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A verification visit occurred on 08/11/2016 from the recertification survey. Based on observation and interview, the facility did not enclose hazardous rooms with proper hardware and fire-rated doors with fire-rated walls in hazardous rooms per NFPA 101 (2000 ed.), sections 19.3.2.1 and 8.4.1. This deficiency occurred in 1 of the 34 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within this smoke compartment.

FINDINGS INCLUDE:

1. On 08/11/2016 at 11 am, observation revealed 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. The room was considered hazardous because it exceeded 50 square feet and contained a quantity of stored combustible materials considered hazardous.

2. On 08/11/2016 at 11:05 am, observation revealed 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 current 90 minute rated fire door 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.

These conditions were confirmed at the time of discovery by an observation and interview with staff A (Director of Operations).
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A verification visit occurred on 08/11/2016 following the recertification survey. Based on interview with staff A, the following findings were not complete in accordance 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. 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 08/11/2016 at 10:46 am interview revealed that on the 3-1C floor in Room 1111, the sprinkler was placed farther than 24 inches from the ceiling.

2. On 08/11/2016 at 10:47 am interview revealed that on the 3-1A floor in the Data Closet 1048A, the room was not sprinkler protected. The data closet had missing ceiling tile around data cables.

3. On 08/11/2016 at 10:48 am interview revealed that on the 5-2A floor in the Elevator Equipment Room, the room was not sprinkler protected. No sprinkler protection or clean agent system protection was provided in this hazardous room.

4. On 08/11/2016 at 10:49 am interview revealed that on the 5-1A floor in the Building 5-2 at Stairwell 5-1, the room was not sprinkler protected. The sprinkler head was missing at the bottom of Stairwell.

5. On 08/11/2016 at 10:51 am interview revealed that on the 3-1B floor in the Corridor outside Medical Records door (in the Finance Corridor), standard sprinkler heads were located greater than 16 feet from one another.

These conditions were confirmed at the time of interview with staff A (Director of Operations).
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A verification visit occurred on 08/11/2016 following the recertification survey. Based on record review and interview with staff A, 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. 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 08/11/2016 at 11:55 am, record review revealed the Annual Wet Sprinkler Inspections were not performed as required by the code in the Psychiatric Crisis Center (PSC).

2. On 08/11/2016 at 11:56 am, record review revealed the annual wet sprinkler inspections were not performed as required by the code with correct follow-up. Sprinkler System Five Year Internal Inspection Report. The Report 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'.

3. On 08/11/2016 at 11:57 am, record review revealed the annual wet sprinkler inspections were not performed as required. Sprinkler System Five Year Internal Inspection Report identified one item incomplete, that 'the hospital complex has no check valve on the suction side of the fire pump'.

4. On 08/11/2016 at 11:58 am, interview revealed the escutcheon ring was not tight to the ceiling in the 3-2D building floor in the Admissions Closet Room next to Interview Office 2105.

5. On 08/11/2016 at 11:59 am, interview revealed the escutcheon ring was not tight to the ceiling in the 3-2D building floor in the Admissions Intake Office Room 2106.

6. On 08/11/2016 at 12:01 pm, interview revealed the escutcheon ring was not tight to the ceiling in the 3-2D building floor in the Patient Crisis Services (PCS) Waiting Room 2109 at Station #1.

7. On 08/11/2016 at 12:02 pm, interview revealed the escutcheon ring was not tight to the ceiling in the 3-2D building floor in the Patient Crisis Services (PCS) Security Room 2113.

These conditions were confirmed at the time of discovery by record review and interview with staff A (Director of Operations).
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A verification visit occurred on 08/11/2016 following the recertification survey. Based on interview with staff A, 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. 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 08/11/2016 at 9:15 am, the interview revealed 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).

This condition was confirmed at the time of discovery by interview with staff A (Director of Operations).
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A verification visit occurred on 08/11/2016 following the recertification survey. Based on interview with staff A, the facility continues to not comply with NFPA 70 (1999 ed.), s. 9-1.2 & Article 110-26(c), National Electrical Code. This deficiency occurred in one of the 34 smoke compartments, and had the potential to affect ALL staff and visitors within this smoke compartment.

FINDINGS INCLUDE:

On 08/11/2016 at 9:32 am, interview revealed the two means of egress were not provided at opposite ends of the working space, 5-2A floor, in the Electrical Sub Station Room, where electrical equipment was rated at greater than 1200 amperes. The single double door exit did not open out-ward with panic hardware.

This condition was confirmed at the time of discovery by interview with staff A (Director of Operations).
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