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Multiple Occupancies - Sections of Ambulatory Health Care Facilities Multiple occupancies shall be in accordance with 6.1.14. Sections of ambulatory health care facilities shall be permitted to be classified as other occupancies, provided they meet both of the following: · The occupancy is not intended to serve ambulatory health care occupants for treatment or customary access · They are separated from the ambulatory health care occupancy by a 1 hour fire resistance rating Ambulatory health care facilities shall be separated from other tenants and occupancies and shall meet all of the following: · Walls have not less than 1 hour fire resistance rating and extend from floor slab to roof slab · Doors are constructed of not less than 1-3/4 inches thick, solid-bonded wood core or equivalent and is equipped with positive latches. · Doors are self-closing and are kept in the closed position, except when in use. · Windows in the barriers are of fixed fire window assemblies per 8.3. Per regulation, ASCs are classified as Ambulatory Health Care Occupancies, regardless of the number of patients served. 20.1.3.2, 21.1.3.3, 20.3.7.1, 21.3.7.1,42 CFR 416.44


Based on schematic review, observation, and staff verification the facility failed to maintain the 1 hour fire rating of its occupancy separation. This has the potential to affect all patients receiving services at the off-site location.

Findings include:

Tour and schematic review of the Surgery Center and Emergency Room was conducted on 08/15/18 between the hours of 1:30 PM and 4:30 PM. During tour the following observations were made:

1. A 1 X 3 inch junction box (pull box) cover was off penetrating the fire rated occupancy separation in the ED waiting room above the vending machines.

2. The double fire rated doors between the Emergency Room space and the specialty area (business occupancy), located between the Material storage and Mechanical room, failed to close to latching position when tested. No sequencer was noted on the doors, one of the doors closed to latching position and the other door got hung up on the astragal causing it to not close to latching position.

3. The double fire rated doors between the Emergency Room space and the specialty area (business occupancy), located toward the front of the building, failed to close to latching position.

4. Multiple conduits open on the end and with open annular space above the drop ceiling on both sides of the double doors between the Emergency Room space and the specialty area toward the front of the building.

5. The nurse manager's office door had no self closing device.

6. A 3 1/3 inch by 12 inch space at the point where the manager's office wall meets the occupancy separation wall of the shell space outside the Nurse Manager's office as seen from the corridor to the left of the Nurse Managers office door.

All findings were verified by Staff AA, Staff BB, Staff CC, Staff DD, and Staff EE at the time of the observations.

Doors with Self-Closing Devices Doors required to be self-closing are permitted to be held open by a release device complying with 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment, entire facility, and all stair enclosure doors upon activation of: · Required manual fire alarm system, and· Local smoke detectors designed to detect smoke passing through the· opening or a required smoke detection system; and· Automatic sprinkler system, if installed; and· Loss of power 20.2.2.4, 20.2.2.5, 21.2.2.4, 21.2.2.5


Based on documentation review and staff interview the facility failed to ensure door releasing devices were tested with the alarm system or tested for loss of power. This has the potential to affect all patients receiving services at the facility.

Findings include:

Review of the fire alarm testing documentation revealed the facility had 6 door hold open devices in the facility. The alarm testing documentation did not show these devices were tested.

Staff AA stated on 08/15/18 at 4:35 PM that the door hold open devices were tested when the facility completed an inventory, a document was provided with a list of the doors and locations but the document did not show the doors hold open devices were tested and passed or failed.

This deficiency substantiates Substantial Allegations OH00099615 and OH00099617

Vertical Openings - Enclosure 2012 EXISTING Vertical openings shall be enclosed or protected per 8.6, unless one of the following conditions exist: 1. Unenclosed vertical openings per 8.6.9.1 are permitted. 2. Unenclosed openings which do not serve as a required means of egress are permitted. 3. Exit access stairs may be unenclosed if they meet the following conditions:Two stories or less a. Building is protected throughout by a supervised sprinkler system per 9.7.1.1(1).b. Total travel distance to outside does not exceed 100 feet. Three stories or less a. Occupant load per story does not exceed 15 people. b. Building is sprinkler protected throughout per 9.7.1.1(1).c. Building contains an automatic smoke detection system per 9.6. d. Activation of the sprinkler system or smoke detection system notifies all occupants of the building. e. Total travel distance to outside does not exceed 100 feet. Floors that are below the street level and are used for storage or any use other than a business occupancy, shall not have any unprotected openings to the business occupancy floors. 21.3.1, 39.3.1.1, 39.3.1.2


Based on schematic review, observation, and staff interview the facility failed to ensure vertical openings fire rated walls were maintained. This has the potential to affect all patients receiving services at the facility.

Findings include:

Tour and schematic review of the Surgery Center and Emergency Room was conducted on 08/15/18 between the hours of 1:30 PM and 4:30 PM. During tour the following observations were made:

1. A 6 inch penetration with 1 1/2 inch sprinkler pipe passing through was noted toward the back of the stairwell above the drop ceiling in Stairwell.

2. No gypsum board from the deck above to about 3 feet down running the length of the stairwell of Stairwell 6 wall as seen from Phase I PACU.

All findings were verified by Staff AA, Staff BB, Staff CC, Staff DD, and Staff EE at the time of the observations.

Staff BB verified Stairwell 6 was built with a 1 hour fire rated barrier with a layer of gypsum board on each side of the wall to the deck above in an interview on 08/15/18 at 3:35 PM.

