HospitalInspections.org

The facility failed to maintain the building construction type per code. Findings include:

During the survey, the following was observed on the First Floor:
1. The Decontamination Room in the O.R. Suite had several unsealed ceiling penetrations above the washer/decontaminator.
2. The Server Room had unsealed conduit ends penetrating the ceiling.

2000 NFPA 101, 19.1.6.2 Health care occupancies shall be limited to the types of building construction shown in Table 19.1.6.2. (See 8.2.1.)
Table 19.1.6.2 Construction Type Limitations
Construction Stories
Type
1 2 3 4 or
More
I(443) X X X X
I(332) X X X X
II(222) X X X X
II(111) X X* X* NP
II(000) X* X* NP NP
III(211) X* X* NP NP
III(200) X* NP NP NP
IV(2HH) X* X* NP NP
V(111) X* X* NP NP
V(000) X* NP NP NP
X: Permitted type of construction.
NP: Not permitted.
*Building requires automatic sprinkler protection. (See 19.3.5.1.)
.

The facility failed to provide corridor doors that would close and resist the passage of smoke. Findings include: During the survey, the door failed to latch, Patient Room 208.


NFPA 101, 19.3.6.3.1 Exception No.2. In the smoke compartments protected throughout by an approved, supervised automatic sprinkler system, doors in corridor walls shall be constructed to resist the passage of smoke and be provided with suitable means of keeping the doors closed.




27382


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

During the survey, the following was observed on the First Floor:
1. The Chapel corridor door did not have positive latching hardware.
2. The C.T. corridor door had a toe stop on it.
3. The corridor double doors of the I.T. Closet at the Lab. did not have an astragal.

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.

2007 CMS - 2786R There is no impediment to the closing of the corridor doors.

2000 NFPA 101, 19.3.6.3.3 Hold-open devices that release when the door is pushed or pulled shall be permitted.

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.

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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 was observed:


1. Unsealed penetrations around a sleeve, and at the end of the sleeve, in the Smoke Barrier, by Patient Room 320.

2. Unsealed penetrations around a sleeve, in the Smoke Barrier, by Clean Supply Room Third Floor.

3. Unsealed penetrations around a group of wiring, in the Smoke Barrier, by Patient Room 311.

4. Unsealed penetrations at the end of a sleeve, in the Smoke Barrier, by Patient Room 242.



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.

NFPA 101, 8.3.2 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.

The facility failed to maintain a hazardous area per code. Findings include:

During the survey, the "Back Forty" Storage Room (shell space) on the First Floor was observed to have automatic sprinkler coverage, but was missing sheetrock in two large places.

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.

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The facility failed to provide a reliable means of egress to the public way. Observed during the survey, the following findings include: During the survey, based upon observation, the Exit Discharge for the South Stairwell, was not provided with an all weather surface to the public way.


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.


NFPA 101, A.7.1.10.1 *A proper means of egress allows unobstructed travel at all times. Any type of barrier including, but not limited to, the accumulations of snow and ice in those climates subject to such accumulations is an impediment to free movement in the means of egress.

The facility failed to conduct fire drills under varying conditions at unexpected times. Findings include:


Documentation provided by the facility during the survey indicated fire
drills were conducted on the third shift on the following dates, and times:

1. First quarter 1/28/2010, at 6:35am Third Shift.

2. Second quarter 4/28/2010, at 6:41am Third Shift.

3. Third quarter 7/28/2010, at 6:31am Third Shift.

4. Fourth quarter 10/26/2010, At 6:25am Third Shift.


NFPA 101, 19.7.1.2 Fire drills shall be conducted at least quarterly on each shift and at unexpected times under varied conditions on all shifts to simulate the unusual conditions occurring in case of fire.

The facility failed to maintain the fire alarm system in proper working order. Findings include: During the survey, while testing the fire alarm, a horn/strobe was not observed in the Central Supply located on the first floor. The fire alarm was not audible in this area during the testing of the fire alarm system.

2000 NFPA 101, 9.6.3.1 Occupant notification shall provide signal notification to alert occupants of fire or other emergency as required by other sections of this Code.

2000 NFPA 101. 9.6.3.8 Audible alarm notification appliances shall be of such a character and so distributed as to be effectively heard above the aveage ambient sound level occurring under normal conditions of occupancy.

