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31165

The facility is required to be in compliance with NFPA 101, Section 19.1.1.1.9 which states facilities that do not provide housing on a 24-hour basis for their occupants shall be classified as other occupancies and shall be covered by other chapters of this Code.

As a result, the Outpatient Services location at 1419 Hancock Street, Quincy, MA 02169 was surveyed under NFPA 101, 2012 edition, Chapter 39 Existing Business Occupancies.

Deficiency:

Based upon observations and staff interview the facility failed to ensure that the premises are protected by a fire alarm system as required.

-Section 39.3.4.1 of Chapter 39 Existing Business Occupancies of the 2012 edition of NFPA 101 Life safety Code states that a fire alarm system in accordance with Section 9.6 shall be provided in all business occupancies where any one of the following conditions exists:
(1) The building is three or more stories in height.
(2) The occupancy is subject to 100 or more occupants above or below the level of exit discharge.
(3) The occupancy is subject to 1000 or more total occupants.

-Section 9.6.1.1 states the provisions of Section 9.6 shall apply only where specifically required by another section of this Code.

-Section 9.6.1.2 states fire detection, alarm, and communications systems installed to make use of an alternative permitted by this Code shall be considered required systems and shall meet the provisions of this Code applicable to required systems.

-Section 9.6.1.3 states a fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code, unless it is an approved existing installation, which shall be permitted to be
continued in use.

-Section 9.6.1.4 states all systems and components shall be approved for the purpose for which they are installed.

-Section 9.6.1.5* states that to ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling
Code.

Findings Include:

During the morning hours of 6/12/17, while conducting the life safety survey, observations and staff interview revealed the following.

1. The outpatient facility is located on the first floor of a three story building and is classified as business occupancy.

2. Although a smoke detector and strobe alarm were observed in the facility's men's room, there was no documentation indicating that the building was equipped with a fire alarm system in accordance with NFPA regulations.

3. When questioned as to the existence of a fire alarm system the facility's Director of Operations stated that the Hospital's Director of Facilities Management would have that information. When contacted the Hospital's Director of Facilities Management stated that the facility identified as building #7 was not equipped with a fire alarm system.

As a result of the finding the facility is found to be non-compliant with Section 39.3.4.1 of Chapter 39 Existing Business Occupancies.

The finding was confirmed by Hospital's Director of Facilities Management.

The facility is required to be in compliance with NFPA 101, Section 19.1.1.1.9 which states facilities that do not provide housing on a 24-hour basis for their occupants shall be classified as other occupancies and shall be covered by other chapters of this Code.

As a result, the Outpatient Services location at 1419 Hancock Street, Quincy, MA 02169 was surveyed under NFPA 101, 2012 edition, Chapter 39 Existing Business Occupancies.

A. Section 39.2.9.1 states Emergency lighting shall be provided in accordance with Section 7.9 in any building where any one of the following conditions exists:
(1) The building is three or more stories in height.
(2) The occupancy is subject to 100 or more occupants above
or below the level of exit discharge.
(3) The occupancy is subject to 1000 or more total occupants.

Section 7.9.3.1 states required emergency lighting system shall be tested in accordance with one of the three options offered by 7.9.3.1.1, 7.9.3.1.2, or 7.9.3.1.3.

Section 7.9.3.1.1 states testing of required emergency lighting systems shall be permitted to be conducted as follows:
(1) Functional testing shall be conducted monthly, with a minimum of 3 weeks and a maximum of 5 weeks between
tests, for not less than 30 seconds, except as otherwise permitted by 7.9.3.1.1(2).
(2)The test interval shall be permitted to be extended beyond 30 days with the approval of the authority having
jurisdiction.
(3) Functional testing shall be conducted annually for a minimum of 1 1/2 hours if the emergency lighting system is battery
powered.
(4) The emergency lighting equipment shall be fully operational for the duration of the tests required by 7.9.3.1.1(1)
and (3).
(5) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having
jurisdiction.

FINDINGS INCLUDE:

1. Documenation was not available to substantiate an annual 1 1/2 hour functional testing of the battery powered emergency lights for units #1, 3, 4 & 5.

Note: The annual 1 1/2 hour functional test of the battery powered emergency lights identified as Units #2,6, 7 & 8 had been completed.

As a result of the lack of the required functional testing of all battery powered emergency lights, the facility is not in compliance with Section 7.9.3.1.1.

