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Based on observations, the facility failed to assure that hazardous areas are enclosed as required. Section 8.2.3.2.1(a) requires door assemblies to be of an approved type installed in accordance with NFPA #80.

THE FINDINGS INCLUDE:

- During the morning hours of 12/12/11 while touring the first floor level, the door to the soiled utility room located adjacent to the rear elevators was observed as being wedged open. When the door was tested for proper operation, the latching mechanism would not engage to secure the door.
In addition, the door's self closing device has a feature to hold the door in the open position when fully extended.

This was observed by The Director of Facilities during the facility tour.

Based on observations and confirmed by staff, horizontal exits are not maintained as required. Section 7.2.4.3.1 states fire barriers separating building areas between which there are horizontal exits shall have a 2-hour fire resistance rating and shall provide a separation that is continuous to ground.

THE FINDINGS INCLUDE:

- During the morning hours of 12/8/11 while touring the 6th floor Operating Suite, the 2-hour fire doors were observed as not operating as required. When the doors were tested for operation, one of the leafs would not close and latch, it hovers approximately 1" from the other leaf. A strong air draft was observed indicating a possible Heating Ventilation Air Conditioning (HVAC) balance problem which is keeping the door from closing & latching.

This was observed by The Director of Facilities during the facility tour.

Based on record review and confirmed by interview, the facility failed to ensure that the fire alarm system is maintained in accordance with NFPA 70. LSC Section 4.6.12.1 requires fire alarm systems to be continuously maintained in proper operating condition. NFPA 72, Section 7.5.2.2 requires permanent records of all inspections, testing, and maintenance of the fire alarm system be provided including detailed information as to the results. Section 7.3.2 and Table 7.3.2(6) require systems with sealed batteries to have the battery charger tested annually, to conduct a 30 minute battery discharge test annually, and to conduct a load voltage test semi-annually. Annually is defined as periods of approximately 12 months.

THE FINDINGS INCLUDE:

- Record review of the fire alarm system inspection reports available on 12/7/11 & 12/8/11 revealed that the vendor contracted to maintain, test and inspect the fire alarm system failed to provide detailed information as to the type of tests performed on the backup batteries. No where on the reports provided is it documented that a 30 minute discharge test and a load voltage test are conducted. The reports only state that batteries are tested. This was confirmed by the Assistant Director of Facilities.

Based on observations and confirmed by staff, the facility failed to ensure that sprinkler heads are installed as required. NFPA 13 section 5-6.4.1.1 states under unobstructed construction, the distance between the sprinkler deflector and the ceiling shall be a minimum of 1 in. (25.4 mm) and a maximum of 12 in. (305 mm).

THE FINDINGS INCLUDE:

- During the morning and afternoon hours of 12/7/11 & 12/8/11, the following locations were observed as not being properly sprinklered:

1) On both the 7th & 6th floor levels, there are eight areas (16 total) which the corridors bump out where additional bedrooms are located. The corridor areas in each of these locations have a stepped soffit ceiling system. With this ceiling configuration, there is a five foot (5') space above the ceiling tiles which is open to the corridor below and not properly protected by the sprinkler system.

2) The 2nd floor corridor outside of the Atrium Conference Room has an approximate six inch (6") gap where the ceiling tiles meet the corridor walls. With this soffit configuration, there is a five foot (5') space above the ceiling tiles which is open to the corridor below and not properly protected by the sprinkler system.

These were observed by The Director of Facilities during the facility tour.

Based on observations, the facility failed to ensure that the main sprinkler control valve is electrically supervised.

THE FINDINGS INCLUDE:

- Observations while touring the facility on the afternoon of December 8, 2011 revealed three (3) valves controlling the flow of water to the automatic sprinkler system that are not electrically supervised. The facility has two (2) water mains entering the building in the basement that merge into a single supply line. Each of the 2 water main's are equipped with a control valve which is not supervised. The water supply for the automatic systems is connected to the main water supply where the 2 lines merge into a single supply downstream of the two main valves. This sprinkler supply line is equipped with a valve that is not supervised. This was observed by the Assistant Director of Facilities during the facility tour.

Based on record review, the facility failed to ensure that the automatic sprinkler system is maintained and inspected as required by NFPA 25. NFPA 25, Sections 1.9 and 1.10 require system components to be inspected and tested in accordance with the intervals specified in the appropriate chapters. Section 9.4.1.2 requires alarm valves and their associated strainers, filters, and restriction orifices to be inspected internally every 5 years. NFPA 25, 5.2.2 requires the pertinent visual observations specified in the checklists under Sections 5.2.2.1 through 5.2.2.5 be performed weekly.