A) Sprinkler coverage was observed during the survey not adequately provided. Findings include: During the survey, the following was observed:


1. Paint on a sprinkler in the Stairwell by Air Handler Number 7 Second Floor.

2. Paint on the sprinkler at the top of Elevators 1 and 2.


1999 NFPA 25, 2-2.1.1 and 2-4.1.2 Sprinklers that are painted, corroded or damaged shall be replaced with new listed sprinklers of the same characteristics, including orifice size, thermal response, and water distribution.


27382


B) The facility failed to provide automatic sprinkler coverage per code. Findings include:

During the survey, the following was observed on the First Floor:
1. The sprinkler head in the X-ray Reading Room was above the ceiling.
2. Hydraulic Elevators #3 and #4 did not have a sidewall sprinkler head installed 2'-0" above the floor of the pit.

1999 NFPA 13, 5-6.5.1.1 Sprinklers shall be located so as to minimize obstructions to discharge as defined in 5-6.5.2 and 5-6.5.3, or additional sprinklers shall be provided to ensure adequate coverage of the hazard.
1999 NFPA 13, 5-13.6.1 Sidewall spray sprinklers shall be installed at the bottom of each elevator hoistway not more than 2 ft (0.61 m) above the floor of the pit.
Exception: For enclosed, noncombustible elevator shafts that do not contain combustible hydraulic fluids, the sprinklers at the bottom of the shaft are not required.
.

The facility failed to provide supervision to the automatic sprinkler system valve. Findings include:

During the survey, in the Materials Management Corridor on the First Floor above the ceiling an automatic sprinkler system shut of valve was observed not to be electronically supervised.

2000 NFPA 101, 9.7.2.1 Where supervised automatic sprinkler systems are required by another section of this Code, supervisory attachments shall be installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm Code, and a distinctive supervisory signal shall be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system. Monitoring shall include, but shall not be limited to, monitoring of control valves, fire pump power supplies and running conditions, water tank levels and temperatures, tank pressure, and air pressure on dry-pipe valves. Supervisory signals shall sound and shall be displayed either at a location within the protected building that is constantly attended by qualified personnel or at an approved, remotely located receiving facility.
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The facility failed to maintain the automatic sprinkler system per code. Findings include:

During the survey, per observation and interview the sprinkler inspections were not being conducted quarterly.
10/07/2010 - 4months
06/21/2010
03/16/2010 - 5 months
10/28/2009

2000 NFPA 101, 9.7.5 All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.
.

The facility failed to provide and maintain the HVAC duct dampers per code. Findings include:

During the survey, the following was observed on the First Floor:
1. The smoke barrier between the Risk Management Office and the Glass Corridor had two HVAC ducts close to the roof deck penetrating the smoke barrier that did not have smoke dampers or access panels.
2. The two hour fire barrier at the Janitor's Storage - above door #0552 had two HVAC ducts penetrating this barrier that did not have access panels; could not verify if there was a fire damper in them.
3. The HVAC ducts penetrating the two hour fire barrier at fire door #0553 did not have fire dampers.
4. The HVAC ducts penetrating the two hour fire barrier at door #0551 did not have fire dampers.
5. The HVAC duct penetrating both sides of the two hour fire barrier corridor did not have a fire damper on either side of the corridor.
6. The HVAC duct penetrating the smoke barrier between the C.T. Corridor and Mamo Film Storage did not have an access panel.
7. The HVAC duct penetrating the smoke barrier between the C.T. Room and Mamo Film Storage did not have smoke dampers or access panels.
8. The smoke damper above door # 0558 did not close under the fire alarm.

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.

1999 NFPA 90A, 3-3.1.1*
Approved fire dampers shall be provided where air ducts penetrate or terminate at openings in walls or partitions required to have a fire resistance rating of 2 hours or more.
Exception*: Fire dampers shall not be required where other openings through the wall are not required to be protected.

1999 NFPA 90A, 3-3.1.2
Approved fire dampers shall be provided in all air transfer openings in partitions that are required to have a fire resistance rating and in which other openings are required to be protected.

1999 NFPA 90A, 3-3.5.1 Smoke dampers shall be installed at or adjacent to the point where air ducts pass through required smoke barriers, but in no case shall a smoke damper be installed more than 2 ft (0.6 m) from the barrier or after the first air duct inlet or outlet, whichever is closer to the smoke barrier.

1999 NFPA 90A, 3-4.5.4 Dampers shall close against the maximum calculated airflow of that portion of the air duct system in which they are installed. Fire dampers shall be tested in accordance with UL 555, Standard for Safety Fire Dampers. Smoke dampers shall be tested in accordance with UL 555S, Standard for Safety Smoke Dampers.