B. Section 39.1.7 Occupant Load. The occupant load, in number of persons for whom means of egress and other provisions are required, shall be determined on the basis of the occupant load factors of Table 7.3.1.2 that are characteristic of the use of the space, or shall be determined as the maximum probable population of the space under consideration, whichever is greater.

Table 7.3.1.2 indicates the occupant load factor for a Business Occupancy is 100 ft2/person.

Section 39.2.4.1 states means of egress shall comply with all of the following, except as otherwise permitted by 39.2.4.2 through 39.2.4.6:
(1) The number of means of egress shall be in accordance with 7.4.1.1 and 7.4.1.3 through 7.4.1.6.
(2) Not less than two separate exits shall be provided on every story.
(3) Not less than two separate exits shall be accessible from every part of every story.

Section 39.2.1.1 states all means of egress shall be in accordance with Chapter 7 and this chapter.

Section 7.1.10.1 states means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

FINDINGS INCLUDE:
1. Square footage of the facility occupied 3rd floor is 6,000 ft2 resulting in an occupant load of the 3rd floor of 60 people in accordance with Section 39.1.7. Based on the occupant load, two exits are required from the third floor.

The provided second exit from the third floor is a fire escape which exits onto a roof and proceeds into another building's unprotected stairway. Several impediments were identified within this means of egress. Impediments included but were not limited to corroded fire escape stairs with a missing railing on the landing,and popping, cupping, and non secured ~ 2" x 8" wood boards. As a result, this exit was not properly maintained and was not in accordance with Section 7.1.10.1.

As a result of the impediments in the means of egress, the facility is not in compliance with Section 7.1.10.1.

These findings were confirmed with satellite Director.

Based on observations and confirmed by staff, the facility failed to ensure that the building is of a conforming construction type. Table 19.1.6.2 requires buildings 3-stories in height to be of at least Type I (443), Type I (332) or Type II (222). If the building is fully sprinklered it may be of Type II (111) construction.

THE FINDINGS INCLUDE:

Observations while touring the facility on 6/12/17 and 6/13/17 and as noted in previous surveys, revealed that the building is of 3-story Type III (211) construction.

This was reviewed with and acknowledged by the facility's Director of Facilities Management and reviewed with the Chief Executive Officer and Director of Facilities Management during the exit conference.

NOTE: This item does not meet NFPA 101 Life Safety Code, 2012 edition; however it would meet an alternative compliance with the Code (Fire Safety Evaluation System - FSES) under equivalency concepts of NFPA 101A, Guide on Alternative Approaches to Life Safety, 2001 edition where such equivalency is requested and approved.

As a result of the findings the facility is found to be non-compliant with NFPA 101, Section 19.1.6.1 and table 19.1.6.1.

Based on observations and confirmed by staff, the facility failed to ensure that corridors are at least a 4' minimum width.

Section 19.2.3.4 states that any required aisle, corridor, or ramp shall be not less than 48 in. (1220 mm) in clear width.

FINDINGS INCLUDE:

On 6/12/17 and 6/13/17 it was observed that the basement level corridor reduces to 43" wide at the Cafeteria.

As a result, the facility failed to comply with section 19.2.3.4.

This was reviewed with and acknowledged by the facility's Director of Facilities Management and reviewed with the Chief Executive Officer and Director of Facilities Management during the exit conference.

NOTE: This item does not meet NFPA 101 Life Safety Code, 2012 edition; however it would meet an alternative compliance with the Code (Fire Safety Evaluation System - FSES) under equivalency concepts of NFPA 101A, Guide on Alternative Approaches to Life Safety, 2013 edition where such equivalency is requested and approved.

Based on observations and confirmed by staff, the facility failed to ensure that egress routes are constructed as required.

Section 7.7.1 states exits shall terminate directly at a public way or at an exterior exit discharge, unless otherwise provided in 7.7.1.2 through 7.7.1.4.

Section 7.7.1.1 states yards, courts, open spaces, or other portions of the exit discharge shall be of the required width and size to provide all occupants with a safe access to a public way.

THE FINDINGS INCLUDE:

On 6/12/17 and 6/13/17, it was observed that exterior egress routes with hard packed surfaces are not provided in all areas of the hospital.

Stair #4 (at Catharine Street) exterior exit discharge terminates at a 48" x 36" concrete slab then to grass. It is not equipped with a hard packed walkway to ensure the means of egress is always free of obstructions that would prevent its use, such as ice, sleet, snow and the need for its removal in climates such as the Northeast region.

