HospitalInspections.org

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The facility failed to maintain the doors protecting the corridor openings per code. Findings include:

During the survey the following are examples of what was observed:

1. The following corridor doors had unsealed hole(s) at the door handles:

a. Conference Room - four unsealed holes
b. Both Storage Rooms past the Lab

2. The Ultrasound corridor door was not positive latching.

3. The Employee Breakroom corridor door had a self-closing device, but was being held open by a chair.
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2000 NFPA 101, 19.3.6.3.1 Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 13/4-in. (4.4-cm) thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke. Compliance with NFPA 80, Standard for Fire Doors and Fire Windows, shall not be required. Clearance between the bottom of the door and the floor covering not exceeding 1 in. (2.5 cm) shall be permitted for corridor doors.
2000 NFPA 101, 19.3.6.3.2 Doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door. Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.2.
2013 CMS - 2786R There is no impediment to the closing of the corridor doors.
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The facility failed to provide exit signs. Findings include:

During the survey, the following is an example of what was observed:

Exit directional signs were observed not to be in place at each end of the kitchen area and no exit sign provided over the side hinged door to the corridor.
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2000 NFPA 101, 7.10.1.4* Exit Access. Access to exits shall be marked by approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent to the occupants. Sign placement shall be such that no point in an exit access corridor is in excess of 100 ft (30 m) from the nearest externally illuminated sign and is not in excess of the marked rating for internally illuminated signs.
7.10.1.7* Visibility. Every sign required in Section 7.10 shall be located and of such size, distinctive color, and design that it is readily visible and shall provide contrast with decorations, interior finish, or other signs. No decorations, furnishings, or equipment that impairs visibility of a sign shall be permitted. No brightly illuminated sign (for other than exit purposes), display, or object in or near the line of
7.10.3* Sign Legend. Signs required by 7.10.1 and 7.10.2 shall have the word EXIT or other appropriate wording in plainly legible letters.
7.10.4* Power Source. Where emergency lighting facilities are required by the applicable provisions of Chapters 11 through 42 for individual occupancies, the signs, other than approved self-luminous signs, shall be illuminated by the emergency lighting facilities. The level of illumination of the signs shall be in accordance with 7.10.6.3 or 7.10.7 for the required emergency lighting duration as specified in 7.9.2.1. However, the level of illumination shall be permitted to decline to 60 percent at the end of the emergency lighting duration.
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The facility failed to provide smoke barriers that would provide at least a half hour fire resistance rating. Findings include:

During the survey, the following are examples of what was observed:

The following smoke barriers had the following unsealed penetrations:

1. Smoke barrier outside the Men's and Women's restroom in the front hallway at the smoke doors, five to six gray wires were observed penetrating the smoke barrier therefore not sealed to resist the passage of smoke.
2. Smoke barrier outside the Men's and Women's restroom in the back hallway at the smoke doors, there was a 12" by 12" HVAC duct penetrating the smoke wall and along the upper left corner of the duct there was a 2" opening not sealed.
3. Smoke barrier in front of Nurse's station at the end of front hall at Bradford Hall entrance, above the smoke doors, there were ten to twelve unsealed gray and black wires passing through a wall sleeve in the smoke barrier.
4. Smoke barrier at Nurse's Station, Bradford Hall there are 3" wall sleeve penetrations with pipes running through sleeves. Pipes are unsealed inside sleeves.
5. Smoke barrier at Nurse's Station, Bradford Hall entrance located above Soiled Utilities room, there is an unsealed roof joist penetrating the smoke barrier.
6. Smoke barrier at Nurse's Station, Bradford Hall entrance, above the smoke doors there was sheetrock patch that was not sealed, a 1" conduit on right side above doors unsealed, and on the Nurse's station side of the doors there was ?" conduit unsealed.
7. Smoke barrier in Bradford Hall above the three wire glass windows - 1" conduit with one white wire passing through conduit was unsealed, fire caulking not intact, and several penetrations above smoke doors Bradford Hall entrance.
8. On Gateway Hall, laundry room above entry door a ?" conduit penetrates the smoke wall with one white wire inside the conduit not sealed.
9. At X-Ray, Lab and ER area could not confirm that the smoke wall was continues from outside wall to outside wall and from floor to roof deck above. The facility could not provide enough information at the time of the survey to verify that smoke barrier is not required.
10. Unsealed penetrations were found around a group of grey wires in the smoke barrier at:
a. In the corridor outside of room 335
b. In the corridor outside of the Sleep Room
c. In the corridor outside of room 303

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2000 NFPA 101, 8.3.6.1 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows: (1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions: a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier. b. It shall be protected by an approved device that is designed for the specific purpose. (2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions: a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier. b. It shall be protected by an approved device that is designed for the specific purpose.

2000 NFPA 101, 19.3.7.3 Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1/2 hour.
2000 NFPA 101, 8.3.2* Continuity. Smoke barriers required by this Code shall be continuous from an outside wall to an outside wall, from a floor to a floor, or from a smoke barrier to a smoke barrier or a combination thereof. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces
2000 NFPA 101, 19.3.7.1 Smoke barriers shall be provided to divide every story used for sleeping rooms for more than 30 patients into not less than two smoke compartments. The size of any such smoke compartment shall not exceed 22,500 ft2 (2100 m2), and the travel distance from any point to reach a door in the required smoke barrier shall not exceed 200 ft (60 m).
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The facility failed to maintain a door in the smoke barrier per code. Findings include:

During the survey, the following is an example of what was observed:

The corridor door for the Bradford Unit Meeting Room located in a smoke barrier was observed with the self-closing device for this door removed.
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2000 NFPA 101, 19.3.7.6 Doors in smoke barriers shall comply with 8.3.4 and shall be self-closing or automatic-closing in accordance with 19.2.2.2.6.
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The facility failed to maintain the hazardous areas per code. Findings include:

During the survey, the following are examples of what was observed:

1. The Storage Room in the E.R. was over 50 sq. ft. with combustibles - the door did not have a self-closing device
2. Patient Room 327 was being used to store Clean Linen and was over 50 sq. ft. - the door did not have a self-closing device
3. In the Dungeon Room, partial basement level, beneath Medical Records there were several penetrations in the ceiling to the right of the entrance door that were unsealed.
4. In the Mechanical Room in the partial basement next to Dietary there was an unsealed penetration in the ceiling 10' in front of entrance doors.
5. In the Dry Storage area adjacent to the kitchen across from the freezers in the left corner of the room there was a ceiling tile not in place and fire caulking not complete.