THE FINDINGS INCLUDE:

- Record review of the quarterly automatic sprinkler system records available on 12/7/11 & 12/8/11 revealed the following:
1) That there is no record of the sprinkler system main alarm valve as being inspected internally within the past 5 years.
2) That weekly inspections of the fire pump are not performed and documented. During an interview with the Director of Facilities on the afternoon of 12/8/11 he said that the inspections are not performed.

Based on observations, record review and confirmed by staff, the facility failed to ensure compliance with NFPA 90A. Section 3.3.1.1 requires approved fire dampers to 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. Section 3.3.1.2 requires approved fire dampers to 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.
Section 2.3.4.1 requires a service opening to 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. Section 2.3.4.2 requires service openings to be identified with letters having a minimum height of 1/2 in. to indicate the location of the fire protection device(s) within. Section 2.3.8 requires fire dampers to be installed in conformance with the conditions of their listings. Section 3.4.6.2 requires fire dampers, including their sleeves; smoke dampers; and ceiling dampers to be installed in accordance with the conditions of their listings and the manufacturer ' s installation instructions.

THE FINDINGS INCLUDE:

- During the morning and afternoon hours of 12/7/11 & 12/8/11, numerous ducts which penetrate the two hour fire rated walls were observed as not being equipped with service openings to verify the presence of fire dampers. In addition to observing these locations, it was stated by the facility that a fire damper survey was recently performed and numerous locations were noted as being deficient. The report states that numerous duct locations are inaccessible and dampers can't be installed without major utility work of other systems. Upon further discussion with the Director of Facilities and the Facilities Consultant, it was said that some locations were inadvertently left off the fire damper log by the vendor performing the damper survey.

The following locations but not limited to were noted as being deficient as fire dampers could not be verified by a visual inspection through an access panel:

1) Fifth Floor: The 2-hour horizontal wall located in the Soiled Utility Room has two ducts without access panels for damper verification.
The Five South shaft has four ducts which were observed penetrating the shaft wall without access panels for damper verification. Two of which are the supply & return for the Dana Farber Wing, and two of which are from the Dana Farber pharmacy clean room.

2) Second Floor: The two-hour wall separating the business occupancy from healthcare occupancy has numerous duct penetrations around the entire area. A total of sixteen ducts were observed during the survey without access panels for damper verification.
The electrical room adjacent to stair #3 has a duct penetrating the two-hour wall with no access panel present.

Note: As stated above, the facility has acknowledged that fire dampers and access panels are lacking in various locations. The facility is currently undergoing phase II of a fire damper project and is still currently identifying new areas of concern.

Based on observations and confirmed by staff interview, the facility failed to inspect the kitchen range automatic extinguishing system as required. NFPA 17A, Section 5.2.1 requires inspections to be conducted on a monthly basis in accordance with the manufacturer's listed installation and maintenance manual or the owner's manual. As a minimum, this "quick check" or inspection shall include verification of the following:
(a) The extinguishing system is in its proper location.
(b) The manual actuators are unobstructed.
(c) The tamper indicators and seals are intact.
(d) The maintenance tag or certificate is in place.
(e) No obvious physical damage or condition exists that might prevent operation.
(f) The pressure gauge(s), if provided, is in operable range.
(g) The nozzle blowoff caps are intact and undamaged.
(h) The hood, duct, and protected cooking appliances have not been replaced, modified, or relocated.
Section 5.2.4 requires at that least monthly, the date the inspection is performed and the initials of the person performing the inspection to be recorded. The records shall be retained until the next semiannual maintenance.
Section 5.2.2 requires that if any deficiencies are found, appropriate corrective action to be taken immediately.
Section 5.2.3 requires personnel making inspections to keep records for those extinguishing systems that were found to require corrective actions.

THE FINDINGS INCLUDE:

- Observations while touring the facility on the afternoon of 12/8/11 revealed that the automatic extinguishing systems protecting the ranges in the kitchen and cafeteria are not inspected monthly. A review of the back of the semi-annual inspection tags dated 10/19/11 used to document monthly inspections revealed the absence of monthly documentation. During an interview with the Assistant Director of Facilities on the afternoon of 12/8/11 he said that the inspections are not performed.

Based on observations and confirmed by staff, the facility failed to ensure that egress corridors are kept clear of all obstructions.

THE FINDINGS INCLUDE:

- During the morning hours of 12/12/11 while touring the first floor level, numerous items were observed as being stored in the egress corridor across from the Post-Anesthesia Care Unit (PACU) entrance. These items include but are not limited to the following:
-Two (2) wheel chairs.
-Three (3) "Geri" type chairs.
-One (1) clean linen cart.

