens' Center, W147, W103, W104, W110, ACU/Pac treatment and recover areas, Ultrasound Nurse ' s station, Mammography room 2, C140 (Angio treatment/x-ray room), W041 procedure room, W021

2. This inspector observed in the presence of the plant engineer, open spliced capped wires which were not installed inside a covered junction box as required. These were found above the drop ceiling tile by the telemetry antennae outside room C348.

3. This inspector observed in the presence of the plant engineer, open spliced capped wires which were not installed inside a covered junction box as required. These were found by the Air Handler marked A1G.

4. This inspector observed in the presence of the plant engineer, an open junction box above the drop ceiling tiles, which was missing its protective cover. (across from D 200 A)

5. This inspector observed in the presence of the plant engineer, an open junction box above the drop ceiling tiles, which was missing its protective cover. (above space marked C 224)

6. This inspector observed in the presence of the plant engineer, an open junction box above the drop ceiling tiles, which was missing its protective cover. (by the Barowsky Center hanging sign)




25654

While surveying the facility with the physical plant manager and safety director, the inspector observed the following deficiencies relating to electrical installations or equipment in the facility:
1. The lighting fixture in the " A " Wing attic cupola appears to be of questionable installation and integrity. The lighting fixture was observed to have several wiring splices and appeared to be supported by the wiring connected to the fixture. The fixture was found to be energized at the time of inspection as evidenced by the fact that an adjacent switch operated the lighting fixture.
2. While surveying the facility with the physical plant director the inspector observed relocatable power taps in violation of the standard located in the following patient care areas:
2a) Room A328C (admissions)
2b) Room A344 (patient exam room)

Relocatable power taps must be used in accordance with their listing and electrical installations must be in accordance with NFPA 99 Standard for Healthcare Facilities and NFPA 70 National Electrical Code. The installation of relocatable power taps in patient care areas is prohibited according the following:

UL White Book (2009 Edition):Page 402 "Relocatable Power Taps XBYS":
"Relocatable power taps are not intended to be permanently secured to
building structures, tables, work benches or similar structures, nor are they
intended to be used as a substitute for fixed wiring.
" Relocatable power taps have not been investigated and are not intended for use with general patient care areas or critical patient care areas of health care facilities as defined in Article 517 of ANSI/NFPA 70, ' 'National Electrical Code.' '

NFPA 70 National Electrical Code: ARTICLE 517 Health Care Facilities:
General
517.1 Scope.
The provisions of this article shall apply to electrical construction and installation criteria in health care facilities that provide services to human beings.

While surveying the facility with the safety director, the inspector observed that the cross corridor doors serving as opening protectives for the underground access corridor to 100 Campus Avenue (hospital side by the morgue) failed to latch in the closed position as required by the standard. This condition was also observed by the safety director.

K 12 Not Met:

1. While surveying the facility with the plant engineer, the inspector observed an unprotected structural steel beam present in the new electrical room outside the new administration suite on the first floor of building G. A fire spray was observed on other structural members and was found to have been scraped off and was not replaced after the work was completed. This does not meet for either a Type II standard.

2. While surveying the facility with the plant engineer, the inspector observed above the drop ceiling tile (tile marked Elevator 8 Sprinkler Value (ground floor H wing) an unprotected structural steel beam. A fire spray was observed on other structural members and was found to have been scraped off and was not replaced after the work was completed. This does not meet for either a Type I standard.



25654

While surveying the facility with the physical plant manager the inspector observed the following deficiencies pertaining to the required construction type of the areas inspected:
1. The door opening into the attic space identified as A442(A) was observed to be a 20 minute rated door that is not provided with a means to self-close the door. The door assembly must carry a minimum rating of at least one-hour and must be provided with a means to self-close and positively latch the door. (Referenced by facility FSES from 1982 stating an equivalent construction type of Type III(211).
2. The wall assembly in the " B " Wing to 4th floor stairwell was observed to have missing or damaged drywall on the attic side of the stairwell. The stairwell must be provided with a complete assembly having a rating of not less than one-hour. (Referenced by facility FSES from 1982 stating an equivalent construction type of Type III(211).
3. The standpipe located across from room A435 penetrates the floor/ceiling assembly and was not adequately sealed around the penetration. (Referenced by facility FSES from 1982 stating an equivalent construction type of Type III(211).
4. Penetrations into the attic space from the 4th floor levels of " A " Wing and " B " Wing were observed around openings where fire dampers had recently been installed. The openings must be sealed with assemblies having a fire resistance rating of not less than one-hour. (Referenced by facility FSES from 1982 stating an equivalent construction type of Type III(211).
5. The structural beams located above the chiller room mezzanine area in the plant engineering section of the building were found to have sections of the beam missing fireproofing material. The designed construction type of the plant engineering section of the building is Type I (332).
6. In room F152 (mechanical) an unprotected steel column was observed that appeared to have a structural function. The designed construction type of the " F " wing of the building is Type II(222).