.

The facility failed to maintain in-service for the kitchen staff. Findings include:

During the survey, per interview with kitchen staff, they did not know the proper procedures for when to manually activate the automatic hood suppression system.


1998 NFPA 96, 8-1.4 Instructions for manually operating the fire-extinguishing system shall be posted conspicuously in the kitchen and shall be reviewed periodically with employees by the management.

.

The facility failed to maintain exits free of all obstructions: Findings include: During the survey, the Exit Discharge at the SouthWest Stairwell, was observed blocked by Eight Carts, preventing egress from the facility to the public way.



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.


27382


The facility failed to maintain the means of egress per code. Findings include:

During the survey, the right side of the double exit doors on the X-ray Corridor on the first floor would not open.

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.
.

The facility failed to maintain/provide a smoke venting system per code. Findings include:

During the survey, the following was observed:
1. The three new O.R.s, when the smoke detectors were tested did not shut down the HVAC. The vent fan did come on.
2. Per interview the Old O.R. 2 did not have a smoke venting system.

1999 NFPA 99, 5-4.1.2 Supply and exhaust systems for windowless anesthetizing locations shall be arranged to automatically vent smoke and products of combustion.

1999 NFPA 99, 5-4.1.3 Ventilating systems for anesthetizing locations shall be provided that automatically (a) prevent recirculation of smoke originating within the surgical suite and (b) prevent the circulation of smoke entering the system intake, without in either case interfering with the exhaust function of the system.

1999 NFPA 99, 5-4.1.4 The electric supply to the ventilating system shall be served by the equipment system of the essential electrical system specified in Chapter 3, " Electrical Systems. "

1999 NFPA 99, 5-6.1.1 Ventilating and humidifying equipment for anesthetizing locations shall be kept in operable condition and be continually operating during surgical procedures (see A-5-4.1).
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The facility failed to maintain the smoke barriers per code. Findings include:

During the survey, the following was observed on the First Floor:
1. The Lab. "Send Out Section" had an unsealed penetration of the smoke barrier with a single blue wire.
2. The Lab. "Chemistry" had an unsealed penetration of the smoke barrier of a bundle of grey wires.
3. The smoke barrier between the corridor and the Pharmacy had an unsealed penetration of a bundle of grey wires with one blue wire.
4. The smoke barrier at door #0557 had an unsealed 2" penetration.
5. The smoke barrier at M.R.I.'s back door was missing sheetrock around a group of pipes at the roof deck.
6. The smoke barrier at M.R.I.'s back door had unsealed mineral wool at the roof deck.

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.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

2000 NFPA 101, 8.3.6.2 Openings occurring at points where floors or smoke barriers meet the outside walls, other smoke barriers, or fire barriers of a building shall meet one of the following conditions:
(1) It shall be filled with a material that is capable of maintaining the smoke resistance of the floor or smoke barrier.
(2) It shall be protected by an approved device that is designed for the specific purpose.
.

A) During the survey, the following was observed:

An extension cord was in use without a surge protector,connected to the Radio Equipment in the Pent house.


1999 NFA 70, Article 240-4, and HFCA Transmittal Notice 22-99 prohibit the use of extension cords without overcurrent protection.


1.Junction box missing a cover behind the Vending Machines First Floor.

2. Junction box missing a cover above the ceiling, at the Smoke barrier, by Patient Room 320.


1999 NFPA 70, 370-25 and 410-12. Each box in completed installations to have a cover, face plate, or fixture canopy.

3. Mircowave plugged into an extension cord in the Maintenance Shop.

4. Refrigerator plugged into a surge protector, in the Male Lounge, on the Third Floor.


Appliances, such as air conditioners and refrigerators, shall plug directly into a receptacle. 1999 NFPA 70, 400-7 and 400-8, and HCFA Transmittal Notice 22-99.



27382


B) The facility failed to maintain the electrical system per code. Findings include:

During the survey, the following was observed on the First Floor:
1. The Board Room had a multi-outlet (3) extension cord plugged into another extension cord.
2. The H.R. File Room had a refrigerator plugged into a surge protector.
3. The Quality Coordinator's Office had a refrigerator plugged into a surge protector.
4. The I.T. Closet next to M.R.I. had a light fixture plugged into an extension cord, that was plugged into a surge protector.
5. The O.R. Office (Nelly's) had a refrigerator plugged into a surge protector.

1999 NFPA 70, 400-7 and 400-8, and HCFA Transmittal Notice 22-99 Appliances, such as air conditioners and refrigerators, shall plug directly into a receptacle.

