HospitalInspections.org

Based on observation and interview, the facility did not provide and maintain the corridor wall construction to protect the corridor from non-corridor spaces like rooms open to the corridor with the required safe-guards per NFPA 101 (2000 ed.), section 19.3.6.1. This deficiency occurred in 1 of the 34 smoke compartments and had the potential to affect 2 staff members and an unknown number of visitors within this smoke compartment.

FINDINGS INCLUDE:

On 06/15/2016 at 11:45 am, on the 5-2 floor in the Building 5-2 at Dietary Dishwashing Room #2339 at Corridor, that the area was not separated from the exit egress corridor by wall construction and did not satisfy all of the requirements for an exception for spaces that are open to the corridor. The space did not have a smoke detector and was not fully observable from a 24 hour occupied location.

This condition was confirmed at the time of discovery by an observation and interview with staff A (Director of Operations), staff B (Op. & Maintenance Supervisor) and staff D (Facilities Operations Mgr.).
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Based on observation and interview, the facility did not provide and maintain smoke barrier door assemblies that meet NFPA 101 (2000 ed.), section 19.3.7.6 for the separation of smoke compartments with closers on all smoke barrier doors and fire-rated window assemblies per fire-rated glazing material meeting NFPA 80 (1999 ed.) Standard for Fire Doors and Fire Windows. These deficiencies occurred in 2 of the 34 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/15/2016 at 9:56 am, on the 3-2D floor in the Admissions Waiting Room 2100, the smoke barrier door would not self-close because the door closer did not have the torque to close the door.

2. On 06/14/2016 at 3:41 pm, on the 4-3B floor in the Corridor outside the Unit Entry Door at the Smoke Barrier, the smoke barrier door had non-compliant windows, the glass was not fire-rated. Glazing was made of non-fire-rated plastic.

These conditions were confirmed at the time of discovery by observation and interview with staff A (Director of Operations), staff B (Op. & Maintenance Supervisor) and staff D (Facilities Operations Mgr.).
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Based on observation and interview, the facility did not enclose hazardous rooms with closers on all fire-rated doors and fire-rated walls in hazardous rooms per NFPA 101 (2000 ed.), sections 19.3.2.1 and 8.4.1. This deficiency occurred in 5 of the 34 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/14/2016 at 3:35 pm, on the 5-3B floor in the Suite 3322, Room 34, the door would not self-close because it was missing a door closer. The space use to be an Inpatient Sleeping Room. The room was considered hazardous because it exceeded 50 square feet and contained a quantity of stored combustible materials considered hazardous.

2. On 06/14/2016 at 3:44 pm, on the 4-4B floor in the Linen Storage Room 41, the door would not self-close. The closer was malfunctioning and would not latch to frame. The room was considered hazardous because it exceeded 50 square feet and contained a quantity of stored combustible materials considered hazardous.

3. On 06/14/2016 at 3:11 pm, on the 4-2A floor in the Wheelchair Washing Room & Storage Room 2217, the fire barrier door could not be verified to have the required fire rating. The room is storing combustible supplies for housekeeping and maintenance shop materials. The door within the 2-hour assembly is labeled for 90 minutes, but the metal door has numerous holes in the door from a removed closer. The room was considered hazardous because it exceeded 50 square feet and contained a quantity of stored combustible materials considered hazardous.

4. On 06/14/2016 at 3:14 pm, on the 4-2A floor in the Fire Pump Room 2218, the fire barrier door could not be verified to have the required fire rating. The room is required to be fire-rated to at least 1-hour per NFPA 13 for Fire Pump Rooms. The current 90 minute rated fire door is warped and will not close and latch to the frame on its own. The room was considered hazardous because it exceeded 50 square feet and contained a quantity of stored combustible materials considered hazardous.

5. On 06/14/2016 at 2:49 pm, on the 3-1B floor in the Fiscal Record Files Area, the enclosing wall was not constructed to a 1-hour fire resistance rating. The wall was missing on two sides of the record files. This space is used to hold large amounts of paper fiscal records. The room was considered hazardous because it exceeded 50 square feet and contained a quantity of stored combustible materials considered hazardous.

These conditions were confirmed at the time of discovery by an observation and interview with staff A (Director of Operations), staff B (Op. & Maintenance Supervisor) and staff D (Facilities Operations Mgr.).
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Based on observation and interview, the facility did not provide egress paths at all times with doors that were unlockable in the egress path per NFPA 101 (2000 ed.), s. 19.2.2.2.4 and level walking surfaces in the path of egress per NFPA 101 (2000 ed.), s. 7.1.6 and 7.1.7. These deficiencies occurred in 4 of the 34 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/14/2016 at 3:17 pm, on the 3-2A floor in the Room 24, the door was locked from the egress side. There is a dead-bolt on the door

2. On 06/14/2016 at 3:20 pm, on the 3-2A floor in the Room 25, the door was locked from the egress side. There is a dead-bolt on the door.

3. On 06/15/2016 at 11:36 am, on the 5-1A floor in the Building 5-2 at Stairwell 5-1, the door was locked from the egress side. The door was locked on the inside of the stairwell that goes to the main corridor.

4. On 06/14/2016 at 3:48 pm, on the 4-4C floor in the Corridor in the Main 4th Floor Corridor, a portion of the path of egress had an abrupt change in elevation of 1 inch. There is a hole in the floor at the expansion joint greater than 1 inch depth that is a tripping hazard.

5. On 06/15/2016 at 11:06 am, on the 5-3B floor in the Children's Adolescent Inpatient Services (CAIPS) Exterior Exit Egress Stoop at Stairwell 5-5, a portion of the path of egress had an abrupt change in elevation in the concrete stoop adjacent to the sidewalk. A hole in the concrete of at least 2" x 24" has been created by soil erosion, causing a trip hazard.

These conditions were confirmed at the time of discovery by observation and interview with staff A (Director of Operations), staff B (Op. & Maintenance Supervisor) and staff D (Facilities Operations Mgr.).
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Based on observation and interview, the facility did not provide and maintain emergency illumination of the interior and exterior means of egress for at least 90 minutes after a power failure including a emergency battery light at the emergency generator ATS switchgear room per NFPA 101 (2000 ed.), 7.8.1.2, 7.9.2.3, & NFPA 110 (1999 ed.), 5-3.1, including continuous lighting of all the egress pathways. These deficiencies occurred in 2 of the 34 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/14/2016 at 3:05 pm, on the 4-2A floor in the Electrical Sub-Station Room, a battery-operated emergency light was not installed in the interior emergency ATS location.

