HospitalInspections.org

Based upon observation and staff interview, the building construction types do not comply with applicable sections of the Code. Failure to conform to permitted construction types for the buildings can result in premature failure of the building structural components causing collapse of the building structure prior to evacuation of occupants.

Findings include:
A. On August 15, 2017 at 9:10am during document review with the VPFM & DPO it was indicated that the 4-story Building A & the 3-story Building B portions of the facility are designated as Type II (000) construction which is not permitted by 19.1.6.1. An FSES dated February 2, 2015 with cover letter dated March 31, 2015 (Revised September 9, 2015) was used to substantiate equivalency to receive initial certification granted on October 22, 2015. This FSES is no longer valid as of this survey and it was conducted under the 2000 edition of NFPA 101 rather than the 2012 edition.

B. On August 16, 2017 at 9:45am while in the company of the EVPA it was observed that the 3-story Building D portion of the facility (the original house) was Type V (000) construction type which is not permitted by 19.1.6.1. The original house is primarily not used by inpatients but movement through this portion of the facility is used to access the Gym which is used by inpatients.

Based on observation during the survey walk-through, exit stair enclosures between floors are not protected. This deficiency could result in fire and smoke on one floor transferring into the exit enclosure or to other floors, thus compromising the safety of patients, staff and visitors during a fire/smoke event.

Findings include:
A. On August 16, 2017, while accompanied with VPFM the following defiencies were observed, which are not in accordance with Sections 19.2.2.3, 19.2.2.4 and 7.2:

1. At 9:30 AM, exit stairs SC-04 on the fourth floor had pipe penetrations from adjacent Janitor closet that was sealed with batt insulation.

2. At 11:30AM, first floor north exit stair in Building A serving all four floors had mechanical equipment and electrical panel under the exposed steel stairs with voids not sealed for at least one hour fire enclosure.

B. On August 16, 2017 at 11:30am while in the company of the VPFM it was observed in the Basement of Building A that the NE exit stair was not separated from the Mechanical/Electrical room under the metal pan portion of the stair. The underside of metal pan stair was exposed in the room and not protected in accordance with 7.1.3.2.1(1) and 7.1.3.2.1(9) (b) iii, and 7.2.2.5.1.1.


13755

C. On August 15, 2017 at 3:30pm while in the company of the VPFM & DPO it was observed in the Basement of Building A that the NW exit stair was not separated from the Janitor room under the metal pan portion of the stair. The underside of metal pan stair was exposed in the room and not protected in accordance with 7.1.3.2.1(1), 7.2.2.5.1.1.

D. On August 15, 2017 at 3:40pm while in the company of the VPFM & DPO it was observed that the east exterior areaway exit discharge stair from the Basement level lacked at least one handrail at the upper-most steel grate portion of the exit stair to comply with 7.2.2.4.1.6.

Based on observations during the survey walk-through, staff interview and review of the facility provided information and floor plans, the 2-hour rated fire barriers do not comply with requirements. This deficiency could affect all patients, staff and visitors if fire/smoke was permitted to extend beyond the barrier.

Findings include:
A. On August 16, 2017 at 10:45am it was observed while accompanied with VPFM, that the designated two hour fire/smoke rated separation between Buildings A and B on the 1st floor had voids between the exposed metal deck and the steel beam that were found not to be fire caulked to resist the passage of fire/smoke. This is not in accordance with Sections 19.1.3.4 and 8.2.1.


13755


B. On August 16, 2017 at 10:25 AM while in the company of the EVPA it was observed that a complete 2-hour separation between Building C Type II (000) construction type and Building D Type V (000) construction type was not defined by any record documents available for review. A portion of Building D floor was observed to extend over/above Building C area without separation to comply with 19.1.6.1.

Based on observation during the survey walk-through, exit discharge paths to the public way are not provided with a maintainable surface meeting the requirements. Failure to provide an unimpeded path away from the building during an evacuation event can compromise the safety and ability of occupants to reach an area of safety.

Findings include:
A. On August 15, 2017 at 3:40pm while in the company of the VPFM & DPO it was observed that the east exit discharge areaway stair from Building A Basement was not provided with a stable and maintainable walking surface to the paved parking lot leading away from the building to the public way to comply with 7.1.10.1 and S&C 05-38 because the path was surfaced with dirt/sand which does not provide a stable, maintainable walking surface in all weather conditions.