This was observed by The Assistant Director of Facilities during the facility tour.

Based on observations and confirmed by staff, the hospital failed to ensure that mobile trash and recycling carts are stored properly within enclosed rooms.

THE FINDINGS INCLUDE:

- During the afternoon hours of 12/8/11 while touring the seventh & sixth floors levels numerous mobile trash containers and recycling containers greater than 32 gallons each were observed being stored in the corridor. Each nursing unit was observed as having one trash and one recycle container present in the corridor

This was observed by The Assistant Director of Facilities during the facility tour.

Based on observations, the facility failed to ensure that fume hoods are in accordance with NFPA 99. NFPA 99,Section 5.6.2 requires warning signs describing the nature of any hazardous effluent content to be posted at fume hoods ' discharge points, access points, and filter locations. Warning signs should include, or reference, information on hazards, and on the changing, handling, and disposal of filters.

THE FINDINGS INCLUDE:

- Observations while touring the facility on the afternoon of 12/8/11 revealed that warning signs are not posted at fume hood discharge points. This was observed by the Assistant Director of Facilities during the facility tour.

Based on observations and confirmed by staff, the facility failed to ensure that extension cords are used in accordance with NFPA 70. Article 305-3 permits temporary wiring to be used during periods of construction, remodeling, maintenance, and repair of buildings, during emergencies, and for a period not to exceed 90 days. Article 400-8 prohibits flexible cords from being use as a substitute for the fixed wiring of a structure. LSC 19.5.1

THE FINDINGS INCLUDE:

- During the afternoon hours of 12/8/11 while touring the first floor Operating Room Suite, two extension cords were observed as being used in the center core storage room. One extension cord is connected to a small refrigerator and the second one is connected to the Omni cell storage system unit.

This was observed by The Assistant Director of Facilities during the facility tour.

Based on observations and confirmed by staff interview, the facility failed to ensure that elevator firefighters service is tested as required. Section 9.4.6 requires all elevators equipped with fire fighter service in accordance with 9.4.4 and 9.4.5 to be subject to a monthly operation with a written record of the findings made and kept on the premises as required by ASME/ANSI A17.1, Safety Code for Elevators and Escalators.

THE FINDINGS INCLUDE:

- Record review of the elevator maintenance records available on 12/7/11 & 12/8/11 revealed that there is no record of the fire fighter service being tested monthly. During an interview with the Director of Facilities on the afternoon of 12/8/11 he said that the fire fighter service is not tested monthly.

Based on observations, the facility failed to assure that hazardous areas are enclosed as required. Section 8.2.3.2.1(a) requires door assemblies to be of an approved type installed in accordance with NFPA #80.

THE FINDINGS INCLUDE:

- During the morning hours of 12/12/11 while touring the first floor level, the door to the soiled utility room located adjacent to the rear elevators was observed as being wedged open. When the door was tested for proper operation, the latching mechanism would not engage to secure the door.
In addition, the door's self closing device has a feature to hold the door in the open position when fully extended.

This was observed by The Director of Facilities during the facility tour.

Based on observations and confirmed by staff, horizontal exits are not maintained as required. Section 7.2.4.3.1 states fire barriers separating building areas between which there are horizontal exits shall have a 2-hour fire resistance rating and shall provide a separation that is continuous to ground.

THE FINDINGS INCLUDE:

- During the morning hours of 12/8/11 while touring the 6th floor Operating Suite, the 2-hour fire doors were observed as not operating as required. When the doors were tested for operation, one of the leafs would not close and latch, it hovers approximately 1" from the other leaf. A strong air draft was observed indicating a possible Heating Ventilation Air Conditioning (HVAC) balance problem which is keeping the door from closing & latching.

This was observed by The Director of Facilities during the facility tour.

Based on record review and confirmed by interview, the facility failed to ensure that the fire alarm system is maintained in accordance with NFPA 70. LSC Section 4.6.12.1 requires fire alarm systems to be continuously maintained in proper operating condition. NFPA 72, Section 7.5.2.2 requires permanent records of all inspections, testing, and maintenance of the fire alarm system be provided including detailed information as to the results. Section 7.3.2 and Table 7.3.2(6) require systems with sealed batteries to have the battery charger tested annually, to conduct a 30 minute battery discharge test annually, and to conduct a load voltage test semi-annually. Annually is defined as periods of approximately 12 months.