2. On 06/15/2016 at 9:42 am, on the 2-1A floor in the Elevator Equipment Room, there was a power cord to the outlet for the emergency lights. Emergency lighting is to be direct wired.

These conditions were confirmed at the time of discovery by observation and interview with staff A (Director of Operations), staff B (Op. & Maintenance Supervisor) and staff D (Facilities Operations Mgr.).
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Based on observation, record review and interview, the facility did not provide a fire alarm system that was installed according to NFPA 72 (1999 edition) sections 1-2.3 & 2-2, and NFPA 101 (2000 ed.), section 9.6.1.4. The facility did not provide a fire alarm system with smoke detectors at required locations. This deficiency occurred in all of the 34 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/13/2016 at 3:25 pm, record review revealed that the smoke detectors were not located in accordance with NFPA 72 requirements. The facility could not produce where all the smoke detectors were located on a plan. Facility could not substantiate all smoke dampers locations, and if they were properly tested for timely smoke sensitivity. Documentation was not provided prior to exiting.

2. On 06/14/2016 at 2:55 pm, observation revealed on the 3-1C floor in the Room 1111, that the smoke detector was not located in accordance with NFPA 72 requirements. A smoke detector was greater than 12 inches below a smooth ceiling.

These conditions were confirmed at the time of discovery by observation, record review and interview with staff A (Director of Operations), staff B (Op. & Maintenance Supervisor) and staff D (Facilities Operations Mgr.).
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Based on review of record documents and interview, the facility did not maintain the fire alarm system according to NFPA 101 (2000 ed.), s. 9.6.1.7, and NFPA 72 (1999 ed.) sections 1-5.2.5 Light & Power Service, 1-5.2.6, 7-4.1 & 7-4.2 maintenance requirements, with required power supply for testing. Also, Fire Alarm Weekly Testing documentation per NFPA 72 (1999 ed.), Chapter 7-5.2.2. These deficiencies would affect all of the 34 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/14/2016 at 10:10 am, reports were not available to identify Secondary Supply Capacity (fuel). Under maximum quiesent load, the secondary supply shall have sufficient capacity to operate a protected premises, central station, or proprietary system for 24 hours. Sufficient fuel shall be available in storage for 6 months of testing plus the capacity.

2. On 06/14/2016 at 2:00 pm, reports were not available to verify that Semi-Annual Inspections were completed. One of the Fire Alarm Semi-Annual Inspection Reports by Aramark Corporation, was missing per the Manufacturer requirement for Clean Agent supporting FM-200 system (Transformer Room) and FE-25 FIKE Fire Supression System (Telco Room). Semi-Annual testing is required per documentation shown on the Clean Agent Report by Aramark Corporation. Dates last reported included 3/5/2015 & 4/6/2016.

3. On 06/14/2016 at 1:50 pm, weekly reports were not available to verify weekly fire alarm system inspections were conducted. The Fire Alarm Weekly Testing document by in-house staff was identified to be missing the entire month of January 2016.

These conditions were confirmed at the time of discovery by a review of record documents and interview with staff A (Director of Operations), staff B (Op. & Maintenance Supervisor) and staff D (Facilities Operations Mgr.).
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Based on review of record documents and interview, the facility did not inspect and test smoke detectors in accordance with manufacturer's specifications per NFPA 101 (2000 ed.), s. 9.6.1.3. Smoke detector sensitivity test records were missing. This deficiency could effect all of the 34 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 06/13/2016 at 3:20 pm, the smoke detector sensitivity test records did not contain all the required information. During a review of the Fire Alarm Annual Test Report, it was found that the document did not show that smoke devices were tested to all the requirements. Surveyor was told all devices were set at 3.5%, and all devices showed the same reading. It could not be confirmed the testing company spot-tested each detector.

This condition was confirmed at the time of discovery by a review of record documents and interview with staff A (Director of Operations), staff B (Op. & Maintenance Supervisor) and staff D (Facilities Operations Mgr.).
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Based on observation and interview, the facility did not provide a sprinkler system that complies with NFPA 101 (2000 ed.), sections 19.1.6, 19.3.5.1, 19.3.5.2, 19.3.5.3 & 9.7 and NFPA 13 (1999 edition), sections 5-5.4.1 & 5-6.3, including sprinklers that were to far from the ceiling, missing sprinkler protection of a space, and sprinklers located to far apart from each other. These deficiencies occurred in 5 of the 34 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/14/2016 at 2:57 pm, on the 3-1C floor in Room 1111, the sprinkler was placed farther than 24 inches from the ceiling. This situation would delay release of water and does not satisfy the listing requirements.

2. On 06/14/2016 at 2:59 pm, on the 3-1A floor in the Data Closet 1048A, the room was not sprinkler protected. The facility was stated to be fully-sprinkled, which required this space to be sprinkled. The data closet had a ceiling that had holes and sprinkler coverage was not provided above the open ceiling. There were also holes where data cables were running through the ceiling and the ceiling was not completely sealed from fire and smoke.

3. On 06/14/2016 at 3:01 pm, on the 5-2A floor in the Elevator Equipment Room, the room was not sprinkler protected. The facility was stated to be fully-sprinkled, which required this space to be sprinkled. No sprinkler protection or clean agent system protection was provided in this hazardous room.

4. On 06/15/2016 at 11:33 am, on the 5-1A floor in the Building 5-2 at Stairwell 5-1, the room was not sprinkler protected. The facility was stated to be fully-sprinkled, which required this space to be sprinkled. The sprinkler head was missing at the bottom of Stairwell.

5. On 06/14/2016 at 2:51 pm, on the 3-1B floor in the Corridor outside Medical Records door, standard sprinkler heads were located greater than 16 feet from one another. Sprinklers cannot be farther from each other than the maximum required separation distance of 15' for standard discharge heads or farther than 7-1/2' from a wall.