B. On August 16, 2017 at 10:00am while in the company of the EVPA it was observed that the SE exterior exit discharge from the Gym building lacked adequate provisions to prevent a trip or fall hazard during exiting from the building to reach the public way to comply with 7.1.10.1 and S&C 05-38 because the concrete landing/steps to ground level were not uniform height and the path traversed a sloping grass area to reach the paved walk leading away from the building.

Based on observation and staff interview, illumination of the exit discharge portion of the means of egress is not provided to maintain illumination of the means of egress in the event of failure of the normal power supply. This deficient practice could affect any patients, staff, and visitors in the building because the failure to maintain illumination of the means of egress can affect all persons in the facility required to utilize the exit(s) by preventing safe and unimpeded access to the public way if the necessary illumination is not present.

Findings include:
On August 15 & 16, 2017 while in the company of the EVPA, it was observed that not all lighting at exit discharge locations were of the instant-on type to provide illumination within the required 10 second period to comply with 19.2.8, 19.2.9 and 7.8 & 7.9.1.3. Locations observed include:

1. On August 15, 2017 at 3:40pm at the east exit discharge areaway stair from the Basement it was observed that one light was High Pressure Sodium (HPS) and one light was incandescent. The requirements of 7.8.1.4 are not met by a single incandescent lamp and 7.9.1.3 is not met by the HPS lighting because the required illumination level is not provided within 10 seconds upon switching from normal power to emergency power.

2. On August 16, 2017 between 9:20am and 10:40am at the west exit discharge doors of Building C, only single High Intensity Discharge (HID) lighting was provided at the 1st floor level. No exit discharge lighting was provided at the Basement level areaway exit discharge stair. The requirements of 7.8.1.4 are not met by single or no lamps/fixtures and 7.9.1.3 is not met by the HID lighting because the required illumination level is not provided within 10 seconds upon switching from normal power to emergency power. Only selected locations had newer LED lighting at the exit discharge locations.

Based on observation during the survey walk-through and record review, not all exit signs are installed and maintained as required. This deficient practice could affect patients, staff, and visitors in the building because their egress under emergency conditions could be impeded if exit signs are not properly installed and maintained.

Finding includes:
A. On August 16, 2017 at 10:50 AM, while accompanied by the VPFM, observation determined the First Floor, north Exit Corridor - at the two hour separation between Building A and B, lacks an exit sign directing occupants toward the second exit to the south to Building B or the exterior door as required by Section 7.10.1.1.


13755


B. On August 16, 2017 at 9:25 AM while in the company of the EVPA, it was observed that Building C corridor leading to the Cafeteria & Classroom south of the designated exit was 52' in length and not in compliance with 19.2.5.2. The dead end condition was not otherwise identified with "NO EXIT" signage.

C. On August 16, 2017 at 10:25 AM while in the company of the EVPA, it was observed that Building D 3rd floor lacked identification of the 2nd exit to comply with 19.2.4.2.

Based on observation during the survey walk-through, not all enclosures for hazardous areas are constructed and maintained as required. This deficient practice could affect patients, staff, and visitors in the building because smoke and fire could pass from the hazardous areas to the remainder of the building if the hazardous areas are not protected as required.

Findings include:
A. On August 16, 2017 at 10:45AM, while accompanied by the VPFM, observation determined that the Electric Panel Room inside the office on first floor in Building B had three holes in the wall between Buildings A and B not in accordance with Sections 19.3.2.1, Table 8.3.4.2, and NFPA 80 2010 6.4.1.1.

B. On August 16, 2017 at 11:35AM, while accompanied by the VPFM, observation determined that the Mechanical/Electrical room under the north exit stairs serving four floors in Building A not in accordance with Sections 19.3.2.1, Table 8.3.4.2, and NFPA 80 2010 6.4.1.1.


13755


C. On August 16,2017 at 9:40am while in the company of the EVPA, it was observed that sprinklered rooms of Building D (original house) were being used for record storage & misc. storage and did not have self-closing doors to comply with 19.3.2.1.3 to separate them from the 1st floor corridor used by inpatients to access the Gym.