K 17 Not Met:

1. While surveying the facility with the plant engineer, this inspector observed that the corridor wall at door location D 203, was not sealed to prevent the passage of smoke from the corridor to the Wound Care room. During the survey, the staff said the hole above and to the left of the doorframe was only recently created to allow for the installation of an automatic push pad and its mechanism which allows the room door to be easier for staff and patients to open it.

2. This inspector observed in the presence of the plant engineer, an open pipe which was located above the drop ceiling in the new Electrical closet in the new Administrative Suite. This wall is required to be smoke tight.

3. This inspector observed in the presence of the plant engineer, ductwork from the janitor's closet to the corridor (marked D 332) which had not been properly sealed around.

While surveying the facility with the safety director the inspector observed the following deficiencies in doors opening into the corridor enclosure from adjacent spaces:
1. The doors opening from patient sleeping rooms identified as B211, A222, and A235 were found to have malfunctioning door latching hardware that was not capable of provide a positive stop for the purpose of latching the door in the closed position.
2. The undercut on the door identified as A115 opening into the corridor from the adjacent office spaces was found to measure approximately 1.5 inches as measured from the finished floor level when the door was closed.




05910

K 18 Not Met:

1. While surveying the facility with the plant engineer, this inspector observed that the corridor door marked D 203, had positive latching hardware which had been taped over and the latch would not engage to keep the door closed in resisting the passage of smoke. During the survey, the staff said the installation of an automatic push pad and its mechanism would allow the room door to open easier for staff and patients. The doorframe had what appeared to be an electric striker plate installed which was not operational.

2. While surveying the facility with the plant engineer, this inspector observed corridor doors marked C 256 and C 257 which were damaged due to hitting and kicking. As a result the lower half of each door had been sprung which would prevent the door from resisting the passage of smoke.

3. While surveying the facility with the plant engineer, this inspector observed a corridor door marked TCO 2554 where the latching and/or closing mechanism failed to engage to maintain the door closed in it's frame.

While surveying the facility with the safety director the inspector observed the following deficiencies in fire resistive vertical opening protection required by the standard:
1. The door opening into the chapel across from room A352 was found to be a wood door with no recognized fire resistance rating measuring 1 3/8 inches thick. The door was also not capable of closing or latching in the closed position as the door lacked any closing or latching device. A glass transom was also located above the door. The opening must be provided with a fire door assembly having a minimum fire resistance rating of not less than one-hour and the transom opening must be protected with fire resistant construction having a rating of not less than one-hour in accordance with NFPA 101 Life Safety Code, sections 19.3.1.1 and 8.2.5 (2000 edition) as adopted by the Code of Federal Regulations.
2. The common wall between the chapel and the adjacent custodial storage room on the 3rd floor of the building was found to be incomplete above the suspended ceiling level as observed from the custodial storage room. The wall must be complete on the storage room side of the common wall.
3. The custodial storage door opening into the " A " Wing stairwell by the chapel was found to have an initial 45 minute rating and appears to have been substantially modified from its original configuration. A fire resistive assembly having a rating at least that of the stairwell enclosure (2 hours) must be provided.
4. The door opening from F152 (mechanical) into the convenience stairwell on " F " Wing was found to be incapable of fully closing and latching with the force applied by the self-closing device on the door.





05910

K 20 Not Met:

1. During the walk-through inspection, this inspector observed in the presence of the facility plant engineer, the wall above the drop ceiling tiles entering the elevator shaft closest to the Womens' Pavillion OR was not sealed tight to the underside of the roof above.

2. During the walk-through inspection, this inspector observed in the presence of the facility plant engineer, the wall above the drop ceiling tiles entering the elevator shaft 1 was not sealed tight to the underside of the floor pan above.