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2000 NFPA 101 19.3.2.1 Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. Hazardous areas shall include, but shall not be restricted to, the following: (1) Boiler and fuel-fired heater rooms (2) Central/bulk laundries larger than 100 ft2 (9.3 m2) (3) Paint shops (4) Repair shops (5) Soiled linen rooms (6) Trash collection rooms (7) Rooms or spaces larger than 50 ft2 (4.6 m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction (8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard.
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A.) The facility failed to maintain the exit access per code. Findings include:

During the survey the following are examples of what was observed:

1. The Physical Therapy Office was observed with two releasing operations on the inside of the door. (a hasp lock and the door handle)
2. The Bradford Unit was observed with full time magnetic locks on the cross corridor doors to this unit, the Nurses' Station for this unit did not have an emergency door release switch.
3. The Maintenance Room on the basement Dietary Floor was observed with a hasp with a padlock on the outside of this door.
4. The door into the Sleep Room was observed with a dead bolt locking device and latching door hardware.
5. The door into the Room 328 was observed with a dead bolt locking device and latching door hardware.
6. The door into the Room 335 was observed with a dead bolt locking device and latching door hardware.
7. The door into the Room 329 was observed with a dead bolt locking device and latching door hardware.
8. The door into the X-Ray Room was observed with a dead bolt locking device and latching door hardware.
9. The door into the Physical Therapy was observed with a dead bolt locking device and latching door hardware.
10. Located next to the elevator, the exit stairway from the basement to ground level had a fan blocking the emergency path of egress.
11. The entry door to the partial basement had a hasp and locking device mounted to the exterior side of the door.
13. The staff was unable to find the key to the courtyard gate padlock.
14. The following doors were observed with more than one releasing operation:
a. Physicians Sleep Room
b. Room 330
c. Room 328
d. Room 327
15. Doors throughout the facility had more than one releasing operation (2 separate door locks) in the path of egress.

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2000 NFPA 101, 7.2.1.5.4 A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 in. (86 cm), and not more than 48 in. (122 cm), above the finished floor. Doors shall be operable with not more than one releasing operation.
Alabama Department of Public Health Memo "Exit Door Locking Arrangements in Health Care Facilities" Revised 08/30/2013
2. Locked egress doors: This hardware is locked during all or part of the day.
Requirements:
B. A manual release switch shall be provided on both sides of each locked door (required only on the egress side of exterior doors). This may be a code pad, or key or card switch.
C. An emergency release switch, or " kill switch, " shall be provided at each nurse station, to disable locks on doors under control of that station or throughout the facility. This release switch shall be capable of being reset only by key or special knowledge. This switch may release doors by means of a key only in psychiatric and infant units.
D. A sign at each nurse station release switch indicating the purpose of the switch, to read, "EMERGENCY DOOR RELEASE".
E. The administration must furnish a written statement of justification which explains the facility's compliance with Exception No. 1 of LSC 18.2.2.2.4 or 19.2.2.2.4.

2000 NFPA 101, 7.2.1.5.1 Doors shall be arranged to be opened readily from the egress side whenever the building is occupied. Locks, if provided, shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side.
2000 NFPA 101, 7.1.10.1 Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.
2000 NFPA 19.3.1.1, 8.2.5.4 and 7.1.3.2.2, An exit enclosure shall provide a continuous protected path of travel to an exit discharge.

NFPA 101, 7.1.10.1 Means of egress shall be continuously maintained free of all obstructions or impediments for full instant use in case of fire or other emergencies.
NFPA 101, 19.7.3 Proper maintenance shall be provided to ensure the dependability of the method of evacuation selected. Health care occupancies that find it necessary to lock exits shall, at all times, maintain an adequate staff qualified to release locks and direct occupants from the immediate danger area to a place of safety in case of fire or other emergency.
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The facility failed to provide a complete written fire safety plan per code. Findings include:

During the survey, the following is an example of what was observed:

The Fire Evacuation Plan does not include the evacuation from smoke compartment to smoke compartment.

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2000 NFPA 101, 19.7.2.2 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

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The facility failed to document fire drills. Findings include:

During the survey the following is an example of what was observed:

The facility failed to provide written fire drill reports to go along with the signature page of the past twelve months fire drills.
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2000 NFPA 101, 19.7.1.2 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.

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Sprinkler coverage was observed during the survey not adequately provided. Findings include:

During the survey, the following are examples of what was observed:

1. Ceiling tiles not setting in ceiling grid appropriately in the ER Bay.
2. Ceiling tiles missing in the Admissions Office.
3. Ceiling tiles missing in the Admissions Office Work Room.
4. Ceiling tiles missing in the Dietary Stairwell.
5. Ceiling tiles missing in the Central Storage (Admin. Wing).
6. Loose escutcheon plates at the ER Bay.

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1999 NFPA 13 5-6. Sprinklers shall be arranged to be in compliance.
2000 NFPA 13, 3-2.7.2 Escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly.
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A.) The facility failed to maintain the automatic sprinkler system per code. Findings include:

During the survey the following are examples of what was observed:

1. The automatic sprinkler pipes were observed being used to support the lay-in ceiling at the smoke barrier doors at the MedSurge's Nurses' Station side.
2. A large (approximately 2' X 2') HVAC duct was observed resting on the automatic sprinkler pipe in the Bradford Unit's corridor outside the Washer and Dryer Room.

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1998 NFPA 25, 2-2.2 Sprinkler pipe and fittings shall be inspected annually from the floor level. Pipe and fittings shall be in good condition and free of mechanical damage, leakage, corrosion, and misalignment. Sprinkler piping shall not be subjected to external loads by materials either resting on the pipe or hung from the pipe.

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B.) The facility failed to perform the required maintenance of the facility sprinkler system. Findings include:

During the survey, the following is an example of what was observed:

1. The fire department connection was not provided with an identification sign.
2. Data plate in West Riser room not legible.