Based on observation during the survey walk-through, not all portions of the building's fire alarm system are installed and maintained as required. This deficient practice could affect patients, staff, or visitors in the building because the fire alarm system could fail to activate under emergency conditions if the components are not properly installed and maintained.

Findings include:
A. On August 15, 2017, while accompanied by the VPFM, observation determined that smoke detectors are located where air flow could prevent their operation as prohibited by NFPA 72-2010, 17.7.4.1. Locations observed include but not limited to the following:

1. 9:15 AM: Building A Fourth Floor elevator lobby by Room A 401.


13755


B. On August 16, 2017 at 9:25am while in the company of the EVPA it was observed that a fire alarm manual pull station was not provioded within 5' of the exterior exit door from the Cafeteria to comply with NFPA 72-2010, 17.14.6.

Based on observation, sprinklers are not installed and maintained in all spaces to comply as a fully sprinklered building. Failure to install and maintain the sprinklered building could compromise the suppression of a fire affecting all occupants of the building during a fire event.

Findings include:
A. On August 15, 2017 at 3:30pm while in the company of the VPFM & DPO it was observed that sprinkler protection was not provided in Building A Basement Janitor room under the NW exit stair to comply with NFPA 13-2010, 8.1.1.



14416

Based on observation the facility failed to install complete building fire suppression system. This deficient practice could result in the delayed response and suppression during a fire event, which may affect patients, staff and visitors.

Finding include
:
B. On 8/16/17 at 9:30 AM accompanied by the DPO, the surveyor observed the lack of fire sprinkler protection for Building D basement water meter room to comply with NFPA 13, 2010, 8.1.1.

Based on observation during the survey walk-through, corridor walls are not resistant to the passage of smoke. Failure to protect the corridor from adjacent spaces can compromise the use of the corridor as a required means of egress during a fire/smoke event originating within the unseparated space.

Findings include:
On August 16, 2017 at 8:55am while in the company of the EVPA it was observed that Building B 1st floor Pharmacy window in the corridor wall was not provided with a means of preventing movement of smoke through the pass-through window assembly to comply with 19.3.6.5.1. The shutter assembly provided was a manually operated perforated assembly.

Based on observation during the survey walk-through, not all smoke barrier partitions are constructed and maintained as required. This deficient practice could affect patients, staff, and visitors in the building if smoke could pass between smoke compartments if the barriers which separate them are not constructed and maintained as required.

Findings include:
A. On August 16, 2017, while accompanied by the VPFM, observation determined that voids through designated smoke barrier walls are not sealed against the passage of smoke as required by 8.5.6.2. Locations observed gaps between the metal deck flutes and exposed beams/walls are not sealed to resist the passage of smoke from Building A smoke compartment to Building B smoke compartment including but not limited to the following :

1. At 10:05 AM between Buildings A and B - Second Floor
2. At 10:45 AM Building B office north wall - First Floor

Based on observation during the survey walk through the facility failed to correctly install components for the elevator firefighter service and recall systems. Failure to install and maintain these systems could result in malfunction and response of the recall function. This deficient practice could affect patients, staff and visitors during a fire event.

Findings include:
On 8/16/17 at 9:00 AM accompanied by the DPO, it was observed in the elevator machine room for elevators 1 & 2 that the heat detector is not installed within 2 feet of the sprinkler head for elevator shutdown to comply with NFPA 101, 2012, 19.5.3 / ANSI A17.1, 2007, 2.8.3.3.2 & NFPA 72, 2010, 21.4.2.

Based on observation and staff interview during the survey walk through the facility failed to install a complete alarm monitoring system for the emergency electrical system. Failure to install and maintain these systems could result in delayed response to electrical system malfunction. This deficient practice could affect patients, staff and visitors during a utility power outage.

The finding is:
A. On 8/16/17 at 10:00 AM accompanied by the DPO it was observed that there is not a remote manual stop station provide for the emergency generator to comply with NFPA 110, 2010, 5.6.5

B. On 8/16/17 at 10:05 AM accompanied by the DPO it was determined through observation and staff interview that a remote audible alarm is not provide at a work station observable by personnel to comply with NFPA 99, 2012 6.4.1.1.17.1.