As a result, the facility failed to comply with 7.7.1.1 requiring hard packed walkways to a public way.

This was reviewed with and acknowledged by the facility's Director of Facilities Management and reviewed with the Chief Executive Officer and Director of Facilities Management during the exit conference.

Based on observations and confirmed by staff interview the facility failed to ensure compliance with Chapter 19,

Section 19.3.1 "Protection of Vertical Openings" , which requires any vertical opening to be enclosed or protected in accordance with Section 8.6, unless otherwise modified by 19.3.1.1 through 19.3.1.8.

Section 19.3.1.1 states where enclosure is provided, the construction shall not have less than a 1-hour fire resistive rating.

FINDINGS INCLUDE:

On 6/12/17 and 6/13/17 the following was noted:

1. The third floor level west stair #3 stair door has a cracked vision panel, and the first floor level west stair #3 stair door has an unsealed gap between top of the door and the door header (frame) when the door is in the closed and latched position.

2. The first floor level west stair #3 has two unsealed 1/2" diameter hole through the door where the door cylinder latch mechanism was replaced with a smaller cylinder leaving the original holes exposed.

As a result, the facility failed to comply with section 19.3.1.1.

This was reviewed with and acknowledged by the facility's Director of Facilities Management and reviewed with the Chief Executive Officer and Director of Facilities Management during the exit conference.

Based on observations and confirmed by staff interview the facility failed to ensure compliance with Chapter 19, Section 19.3.1 "Protection of Vertical Openings" , which requires any vertical opening to be enclosed or protected in accordance with Section 8.6, unless otherwise modified by 19.3.1.1 through 19.3.1.8.

Section 19.3.1.1 states where enclosure is provided, the construction shall not have less than a 1-hour fire resistive rating.

FINDINGS INCLUDE:

The first floor level east stair #5 has two unsealed 1/2" diameter hole through the door where the door cylinder latch mechanism was replaced with a smaller cylinder leaving the original holes exposed.

As a result, the facility failed to comply with section 19.3.1.1.

This was reviewed with and acknowledged by the facility's Director of Facilities Management and reviewed with the Chief Executive Officer and Director of Facilities Management during the exit conference.

Based on observations, the facility failed to ensure that hazardous areas were enclosed as required.

Hazardous areas are:
1. Protected by a fire barrier having 1-hour fire resistance rating (with 3/4-hour fire rated doors) or
2. An automatic fire extinguishing system in accordance with 8.7.1.
When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4.

Section 8.4.3.4 states that door clearances shall be in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives.

Section 8.4.3.5 states that doors shall be self-closing or automatic-closing in accordance with 7.2.1.8.

NFPA 80, section 7.1.4 Operation of Doors.
Section 7.1.4.1 states that the doors shall swing easily and freely on their hinges.
Section 7.1.4.2 states that the latches shall operate freely.


THE FINDINGS INCLUDE:

Observations while touring the facility on 6/13/17 revealed that neither the third floor level (west) Soiled Utility Biohazard Closet (#305 C ) nor the medical records / laboratory storage closet corridor doors were equipped with a self closing device(s).

As a result of the deficiency, the facility failed to maintain compliance with section 8.4.3.4 and NFPA 80, section 7.1.4.2

This was reviewed with and acknowledged by the facility's Director of Facilities Management and reviewed with the Chief Executive Officer and Director of Facilities Management during the exit conference.

Based on observations and records provided, the facility failed to properly maintain the sprinkler system.

NFPA #25 section 4.1.1 states the property owner or designated representative shall be responsible for properly maintaining a water based fire protection system.

Section 4.1.1.1.1 states inspection, testing, maintenance, and impairment shall be implemented in accordance with procedures meeting those established in this document and in accordance with the manufacturer's instructions.

Section 4.1.1.2 states inspection, testing, and maintenance shall be performed by personnel who have developed competence through training and experience.

Section 5.3.1.1 states where required by this section, sample sprinklers shall be submitted to a recognized testing laboratory acceptable to the authority having jurisdiction for field service testing.

Section 5.3.1.1.1 states where sprinklers have been in service for 50 years, they shall be replaced or representative samples from one or more sample areas shall be tested.

Section 5.3.1.2 states a representative sample of sprinklers for testing per 5.3.1.1.1 shall consist of a minimum of not less than four sprinklers or 1 percent of the number of sprinklers per individual sprinkler sample, whichever is greater.