These conditions were confirmed at the time of discovery by observation and interview with staff A (Director of Operations), staff B (Op. & Maintenance Supervisor) and staff D (Facilities Operations Mgr.).
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Based on observation, interview and a review of facility documents, the facility did not maintain the sprinkler system in a reliable operating condition that included a complete inspection program as required by NFPA 25 (1998 ed.), sections 2-2 & 2-3.1.1, Table 2-1 (Summary of Sprinkler System) and Table 9-1 (Summary of Valves) & NFPA 25 (1998 ed.), 1-11.1. The sprinkler system did not have all required sprinkler system inspections, intact escutcheon rings, ceilings sealed above the sprinklers to collect heat, weekly tests of the fire pump, and a complete accounting of the appropriate quantity of spare sprinklers.
These deficiencies had the potential to affect all of the 34 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/14/2016 at 10:30 am, during a review of facility documents the Annual Wet Sprinkler Inspections were not performed as required by the code as seen in the Annual Sprinkler System Inspection Report by Grunau Fire Inspection, dated June 12, 2015. The 10-year Head Inspection Testing of sprinkler heads, identified the heads installed in the Psychiatric Crisis Center (PSC) in 1985 are in need of being replaced after testing. Surveyor was told they no longer make this type 'head' and must be replaced to be maintained. Todays date is June 14, 2016 almost one year after the Annual Report. These heads are required to be tested starting at 20 years after being installed in 1985, and again every 10 years after 2005 per NFPA 25 Table 2-1 Summary of Sprinkler System Inspection, Testing, and Maintenance. This 10 year inspection in the Annual Report showed they needed to be replaced.

2. On 06/14/2016 at 11:00 am, during a review of facility documents the annual wet sprinkler inspections were not performed as required by the code with correct follow-up. Sprinkler System Five Year Internal Inspection Report by Grunau Fire Protection, dated June 12, 2015. Identified three items (10" water check valve, 10" water shut-off & 1" valve trim check valve) that needed to be tested at the 5 Year testing period and the comment in the report stated 'Unknown'. Correction of this deficiency was never completed since written almost a year ago.

3. On 06/14/2016 at 11:45 am, during a review of facility documents the annual wet sprinkler inspections were not performed as required. The Annual Sprinkler System Inspection Report by Grunau Fire Protection, dated June 12, 2015, identified one item incomplete. Report notes 'no' Quick Response (QR) heads on-site. Table 2-1 Summary of Sprinkler System Inspection, Testing, and Maintenance, states Sprinklers - fast response, shall be tested at 20 years after original install (1985) and 10 years thereafter per NFPA 25. This information is missing.

4. On 06/14/2016 at 1:30 pm, during a review of facility documents the annual wet sprinkler inspections were not performed as required. Sprinkler System Five Year Internal Inspection Report by Grunau Fire Protection, dated June 12, 2015, identified one item incomplete. Report notes 'the hospital complex has no check valve on the suction side of the fire pump'. The Code requires double check valves per NFPA 101 (2000 ed.) s. 4.6.7 Modernization or Renovation. Sprinkler System with Fire Pump was installed after building was originally completed and occupied. This then relates to Modernization or Renovation at time of Fire Pump install for existing conditions.

5. On 06/14/2016 at 2:45 pm, on the 3-1A floor in the Vending Area of Corridor, the escutcheon ring on the sprinkler was not tight to ceiling.

6. On 06/15/2016 at 9:50 am, on the 2-2A floor in the Access Clinic Room 2006-1, the escutcheon rings on the sprinklers were not tight to ceiling at several locations within the Access Clinic.

7. On 06/15/2016 at 9:59 am, on the 3-2D floor in the Admissions Closet Room next to Interview Office 2105, the escutcheon ring on the sprinkler was not tight to the ceiling.

8. On 06/15/2016 at 10:02 am, on the 3-2D floor in the Admissions Intake Office Room 2106, the escutcheon ring on the sprinkler was not tight to the ceiling.

9. On 06/15/2016 at 10:05 am, on the 3-2D floor in the Patient Crisis Services (PCS) Waiting Room 2109 at Station #1, the escutcheon ring on the sprinkler was not tight to the ceiling.

10. On 06/15/2016 at 10:08 am, on the 3-2D floor in the Patient Crisis Services (PCS) Security Room 2113, the escutcheon ring on the sprinkler was not tight to the ceiling.

11. On 06/15/2016 at 10:30 am, on the 4-3A floor in the Intensive Treatment Unit (ITU) Inpatient Sleeping Rooms, Toilets and Chart Room #1, #20, #26, #34, #37 and #38, that the escutcheon rings on the sprinklers were missing.

12. On 06/15/2016 at 11:10 am, on the 5-3B floor in the Children's Adolescent Inpatient Services (CAIPS) Room #13, the escutcheon ring on the sprinkler was not tight to the ceiling.

13. On 06/15/2016 at 11:14 am, on the 5-3B floor in the Children's Adolescent Inpatient Services (CAIPS) I.P.Toilet/Shower Room #26, the escutcheon ring on the sprinkler was missing. It was also noticed these sprinkler heads are not the non-hanging type required to be installed in a Psychiatric Hospital.

14. On 06/14/2016 at 2:47 pm, on the 3-1B floor in the Fiscal Records, there was two unsealed holes near the ceiling. These holes included two 24" x 48" open ceiling tiles.

15. On 06/14/2016 at 2:53 pm, on the 3-1B floor in the Corridor outside Medical Records door, there were several unsealed holes near the ceiling. The holes included several ceiling splines missing between ceiling tiles.

16. On 06/14/2016 at 3:38 pm, on the 5-3B floor in the Corridor outside Room 3304, there was one unsealed hole near the ceiling. The hole included a 2" x 5" opening in the ceiling.

17. On 06/15/2016 at 9:53 am, on the 2-2A floor in the Data Closet within Access Clinic 2006-1, there were several unsealed holes near the ceiling. The holes included several 1 inch diameter holes in the ceiling from data cables and conduits.

18. On 06/15/2016 at 10:18 am, on the 4-3A floor in the Intensive Treatment Unit (ITU) Offices #1 & #2, there was one unsealed hole near the ceiling. The hole included a 5 inch closure plank that was removed at the raised ceiling area.

19. On 06/15/2016 at 10:42 am, on the 4-3A floor in the Intensive Treatment Unit (ITU) Storage Room #19 & Electrical/Data Closet #23, there was one unsealed hole near the ceiling. The hole included a 1" diameter hole from conduits or cables.

20. On 06/15/2016 at 11:12 am, on the 5-3B floor in the Corridor outside Children's Adolescent Inpatient Services (CAIPS) Exam Room #3305-15, there was more than one unsealed holes near the ceiling. The holes included 4 ceiling tiles ajar and one 1/2" diameter hole around the escutcheon ring.