The facility failed to maintain the building construction type per code. Findings include:

During the survey, the following was observed on the First Floor:
1. The Decontamination Room in the O.R. Suite had several unsealed ceiling penetrations above the washer/decontaminator.
2. The Server Room had unsealed conduit ends penetrating the ceiling.

2000 NFPA 101, 19.1.6.2 Health care occupancies shall be limited to the types of building construction shown in Table 19.1.6.2. (See 8.2.1.)
Table 19.1.6.2 Construction Type Limitations
Construction Stories
Type
1 2 3 4 or
More
I(443) X X X X
I(332) X X X X
II(222) X X X X
II(111) X X* X* NP
II(000) X* X* NP NP
III(211) X* X* NP NP
III(200) X* NP NP NP
IV(2HH) X* X* NP NP
V(111) X* X* NP NP
V(000) X* NP NP NP
X: Permitted type of construction.
NP: Not permitted.
*Building requires automatic sprinkler protection. (See 19.3.5.1.)
.

The facility failed to provide corridor doors that would close and resist the passage of smoke. Findings include: During the survey, the door failed to latch, Patient Room 208.


NFPA 101, 19.3.6.3.1 Exception No.2. In the smoke compartments protected throughout by an approved, supervised automatic sprinkler system, doors in corridor walls shall be constructed to resist the passage of smoke and be provided with suitable means of keeping the doors closed.




27382


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

During the survey, the following was observed on the First Floor:
1. The Chapel corridor door did not have positive latching hardware.
2. The C.T. corridor door had a toe stop on it.
3. The corridor double doors of the I.T. Closet at the Lab. did not have an astragal.

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.

2007 CMS - 2786R There is no impediment to the closing of the corridor doors.

2000 NFPA 101, 19.3.6.3.3 Hold-open devices that release when the door is pushed or pulled shall be permitted.

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.

.

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 was observed:


1. Unsealed penetrations around a sleeve, and at the end of the sleeve, in the Smoke Barrier, by Patient Room 320.

2. Unsealed penetrations around a sleeve, in the Smoke Barrier, by Clean Supply Room Third Floor.

3. Unsealed penetrations around a group of wiring, in the Smoke Barrier, by Patient Room 311.

4. Unsealed penetrations at the end of a sleeve, in the Smoke Barrier, by Patient Room 242.



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.

NFPA 101, 8.3.2 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.

The facility failed to maintain a hazardous area per code. Findings include:

During the survey, the "Back Forty" Storage Room (shell space) on the First Floor was observed to have automatic sprinkler coverage, but was missing sheetrock in two large places.

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.

.

The facility failed to provide a reliable means of egress to the public way. Observed during the survey, the following findings include: During the survey, based upon observation, the Exit Discharge for the South Stairwell, was not provided with an all weather surface to the public way.


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.


NFPA 101, A.7.1.10.1 *A proper means of egress allows unobstructed travel at all times. Any type of barrier including, but not limited to, the accumulations of snow and ice in those climates subject to such accumulations is an impediment to free movement in the means of egress.

The facility failed to conduct fire drills under varying conditions at unexpected times. Findings include:


Documentation provided by the facility during the survey indicated fire
drills were conducted on the third shift on the following dates, and times:

1. First quarter 1/28/2010, at 6:35am Third Shift.

2. Second quarter 4/28/2010, at 6:41am Third Shift.

3. Third quarter 7/28/2010, at 6:31am Third Shift.

4. Fourth quarter 10/26/2010, At 6:25am Third Shift.


NFPA 101, 19.7.1.2 Fire drills shall be conducted at least quarterly on each shift and at unexpected times under varied conditions on all shifts to simulate the unusual conditions occurring in case of fire.

The facility failed to maintain the fire alarm system in proper working order. Findings include: During the survey, while testing the fire alarm, a horn/strobe was not observed in the Central Supply located on the first floor. The fire alarm was not audible in this area during the testing of the fire alarm system.

2000 NFPA 101, 9.6.3.1 Occupant notification shall provide signal notification to alert occupants of fire or other emergency as required by other sections of this Code.

2000 NFPA 101. 9.6.3.8 Audible alarm notification appliances shall be of such a character and so distributed as to be effectively heard above the aveage ambient sound level occurring under normal conditions of occupancy.