Section 5.3.1.3 states where one sprinkler within a representative sample fails to meet the test requirement, all sprinklers within the area represented by that sample shall be replaced.

Section 5.3.1.1.1.1 states test procedures shall be repeated at 10-year intervals.

THE FINDINGS INCLUDE:

During the afternoon hours of 6/12/17 , it was observed that the basement area is equipped with sprinkler heads having a stamped date of 1965, greater than 50-years since manufacturing. These heads were observed in the West Building's third floor level. Further discussion revealed that the facility documented several sprinkler heads on the third floor level to be dated 1965. Facility staff also acknowledged that no sprinkler heads were sent for testing as described in sections 5.3.1.1.1 and 5.3.1.2.

As a result, the facility currently has sprinkler heads which are over 50-years in age and have not been subjected to any type of testing per section 5.3.1.1.1.

This was acknowledged by the Administrator and Director of Maintenance during the exit interview process.

Based on observations and confirmed by staff the facility failed to ensure compliance with Chapter 19.

Section 19.3.6.3.1 states doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be doors constructed to resist the passage of smoke and shall be constructed of materials such as the following:
(1) 13/4 in. (44 mm) thick, solid-bonded core wood
(2) Material that resists fire for a minimum of 20 minutes

Section 19.3.6.3.2 states that the requirements of 19.3.6.3.1 shall not apply where otherwise permitted by either of the following:
(1) Doors to toilet rooms, bathrooms, shower rooms, sink closets, and similar auxiliary spaces that do not contain
flammable or combustible materials shall not be required to comply with 19.3.6.3.1.
(2) In smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.7, the door construction materials requirements of 19.3.6.3.1 shall not be mandatory, but the doors shall be constructed to resist the passage of smoke.

Findings Include:

On 6/13/17 the following was noted:

1. The corridor doors to patient rooms: #215 A, #215, #214, #212, #211, and #210 all had two (2) 1/2 inch diameter holes through the door where the door stop device was removed from the door.

2. The corridor door to patient room # 133 and #116 were not smoke tight as a gap between the door and the door header (frame) existed while the door was in the latched position.

3. The corridor door to the office, #106 has a 3/8" unsealed gap at the meeting edge of the upper and lower leaf.

As a result of the finding the facility is found to be non-compliant with section 19.3.6.3.2(2) and section 19.3.6.3.5.

This was reviewed with and acknowledged by the facility's Director of Facilities Management and reviewed with the Chief Executive Officer and Director of Facilities Management during the exit conference.

Based on document review , the facility failed to provide a detailed written fire plan in accordance with the requirements and failed to properly train staff.

Section 19.7.2.3.2 states all health care occupancy personnel shall be instructed in the use of the code phrase to ensure transmission of an alarm under any of the following conditions:
(1) When the individual who discovers a fire must immediately go to the aid of an endangered person
(2) During a malfunction of the building fire alarm system

Section 19.7.2.3.3 states personnel hearing the code announced shall first activate the building fire alarm using the nearest manual fire alarm box and then shall execute immediately their duties as outlined in the fire safety plan.

FINDINGS INCLUDE:

On 6/12/17 and 6/13/17, review of the facility's fire plan revealed the following:

1. The fire emergency preparedness plan does not direct staff to call out a code phrase before going to the aid of an endangered person.

2. The fire safety plan does not include information regarding procedures to follow in the event that the fire alarm system is not functioning.

As a result of the findings the facility is found to be non-compliant with NFPA 101, Section 19.7.2.3.2

This was reviewed with and acknowledged by the facility's Director of Facilities Management and reviewed with the Chief Executive Officer and Director of Facilities Management during the exit conference.

Based on document review , the facility failed to provide a detailed written fire plan in accordance with the requirements and failed to properly train staff. Section 19.7.2.3.2 states all health care occupancy personnel shall be instructed in the use of the code phrase to ensure transmission of an alarm under any of the following conditions:
(1) When the individual who discovers a fire must immediately go to the aid of an endangered person
(2) During a malfunction of the building fire alarm system

Section 19.7.2.3.3 states personnel hearing the code announced shall first activate the building fire alarm using the nearest manual fire alarm box and then shall execute immediately their duties as outlined in the fire safety plan.

FINDINGS INCLUDE:

On 6/12/17 and 6/13/17, review of the facility's fire plan revealed the following:

1. The fire emergency preparedness plan does not direct staff to call out a code phrase before going to the aid of an endangered person.