3. During the walk-through inspection, this inspector observed in the presence of the plant engineer, three open electrical conduits passed through the corridor wall into the elevator shafts, at the elevators outside the new registration area.

4. During the walk-through inspection, this inspector observed in the presence of the facility plant engineer, the wall above the drop ceiling tiles entering the elevator shaft (ground floor level Womens' Pavillion, elevator closest to stair WS 1-0) 1 was not sealed tight to the underside of the floor pan above.

5. During the walk-through inspection, this inspector observed in the presence of the facility's plant engineer, a large open conduit in the floor in the Room used as a Cath Lab at the "Monitoring Area." This allows for an unprotected vertical opening between floors and fails to maintain the required one hour separation.

While surveying the facility with the safety director the inspector observed the following deficiencies in the facility smoke barriers sampled for inspection:
1. Openings in the smoke barrier at the attic level between " A " Wing and " B " Wing. Small utility penetrations in the smoke barrier were observed and the seams between the smoke barrier wall assembly and the ceiling were not properly sealed. (Referenced by facility FSES from 1982).
2. Expanding foam insulation was observed to have been utilized to partially fill an opening in the smoke barrier wall assembly above the suspended ceiling on " B " Wing adjacent to the smoke barrier doors identified as AB1-3 (across the corridor from purchasing). The expanding foam insulation does not carry any recognized fire resistive rating.




05910

K 25 Not Met:

1. This inspector observed in the presence of the plant engineer, an open electrical conduit which was located above the drop ceiling by D431 through a required fire wall. This wall is required to be at least one-hour fire rated.

2. This inspector observed in the presence of the plant engineer, an open electrical conduit which was located above the drop ceiling by E231 B through a required fire wall. This wall is required to be at least one-hour fire rated.

3. This inspector observed in the presence of the plant engineer, an open electrical conduit which was located above the drop ceiling G 1019 through a required fire wall. This wall is required to be at least one-hour fire rated.

4. While surveying the facility with the plant engineer, this inspector observed that the fire/smoke barrier between " C " and " D " wings (above the ceiling tiles), at the cross corridor door location, had walls that were not fully sealed wall to wall and had an open electrical conduit passing through it.

While surveying the facility with the safety director, the inspector observed that the smoke partition doors adjacent to B114 did not fully close as required by the standard due to a mechanical defect. This condition was also observed by the safety director and the physical plant manager.

While surveying the facility with the safety director the inspector observed the following deficiencies relating to hazard area protection in accordance with the standard:
1. The door to room B220 (gift shop storage room) lacks a self-closing device. In addition the door is provided with a mail slot that fully penetrates the door slab. The quantity of combustible storage observed in the room warrants classification as a hazard area in accordance with the standard.
2. Penetrations through the required fire barrier at the wall and ceiling level in A111 (elevator machinery room) were observed.
3. The hazardous stores room (E036) door opening into the corridor is currently a door with no recognized fire resistive rating or self-closing capability. The door assembly must be a rated assembly with a minimum 45 minute fire resistive rating that is capable of self-closing and positively latching in the closed position in accordance with NFPA 101 Life Safety Code, sections 19.3.2.1 and 8.4.1.1(3) as adopted by the Code of Federal Regulations.
4. A single unprotected conduit penetration was observed between E036 storage and the adjacent corridor near the door opening to the space from the corridor.
5. The door accessing room E014 (storage) is not equipped with a self-closing device as required by the standard.
6. The door accessing room W016 (medical records and lab storage) from the corridor was not capable of fully closing and latching at the time of inspection due to a mechanical defect.





05910

K 29 Not Met:

1. During the survey of the facility this inspector, in the presence of the plant engineer observed the elevator machine room marked W 042 (ground floor Womens' Pavillion) had walls which were not tight to the underside of the floor deck above. These had not been sealed as required to maintain the required one hour fire rated separation.

2. During the survey of the facility this inspector in the presence of the plant engineer observed above the drop ceiling tile, the soiled utility room (room W 211) had walls between the A) corridor and the room, B) the room to the Womens' Pavillion OR Scrub space which were not tight to the underside of the roof deck above. These had not been sealed as required to maintain the required one hour fire rated separation.