THE FINDINGS INCLUDE:

- Record review of the fire alarm system inspection reports available on 12/7/11 & 12/8/11 revealed that the vendor contracted to maintain, test and inspect the fire alarm system failed to provide detailed information as to the type of tests performed on the backup batteries. No where on the reports provided is it documented that a 30 minute discharge test and a load voltage test are conducted. The reports only state that batteries are tested. This was confirmed by the Assistant Director of Facilities.

Based on observations and confirmed by staff, the facility failed to ensure that sprinkler heads are installed as required. NFPA 13 section 5-6.4.1.1 states under unobstructed construction, the distance between the sprinkler deflector and the ceiling shall be a minimum of 1 in. (25.4 mm) and a maximum of 12 in. (305 mm).

THE FINDINGS INCLUDE:

- During the morning and afternoon hours of 12/7/11 & 12/8/11, the following locations were observed as not being properly sprinklered:

1) On both the 7th & 6th floor levels, there are eight areas (16 total) which the corridors bump out where additional bedrooms are located. The corridor areas in each of these locations have a stepped soffit ceiling system. With this ceiling configuration, there is a five foot (5') space above the ceiling tiles which is open to the corridor below and not properly protected by the sprinkler system.

2) The 2nd floor corridor outside of the Atrium Conference Room has an approximate six inch (6") gap where the ceiling tiles meet the corridor walls. With this soffit configuration, there is a five foot (5') space above the ceiling tiles which is open to the corridor below and not properly protected by the sprinkler system.

These were observed by The Director of Facilities during the facility tour.

Based on observations, the facility failed to ensure that the main sprinkler control valve is electrically supervised.

THE FINDINGS INCLUDE:

- Observations while touring the facility on the afternoon of December 8, 2011 revealed three (3) valves controlling the flow of water to the automatic sprinkler system that are not electrically supervised. The facility has two (2) water mains entering the building in the basement that merge into a single supply line. Each of the 2 water main's are equipped with a control valve which is not supervised. The water supply for the automatic systems is connected to the main water supply where the 2 lines merge into a single supply downstream of the two main valves. This sprinkler supply line is equipped with a valve that is not supervised. This was observed by the Assistant Director of Facilities during the facility tour.

Based on record review, the facility failed to ensure that the automatic sprinkler system is maintained and inspected as required by NFPA 25. NFPA 25, Sections 1.9 and 1.10 require system components to be inspected and tested in accordance with the intervals specified in the appropriate chapters. Section 9.4.1.2 requires alarm valves and their associated strainers, filters, and restriction orifices to be inspected internally every 5 years. NFPA 25, 5.2.2 requires the pertinent visual observations specified in the checklists under Sections 5.2.2.1 through 5.2.2.5 be performed weekly.

THE FINDINGS INCLUDE:

- Record review of the quarterly automatic sprinkler system records available on 12/7/11 & 12/8/11 revealed the following:
1) That there is no record of the sprinkler system main alarm valve as being inspected internally within the past 5 years.
2) That weekly inspections of the fire pump are not performed and documented. During an interview with the Director of Facilities on the afternoon of 12/8/11 he said that the inspections are not performed.

Based on observations, record review and confirmed by staff, the facility failed to ensure compliance with NFPA 90A. Section 3.3.1.1 requires approved fire dampers to 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. Section 3.3.1.2 requires approved fire dampers to 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.
Section 2.3.4.1 requires a service opening to 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. Section 2.3.4.2 requires service openings to be identified with letters having a minimum height of 1/2 in. to indicate the location of the fire protection device(s) within. Section 2.3.8 requires fire dampers to be installed in conformance with the conditions of their listings. Section 3.4.6.2 requires fire dampers, including their sleeves; smoke dampers; and ceiling dampers to be installed in accordance with the conditions of their listings and the manufacturer ' s installation instructions.

THE FINDINGS INCLUDE:

- During the morning and afternoon hours of 12/7/11 & 12/8/11, numerous ducts which penetrate the two hour fire rated walls were observed as not being equipped with service openings to verify the presence of fire dampers. In addition to observing these locations, it was stated by the facility that a fire damper survey was recently performed and numerous locations were noted as being deficient. The report states that numerous duct locations are inaccessible and dampers can't be installed without major utility work of other systems. Upon further discussion with the Director of Facilities and the Facilities Consultant, it was said that some locations were inadvertently left off the fire damper log by the vendor performing the damper survey.

The following locations but not limited to were noted as being deficient as fire dampers could not be verified by a visual inspection through an access panel:

1) Fifth Floor: The 2-hour horizontal wall located in the Soiled Utility Room has two ducts without access panels for damper verification.
The Five South shaft has four ducts which were observed penetrating the shaft wall without access panels for damper verification. Two of which are the supply & return for the Dana Farber Wing, and two of which are from the Dana Farber pharmacy clean room.

