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32670

32670

This is a verification visit done May 27- June 3, 2016, after a standard Verification Survey for Life Safety Code compliance was conducted by the Wisconsin Division of Quality Assurance on February 1-3, 2016. The Monroe Clinic was found to be NOT in compliance with the following applicable regulations for hospital participation in Medicare-Medicaid:

42 CFR 482.41 Condition of Participation: Physical Environment was NOT MET
42 CFR 482.41(b) Standard: Safety from Fire was NOT MET
NFPA 101 (2000 edition)-Life Safety Code (Chapter 18-New Healthcare) was NOT MET

The Monroe Clinic {Hospital} was a 4-story structure built in 2011, with Type (2,2,2) construction. The building also had a business occupancy, Administrative offices, pharmacy clinic and other outpatient clinics that were attached to the health care occupancy via a building connector but it is separated with 2-hour rated construction. The facility was fully sprinkled. The facility had an emergency generator that provided power to the emergency loads. The facility contained thirteen smoke compartments. The Monroe Clinic is licensed for 95 beds, with a census of 34, 39 and 36 inpatients at the time of the survey. Six federal deficiencies of the Life Safety Code were cited for this building. There are six other medical office buildings that were surveyed out a total of 13 sites.

The cumulative effect of these deficiencies has the potential to affect the safety of all patients receiving services at the hospital.

The facility was found to contain the following deficiencies.

K29: Hazardous areas without rated wall, door closers and rated doors
K39: Corridor width not maintained.
K46: Lacking emergency lighting reliability.
K50: Fire drills not done correctly.
K56: Sprinkler system was not compliant to NFPA 13 minimum standards.
K75: Proper storage and handling of rubbish and soiled materials.
K130: (At the Outpatient buildings) exiting, exit signage, fire dampers, improper vertical enclosures, hazardous rooms, sprinklers, sprinkler maintenance,electrical, dead end corridors, locked doors and room wall finishes.

Please refer to the full description and findings within the specific K-tag deficiencies for the appropriate building found later in this report.

This is a verification visit done May 27- June 3, 2016, after a standard Verification Survey for Life Safety Code compliance was conducted by the Wisconsin Division of Quality Assurance on February 1-3, 2016. The Monroe Clinic was found to be NOT in compliance with the following applicable regulations for hospital participation in Medicare-Medicaid:

42 CFR 482.41 Condition of Participation: Physical Environment was NOT MET
42 CFR 482.41(b) Standard: Safety from Fire was NOT MET
NFPA 101 (2000 edition)-Life Safety Code (Chapter 18-New Healthcare) was NOT MET

The Monroe Clinic {Hospital} was a 4-story structure built in 2011, with Type (2,2,2) construction. The building also had a business occupancy, Administrative offices, pharmacy clinic and other outpatient clinics that were attached to the health care occupancy via a building connector but it is separated with 2-hour rated construction. The facility was fully sprinkled. The facility had an emergency generator that provided power to the emergency loads. The facility contained thirteen smoke compartments. The Monroe Clinic is licensed for 95 beds, with a census of 34, 39 and 36 inpatients at the time of the survey. Six federal deficiencies of the Life Safety Code were cited for this building. There are six other medical office buildings that were surveyed out a total of 13 sites.

The cumulative effect of these deficiencies has the potential to affect the safety of all patients receiving services at the hospital.

The facility was found to contain the following deficiencies.

K29: Hazardous areas without rated wall, door closers and rated doors
K39: Corridor width not maintained.
K46: Lacking emergency lighting reliability.
K50: Fire drills not done correctly.
K56: Sprinkler system was not compliant to NFPA 13 minimum standards.
K75: Proper storage and handling of rubbish and soiled materials.
K130: (At the Outpatient buildings) exiting, exit signage, fire dampers, improper vertical enclosures, hazardous rooms, sprinklers, sprinkler maintenance,electrical, dead end corridors, locked doors and room wall finishes
Please refer to the full description and findings within the specific K-tag deficiencies for the appropriate building found later in this report.

Please refer to the full description and findings within the specific K-tag deficiencies for the appropriate building found later in this report.

Based on observation and staff interviews, the facility did not construct, install and maintain a proper ventilation control system in the clean sterile storage supply area. The facility did not have a ventilation system that was installed and maintained in accordance with state regulations and manufacturer recommendations. This deficiency occurred in 1 of the 13 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 6/3/2016 at 10:20 AM and previously on 02/01/2016 at 4:10 PM, observation revealed on the Lobby level floor in the the Central clean sterile supply storage room in the OR area, that the ventilation to the space could not be confirmed to be compliant with accepted standards. The central clean sterile supply storage room had negative ventilation. Air was flowing from two sub-sterile rooms into the central clean sterile supply storage room. Clean sterile supply storage room is required to have 2 outside air changes, 4 air changes total and be positive air pressure to the corridor per Guidelines for Design and Construction of Health Care Facilities (FGI Guidelines) and American Society of Heating Refrigeration, and Air Conditioning Engineers (ASHRAE) 170. This situation was not compliant with 42 CFR 482.41(c)(4). This condition was confirmed at the time of discovery by a concurrent observation and interview with staff staff W (Facilities Engineer).

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