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2000 NFPA 101, 9.7.5 Maintenance and Testing. ... in accordance with NFPA 25, ...
1998 NFPA 25, 9-7.1 Fire department connections shall be inspected quarterly. The inspection shall verify the following: (a) The fire department connections are visible and accessible. (b) Couplings or swivels are not damaged and rotate smoothly. (c) Plugs or caps are in place and undamaged. (d) Gaskets are in place and in good condition. (e) Identification signs are in place. (f) The check valve is not leaking. (g) The automatic drain valve is in place and operating properly.
1998 NFPA 25, 2-2.7* Hydraulic Nameplate. The hydraulic nameplate, if provided, shall be inspected quarterly to verify that it is attached securely to the sprinkler riser and is legible. A-2-2.7 The hydraulic nameplate should be secured to the riser with durable wire, chain, or equivalent. (See Figure A-2-2.7.)
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C.) Sprinkler coverage was observed during the survey not adequately provided. Findings include:

During the survey, the following is an example of what was observed:

In the West Riser Room, two holes covered with black plastic and tape, were observed in the ceiling above the riser manifold.
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NFPA, 5-5.4.2 Deflectors of sprinklers shall be aligned parallel to ceilings, roofs, or the incline of stairs.

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D) The facility failed to provide documentation during the survey that included quarterly sprinkler system inspection reports for the year 2013.
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1998 NFPA 25 1-8* Records. Records of inspections, tests, and maintenance of the system and its components shall be made available to the authority having jurisdiction upon request. Typical records include, but are not limited to, valve inspections; flow, drain, and pump tests; and trip tests of dry pipe, deluge, and preaction valves.

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E.) The facility failed to maintain the automatic sprinkler system per code. Findings include:

During the survey the following are examples of what was observed:

1. No FDC signs were observed at either (2) fire department connections.
2. The plastic caps that protect the FDC connections were broken.

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1998 NFPA 25, 9-7.1 Fire department connections shall be inspected quarterly. The inspection shall verify the following: (a) The fire department connections are visible and accessible. (b) Couplings or swivels are not damaged and rotate smoothly. (c) Plugs or caps are in place and undamaged. (d) Gaskets are in place and in good condition. (e) Identification signs are in place. (f) The check valve is not leaking. (g )The automatic drain valve is in place and operating properly.
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The facility failed to maintain the fire extinguishers per code. Findings include:

During the survey, the following is an example of what was observed:

1. The fire extinguishers in the Lab had not been inspected annually.
2. The fire extinguisher in the old ER at the entrance from Administration hallway had not been inspected annually.
3. The fire extinguisher across from room 330 had not been inspected monthly for 01/2014, 02/2014, 03/2014, 04/2014 and 05/2014.

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1998 NFPA 10, 4-4.1 Frequency. Fire extinguishers shall be subjected to maintenance at intervals of not more than 1 year, at the time of hydrostatic test, or when specifically indicated by an inspection.
1998 NFPA 10, 4-4.4* Maintenance Recordkeeping. Each fire extinguisher shall have a tag or label securely attached that indicates the month and year the maintenance was performed and that identifies the person performing the service.
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The facility failed to provide noncombustible ashtrays for disposing of cigarette butts and ashes. Findings include:

During the survey, the following is an example of what was observed:

1. The designated smoking area at the end of Gateway Hallway was not provided with noncombustible ashtrays for disposing of cigarette butts. Excessive cigarette butts (75+) observed throughout smoking area on the ground.
2. The metal container with self-closing cover device was observed with combustible trash in it.
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The facility failed to maintain HVAC per code. Findings include:

During the survey the following is an example of what was observed:

1. The smoke damper for the HVAC duct passing through the smoke barrier at the Employees Women's Toilet did not have a service panel.
2. The facility could not provide any documentation to verify that the dampers had been serviced over the past six years.

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2000 NFPA 90A, 3-4.7 Maintenance. At least every 4 years, fusible links (where applicable) 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.
Exception, S&C-10-04-LSC (6-year damper testing interval)
1999 NFPA 90A, 2-3.4.1 A service opening shall be provided in air ducts adjacent to each fire damper, smoke damper, and smoke detector. The opening shall be large enough to permit maintenance and resetting of the device.
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The facility failed to maintain the dietary hood. Findings include:

During the survey, the following is an example of what was observed:

Internal hood joint seam, at end of hood where switches were located, were not sealed to make seam grease tight.
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1998 NFPA 96, 2-1.2 All seams, joints, and penetrations of the hood enclosure that direct and capture grease-laden vapors and exhaust gases shall have a liquid tight continuous external weld to the hood ' s lower outermost perimeter. Internal hood joints, seams, filter support frames, and appendages attached inside the hood need not be welded but shall be sealed or otherwise made grease tight.
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The facility failed to prohibit portable space heating devices per code. Findings include:

During the survey, the following are examples of what was observed:

1. A portable space heating device was observed being stored in the Maintenance Office.
2. Two portable space heating devices were observed being stored in the Data Room inside
the Admissions Office.

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2000 NFPA 101, 19.7.8 Portable space-heating devices shall be prohibited in all health care occupancies. Exception: Portable space-heating devices shall be permitted to be used in nonsleeping staff and employee areas where the heating elements of such devices do not exceed 212?F (100?C).
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The facility failed to maintain the laundry chute discharge door. Findings include:

During the survey, the following is an example of what was observed:

In the Soiled Linen room located in the partial basement outside the Dietary Hall, the laundry chute discharge door was tied open with a piece of wire, which prevented the door from closing in the case of a fire.
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1999 NFPA 82, 3-2.2.9 Chute Discharge Doors. Gravity chutes shall be constructed so that the base opening of the chute or shaft, or both, shall be protected by an approved automatic-closing or self-closing 1-hour fire door suitable for a Class B opening.
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The facility failed to maintain the medical gas storage per code. Findings include:

During the survey, the following is an example of what was observed:

The oxygen cylinders were observed not to be individually secured within the Medical Gas storage area in the basement next to Dietary.
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1999 NFPA 99 4-3.1.1.2 Storage Requirements (Location, Construction, Arrangement).
(a) * Nonflammable Gases (Any Quantity; In-Storage, Connected, or Both)
3. Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation.
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The facility failed to maintain the Piped in Medical Gas per code. Findings include:

During the survey, the following is an example of what was observed:
The facility could not provide any documentation to verify that the Piped in Medical Gas System had been inspected within the last year.
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1999 NFPA 99, 4-3.5.2.3 Patient Gas Systems - Level 1. (a) Piping systems shall not be used for the distribution of flammable anesthetic gases. (b) Nonflammable medical gas systems used to supply gases for respiratory therapy shall be installed in accordance with 4-3.1 of this chapter. (c) Maintenance programs in accordance with the manufacturers ' recommendations shall be established for the medical air compressor supply system as connected in each individual installation. (d) The responsible authority of the facility shall establish procedures to ensure that all signal warnings are promptly evaluated and that all necessary measures are taken to reestablish the proper functions of the medical gas system. (e) Piping systems for gases shall not be used as a grounding electrode. (f) The facility shall have the capability and organization to implement a plan to cope with a complete loss of any medical gas system. (g) A periodic testing procedure for nonflammable medical gas and related alarm systems shall be implemented. (h) The test specified in 4-3.4.1.3(i) shall be conducted on the downstream portions of the medical gas piping system whenever a system is breached or whenever modifications are made or maintenance performed. (i) Periodic retesting of audible and visual alarm indicators shall be performed to determine that they are functioning properly, and records of the test shall be maintained until the next test.

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A.) Facility failed to maintain side hinged doors in a means of egress. Findings include:
During the survey, the following is an example of what was observed:
The side hinged egress door in the corridor wall at the kitchen was observed blocked by equipment preventing the use of the door as a means of egress. The cart roll down door was observed as the means of egress from the kitchen to the corridor. (This roll down door does not meet the requirements for a door used as means of egress.)
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2000 NFPA 101 19.2.2, 19.2.2.2.1 Doors complying with 7.2.1 shall be permitted.
7.2.1.4.1* Any door in a means of egress shall be of the side-hinged or pivoted-swinging type. The door shall be designed and installed so that it is capable of swinging from any position to the full required width of the opening in which it is installed.
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B.) The facility failed to maintain the doors held open in the exit passageway. Findings include:
During the survey, the following is an example of what was observed:
During the testing of the fire alarm system the roll up door which was observed held open failed to close during the activation of the fire alarm system.
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2000 NFPA 101, 19.2.2.2.6* Any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8.2. The automatic sprinkler system, if provided, and the fire alarm system, and the systems required by 7.2.1.8.2 shall be arranged to initiate the closing action of all such doors throughout the smoke compartment or throughout the entire facility.
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The facility failed to maintain the medical gas warning system per code. Findings include:

During the survey the following are examples of what was observed:

1. The following medical gas alarm panels were not working when tested in the following areas:
a. E.R.
b. Bradford Unit's Nurses' Station
c. MedSurge Unit's Nurses' Station

2. The medical gas alarm panel outside the Medical Gas Room appeared to be working when tested, but was not located at a nurses' station or other location that would provide for responsible surveillance.
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1999 NFPA 99, 4-3.1.2.2 Gas Warning Systems.
1999 NFPA 99, 4-4.1
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A.) The facility failed to maintain the electrical wiring and equipment per code. Findings include:

During the survey, the following is an example of what was observed:

There was a homemade extension cord plugged into an electrical outlet in the corridor in between the Maintenance Rooms across from the Lab. The homemade extension cord went through the corridor wall into the Maintenance Room behind the electrical outlet and had an electrical cord from a light fixture plugged into the homemade extension cord.

B.) The facility failed to provide approved electrical utilities. Findings include:

During the survey, the following are examples of what was observed:

1. Electrical panel cover plate not in place in Elevator Equipment Room.
2. In Admissions office, an electrical cover plate was missing in the data closet.
3. In Councilor's Office on Gateway Hallway, refrigerator was plugged into surge protector and surge protector was plugged into wall outlet.
4. In Administration Area on Gateway Hallway at the end cubicle next to wall, a surge protector was plugged into an extension cord and extension cord was plugged into electrical outlet.
5. On the Bradford Hallway in the Employee Lounge, two refrigerators were plugged into a surge protector and surge protector was plugged into electrical outlet.
6. Refrigerator in Laboratory plugged into a surge protector and surge protector plugged into electrical outlet.

C.) The facility failed to maintain the electrical wiring and equipment per code per code. Findings include:

During the survey the following are examples of what was observed:

1. Electrical junction boxes were observed without their covers in the following locations:
a. Above the ceiling in the center of the Asst. Administrators office. (1)
b. Above the ceiling in the center of the Mammography room. (1)
c. At the ceiling of the partial basement. (6)

2. Flexible cords were observed being used in the following locations:

a. Inside the Dietary storage area there was an extension cord plugged into the wall and running up into the ceiling.
b. Inside the deep freezer an extension cord is being used to supply power to the fan unit.

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1999 NFPA 70, 370-25. Covers and Canopies In completed installations, each box shall have a cover, faceplate, or fixture canopy.

1999 NFPA 70, 410-12. Outlet Boxes to Be Covered In a completed installation, each outlet box shall be provided with a cover unless covered by means of a fixture canopy, lampholder, receptacle, or similar device.

1990 NFPA 70, 400-7 and 400-8, and HCFA Transmittal Notice 22-99 The 1984 edition of the National Electric Code restricts the use of extension cords to temporary short term uses. It is the policy of HCFA to prohibit non-circuit breaker protected extension cords in health care. The limited use of circuit breaker protected power strips is acceptable, provided the current is limited to 15 amps or less, and no major appliances such as air conditioners, refrigerators, or heating units are connected to the power strip.

1999 NFPA 70, 400-7 (b) Attachment Plugs. Where used as permitted in subsections (a)(3), (a)(6), and (a)(8), each flexible cord shall be equipped with an attachment plug and shall be energized from a receptacle outlet.