2) Second Floor: The two-hour wall separating the business occupancy from healthcare occupancy has numerous duct penetrations around the entire area. A total of sixteen ducts were observed during the survey without access panels for damper verification.
The electrical room adjacent to stair #3 has a duct penetrating the two-hour wall with no access panel present.

Note: As stated above, the facility has acknowledged that fire dampers and access panels are lacking in various locations. The facility is currently undergoing phase II of a fire damper project and is still currently identifying new areas of concern.

Based on observations and confirmed by staff interview, the facility failed to inspect the kitchen range automatic extinguishing system as required. NFPA 17A, Section 5.2.1 requires inspections to be conducted on a monthly basis in accordance with the manufacturer's listed installation and maintenance manual or the owner's manual. As a minimum, this "quick check" or inspection shall include verification of the following:
(a) The extinguishing system is in its proper location.
(b) The manual actuators are unobstructed.
(c) The tamper indicators and seals are intact.
(d) The maintenance tag or certificate is in place.
(e) No obvious physical damage or condition exists that might prevent operation.
(f) The pressure gauge(s), if provided, is in operable range.
(g) The nozzle blowoff caps are intact and undamaged.
(h) The hood, duct, and protected cooking appliances have not been replaced, modified, or relocated.
Section 5.2.4 requires at that least monthly, the date the inspection is performed and the initials of the person performing the inspection to be recorded. The records shall be retained until the next semiannual maintenance.
Section 5.2.2 requires that if any deficiencies are found, appropriate corrective action to be taken immediately.
Section 5.2.3 requires personnel making inspections to keep records for those extinguishing systems that were found to require corrective actions.

THE FINDINGS INCLUDE:

- Observations while touring the facility on the afternoon of 12/8/11 revealed that the automatic extinguishing systems protecting the ranges in the kitchen and cafeteria are not inspected monthly. A review of the back of the semi-annual inspection tags dated 10/19/11 used to document monthly inspections revealed the absence of monthly documentation. During an interview with the Assistant Director of Facilities on the afternoon of 12/8/11 he said that the inspections are not performed.

Based on observations and confirmed by staff, the facility failed to ensure that egress corridors are kept clear of all obstructions.

THE FINDINGS INCLUDE:

- During the morning hours of 12/12/11 while touring the first floor level, numerous items were observed as being stored in the egress corridor across from the Post-Anesthesia Care Unit (PACU) entrance. These items include but are not limited to the following:
-Two (2) wheel chairs.
-Three (3) "Geri" type chairs.
-One (1) clean linen cart.

This was observed by The Assistant Director of Facilities during the facility tour.

Based on observations and confirmed by staff, the hospital failed to ensure that mobile trash and recycling carts are stored properly within enclosed rooms.

THE FINDINGS INCLUDE:

- During the afternoon hours of 12/8/11 while touring the seventh & sixth floors levels numerous mobile trash containers and recycling containers greater than 32 gallons each were observed being stored in the corridor. Each nursing unit was observed as having one trash and one recycle container present in the corridor

This was observed by The Assistant Director of Facilities during the facility tour.

Based on observations and confirmed by staff, the facility failed to ensure that extension cords are used in accordance with NFPA 70. Article 305-3 permits temporary wiring to be used during periods of construction, remodeling, maintenance, and repair of buildings, during emergencies, and for a period not to exceed 90 days. Article 400-8 prohibits flexible cords from being use as a substitute for the fixed wiring of a structure. LSC 19.5.1

THE FINDINGS INCLUDE:

- During the afternoon hours of 12/8/11 while touring the first floor Operating Room Suite, two extension cords were observed as being used in the center core storage room. One extension cord is connected to a small refrigerator and the second one is connected to the Omni cell storage system unit.

This was observed by The Assistant Director of Facilities during the facility tour.

Based on observations and confirmed by staff interview, the facility failed to ensure that elevator firefighters service is tested as required. Section 9.4.6 requires all elevators equipped with fire fighter service in accordance with 9.4.4 and 9.4.5 to be subject to a monthly operation with a written record of the findings made and kept on the premises as required by ASME/ANSI A17.1, Safety Code for Elevators and Escalators.

THE FINDINGS INCLUDE:

- Record review of the elevator maintenance records available on 12/7/11 & 12/8/11 revealed that there is no record of the fire fighter service being tested monthly. During an interview with the Director of Facilities on the afternoon of 12/8/11 he said that the fire fighter service is not tested monthly.