This deficiency substantiates Substantial Allegations OH00099615 and OH00099617

Hazardous Areas - Enclosure Hazardous areas must meet one of the following: Contain 1 hour rated enclosure when non-sprinklered Sprinkler protected with smoke resistive separation Severe Hazard locations contain sprinkler protection and 1 hour separation with 3/4 hour rated self-closing doors 20.3.2, 21.3.2, 38.3.2, 38.3.2.2, 39.3.2.1, 39.3.2.2, 8.7


Based on observation and staff verification the facility failed to maintain the identified 1 hour fire rating of its hazardous area walls on the first floor. This has the potential to affect all patients receiving services at the facility.

Finding include:

Observation in the corridor outside the Material storage, Biomed, Mechanical room, and supply room completed on 08/15/18 at 4:05 PM revealed multiple penetrations varying in size and shape not sealed with a fire rated material and the walls not sealed at deck above with a fire rated material.

These findings were verified by Staff AA, Staff BB, Staff CC, Staff DD, and Staff EE at the time of the observation.

Fire Alarm Systems - Testing and Maintenance A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.6.1.3, 9.6.1.5

Based on documentation review and staff verification the facility failed to ensure notification devices were at least tested annually. This has the potential to affect all patients receiving services at the facility.

Findings include:

Review of the fire alarm system testing completed on 08/15/18 between the hours of 9:30 AM and 11:30 AM revealed no documentation that the strobes or horns for the alarm system passed or failed during the fire alarm testing completed on 03/05/18 and on 02/13/17.

These findings were verified by Staff CC at the time of the documentation review.

This deficiency substantiates Substantial Allegations OH00099615 and OH00099617.

Subdivision of Building Spaces - Smoke Barrier Construction 2012 EXISTING
Smoke barriers shall be constructed to a 1/2 hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier. 21.3.7.5, 21.3.7.6, 8.5


Based on schematic review, observation, and staff verification the facility failed to maintain the fire rating of the 1 hour fire rated smoke barriers. This has the potential to affect all patients receiving services at the facility.

Findings include:

Tour and schematic review of the Surgery Center and Emergency Room was conducted on 08/15/18 between the hours of 1:30 PM and 4:30 PM. During tour the following observations were made:

1. A 1/2 inch red conduit open on end with red data cable and 1/2 inch flex conduit open on end with gray data cables above the door from the elevator corridor to the PACU on the 2nd floor.

2. A 10 inch flex HVAC duct with open annular space in the fire rated wall adjacent to soiled utility room and next to PACU 9 .

3. A 6 inch by 6 inch junction box with no cover with a 1/2 inch conduit penetrating the fire rated smoke barrier above the double doors between PACU 9 and PACU 10.

4. 8 to 12 half inch holes located in the I beam at the top of the wall of the back wall of PACU 10.

5. Multiple penetrations varying in size and shape behind the "false" wall containing HVAC ducts to the right of the double doors from Phase I PACU to the Operating Rooms.

6. A 1 inch yellow conduit with blue and green data cables in the fire wall as seen from inside induction room 2.

7. A penetration to the right of the HVAC duct with open annular space in the fire wall from inside the anesthesia room.

8. A 1 inch conduit open on the end in the wall in the men's locker room above the machine to return surgical scrubs.

9. An un-rated material used to seal penetrations and at deck in the fire rated smoke barrier as seen from inside Exam room 4.

10. Multiple conduits varying in size open on the end, non rated material around penetrations, and a 12 inch flex HVAC duct penetrating the corner with open space around it as seen from inside the trauma room.

All findings were verified by Staff AA, Staff BB, Staff CC, Staff DD, and Staff EE at the time of the tour.

This deficiency substantiates Substantial Allegations OH00099615 and OH00099617

Fire Drills Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at unexpected times under varying conditions, at least quarterly on each shift The staff is familiar with procedures and is aware that drills are part of established routine. Responsibility for planning and conducting drills is assigned only to competent persons who are qualified to exercise leadership. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms.
20.7.1.4 through 20.7.14.7


Based on documentation review and staff verification the facility failed to ensure fire drills were conducted at varying times. This has the potential to affect all patients receiving services at the facility.

Findings include:

Review of the Fire Drill documentation completed on 08/15/18 at 9:50 AM revealed 3 of the quarterly fire drills conducted on day shift were less than an hour apart. The drill conducted on 09/07/17 was completed at 10:29 AM, the drill conducted on 03/29/18 was completed at 11:00 AM, and the drill conducted on 06/25/18 was completed at 10:15 AM.

These findings were verified by Staff CC at the time of the document review.

This deficiency substantiates Substantial Allegations OH00099615 and OH00099617

Electrical Systems - Maintenance and Testing Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered, are tested after initial installation, replacement or servicing. Additional testing is performed at intervals defined by documented performance data. Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. Line isolation monitors (LIM), if installed, are tested at intervals of less than or equal to 1 month by actuating the LIM test switch per 6.3.2.6.3.6, which activates both visual and audible alarm. For, LIM circuits with automated self-testing, this manual test is performed at intervals less than or equal to 12 months. LIM circuits are tested per 6.3.3.3.2 after any repair or renovation to the electric distribution system. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results. 6.3.4 (NFPA 99)


Based on documentation review and staff interview the facility failed to show initial testing of hospital grade receptacles. This has the potential to affect all patients receiving services at the facility.

Findings include:

Documentation review completed on 08/15/18 at 11:20 AM revealed a drawing showing the location of the receptacles with dates but did not show the readings of the testing.

Interview with Staff AA completed on 08/15/18 at 11:20 AM revealed on initial testing the analyzer data was lost, they just bought a brand new one and are working on getting it calibrated. Staff AA also stated that on the prints it reveals when receptacles were tested. Staff AA also verified there was no data on the document provided.

This deficiency substantiates Substantial Allegations OH00099615 and OH00099617