1999 NFPA 70, 400-8. Uses Not Permitted
Unless specifically permitted in Section 400-7, flexible cords and cables shall not be used for the following:
1. As a substitute for the fixed wiring of a structure
2. Where run through holes in walls, structural ceilings suspended ceilings, dropped ceilings, or floors
3. Where run through doorways, windows, or similar openings
4. Where attached to building surfaces
Exception: Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of Section 364-8.
5. Where concealed behind building walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
6. Where installed in raceways, except as otherwise permitted in this Code

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The facility failed to maintain the doors protecting the corridor openings per code. Findings include:

During the survey the following are examples of what was observed:

1. The following corridor doors had unsealed hole(s) at the door handles:

a. Conference Room - four unsealed holes
b. Both Storage Rooms past the Lab

2. The Ultrasound corridor door was not positive latching.

3. The Employee Breakroom corridor door had a self-closing device, but was being held open by a chair.
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2000 NFPA 101, 19.3.6.3.1 Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 13/4-in. (4.4-cm) thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke. Compliance with NFPA 80, Standard for Fire Doors and Fire Windows, shall not be required. Clearance between the bottom of the door and the floor covering not exceeding 1 in. (2.5 cm) shall be permitted for corridor doors.
2000 NFPA 101, 19.3.6.3.2 Doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door. Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.2.
2013 CMS - 2786R There is no impediment to the closing of the corridor doors.
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The facility failed to provide exit signs. Findings include:

During the survey, the following is an example of what was observed:

Exit directional signs were observed not to be in place at each end of the kitchen area and no exit sign provided over the side hinged door to the corridor.
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2000 NFPA 101, 7.10.1.4* Exit Access. Access to exits shall be marked by approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent to the occupants. Sign placement shall be such that no point in an exit access corridor is in excess of 100 ft (30 m) from the nearest externally illuminated sign and is not in excess of the marked rating for internally illuminated signs.
7.10.1.7* Visibility. Every sign required in Section 7.10 shall be located and of such size, distinctive color, and design that it is readily visible and shall provide contrast with decorations, interior finish, or other signs. No decorations, furnishings, or equipment that impairs visibility of a sign shall be permitted. No brightly illuminated sign (for other than exit purposes), display, or object in or near the line of
7.10.3* Sign Legend. Signs required by 7.10.1 and 7.10.2 shall have the word EXIT or other appropriate wording in plainly legible letters.
7.10.4* Power Source. Where emergency lighting facilities are required by the applicable provisions of Chapters 11 through 42 for individual occupancies, the signs, other than approved self-luminous signs, shall be illuminated by the emergency lighting facilities. The level of illumination of the signs shall be in accordance with 7.10.6.3 or 7.10.7 for the required emergency lighting duration as specified in 7.9.2.1. However, the level of illumination shall be permitted to decline to 60 percent at the end of the emergency lighting duration.
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The facility failed to provide smoke barriers that would provide at least a half hour fire resistance rating. Findings include:

During the survey, the following are examples of what was observed:

The following smoke barriers had the following unsealed penetrations:

1. Smoke barrier outside the Men's and Women's restroom in the front hallway at the smoke doors, five to six gray wires were observed penetrating the smoke barrier therefore not sealed to resist the passage of smoke.
2. Smoke barrier outside the Men's and Women's restroom in the back hallway at the smoke doors, there was a 12" by 12" HVAC duct penetrating the smoke wall and along the upper left corner of the duct there was a 2" opening not sealed.
3. Smoke barrier in front of Nurse's station at the end of front hall at Bradford Hall entrance, above the smoke doors, there were ten to twelve unsealed gray and black wires passing through a wall sleeve in the smoke barrier.
4. Smoke barrier at Nurse's Station, Bradford Hall there are 3" wall sleeve penetrations with pipes running through sleeves. Pipes are unsealed inside sleeves.
5. Smoke barrier at Nurse's Station, Bradford Hall entrance located above Soiled Utilities room, there is an unsealed roof joist penetrating the smoke barrier.
6. Smoke barrier at Nurse's Station, Bradford Hall entrance, above the smoke doors there was sheetrock patch that was not sealed, a 1" conduit on right side above doors unsealed, and on the Nurse's station side of the doors there was ?" conduit unsealed.
7. Smoke barrier in Bradford Hall above the three wire glass windows - 1" conduit with one white wire passing through conduit was unsealed, fire caulking not intact, and several penetrations above smoke doors Bradford Hall entrance.
8. On Gateway Hall, laundry room above entry door a ?" conduit penetrates the smoke wall with one white wire inside the conduit not sealed.
9. At X-Ray, Lab and ER area could not confirm that the smoke wall was continues from outside wall to outside wall and from floor to roof deck above. The facility could not provide enough information at the time of the survey to verify that smoke barrier is not required.
10. Unsealed penetrations were found around a group of grey wires in the smoke barrier at:
a. In the corridor outside of room 335
b. In the corridor outside of the Sleep Room
c. In the corridor outside of room 303

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2000 NFPA 101, 8.3.6.1 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows: (1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions: a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier. b. It shall be protected by an approved device that is designed for the specific purpose. (2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions: a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier. b. It shall be protected by an approved device that is designed for the specific purpose.

2000 NFPA 101, 19.3.7.3 Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1/2 hour.
2000 NFPA 101, 8.3.2* Continuity. Smoke barriers required by this Code shall be continuous from an outside wall to an outside wall, from a floor to a floor, or from a smoke barrier to a smoke barrier or a combination thereof. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces
2000 NFPA 101, 19.3.7.1 Smoke barriers shall be provided to divide every story used for sleeping rooms for more than 30 patients into not less than two smoke compartments. The size of any such smoke compartment shall not exceed 22,500 ft2 (2100 m2), and the travel distance from any point to reach a door in the required smoke barrier shall not exceed 200 ft (60 m).
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The facility failed to maintain a door in the smoke barrier per code. Findings include:

During the survey, the following is an example of what was observed:

The corridor door for the Bradford Unit Meeting Room located in a smoke barrier was observed with the self-closing device for this door removed.
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2000 NFPA 101, 19.3.7.6 Doors in smoke barriers shall comply with 8.3.4 and shall be self-closing or automatic-closing in accordance with 19.2.2.2.6.
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The facility failed to maintain the hazardous areas per code. Findings include:

During the survey, the following are examples of what was observed:

1. The Storage Room in the E.R. was over 50 sq. ft. with combustibles - the door did not have a self-closing device
2. Patient Room 327 was being used to store Clean Linen and was over 50 sq. ft. - the door did not have a self-closing device
3. In the Dungeon Room, partial basement level, beneath Medical Records there were several penetrations in the ceiling to the right of the entrance door that were unsealed.
4. In the Mechanical Room in the partial basement next to Dietary there was an unsealed penetration in the ceiling 10' in front of entrance doors.
5. In the Dry Storage area adjacent to the kitchen across from the freezers in the left corner of the room there was a ceiling tile not in place and fire caulking not complete.

