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If the building has a common wall with a nonconforming building, the common wall is a fire barrier having at least a two hour fire resistance rating constructed of materials as required for the addition. Communicating openings occur only in corridors and shall be protected by approved self-closing fire doors with at least 1 1/2 hour fire resistance rating
19.1.1.4.1, 19.1.1.4.2.

FINDINGS INCLUDE:

On 3/29/2016 between 9:30 AM and 2:30 PM, during the inspection a penetration was observed around cables above the ceiling tiles in the 2 hour fire separation between the CT Department and the Hospital.

This deficient practice was verfied by the Maintenance Supervisor.

If the building has a common wall with a nonconforming building, the common wall is a fire barrier having at least a two hour fire resistance rating constructed of materials as required for the addition. Communicating openings occur only in corridors and shall be protected by approved self-closing fire doors with at least 11/2 hour fire resistance rating 18.1.1.4.1, 18.1.1.4.2, 18.2.3.2.

FINDINGS INCLUDE:

On 3/29/2016 between 9:30 AM and 2:30 PM, during the inspection a penetration was observed around cables above the ceiling tiles in the 2 hour fire separation between the CT Department and the Hospital.

This deficient practice was verfied by the Maintenance Supervisor.

All required smoke detectors, including those activating door hold-open devices, are approved, maintained, inspected and tested in accordance with the manufacturer's specifications. 9.6.1.3


FINDINGS INCLUDE:

On 3/29/2016 between 9:30 AM and 2:30 PM, during a review of available records provided by facility staff, no documentation could be provided verifying the the facility's smoke detector sensitivity testing was conducted.

This deficient practice was verfied by the Maintenance Supervisor.

Where a required automatic sprinkler system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction is notified, and the building is evacuated or an approved fire watch system is provided for all parties left unprotected by the shutdown until the sprinkler system has been returned to service. 9.7.6.1



Findings include:

During documentatation review between 9:30 AM and 2:30 PM on 3/29/2016, observation and documentation reviewed revealed that there was not a single plan for the out of service plan for the fire sprinkler system.


This deficient practice was confirmed by the Facility Maintenance Director at the time of discovery.

Where a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction is notified, and the building is evacuated or an approved fire watch is provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service. 9.6.1.8


Findings include:

During documentatation review between 9:30 AM and 2:30 PM on 3/29/2016, observation and documentation reviewed revealed that there was not a single plan for the out of service plan for the fire alarm system.


This deficient practice was confirmed by the Facility Maintenance Director at the time of discovery.

If the building has a common wall with a nonconforming building, the common wall is a fire barrier having at least a two hour fire resistance rating constructed of materials as required for the addition. Communicating openings occur only in corridors and shall be protected by approved self-closing fire doors with at least 1 1/2 hour fire resistance rating
19.1.1.4.1, 19.1.1.4.2.

FINDINGS INCLUDE:

On 3/29/2016 between 9:30 AM and 2:30 PM, during the inspection a penetration was observed around cables above the ceiling tiles in the 2 hour fire separation between the CT Department and the Hospital.

This deficient practice was verfied by the Maintenance Supervisor.

If the building has a common wall with a nonconforming building, the common wall is a fire barrier having at least a two hour fire resistance rating constructed of materials as required for the addition. Communicating openings occur only in corridors and shall be protected by approved self-closing fire doors with at least 11/2 hour fire resistance rating 18.1.1.4.1, 18.1.1.4.2, 18.2.3.2.

FINDINGS INCLUDE:

On 3/29/2016 between 9:30 AM and 2:30 PM, during the inspection a penetration was observed around cables above the ceiling tiles in the 2 hour fire separation between the CT Department and the Hospital.

This deficient practice was verfied by the Maintenance Supervisor.

All required smoke detectors, including those activating door hold-open devices, are approved, maintained, inspected and tested in accordance with the manufacturer's specifications. 9.6.1.3


FINDINGS INCLUDE:

On 3/29/2016 between 9:30 AM and 2:30 PM, during a review of available records provided by facility staff, no documentation could be provided verifying the the facility's smoke detector sensitivity testing was conducted.

This deficient practice was verfied by the Maintenance Supervisor.

Electrical wiring and equipment shall be in accordance with National Electrical Code. 9-1.2 (NFPA 99) 18.9.1, 19.9.1


FINDINGS INCLUDE:

During the Facility Inspection on March 29, 2016, between the hours of 09:30 AM and
2:30 PM, the following was observed:

a.) 2 extension cords were observed being used as fixed wiring in the Medical Records Office.
b.) 2 extension cords were observed being used as fixed wiring in the Boiler Room.
c.) a electrical junction box above the lay in ceiling at the the south/elevator smoke barrier was observed without a cover.

These defieicent practices were also observed by the Maintenance Supervisor.

Where a required automatic sprinkler system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction is notified, and the building is evacuated or an approved fire watch system is provided for all parties left unprotected by the shutdown until the sprinkler system has been returned to service. 9.7.6.1



Findings include:

During documentatation review between 9:30 AM and 2:30 PM on 3/29/2016, observation and documentation reviewed revealed that there was not a single plan for the out of service plan for the fire sprinkler system.


This deficient practice was confirmed by the Facility Maintenance Director at the time of discovery.

Where a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction is notified, and the building is evacuated or an approved fire watch is provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service. 9.6.1.8


Findings include:

During documentatation review between 9:30 AM and 2:30 PM on 3/29/2016, observation and documentation reviewed revealed that there was not a single plan for the out of service plan for the fire alarm system.


This deficient practice was confirmed by the Facility Maintenance Director at the time of discovery.