A) Sprinkler coverage was observed during the survey not adequately provided. Findings include: During the survey, the following was observed:


1. Paint on a sprinkler in the Stairwell by Air Handler Number 7 Second Floor.

2. Paint on the sprinkler at the top of Elevators 1 and 2.


1999 NFPA 25, 2-2.1.1 and 2-4.1.2 Sprinklers that are painted, corroded or damaged shall be replaced with new listed sprinklers of the same characteristics, including orifice size, thermal response, and water distribution.


27382


B) The facility failed to provide automatic sprinkler coverage per code. Findings include:

During the survey, the following was observed on the First Floor:
1. The sprinkler head in the X-ray Reading Room was above the ceiling.
2. Hydraulic Elevators #3 and #4 did not have a sidewall sprinkler head installed 2'-0" above the floor of the pit.

1999 NFPA 13, 5-6.5.1.1 Sprinklers shall be located so as to minimize obstructions to discharge as defined in 5-6.5.2 and 5-6.5.3, or additional sprinklers shall be provided to ensure adequate coverage of the hazard.
1999 NFPA 13, 5-13.6.1 Sidewall spray sprinklers shall be installed at the bottom of each elevator hoistway not more than 2 ft (0.61 m) above the floor of the pit.
Exception: For enclosed, noncombustible elevator shafts that do not contain combustible hydraulic fluids, the sprinklers at the bottom of the shaft are not required.
.

The facility failed to provide supervision to the automatic sprinkler system valve. Findings include:

During the survey, in the Materials Management Corridor on the First Floor above the ceiling an automatic sprinkler system shut of valve was observed not to be electronically supervised.

2000 NFPA 101, 9.7.2.1 Where supervised automatic sprinkler systems are required by another section of this Code, supervisory attachments shall be installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm Code, and a distinctive supervisory signal shall be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system. Monitoring shall include, but shall not be limited to, monitoring of control valves, fire pump power supplies and running conditions, water tank levels and temperatures, tank pressure, and air pressure on dry-pipe valves. Supervisory signals shall sound and shall be displayed either at a location within the protected building that is constantly attended by qualified personnel or at an approved, remotely located receiving facility.
.

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

During the survey, per observation and interview the sprinkler inspections were not being conducted quarterly.
10/07/2010 - 4months
06/21/2010
03/16/2010 - 5 months
10/28/2009

2000 NFPA 101, 9.7.5 All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.
.

The facility failed to provide and maintain the HVAC duct dampers per code. Findings include:

During the survey, the following was observed on the First Floor:
1. The smoke barrier between the Risk Management Office and the Glass Corridor had two HVAC ducts close to the roof deck penetrating the smoke barrier that did not have smoke dampers or access panels.
2. The two hour fire barrier at the Janitor's Storage - above door #0552 had two HVAC ducts penetrating this barrier that did not have access panels; could not verify if there was a fire damper in them.
3. The HVAC ducts penetrating the two hour fire barrier at fire door #0553 did not have fire dampers.
4. The HVAC ducts penetrating the two hour fire barrier at door #0551 did not have fire dampers.
5. The HVAC duct penetrating both sides of the two hour fire barrier corridor did not have a fire damper on either side of the corridor.
6. The HVAC duct penetrating the smoke barrier between the C.T. Corridor and Mamo Film Storage did not have an access panel.
7. The HVAC duct penetrating the smoke barrier between the C.T. Room and Mamo Film Storage did not have smoke dampers or access panels.
8. The smoke damper above door # 0558 did not close under the fire alarm.

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.

1999 NFPA 90A, 3-3.1.1*
Approved fire dampers shall be provided where air ducts penetrate or terminate at openings in walls or partitions required to have a fire resistance rating of 2 hours or more.
Exception*: Fire dampers shall not be required where other openings through the wall are not required to be protected.

1999 NFPA 90A, 3-3.1.2
Approved fire dampers shall be provided in all air transfer openings in partitions that are required to have a fire resistance rating and in which other openings are required to be protected.

1999 NFPA 90A, 3-3.5.1 Smoke dampers shall be installed at or adjacent to the point where air ducts pass through required smoke barriers, but in no case shall a smoke damper be installed more than 2 ft (0.6 m) from the barrier or after the first air duct inlet or outlet, whichever is closer to the smoke barrier.

1999 NFPA 90A, 3-4.5.4 Dampers shall close against the maximum calculated airflow of that portion of the air duct system in which they are installed. Fire dampers shall be tested in accordance with UL 555, Standard for Safety Fire Dampers. Smoke dampers shall be tested in accordance with UL 555S, Standard for Safety Smoke Dampers.


.