21. On 06/15/2016 at 11:22 am, on the 5-3B floor in the Children's Adolescent Inpatient Services (CAIPS) Corridor, there was one unsealed hole near the ceiling. The hole included a 1" diameter hole near the smoke barrier between Inpatient Units.

22. On 06/14/2016 at 1:15 pm, during a review of facility documents the facility could not verify that the fire pump system's weekly 10-minute churn test was performed. Fire Pump Weekly Testing (in-house service) identified an average of 3 Weeks of Testing per Month. After staff re-evaluated its computer program for Fire Pump Weekly testing, including churn testing, it reported the program was missing one week per Month in the 'automated' Preventative Maintenance (PM) computer program.

23. On 06/14/2016 at 11:30 am, during a review of facility documents the quarterly wet sprinkler inspections were not performed as required. Quarterly Sprinkler System Inspection Reports by Grunau Fire Protection, dated (4/9/2015, 7/2/2015, 12/19/2015 & 3/12/2016) were not in compliance. The 4/9/2015 Quarterly Sprinkler Testing Report was beyond the 12 Month requirement. No recent Quarterly Inspection and Testing Report could be provided at time of survey exit.

24. On 06/15/2016 at 9:22 am, the cabinet of spare sprinklers did not contain two spare heads for the each type of sprinkler that was observed in the facility. Spare sprinklers were not provided for Upright Head #UL804A and Gruman SSU 735A.

These conditions were confirmed at the time of discovery by observations, review of facility documents and interviews with staff A (Director of Operations), staff B (Op. & Maintenance Supervisor) and staff D (Facilities Operations Mgr.).
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Based on observation, review of documents and interview, the facility did not provide a ventilation system in accordance with manufacturer specifications and NFPA 90A with ventilation systems that comply with NFPA 101 (2000 ed.), 19.5.2.1, section 9.2, and NFPA 90A, sections 2-3.2.1.4, 3-4.5.1, 3-4.5.2, 3-4.5.3, 3-4.5.4 & 3-4.7 including required damper maintenance and compliant air distribution installation. These deficiencies had the potential to affect all of the 34 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.


FINDINGS INCLUDE:

1. On 06/15/2016 at 11:08 am, observation revealed on the 5-3B floor in the Children's Adolescent Inpatient Services (CAIPS) Room #13, that the space was not provided with a compliant ventilation system including a supply air defuser grille. The supply grille was missing at the ceiling.

2. On 06/14/2016 at 2:30 pm, during a review of record documents it was discovered that not all required maintenance procedures were performed. Damper maintenance documents were missing for both fire dampers and smoke dampers.

3. On 06/15/2016 at 10:25 am, observation revealed on the 4-3A floor in the Intensive Treatment Unit (ITU) Patient Laundry Room #10, that a flexible duct (air connector) was installed through the rated wall of the space.

4. On 06/15/2016 at 11:07 am, observation revealed on the 5-3B floor in the Children's Adolescent Inpatient Services (CAIPS) Laundry Room #10, that a flexible duct (air connector) was installed through the rated wall of the space.

These conditions were confirmed at the time of discovery by observation, review of record documents and interview with staff A (Director of Operations), staff B (Op. & Maintenance Sprvsr) and staff D (Facilities Operations Mgr.).
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Based on interview and a review of record documents, the facility did not test the emergency electrical generator in accordance with NFPA 110 (1999 ed.), sections 6-3.4 & 6-4 (Level 1 EPSS), with a complete testing program for emergency generators. A written record shall include: (a) The date of the Maintenance Report. (b) Identification of the Servicing Personnel and Company they represent. (c) Notification of any unsatisfactor condition and the corrective action taken, including parts replaced & (d) Testing of any repair for the appropriate time as recommended by the manufacturer.
This deficiency would affect all of the 34 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 06/14/2016 at 10:15 am, the emergency generator was shutting-down shortly after starting up. No explanation was given why this was happening, but the Outside Emergency Generator Technicians were 'on-site' this day (06/14/2016) looking into the problem. It was through review of record documents that a written record of the EPSS inspections, tests, exercising, operations, and repairs 'was missing.'

This condition was confirmed at the time of discovery by a review of record documents and interview with staff A (Director of Operations), staff B (Op. & Maintenance Sprvsr) and staff D (Facilities Operations Mgr.).
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Based on observation, review of record documents and interview, the facility did not provide a Type 1 Essential Electrical System that was divided with three branches in accordance with NFPA 99 (1999 ed.), s. 3-4.2.2.2, plus NFPA 70 (1999 ed.) Article 517-25 & 30 (a,b,c & d) EES. Did not have calculations as to the correct amount of fuel per NFPA 99 (1999 ed.) section 3-4.1.1.13 Fuel Supply and NFPA 110 sections 3-1.1 & 3-4.2. Did not meet Emergency Preparedness under NFPA 101 (2000 ed.) s. 4.5.1 Multiple Safeguards. These deficiencies occurred in all of the 34 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/14/2016 at 9:50 am, the Type 1 Essential Electrical System did not have three branches with appropriate switches and electrical raceways feeding the different branches (Life Safety, Emergency & Equipment). Currently all power is inter-mixed between life safety, critical and equipment needs.

2. On 06/14/2016 at 10:00 am, the Type 1 Essential Electrical System did not have a calculation as to the correct amount of fuel required to run the emergency generator under load for the required amount of time during a catastrophic event.

These conditions were confirmed at the time of discovery by observation, review of record documents and interview with staff A (Director of Operations), staff B (Op. & Maintenance Sprvsr) and staff D (Facilities Operations Mgr.).
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Based on observation and interview, the facility did not provide and maintain an electrical installation compliant with NFPA 70 (1999 ed.), s. 9-1.2 & Article 110-26(c), National Electrical Code, with two exits from a high amperage room. This deficiency occurred in one of the 34 smoke compartments, and had the potential to affect staff and visitors within this smoke compartment.

FINDINGS INCLUDE:

On 06/14/2016 at 3:08 pm, on the 5-2A floor in the Electrical Sub Station Room, that two means of egress was not provided at each end of the working space, which had equipment rated at greater than 1200 amperes or more. The electrical switch gear is greater than 66,000 amps in the room (Electrical Panels included: 13,860 amps + 13,530 amps + 13,200 amps + 12,870 amps + 12,540 amps) and the doors did not open out-ward with panic hardware. There is only one set of doors to the space.