3. During the survey of the facility this inspector, in the presence of the plant engineer observed above the drop ceiling tile, the large ICU (suite) storage room had walls between the A) corridor and the room, B) the clean and soiled utility spaces, which were not tight to the underside of the roof deck above and had open electrical conduit passing through from the storage room to the suite. These had not been sealed as required to maintain the required one hour fire rated separation.

4. During the survey of the facility with the plant engineer, this inspector observed an open electrical conduit from the soiled utility room (C 348) into the corridor which was not sealed as required.

5. During the survey of the facility with the plant engineer, this inspector observed open electrical conduits in the electrical closet containing the panel marked 3 C 1 and across from room C 334 which was not sealed as required.

K 33 Not Met:

1. This inspector observed in the presence of the plant engineer, an open electrical conduit which was located above the drop ceiling at door D2-1FD through a required fire wall. This wall is required to be at least one-hour fire rated.

2. This inspector observed in the presence of the plat engineer, missing gypsum wallboard above the drop ceiling till at the door marked D3-2FD. Additionally possible fire rated mineral wool batting which in some location was installed had not been sealed over with a rated compound to finish the listed assembly to maintain the one-hour or greater rating.

3. This inspector observed in the presence of the plant engineer, penetrations from the corridor into WC-1 stair on the 1st floor level of the Women ' s center, through a required fire wall. This wall is required to be at least one-hour fire rated.

4. This inspector observed in the presence of the plant engineer, an open electrical conduit above the drop ceiling tiles, from the corridor into WC-2 stair on the 1st floor level of the Womens' center, through a required fire wall. Additionally the wall was not properly sealed to the underside of the floor pan above. This wall is required to be at least one-hour fire rated.

5. This inspector observed in the presence of the plant engineer, penetrations above the drop ceiling tiles, from the corridor into WC-3 stair on the 1st floor level, through a required fire wall. Additionally the wall was not properly sealed to the underside of the floor pan above. This wall is required to be at least one-hour fire rated.

6. This inspector observed in the presence of the plant engineer, at stair WS 1-0, possible fire rated mineral wool batting which in some location was installed had not been sealed over with a rated compound to finish the listed assembly to maintain the one-hour or greater rating.

While surveying the facility with the physical plant manager, the inspector observed that the doors from the following patient rooms opening into the corridor do not comply with NFPA 101 Life Safety Code, section 7.2.1.4.4:
During its swing, any door leaf in a means of egress shall leave not less than one-half of the required width of an aisle, a corridor, a passageway, or a landing unobstructed and shall project not more than 7 in. into the required width of an aisle, a corridor, a passageway, or a landing, when fully open.
1. " A " Wing patient exam room A344.
2. " A " Wing patient room A346
3. " A " Wing patient room A347
4. " A " Wing patient room A348
The doors noted open into the required 8 foot clear corridor width at least half the required clear width of the corridor and project more than 7 inches into the corridor when fully opened.

While surveying the facility with the physical plant manager, the inspector observed that the attic space lacks sufficient manual fire alarm pull stations and notification appliances in accordance with NFPA 72 National Fire Alarm Code (1999 edition) as referenced by NFPA 101 Life Safety Code, sections 19.3.4 and 9.6 (2000 edition). The following deficiencies were observed and were referenced by the FSES validation study that was commissioned voluntarily by the facility for the 1982 FSES for the " A " and " B " Wings of the facility in July of 2012:
1. Manual fire alarm pull stations must be provided within five feet of every exit from the attic level of the building in accordance with NFPA 72 National Fire Alarm Code, section 2-8 (1999 edition).
2. Notification appliances must be provided in accordance with NFPA 72 National Fire Alarm Code, Chapter 4 (1999 edition).

While surveying the facility with the physical plant manager and safety director, the inspector observed the following deficiencies relating to the building fire sprinkler system:
1. No fire sprinkler coverage was observed in the storage closet located adjacent to room B301.
2. Room B210 (telecommunications closet) was observed to lack fire sprinkler coverage below the suspended ceiling grid in the room.
3. The elevator # 5 entrance vestibule lacks fire sprinkler coverage below the suspended ceiling grid.
4. Duct work was observed to be supported by fire sprinkler piping in the " B " Wing attic adjacent to air handling unit B4 MAU.