The facility failed to maintain in-service for the kitchen staff. Findings include:

During the survey, per interview with kitchen staff, they did not know the proper procedures for when to manually activate the automatic hood suppression system.


1998 NFPA 96, 8-1.4 Instructions for manually operating the fire-extinguishing system shall be posted conspicuously in the kitchen and shall be reviewed periodically with employees by the management.

.

The facility failed to maintain exits free of all obstructions: Findings include: During the survey, the Exit Discharge at the SouthWest Stairwell, was observed blocked by Eight Carts, preventing egress from the facility to the public way.



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.


27382


The facility failed to maintain the means of egress per code. Findings include:

During the survey, the right side of the double exit doors on the X-ray Corridor on the first floor would not open.

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.
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The facility failed to maintain/provide a smoke venting system per code. Findings include:

During the survey, the following was observed:
1. The three new O.R.s, when the smoke detectors were tested did not shut down the HVAC. The vent fan did come on.
2. Per interview the Old O.R. 2 did not have a smoke venting system.

1999 NFPA 99, 5-4.1.2 Supply and exhaust systems for windowless anesthetizing locations shall be arranged to automatically vent smoke and products of combustion.

1999 NFPA 99, 5-4.1.3 Ventilating systems for anesthetizing locations shall be provided that automatically (a) prevent recirculation of smoke originating within the surgical suite and (b) prevent the circulation of smoke entering the system intake, without in either case interfering with the exhaust function of the system.

1999 NFPA 99, 5-4.1.4 The electric supply to the ventilating system shall be served by the equipment system of the essential electrical system specified in Chapter 3, " Electrical Systems. "

1999 NFPA 99, 5-6.1.1 Ventilating and humidifying equipment for anesthetizing locations shall be kept in operable condition and be continually operating during surgical procedures (see A-5-4.1).
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The facility failed to maintain the smoke barriers per code. Findings include:

During the survey, the following was observed on the First Floor:
1. The Lab. "Send Out Section" had an unsealed penetration of the smoke barrier with a single blue wire.
2. The Lab. "Chemistry" had an unsealed penetration of the smoke barrier of a bundle of grey wires.
3. The smoke barrier between the corridor and the Pharmacy had an unsealed penetration of a bundle of grey wires with one blue wire.
4. The smoke barrier at door #0557 had an unsealed 2" penetration.
5. The smoke barrier at M.R.I.'s back door was missing sheetrock around a group of pipes at the roof deck.
6. The smoke barrier at M.R.I.'s back door had unsealed mineral wool at the roof deck.

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.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

2000 NFPA 101, 8.3.6.2 Openings occurring at points where floors or smoke barriers meet the outside walls, other smoke barriers, or fire barriers of a building shall meet one of the following conditions:
(1) It shall be filled with a material that is capable of maintaining the smoke resistance of the floor or smoke barrier.
(2) It shall be protected by an approved device that is designed for the specific purpose.
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A) During the survey, the following was observed:

An extension cord was in use without a surge protector,connected to the Radio Equipment in the Pent house.


1999 NFA 70, Article 240-4, and HFCA Transmittal Notice 22-99 prohibit the use of extension cords without overcurrent protection.


1.Junction box missing a cover behind the Vending Machines First Floor.

2. Junction box missing a cover above the ceiling, at the Smoke barrier, by Patient Room 320.


1999 NFPA 70, 370-25 and 410-12. Each box in completed installations to have a cover, face plate, or fixture canopy.

3. Mircowave plugged into an extension cord in the Maintenance Shop.

4. Refrigerator plugged into a surge protector, in the Male Lounge, on the Third Floor.


Appliances, such as air conditioners and refrigerators, shall plug directly into a receptacle. 1999 NFPA 70, 400-7 and 400-8, and HCFA Transmittal Notice 22-99.



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B) The facility failed to maintain the electrical system per code. Findings include:

During the survey, the following was observed on the First Floor:
1. The Board Room had a multi-outlet (3) extension cord plugged into another extension cord.
2. The H.R. File Room had a refrigerator plugged into a surge protector.
3. The Quality Coordinator's Office had a refrigerator plugged into a surge protector.
4. The I.T. Closet next to M.R.I. had a light fixture plugged into an extension cord, that was plugged into a surge protector.
5. The O.R. Office (Nelly's) had a refrigerator plugged into a surge protector.

1999 NFPA 70, 400-7 and 400-8, and HCFA Transmittal Notice 22-99 Appliances, such as air conditioners and refrigerators, shall plug directly into a receptacle.