This condition was confirmed at the time of discovery by an observation and interview with staff A (Director of Operations), staff B (Op. & Maintenance Sprvsr) and staff D (Facilities Operations Mgr.).
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Based on observation and interview, the facility did not provide and maintain the corridor wall construction to protect the corridor from non-corridor spaces like rooms open to the corridor with the required safe-guards per NFPA 101 (2000 ed.), section 19.3.6.1. This deficiency occurred in 1 of the 34 smoke compartments and had the potential to affect 2 staff members and an unknown number of visitors within this smoke compartment.

FINDINGS INCLUDE:

On 06/15/2016 at 11:45 am, on the 5-2 floor in the Building 5-2 at Dietary Dishwashing Room #2339 at Corridor, that the area was not separated from the exit egress corridor by wall construction and did not satisfy all of the requirements for an exception for spaces that are open to the corridor. The space did not have a smoke detector and was not fully observable from a 24 hour occupied location.

This condition was confirmed at the time of discovery by an observation and interview with staff A (Director of Operations), staff B (Op. & Maintenance Supervisor) and staff D (Facilities Operations Mgr.).
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Based on observation and interview, the facility did not provide and maintain smoke barrier door assemblies that meet NFPA 101 (2000 ed.), section 19.3.7.6 for the separation of smoke compartments with closers on all smoke barrier doors and fire-rated window assemblies per fire-rated glazing material meeting NFPA 80 (1999 ed.) Standard for Fire Doors and Fire Windows. These deficiencies occurred in 2 of the 34 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/15/2016 at 9:56 am, on the 3-2D floor in the Admissions Waiting Room 2100, the smoke barrier door would not self-close because the door closer did not have the torque to close the door.

2. On 06/14/2016 at 3:41 pm, on the 4-3B floor in the Corridor outside the Unit Entry Door at the Smoke Barrier, the smoke barrier door had non-compliant windows, the glass was not fire-rated. Glazing was made of non-fire-rated plastic.

These conditions were confirmed at the time of discovery by observation and interview with staff A (Director of Operations), staff B (Op. & Maintenance Supervisor) and staff D (Facilities Operations Mgr.).
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Based on observation and interview, the facility did not enclose hazardous rooms with closers on all fire-rated doors and fire-rated walls in hazardous rooms per NFPA 101 (2000 ed.), sections 19.3.2.1 and 8.4.1. This deficiency occurred in 5 of the 34 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/14/2016 at 3:35 pm, on the 5-3B floor in the Suite 3322, Room 34, the door would not self-close because it was missing a door closer. The space use to be an Inpatient Sleeping Room. The room was considered hazardous because it exceeded 50 square feet and contained a quantity of stored combustible materials considered hazardous.

2. On 06/14/2016 at 3:44 pm, on the 4-4B floor in the Linen Storage Room 41, the door would not self-close. The closer was malfunctioning and would not latch to frame. The room was considered hazardous because it exceeded 50 square feet and contained a quantity of stored combustible materials considered hazardous.

3. On 06/14/2016 at 3:11 pm, on the 4-2A floor in the Wheelchair Washing Room & Storage Room 2217, the fire barrier door could not be verified to have the required fire rating. The room is storing combustible supplies for housekeeping and maintenance shop materials. The door within the 2-hour assembly is labeled for 90 minutes, but the metal door has numerous holes in the door from a removed closer. The room was considered hazardous because it exceeded 50 square feet and contained a quantity of stored combustible materials considered hazardous.

4. On 06/14/2016 at 3:14 pm, on the 4-2A floor in the Fire Pump Room 2218, the fire barrier door could not be verified to have the required fire rating. The room is required to be fire-rated to at least 1-hour per NFPA 13 for Fire Pump Rooms. The current 90 minute rated fire door is warped and will not close and latch to the frame on its own. The room was considered hazardous because it exceeded 50 square feet and contained a quantity of stored combustible materials considered hazardous.

5. On 06/14/2016 at 2:49 pm, on the 3-1B floor in the Fiscal Record Files Area, the enclosing wall was not constructed to a 1-hour fire resistance rating. The wall was missing on two sides of the record files. This space is used to hold large amounts of paper fiscal records. The room was considered hazardous because it exceeded 50 square feet and contained a quantity of stored combustible materials considered hazardous.

These conditions were confirmed at the time of discovery by an observation and interview with staff A (Director of Operations), staff B (Op. & Maintenance Supervisor) and staff D (Facilities Operations Mgr.).
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Based on observation and interview, the facility did not provide egress paths at all times with doors that were unlockable in the egress path per NFPA 101 (2000 ed.), s. 19.2.2.2.4 and level walking surfaces in the path of egress per NFPA 101 (2000 ed.), s. 7.1.6 and 7.1.7. These deficiencies occurred in 4 of the 34 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/14/2016 at 3:17 pm, on the 3-2A floor in the Room 24, the door was locked from the egress side. There is a dead-bolt on the door

2. On 06/14/2016 at 3:20 pm, on the 3-2A floor in the Room 25, the door was locked from the egress side. There is a dead-bolt on the door.

3. On 06/15/2016 at 11:36 am, on the 5-1A floor in the Building 5-2 at Stairwell 5-1, the door was locked from the egress side. The door was locked on the inside of the stairwell that goes to the main corridor.

4. On 06/14/2016 at 3:48 pm, on the 4-4C floor in the Corridor in the Main 4th Floor Corridor, a portion of the path of egress had an abrupt change in elevation of 1 inch. There is a hole in the floor at the expansion joint greater than 1 inch depth that is a tripping hazard.

5. On 06/15/2016 at 11:06 am, on the 5-3B floor in the Children's Adolescent Inpatient Services (CAIPS) Exterior Exit Egress Stoop at Stairwell 5-5, a portion of the path of egress had an abrupt change in elevation in the concrete stoop adjacent to the sidewalk. A hole in the concrete of at least 2" x 24" has been created by soil erosion, causing a trip hazard.

These conditions were confirmed at the time of discovery by observation and interview with staff A (Director of Operations), staff B (Op. & Maintenance Supervisor) and staff D (Facilities Operations Mgr.).
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Based on observation and interview, the facility did not provide and maintain emergency illumination of the interior and exterior means of egress for at least 90 minutes after a power failure including a emergency battery light at the emergency generator ATS switchgear room per NFPA 101 (2000 ed.), 7.8.1.2, 7.9.2.3, & NFPA 110 (1999 ed.), 5-3.1, including continuous lighting of all the egress pathways. These deficiencies occurred in 2 of the 34 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/14/2016 at 3:05 pm, on the 4-2A floor in the Electrical Sub-Station Room, a battery-operated emergency light was not installed in the interior emergency ATS location.