05910

K 56 Not Met:

During the walk-through inspection of the facility, in the presence of the plant engineer a dirty sprinkler head by air handler unit AHU-H1 (H wing) was observed covered with what appeared to be fire spray from when the spray was applied to the structural beams above. Additionally due to duct work in that same general area (above the chemical shot feeder) a section of sprinkler pipe was found to be missing a sprinkler head in order to provide proper sprinkler coverage of the area due to the obstruction caused by the section of duct.

K 71 Not Met:

1. This inspector observed in the presence of the plant engineer, penetrations around various pipes, above the drop ceiling tiles, from the corridor into the space containing the opening for the laundry and dust (dirt) chutes, through a required fire wall (by door mark D2- 2FD). Additionally above the dropping ceiling the wall was missing gypsum wallboard and penetrates were observed at the location marked C 226. These walls are required to be at least one-hour fire rated.

2. This inspector observed in the presence of the plant engineer, possible fire rated mineral wool batting which in some location was installed but had not been sealed over with a rated compound to finish the listed assembly to maintain the one-hour or greater fire rating, from the janitor's closet into the space containing the opening for the laundry and dust (dirt) chutes, through a required fire wall (space marked D 332).

K 72 Not Met:

While surveying the facility with the plant engineer, this inspector observed that a rolling cart shelf(s) (used to restock the changing rooms) containing clean changing gowns (extras after restocking) was stored in the hallway outside the cardiac stress testing area along with a movable exam table from the cardiac stress testing room. In discussing this with a radiology person, it was determined the movable exam table moves in and out of the room based on the needs of the patient (if they are arrive by wheelchair, walk-in or another department) and no plan for moving it out of the hallway if an emergency had been established. However the radiology person did state that this area is due to be remodeled in the near future and space needs to be established to prevent this from happening.

While surveying the facility with the physical plant manager, the inspector observed an unsecured " E " size oxygen cylinder that was not adequately secured from falling or being knocked over in room A331A (Behavioral Unit). The cylinder was properly secured by nursing staff at the time of observation.

While surveying the facility with the physical plant manager and safety director, the inspector observed an unsecured acetylene cylinder located the storage/maintenance area designated as E014. In accordance with NFPA 1 Uniform Fire Code, section 63.2.3.1.3.1 (2006 edition) adopted pursuant to Maine Law (Title 25 MRSA, Section 2452) the storage (or use) of flammable gases is prohibited in other than storage or industrial occupancies.





00466

K-130 Not Met. 99 Campus Ave.
While surveying the business office, Inspector observed that pieces of sheetrock had been removed from the ceiling of the boiler room to accommodate pipe hangers. Safety person was made aware of the condition.

K-130 Not Met 99 Campus Ave.
While surveying the facility with Safety person, this inspector observed that the elevator firefighters recall test form was not completed for Years 2011 and 2012 to date

K-130 Not Met 99 Campus.
While evaluating the sprinkler services tags and speaking with Hospital Engineer, it was noted that the required 5 year obstruction/internal examination testing had not been performed for this system
Ref NFPA 25 Chapter 14 section 14.2 .1 2011 Edition

K-130 Not Met. St Mary's Renaissance School.
While surveying this facility with the Safety person, this inspector observed the following deficiencies:
a. Required hand rails and guards were not provided for the interior and exterior stairs on south side of
first floor.
b. The southwest exit double doors do not open easily when activating the panic hardware.
c. Inspection observed combustible storage underneath an interior exit stair.
d. Records for testing of all emergency systems and egress drills were not available onsite for review.

.

K 143 Not Met:

While surveying the facility with the plant engineer, this inspector observed liquid oxygen being stored in an oxygen room (D220) set up with mechanical ventilation. But no signs could be found for when transferring was occurring, which could be posted to indicate when the operation was taking place.

K147 Not Met:

While surveying the facility with the plant engineer, this inspector observed numerous relocatable power taps providing power to a variety of items located both in general patient care areas and in critical care areas.

NFPA 99 Standard for Healthcare Facilities, defines general care areas as patient bedrooms, examining rooms, treatment rooms, clinics, and similar areas in which it is intended that the patient will come in contact with ordinary appliances such as a nurse-call system, electric beds, examining lamps, telephones, and entertainment devices. Critical Care Areas are defined as those special care units, intensive care units, coronary care units, angiography laboratories, cardiac catheterization laboratories, delivery rooms, operating rooms, postanesthesia recovery rooms, emergency departments, and similar areas in which patients are intended to be subjected to invasive procedures and connected to line-operated, patient-care-related electrical appliances.