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2000 NFPA 101 19.3.2.1 Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. Hazardous areas shall include, but shall not be restricted to, the following: (1) Boiler and fuel-fired heater rooms (2) Central/bulk laundries larger than 100 ft2 (9.3 m2) (3) Paint shops (4) Repair shops (5) Soiled linen rooms (6) Trash collection rooms (7) Rooms or spaces larger than 50 ft2 (4.6 m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction (8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard.
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A.) The facility failed to maintain the exit access per code. Findings include:

During the survey the following are examples of what was observed:

1. The Physical Therapy Office was observed with two releasing operations on the inside of the door. (a hasp lock and the door handle)
2. The Bradford Unit was observed with full time magnetic locks on the cross corridor doors to this unit, the Nurses' Station for this unit did not have an emergency door release switch.
3. The Maintenance Room on the basement Dietary Floor was observed with a hasp with a padlock on the outside of this door.
4. The door into the Sleep Room was observed with a dead bolt locking device and latching door hardware.
5. The door into the Room 328 was observed with a dead bolt locking device and latching door hardware.
6. The door into the Room 335 was observed with a dead bolt locking device and latching door hardware.
7. The door into the Room 329 was observed with a dead bolt locking device and latching door hardware.
8. The door into the X-Ray Room was observed with a dead bolt locking device and latching door hardware.
9. The door into the Physical Therapy was observed with a dead bolt locking device and latching door hardware.
10. Located next to the elevator, the exit stairway from the basement to ground level had a fan blocking the emergency path of egress.
11. The entry door to the partial basement had a hasp and locking device mounted to the exterior side of the door.
13. The staff was unable to find the key to the courtyard gate padlock.
14. The following doors were observed with more than one releasing operation:
a. Physicians Sleep Room
b. Room 330
c. Room 328
d. Room 327
15. Doors throughout the facility had more than one releasing operation (2 separate door locks) in the path of egress.

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2000 NFPA 101, 7.2.1.5.4 A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 in. (86 cm), and not more than 48 in. (122 cm), above the finished floor. Doors shall be operable with not more than one releasing operation.
Alabama Department of Public Health Memo "Exit Door Locking Arrangements in Health Care Facilities" Revised 08/30/2013
2. Locked egress doors: This hardware is locked during all or part of the day.
Requirements:
B. A manual release switch shall be provided on both sides of each locked door (required only on the egress side of exterior doors). This may be a code pad, or key or card switch.
C. An emergency release switch, or " kill switch, " shall be provided at each nurse station, to disable locks on doors under control of that station or throughout the facility. This release switch shall be capable of being reset only by key or special knowledge. This switch may release doors by means of a key only in psychiatric and infant units.
D. A sign at each nurse station release switch indicating the purpose of the switch, to read, "EMERGENCY DOOR RELEASE".
E. The administration must furnish a written statement of justification which explains the facility's compliance with Exception No. 1 of LSC 18.2.2.2.4 or 19.2.2.2.4.

2000 NFPA 101, 7.2.1.5.1 Doors shall be arranged to be opened readily from the egress side whenever the building is occupied. Locks, if provided, shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side.
2000 NFPA 101, 7.1.10.1 Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.
2000 NFPA 19.3.1.1, 8.2.5.4 and 7.1.3.2.2, An exit enclosure shall provide a continuous protected path of travel to an exit discharge.

NFPA 101, 7.1.10.1 Means of egress shall be continuously maintained free of all obstructions or impediments for full instant use in case of fire or other emergencies.
NFPA 101, 19.7.3 Proper maintenance shall be provided to ensure the dependability of the method of evacuation selected. Health care occupancies that find it necessary to lock exits shall, at all times, maintain an adequate staff qualified to release locks and direct occupants from the immediate danger area to a place of safety in case of fire or other emergency.
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The facility failed to provide a complete written fire safety plan per code. Findings include:

During the survey, the following is an example of what was observed:

The Fire Evacuation Plan does not include the evacuation from smoke compartment to smoke compartment.

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2000 NFPA 101, 19.7.2.2 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

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The facility failed to document fire drills. Findings include:

During the survey the following is an example of what was observed:

The facility failed to provide written fire drill reports to go along with the signature page of the past twelve months fire drills.
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2000 NFPA 101, 19.7.1.2 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.

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Sprinkler coverage was observed during the survey not adequately provided. Findings include:

During the survey, the following are examples of what was observed:

1. Ceiling tiles not setting in ceiling grid appropriately in the ER Bay.
2. Ceiling tiles missing in the Admissions Office.
3. Ceiling tiles missing in the Admissions Office Work Room.
4. Ceiling tiles missing in the Dietary Stairwell.
5. Ceiling tiles missing in the Central Storage (Admin. Wing).
6. Loose escutcheon plates at the ER Bay.

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1999 NFPA 13 5-6. Sprinklers shall be arranged to be in compliance.
2000 NFPA 13, 3-2.7.2 Escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly.
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A.) The facility failed to maintain the automatic sprinkler system per code. Findings include:

During the survey the following are examples of what was observed:

1. The automatic sprinkler pipes were observed being used to support the lay-in ceiling at the smoke barrier doors at the MedSurge's Nurses' Station side.
2. A large (approximately 2' X 2') HVAC duct was observed resting on the automatic sprinkler pipe in the Bradford Unit's corridor outside the Washer and Dryer Room.

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1998 NFPA 25, 2-2.2 Sprinkler pipe and fittings shall be inspected annually from the floor level. Pipe and fittings shall be in good condition and free of mechanical damage, leakage, corrosion, and misalignment. Sprinkler piping shall not be subjected to external loads by materials either resting on the pipe or hung from the pipe.

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B.) The facility failed to perform the required maintenance of the facility sprinkler system. Findings include:

During the survey, the following is an example of what was observed:

1. The fire department connection was not provided with an identification sign.
2. Data plate in West Riser room not legible.