2. On 06/15/2016 at 9:42 am, on the 2-1A floor in the Elevator Equipment Room, there was a power cord to the outlet for the emergency lights. Emergency lighting is to be direct wired.

These conditions were confirmed at the time of discovery by observation and interview with staff A (Director of Operations), staff B (Op. & Maintenance Supervisor) and staff D (Facilities Operations Mgr.).
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Based on observation, record review and interview, the facility did not provide a fire alarm system that was installed according to NFPA 72 (1999 edition) sections 1-2.3 & 2-2, and NFPA 101 (2000 ed.), section 9.6.1.4. The facility did not provide a fire alarm system with smoke detectors at required locations. This deficiency occurred in all of the 34 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/13/2016 at 3:25 pm, record review revealed that the smoke detectors were not located in accordance with NFPA 72 requirements. The facility could not produce where all the smoke detectors were located on a plan. Facility could not substantiate all smoke dampers locations, and if they were properly tested for timely smoke sensitivity. Documentation was not provided prior to exiting.

2. On 06/14/2016 at 2:55 pm, observation revealed on the 3-1C floor in the Room 1111, that the smoke detector was not located in accordance with NFPA 72 requirements. A smoke detector was greater than 12 inches below a smooth ceiling.

These conditions were confirmed at the time of discovery by observation, record review and interview with staff A (Director of Operations), staff B (Op. & Maintenance Supervisor) and staff D (Facilities Operations Mgr.).
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Based on review of record documents and interview, the facility did not maintain the fire alarm system according to NFPA 101 (2000 ed.), s. 9.6.1.7, and NFPA 72 (1999 ed.) sections 1-5.2.5 Light & Power Service, 1-5.2.6, 7-4.1 & 7-4.2 maintenance requirements, with required power supply for testing. Also, Fire Alarm Weekly Testing documentation per NFPA 72 (1999 ed.), Chapter 7-5.2.2. These deficiencies would affect all of the 34 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/14/2016 at 10:10 am, reports were not available to identify Secondary Supply Capacity (fuel). Under maximum quiesent load, the secondary supply shall have sufficient capacity to operate a protected premises, central station, or proprietary system for 24 hours. Sufficient fuel shall be available in storage for 6 months of testing plus the capacity.

2. On 06/14/2016 at 2:00 pm, reports were not available to verify that Semi-Annual Inspections were completed. One of the Fire Alarm Semi-Annual Inspection Reports by Aramark Corporation, was missing per the Manufacturer requirement for Clean Agent supporting FM-200 system (Transformer Room) and FE-25 FIKE Fire Supression System (Telco Room). Semi-Annual testing is required per documentation shown on the Clean Agent Report by Aramark Corporation. Dates last reported included 3/5/2015 & 4/6/2016.

3. On 06/14/2016 at 1:50 pm, weekly reports were not available to verify weekly fire alarm system inspections were conducted. The Fire Alarm Weekly Testing document by in-house staff was identified to be missing the entire month of January 2016.

These conditions were confirmed at the time of discovery by a review of record documents and interview with staff A (Director of Operations), staff B (Op. & Maintenance Supervisor) and staff D (Facilities Operations Mgr.).
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Based on review of record documents and interview, the facility did not inspect and test smoke detectors in accordance with manufacturer's specifications per NFPA 101 (2000 ed.), s. 9.6.1.3. Smoke detector sensitivity test records were missing. This deficiency could effect all of the 34 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 06/13/2016 at 3:20 pm, the smoke detector sensitivity test records did not contain all the required information. During a review of the Fire Alarm Annual Test Report, it was found that the document did not show that smoke devices were tested to all the requirements. Surveyor was told all devices were set at 3.5%, and all devices showed the same reading. It could not be confirmed the testing company spot-tested each detector.

This condition was confirmed at the time of discovery by a review of record documents and interview with staff A (Director of Operations), staff B (Op. & Maintenance Supervisor) and staff D (Facilities Operations Mgr.).
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Based on observation and interview, the facility did not provide a sprinkler system that complies with NFPA 101 (2000 ed.), sections 19.1.6, 19.3.5.1, 19.3.5.2, 19.3.5.3 & 9.7 and NFPA 13 (1999 edition), sections 5-5.4.1 & 5-6.3, including sprinklers that were to far from the ceiling, missing sprinkler protection of a space, and sprinklers located to far apart from each other. These deficiencies occurred in 5 of the 34 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/14/2016 at 2:57 pm, on the 3-1C floor in Room 1111, the sprinkler was placed farther than 24 inches from the ceiling. This situation would delay release of water and does not satisfy the listing requirements.

2. On 06/14/2016 at 2:59 pm, on the 3-1A floor in the Data Closet 1048A, the room was not sprinkler protected. The facility was stated to be fully-sprinkled, which required this space to be sprinkled. The data closet had a ceiling that had holes and sprinkler coverage was not provided above the open ceiling. There were also holes where data cables were running through the ceiling and the ceiling was not completely sealed from fire and smoke.

3. On 06/14/2016 at 3:01 pm, on the 5-2A floor in the Elevator Equipment Room, the room was not sprinkler protected. The facility was stated to be fully-sprinkled, which required this space to be sprinkled. No sprinkler protection or clean agent system protection was provided in this hazardous room.

4. On 06/15/2016 at 11:33 am, on the 5-1A floor in the Building 5-2 at Stairwell 5-1, the room was not sprinkler protected. The facility was stated to be fully-sprinkled, which required this space to be sprinkled. The sprinkler head was missing at the bottom of Stairwell.

5. On 06/14/2016 at 2:51 pm, on the 3-1B floor in the Corridor outside Medical Records door, standard sprinkler heads were located greater than 16 feet from one another. Sprinklers cannot be farther from each other than the maximum required separation distance of 15' for standard discharge heads or farther than 7-1/2' from a wall.