2. The fire safety plan does not include information regarding procedures to follow in the event that the fire alarm system is not functioning.

As a result of the findings the facility is found to be non-compliant with NFPA 101, Section 19.7.2.3.2

This was reviewed with and acknowledged by the facility's Director of Facilities Management and reviewed with the Chief Executive Officer and Director of Facilities Management during the exit conference.

Based on observations and confirmed by staff, the facility failed to ensure that fire drills are conducted quarterly on each shift utilizing various times and conditions.

Section 19.7.1.6 states that fire drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions.

Section 19.7.1.7 allows for when drills are conducted between 9:00 p.m. and 6:00 a.m. (2100 hours and 0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.

FINDINGS INCLUDE:

On 6/13/17 while performing the record review process, it was observed that the fire drills were not conducted as required. The fire drills for the first shift (7:00 A.M. - 3:00 P.M.) , the second shift (3:00 P.M. - 11:00 P.M.) and the third shift (11:00 P.M. - 7:00 A.M.) were documented as occurring at the following times:

- On 2/24/17 at 11:30 A.M. (documentation indicated failed to pull station),
- On 12/5/16, at 2:30 P.M. (sprinkler activation),
- On 8/4/16, at 11:00 A.M.,
- On 6/24/16, at 8:30 A.M.,
- On 3/10/16, at 11:46 A.M.,

- On 3/24/17, at 5:40 P.M.,
-On 12/27/16, at 7:15 P.M.,
- On 9/28/16, at 6:25 P.M.,
- On 6/30/16, at 3:50 P.M.,
- On 3/24/16, at 4:45 P.M. (documented as failed to dial 3456),

- On 3/31/17, at 4:40 A.M.,
- On 12/31/16, at 6:15 A.M.,
- On 9/30/16, at 2:58 A.M.,
- On 6/29/16, at 5:30 A.M., and
-On 3/16/16, at 1:05 A.M.

Thirteen of fifteen fire drills noted above failed to document how the drill was initiated the fire drills were documented as neither utilizing the audible alarm nor a coded announcement. There is no documentation to substantiate how each of the 13 drills were initiated.

As a result, the facility failed to comply with section 19.7.1.6 and 19.7.1.7

This was reviewed with and acknowledged by the facility's Director of Facilities Management and reviewed with the Chief Executive Officer and Director of Facilities Management during exit conference.

Based on observations and confirmed by staff, the facility failed to ensure that fire drills are conducted quarterly on each shift utilizing various times and conditions.

Section 19.7.1.6 states that fire drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions.

Section 19.7.1.7 allows for when drills are conducted between 9:00 p.m. and 6:00 a.m. (2100 hours and 0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.

FINDINGS INCLUDE:

On 6/13/17 while performing the record review process, it was observed that the fire drills were not conducted as required. The fire drills for the first shift (7:00 A.M. - 3:00 P.M.) , the second shift (3:00 P.M. - 11:00 P.M.) and the third shift (11:00 P.M. - 7:00 A.M.) were documented as occurring at the following times:

- On 2/24/17 at 11:30 A.M. (documentation indicated failed to pull station),
- On 12/5/16, at 2:30 P.M. (sprinkler activation),
- On 8/4/16, at 11:00 A.M.,
- On 6/24/16, at 8:30 A.M.,
- On 3/10/16, at 11:46 A.M.,

- On 3/24/17, at 5:40 P.M.,
-On 12/27/16, at 7:15 P.M.,
- On 9/28/16, at 6:25 P.M.,
- On 6/30/16, at 3:50 P.M.,
- On 3/24/16, at 4:45 P.M. (documented as failed to dial 3456),

- On 3/31/17, at 4:40 A.M.,
- On 12/31/16, at 6:15 A.M.,
- On 9/30/16, at 2:58 A.M.,
- On 6/29/16, at 5:30 A.M., and
-On 3/16/16, at 1:05 A.M.

Thirteen of fifteen fire drills noted above failed to document how the drill was initiated the fire drills were documented as neither utilizing the audible alarm nor a coded announcement. There is no documentation to substantiate how each of the 13 drills were initiated.

As a result, the facility failed to comply with section 19.7.1.6 and 19.7.1.7

This was reviewed with and acknowledged by the facility's Director of Facilities Management and reviewed with the Chief Executive Officer and Director of Facilities Management during the exit conference.