Relocatable power taps must be used in accordance with their listing and electrical installations must be in accordance with NFPA 99 Standard for Healthcare Facilities and NFPA 70 National Electrical Code. The installation of relocatable power taps in patient (resident) care areas is prohibited according the following:
UL White Book (2009 Edition):
"Relocatable power taps are not intended to be permanently secured to
building structures, tables, work benches or similar structures, nor are they
intended to be used as a substitute for fixed wiring.
" Relocatable power taps have not been investigated and are not intended for use with general patient care areas or critical patient care areas of health care facilities as defined in Article 517 of ANSI/NFPA 70, ' 'National Electrical Code.' '

NFPA 70 National Electrical Code: ARTICLE 517 Health Care Facilities:
I. General
517.1 Scope.
The provisions of this article shall apply to electrical construction and installation criteria in health care facilities that provide services to human beings.

1. While surveying the facility with the physical plant director the inspector observed many relocatable power taps being used in lieu of fixed wiring, in violation of the standard located in the following patient care areas: Rooms D416, D418 (Detox), D409 B, D405 D (Case Manager ' s office where patients are seen), Detox Nurse ' s station open to corridor, D431, D430 (Detox), C 445, C 464, C 346, Open Nurse ' s station " C " Wing 3rd floor (open to corridor), room across from D 200A, D219A, ICU Family Conference Room, ICU Open Nurse ' s station, Open Nurse ' s station 2nd floor " C " wing (open to corridor), Women ' s Center Exam rooms 1, 2, 3, 4, 6, 7, 8, 9, 10, Pod 1 Nurse ' s station, Pod 2 Nurse ' s station, room W123, W117, W113 (doctors ' offices where patients are seen), Reception for Womens' Center, W147, W103, W104, W110, ACU/Pac treatment and recover areas, Ultrasound Nurse ' s station, Mammography room 2, C140 (Angio treatment/x-ray room), W041 procedure room, W021

2. This inspector observed in the presence of the plant engineer, open spliced capped wires which were not installed inside a covered junction box as required. These were found above the drop ceiling tile by the telemetry antennae outside room C348.

3. This inspector observed in the presence of the plant engineer, open spliced capped wires which were not installed inside a covered junction box as required. These were found by the Air Handler marked A1G.

4. This inspector observed in the presence of the plant engineer, an open junction box above the drop ceiling tiles, which was missing its protective cover. (across from D 200 A)

5. This inspector observed in the presence of the plant engineer, an open junction box above the drop ceiling tiles, which was missing its protective cover. (above space marked C 224)

6. This inspector observed in the presence of the plant engineer, an open junction box above the drop ceiling tiles, which was missing its protective cover. (by the Barowsky Center hanging sign)




25654

While surveying the facility with the physical plant manager and safety director, the inspector observed the following deficiencies relating to electrical installations or equipment in the facility:
1. The lighting fixture in the " A " Wing attic cupola appears to be of questionable installation and integrity. The lighting fixture was observed to have several wiring splices and appeared to be supported by the wiring connected to the fixture. The fixture was found to be energized at the time of inspection as evidenced by the fact that an adjacent switch operated the lighting fixture.
2. While surveying the facility with the physical plant director the inspector observed relocatable power taps in violation of the standard located in the following patient care areas:
2a) Room A328C (admissions)
2b) Room A344 (patient exam room)

Relocatable power taps must be used in accordance with their listing and electrical installations must be in accordance with NFPA 99 Standard for Healthcare Facilities and NFPA 70 National Electrical Code. The installation of relocatable power taps in patient care areas is prohibited according the following:

UL White Book (2009 Edition):Page 402 "Relocatable Power Taps XBYS":
"Relocatable power taps are not intended to be permanently secured to
building structures, tables, work benches or similar structures, nor are they
intended to be used as a substitute for fixed wiring.
" Relocatable power taps have not been investigated and are not intended for use with general patient care areas or critical patient care areas of health care facilities as defined in Article 517 of ANSI/NFPA 70, ' 'National Electrical Code.' '

NFPA 70 National Electrical Code: ARTICLE 517 Health Care Facilities:
General
517.1 Scope.
The provisions of this article shall apply to electrical construction and installation criteria in health care facilities that provide services to human beings.