These conditions were confirmed at the time of discovery by observation and interview with staff A (Director of Operations), staff B (Op. & Maintenance Supervisor) and staff D (Facilities Operations Mgr.).
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Based on observation, interview and a review of facility documents, the facility did not maintain the sprinkler system in a reliable operating condition that included a complete inspection program as required by NFPA 25 (1998 ed.), sections 2-2 & 2-3.1.1, Table 2-1 (Summary of Sprinkler System) and Table 9-1 (Summary of Valves) & NFPA 25 (1998 ed.), 1-11.1. The sprinkler system did not have all required sprinkler system inspections, intact escutcheon rings, ceilings sealed above the sprinklers to collect heat, weekly tests of the fire pump, and a complete accounting of the appropriate quantity of spare sprinklers.
These deficiencies had the potential to affect all of the 34 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/14/2016 at 10:30 am, during a review of facility documents the Annual Wet Sprinkler Inspections were not performed as required by the code as seen in the Annual Sprinkler System Inspection Report by Grunau Fire Inspection, dated June 12, 2015. The 10-year Head Inspection Testing of sprinkler heads, identified the heads installed in the Psychiatric Crisis Center (PSC) in 1985 are in need of being replaced after testing. Surveyor was told they no longer make this type 'head' and must be replaced to be maintained. Todays date is June 14, 2016 almost one year after the Annual Report. These heads are required to be tested starting at 20 years after being installed in 1985, and again every 10 years after 2005 per NFPA 25 Table 2-1 Summary of Sprinkler System Inspection, Testing, and Maintenance. This 10 year inspection in the Annual Report showed they needed to be replaced.

2. On 06/14/2016 at 11:00 am, during a review of facility documents the annual wet sprinkler inspections were not performed as required by the code with correct follow-up. Sprinkler System Five Year Internal Inspection Report by Grunau Fire Protection, dated June 12, 2015. Identified three items (10" water check valve, 10" water shut-off & 1" valve trim check valve) that needed to be tested at the 5 Year testing period and the comment in the report stated 'Unknown'. Correction of this deficiency was never completed since written almost a year ago.

3. On 06/14/2016 at 11:45 am, during a review of facility documents the annual wet sprinkler inspections were not performed as required. The Annual Sprinkler System Inspection Report by Grunau Fire Protection, dated June 12, 2015, identified one item incomplete. Report notes 'no' Quick Response (QR) heads on-site. Table 2-1 Summary of Sprinkler System Inspection, Testing, and Maintenance, states Sprinklers - fast response, shall be tested at 20 years after original install (1985) and 10 years thereafter per NFPA 25. This information is missing.

4. On 06/14/2016 at 1:30 pm, during a review of facility documents the annual wet sprinkler inspections were not performed as required. Sprinkler System Five Year Internal Inspection Report by Grunau Fire Protection, dated June 12, 2015, identified one item incomplete. Report notes 'the hospital complex has no check valve on the suction side of the fire pump'. The Code requires double check valves per NFPA 101 (2000 ed.) s. 4.6.7 Modernization or Renovation. Sprinkler System with Fire Pump was installed after building was originally completed and occupied. This then relates to Modernization or Renovation at time of Fire Pump install for existing conditions.

5. On 06/14/2016 at 2:45 pm, on the 3-1A floor in the Vending Area of Corridor, the escutcheon ring on the sprinkler was not tight to ceiling.

6. On 06/15/2016 at 9:50 am, on the 2-2A floor in the Access Clinic Room 2006-1, the escutcheon rings on the sprinklers were not tight to ceiling at several locations within the Access Clinic.

7. On 06/15/2016 at 9:59 am, on the 3-2D floor in the Admissions Closet Room next to Interview Office 2105, the escutcheon ring on the sprinkler was not tight to the ceiling.

8. On 06/15/2016 at 10:02 am, on the 3-2D floor in the Admissions Intake Office Room 2106, the escutcheon ring on the sprinkler was not tight to the ceiling.

9. On 06/15/2016 at 10:05 am, on the 3-2D floor in the Patient Crisis Services (PCS) Waiting Room 2109 at Station #1, the escutcheon ring on the sprinkler was not tight to the ceiling.

10. On 06/15/2016 at 10:08 am, on the 3-2D floor in the Patient Crisis Services (PCS) Security Room 2113, the escutcheon ring on the sprinkler was not tight to the ceiling.

11. On 06/15/2016 at 10:30 am, on the 4-3A floor in the Intensive Treatment Unit (ITU) Inpatient Sleeping Rooms, Toilets and Chart Room #1, #20, #26, #34, #37 and #38, that the escutcheon rings on the sprinklers were missing.

12. On 06/15/2016 at 11:10 am, on the 5-3B floor in the Children's Adolescent Inpatient Services (CAIPS) Room #13, the escutcheon ring on the sprinkler was not tight to the ceiling.

13. On 06/15/2016 at 11:14 am, on the 5-3B floor in the Children's Adolescent Inpatient Services (CAIPS) I.P.Toilet/Shower Room #26, the escutcheon ring on the sprinkler was missing. It was also noticed these sprinkler heads are not the non-hanging type required to be installed in a Psychiatric Hospital.

14. On 06/14/2016 at 2:47 pm, on the 3-1B floor in the Fiscal Records, there was two unsealed holes near the ceiling. These holes included two 24" x 48" open ceiling tiles.

15. On 06/14/2016 at 2:53 pm, on the 3-1B floor in the Corridor outside Medical Records door, there were several unsealed holes near the ceiling. The holes included several ceiling splines missing between ceiling tiles.

16. On 06/14/2016 at 3:38 pm, on the 5-3B floor in the Corridor outside Room 3304, there was one unsealed hole near the ceiling. The hole included a 2" x 5" opening in the ceiling.

17. On 06/15/2016 at 9:53 am, on the 2-2A floor in the Data Closet within Access Clinic 2006-1, there were several unsealed holes near the ceiling. The holes included several 1 inch diameter holes in the ceiling from data cables and conduits.

18. On 06/15/2016 at 10:18 am, on the 4-3A floor in the Intensive Treatment Unit (ITU) Offices #1 & #2, there was one unsealed hole near the ceiling. The hole included a 5 inch closure plank that was removed at the raised ceiling area.

19. On 06/15/2016 at 10:42 am, on the 4-3A floor in the Intensive Treatment Unit (ITU) Storage Room #19 & Electrical/Data Closet #23, there was one unsealed hole near the ceiling. The hole included a 1" diameter hole from conduits or cables.

20. On 06/15/2016 at 11:12 am, on the 5-3B floor in the Corridor outside Children's Adolescent Inpatient Services (CAIPS) Exam Room #3305-15, there was more than one unsealed holes near the ceiling. The holes included 4 ceiling tiles ajar and one 1/2" diameter hole around the escutcheon ring.

21. On 06/15/2016 at 11:22 am, on the 5-3B floor in the Children's Adolescent Inpatient Services (CAIPS) Corridor, there was one unsealed hole near the ceiling. The hole included a 1" diameter hole near the smoke barrier between Inpatient Units.