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2000 NFPA 101, 9.7.5 Maintenance and Testing. ... in accordance with NFPA 25, ...
1998 NFPA 25, 9-7.1 Fire department connections shall be inspected quarterly. The inspection shall verify the following: (a) The fire department connections are visible and accessible. (b) Couplings or swivels are not damaged and rotate smoothly. (c) Plugs or caps are in place and undamaged. (d) Gaskets are in place and in good condition. (e) Identification signs are in place. (f) The check valve is not leaking. (g) The automatic drain valve is in place and operating properly.
1998 NFPA 25, 2-2.7* Hydraulic Nameplate. The hydraulic nameplate, if provided, shall be inspected quarterly to verify that it is attached securely to the sprinkler riser and is legible. A-2-2.7 The hydraulic nameplate should be secured to the riser with durable wire, chain, or equivalent. (See Figure A-2-2.7.)
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C.) Sprinkler coverage was observed during the survey not adequately provided. Findings include:

During the survey, the following is an example of what was observed:

In the West Riser Room, two holes covered with black plastic and tape, were observed in the ceiling above the riser manifold.
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NFPA, 5-5.4.2 Deflectors of sprinklers shall be aligned parallel to ceilings, roofs, or the incline of stairs.

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D) The facility failed to provide documentation during the survey that included quarterly sprinkler system inspection reports for the year 2013.
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1998 NFPA 25 1-8* Records. Records of inspections, tests, and maintenance of the system and its components shall be made available to the authority having jurisdiction upon request. Typical records include, but are not limited to, valve inspections; flow, drain, and pump tests; and trip tests of dry pipe, deluge, and preaction valves.

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E.) The facility failed to maintain the automatic sprinkler system per code. Findings include:

During the survey the following are examples of what was observed:

1. No FDC signs were observed at either (2) fire department connections.
2. The plastic caps that protect the FDC connections were broken.

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1998 NFPA 25, 9-7.1 Fire department connections shall be inspected quarterly. The inspection shall verify the following: (a) The fire department connections are visible and accessible. (b) Couplings or swivels are not damaged and rotate smoothly. (c) Plugs or caps are in place and undamaged. (d) Gaskets are in place and in good condition. (e) Identification signs are in place. (f) The check valve is not leaking. (g )The automatic drain valve is in place and operating properly.
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The facility failed to maintain the fire extinguishers per code. Findings include:

During the survey, the following is an example of what was observed:

1. The fire extinguishers in the Lab had not been inspected annually.
2. The fire extinguisher in the old ER at the entrance from Administration hallway had not been inspected annually.
3. The fire extinguisher across from room 330 had not been inspected monthly for 01/2014, 02/2014, 03/2014, 04/2014 and 05/2014.

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1998 NFPA 10, 4-4.1 Frequency. Fire extinguishers shall be subjected to maintenance at intervals of not more than 1 year, at the time of hydrostatic test, or when specifically indicated by an inspection.
1998 NFPA 10, 4-4.4* Maintenance Recordkeeping. Each fire extinguisher shall have a tag or label securely attached that indicates the month and year the maintenance was performed and that identifies the person performing the service.
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The facility failed to provide noncombustible ashtrays for disposing of cigarette butts and ashes. Findings include:

During the survey, the following is an example of what was observed:

1. The designated smoking area at the end of Gateway Hallway was not provided with noncombustible ashtrays for disposing of cigarette butts. Excessive cigarette butts (75+) observed throughout smoking area on the ground.
2. The metal container with self-closing cover device was observed with combustible trash in it.
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The facility failed to maintain HVAC per code. Findings include:

During the survey the following is an example of what was observed:

1. The smoke damper for the HVAC duct passing through the smoke barrier at the Employees Women's Toilet did not have a service panel.
2. The facility could not provide any documentation to verify that the dampers had been serviced over the past six years.

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2000 NFPA 90A, 3-4.7 Maintenance. At least every 4 years, fusible links (where applicable) 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.
Exception, S&C-10-04-LSC (6-year damper testing interval)
1999 NFPA 90A, 2-3.4.1 A service opening shall be provided in air ducts adjacent to each fire damper, smoke damper, and smoke detector. The opening shall be large enough to permit maintenance and resetting of the device.
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The facility failed to maintain the dietary hood. Findings include:

During the survey, the following is an example of what was observed:

Internal hood joint seam, at end of hood where switches were located, were not sealed to make seam grease tight.
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1998 NFPA 96, 2-1.2 All seams, joints, and penetrations of the hood enclosure that direct and capture grease-laden vapors and exhaust gases shall have a liquid tight continuous external weld to the hood ' s lower outermost perimeter. Internal hood joints, seams, filter support frames, and appendages attached inside the hood need not be welded but shall be sealed or otherwise made grease tight.
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The facility failed to prohibit portable space heating devices per code. Findings include:

During the survey, the following are examples of what was observed:

1. A portable space heating device was observed being stored in the Maintenance Office.
2. Two portable space heating devices were observed being stored in the Data Room inside
the Admissions Office.

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2000 NFPA 101, 19.7.8 Portable space-heating devices shall be prohibited in all health care occupancies. Exception: Portable space-heating devices shall be permitted to be used in nonsleeping staff and employee areas where the heating elements of such devices do not exceed 212?F (100?C).
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The facility failed to maintain the laundry chute discharge door. Findings include:

During the survey, the following is an example of what was observed:

In the Soiled Linen room located in the partial basement outside the Dietary Hall, the laundry chute discharge door was tied open with a piece of wire, which prevented the door from closing in the case of a fire.
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1999 NFPA 82, 3-2.2.9 Chute Discharge Doors. Gravity chutes shall be constructed so that the base opening of the chute or shaft, or both, shall be protected by an approved automatic-closing or self-closing 1-hour fire door suitable for a Class B opening.
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The facility failed to maintain the medical gas storage per code. Findings include:

During the survey, the following is an example of what was observed:

The oxygen cylinders were observed not to be individually secured within the Medical Gas storage area in the basement next to Dietary.
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1999 NFPA 99 4-3.1.1.2 Storage Requirements (Location, Construction, Arrangement).
(a) * Nonflammable Gases (Any Quantity; In-Storage, Connected, or Both)
3. Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation.
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The facility failed to maintain the Piped in Medical Gas per code. Findings include:

During the survey, the following is an example of what was observed:
The facility could not provide any documentation to verify that the Piped in Medical Gas System had been inspected within the last year.
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1999 NFPA 99, 4-3.5.2.3 Patient Gas Systems - Level 1. (a) Piping systems shall not be used for the distribution of flammable anesthetic gases. (b) Nonflammable medical gas systems used to supply gases for respiratory therapy shall be installed in accordance with 4-3.1 of this chapter. (c) Maintenance programs in accordance with the manufacturers ' recommendations shall be established for the medical air compressor supply system as connected in each individual installation. (d) The responsible authority of the facility shall establish procedures to ensure that all signal warnings are promptly evaluated and that all necessary measures are taken to reestablish the proper functions of the medical gas system. (e) Piping systems for gases shall not be used as a grounding electrode. (f) The facility shall have the capability and organization to implement a plan to cope with a complete loss of any medical gas system. (g) A periodic testing procedure for nonflammable medical gas and related alarm systems shall be implemented. (h) The test specified in 4-3.4.1.3(i) shall be conducted on the downstream portions of the medical gas piping system whenever a system is breached or whenever modifications are made or maintenance performed. (i) Periodic retesting of audible and visual alarm indicators shall be performed to determine that they are functioning properly, and records of the test shall be maintained until the next test.

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A.) Facility failed to maintain side hinged doors in a means of egress. Findings include:
During the survey, the following is an example of what was observed:
The side hinged egress door in the corridor wall at the kitchen was observed blocked by equipment preventing the use of the door as a means of egress. The cart roll down door was observed as the means of egress from the kitchen to the corridor. (This roll down door does not meet the requirements for a door used as means of egress.)
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2000 NFPA 101 19.2.2, 19.2.2.2.1 Doors complying with 7.2.1 shall be permitted.
7.2.1.4.1* Any door in a means of egress shall be of the side-hinged or pivoted-swinging type. The door shall be designed and installed so that it is capable of swinging from any position to the full required width of the opening in which it is installed.
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B.) The facility failed to maintain the doors held open in the exit passageway. Findings include:
During the survey, the following is an example of what was observed:
During the testing of the fire alarm system the roll up door which was observed held open failed to close during the activation of the fire alarm system.
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2000 NFPA 101, 19.2.2.2.6* Any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8.2. The automatic sprinkler system, if provided, and the fire alarm system, and the systems required by 7.2.1.8.2 shall be arranged to initiate the closing action of all such doors throughout the smoke compartment or throughout the entire facility.
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The facility failed to maintain the medical gas warning system per code. Findings include:

During the survey the following are examples of what was observed:

1. The following medical gas alarm panels were not working when tested in the following areas:
a. E.R.
b. Bradford Unit's Nurses' Station
c. MedSurge Unit's Nurses' Station

2. The medical gas alarm panel outside the Medical Gas Room appeared to be working when tested, but was not located at a nurses' station or other location that would provide for responsible surveillance.
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1999 NFPA 99, 4-3.1.2.2 Gas Warning Systems.
1999 NFPA 99, 4-4.1
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A.) The facility failed to maintain the electrical wiring and equipment per code. Findings include:

During the survey, the following is an example of what was observed:

There was a homemade extension cord plugged into an electrical outlet in the corridor in between the Maintenance Rooms across from the Lab. The homemade extension cord went through the corridor wall into the Maintenance Room behind the electrical outlet and had an electrical cord from a light fixture plugged into the homemade extension cord.

B.) The facility failed to provide approved electrical utilities. Findings include:

During the survey, the following are examples of what was observed:

1. Electrical panel cover plate not in place in Elevator Equipment Room.
2. In Admissions office, an electrical cover plate was missing in the data closet.
3. In Councilor's Office on Gateway Hallway, refrigerator was plugged into surge protector and surge protector was plugged into wall outlet.
4. In Administration Area on Gateway Hallway at the end cubicle next to wall, a surge protector was plugged into an extension cord and extension cord was plugged into electrical outlet.
5. On the Bradford Hallway in the Employee Lounge, two refrigerators were plugged into a surge protector and surge protector was plugged into electrical outlet.
6. Refrigerator in Laboratory plugged into a surge protector and surge protector plugged into electrical outlet.

C.) The facility failed to maintain the electrical wiring and equipment per code per code. Findings include:

During the survey the following are examples of what was observed:

1. Electrical junction boxes were observed without their covers in the following locations:
a. Above the ceiling in the center of the Asst. Administrators office. (1)
b. Above the ceiling in the center of the Mammography room. (1)
c. At the ceiling of the partial basement. (6)

2. Flexible cords were observed being used in the following locations:

a. Inside the Dietary storage area there was an extension cord plugged into the wall and running up into the ceiling.
b. Inside the deep freezer an extension cord is being used to supply power to the fan unit.

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1999 NFPA 70, 370-25. Covers and Canopies In completed installations, each box shall have a cover, faceplate, or fixture canopy.

1999 NFPA 70, 410-12. Outlet Boxes to Be Covered In a completed installation, each outlet box shall be provided with a cover unless covered by means of a fixture canopy, lampholder, receptacle, or similar device.

1990 NFPA 70, 400-7 and 400-8, and HCFA Transmittal Notice 22-99 The 1984 edition of the National Electric Code restricts the use of extension cords to temporary short term uses. It is the policy of HCFA to prohibit non-circuit breaker protected extension cords in health care. The limited use of circuit breaker protected power strips is acceptable, provided the current is limited to 15 amps or less, and no major appliances such as air conditioners, refrigerators, or heating units are connected to the power strip.

1999 NFPA 70, 400-7 (b) Attachment Plugs. Where used as permitted in subsections (a)(3), (a)(6), and (a)(8), each flexible cord shall be equipped with an attachment plug and shall be energized from a receptacle outlet.

1999 NFPA 70, 400-8. Uses Not Permitted
Unless specifically permitted in Section 400-7, flexible cords and cables shall not be used for the following:
1. As a substitute for the fixed wiring of a structure
2. Where run through holes in walls, structural ceilings suspended ceilings, dropped ceilings, or floors
3. Where run through doorways, windows, or similar openings
4. Where attached to building surfaces
Exception: Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of Section 364-8.
5. Where concealed behind building walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
6. Where installed in raceways, except as otherwise permitted in this Code

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