22. On 06/14/2016 at 1:15 pm, during a review of facility documents the facility could not verify that the fire pump system's weekly 10-minute churn test was performed. Fire Pump Weekly Testing (in-house service) identified an average of 3 Weeks of Testing per Month. After staff re-evaluated its computer program for Fire Pump Weekly testing, including churn testing, it reported the program was missing one week per Month in the 'automated' Preventative Maintenance (PM) computer program.

23. On 06/14/2016 at 11:30 am, during a review of facility documents the quarterly wet sprinkler inspections were not performed as required. Quarterly Sprinkler System Inspection Reports by Grunau Fire Protection, dated (4/9/2015, 7/2/2015, 12/19/2015 & 3/12/2016) were not in compliance. The 4/9/2015 Quarterly Sprinkler Testing Report was beyond the 12 Month requirement. No recent Quarterly Inspection and Testing Report could be provided at time of survey exit.

24. On 06/15/2016 at 9:22 am, the cabinet of spare sprinklers did not contain two spare heads for the each type of sprinkler that was observed in the facility. Spare sprinklers were not provided for Upright Head #UL804A and Gruman SSU 735A.

These conditions were confirmed at the time of discovery by observations, review of facility documents and interviews with staff A (Director of Operations), staff B (Op. & Maintenance Supervisor) and staff D (Facilities Operations Mgr.).
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Based on observation, review of documents and interview, the facility did not provide a ventilation system in accordance with manufacturer specifications and NFPA 90A with ventilation systems that comply with NFPA 101 (2000 ed.), 19.5.2.1, section 9.2, and NFPA 90A, sections 2-3.2.1.4, 3-4.5.1, 3-4.5.2, 3-4.5.3, 3-4.5.4 & 3-4.7 including required damper maintenance and compliant air distribution installation. These deficiencies had the potential to affect all of the 34 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.


FINDINGS INCLUDE:

1. On 06/15/2016 at 11:08 am, observation revealed on the 5-3B floor in the Children's Adolescent Inpatient Services (CAIPS) Room #13, that the space was not provided with a compliant ventilation system including a supply air defuser grille. The supply grille was missing at the ceiling.

2. On 06/14/2016 at 2:30 pm, during a review of record documents it was discovered that not all required maintenance procedures were performed. Damper maintenance documents were missing for both fire dampers and smoke dampers.

3. On 06/15/2016 at 10:25 am, observation revealed on the 4-3A floor in the Intensive Treatment Unit (ITU) Patient Laundry Room #10, that a flexible duct (air connector) was installed through the rated wall of the space.

4. On 06/15/2016 at 11:07 am, observation revealed on the 5-3B floor in the Children's Adolescent Inpatient Services (CAIPS) Laundry Room #10, that a flexible duct (air connector) was installed through the rated wall of the space.

These conditions were confirmed at the time of discovery by observation, review of record documents and interview with staff A (Director of Operations), staff B (Op. & Maintenance Sprvsr) and staff D (Facilities Operations Mgr.).
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Based on interview and a review of record documents, the facility did not test the emergency electrical generator in accordance with NFPA 110 (1999 ed.), sections 6-3.4 & 6-4 (Level 1 EPSS), with a complete testing program for emergency generators. A written record shall include: (a) The date of the Maintenance Report. (b) Identification of the Servicing Personnel and Company they represent. (c) Notification of any unsatisfactor condition and the corrective action taken, including parts replaced & (d) Testing of any repair for the appropriate time as recommended by the manufacturer.
This deficiency would affect all of the 34 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 06/14/2016 at 10:15 am, the emergency generator was shutting-down shortly after starting up. No explanation was given why this was happening, but the Outside Emergency Generator Technicians were 'on-site' this day (06/14/2016) looking into the problem. It was through review of record documents that a written record of the EPSS inspections, tests, exercising, operations, and repairs 'was missing.'

This condition was confirmed at the time of discovery by a review of record documents and interview with staff A (Director of Operations), staff B (Op. & Maintenance Sprvsr) and staff D (Facilities Operations Mgr.).
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Based on observation, review of record documents and interview, the facility did not provide a Type 1 Essential Electrical System that was divided with three branches in accordance with NFPA 99 (1999 ed.), s. 3-4.2.2.2, plus NFPA 70 (1999 ed.) Article 517-25 & 30 (a,b,c & d) EES. Did not have calculations as to the correct amount of fuel per NFPA 99 (1999 ed.) section 3-4.1.1.13 Fuel Supply and NFPA 110 sections 3-1.1 & 3-4.2. Did not meet Emergency Preparedness under NFPA 101 (2000 ed.) s. 4.5.1 Multiple Safeguards. These deficiencies occurred in all of the 34 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/14/2016 at 9:50 am, the Type 1 Essential Electrical System did not have three branches with appropriate switches and electrical raceways feeding the different branches (Life Safety, Emergency & Equipment). Currently all power is inter-mixed between life safety, critical and equipment needs.

2. On 06/14/2016 at 10:00 am, the Type 1 Essential Electrical System did not have a calculation as to the correct amount of fuel required to run the emergency generator under load for the required amount of time during a catastrophic event.

These conditions were confirmed at the time of discovery by observation, review of record documents and interview with staff A (Director of Operations), staff B (Op. & Maintenance Sprvsr) and staff D (Facilities Operations Mgr.).
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Based on observation and interview, the facility did not provide and maintain an electrical installation compliant with NFPA 70 (1999 ed.), s. 9-1.2 & Article 110-26(c), National Electrical Code, with two exits from a high amperage room. This deficiency occurred in one of the 34 smoke compartments, and had the potential to affect staff and visitors within this smoke compartment.

FINDINGS INCLUDE:

On 06/14/2016 at 3:08 pm, on the 5-2A floor in the Electrical Sub Station Room, that two means of egress was not provided at each end of the working space, which had equipment rated at greater than 1200 amperes or more. The electrical switch gear is greater than 66,000 amps in the room (Electrical Panels included: 13,860 amps + 13,530 amps + 13,200 amps + 12,870 amps + 12,540 amps) and the doors did not open out-ward with panic hardware. There is only one set of doors to the space.

This condition was confirmed at the time of discovery by an observation and interview with staff A (Director of Operations), staff B (Op. & Maintenance Sprvsr) and staff D (Facilities Operations Mgr.).
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