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Based on observation of the physical environment, it was determined that the facility staff failed to provide a safe and hazard free environment by not sealing holes and gaps in the ceilings of corridors or exit ways.

The findings include:

During the initial survey on November 13, 2012 with the Safety Manager, it was observed between 9:00 am and 2:00 pm that there was a 4" x 4" hole in the ceiling above the sprinkler riser piping in Stairwell B, ground floor level.

This penetration could have the possibility of affecting 20 % of occupants of the facility and could allow smoke to travel above the ceiling or from one section to another in the event of an emergency and could delay egress through this stairwell.

Based on observation of the physical environment, it was determined that the facility staff failed to provide a safe and hazard free environment by not sealing holes and gaps in the ceilings.

The findings include:

During the initial survey on November 14, 2012 with the Safety Manager, it was observed between 9:00 am and 2:00 pm that the main fire alarm control panel room had one missing ceiling tile (small) and several gaps and holes around pipes and conduits that penetrated the ceiling tiles.

These penetrations could have the possibility of affecting 25 % of occupants of the facility and could allow smoke to travel above the ceiling or from one section to another in the event of an emergency.

Based on observation of the physical environment, it was determined that the facility staff failed to provide a safe and hazard free environment by not having all doors protecting corridor openings closing tightly in their frames or ready to close without impediments

The findings include:

During the initial survey on November 13 and 14, 2012 with the Safety Manager, it was observed between 9:00 am and 2:00 pm on both days that:

1.) the door to patient room #273 had a large gap between the face of the door and the frame (larger than 1");

2.) the door to patient room # 3139 was held open with a trash can - when the can was removed the door drifted shut.

Item #1 could allow smoke to pass between the corridor and the room and could effect the patients of the listed room and up to 20% of the patients in the corridor. Item #2 could delay the closing of the door by staff in the event of an emergency.

Based on review of facility documents and interview with facility staff it was determined that the facility staff failed to provide a safe and hazard free environment by not fulfilling all fire alarm system testing and maintenance requirements of NFPA 72 and NFPA 101.
The findings include:
During the initial survey on November 13 & 14, 2012 it was determined through observation of the physical environment, review of the facility's documents, and confirmed through interview with the Director of Facilities and the Manager of Facilities, that the building fire alarm system was not documented as having been maintained as required by NFPA 72.
Specifically, there are duct detectors in both the Tower (approximately 6) and Main Building (approximately 50) that have not been tested as required. In addition, on November 13, 14, and 19, 2012 the main fire alarm annunciators at the lobby indicated an ongoing " TROUBLE " condition which was not corrected.
The fire alarm system was last documented as being tested in July through September of 2012 by ARK Services.
Failure to properly maintain all components of the building fire alarm system has the potential to promote harm to occupants of the facility in the event of a fire. This has the possibility of affecting 100 % of the occupants of the facility
Notes- The Tower and Main building fire alarm systems are not interconnected. Both systems are monitored off site as well as at the Security Office on site. All indicating devices should be listed and addressed individually on the inspection reports.

Based on observation of the physical environment, review of the facility's records, and interviews with facility staff, it was determined that the facility staff failed to provide a safe and hazard free environment by not maintaining the water based fire suppression systems as required.

The findings include:

During the initial survey on November 13 and 14, 2012, it was observed between 9:00 am and 2:00 pm on both days, and a follow-up visit on November 19, that:

1.) it was determined through a review of the facility's records, observation of the physical environment, and confirmed through interview with the Director of Facilities and the Manager of Facilities that the standpipe system in the facility was not documented as having been inspected, serviced, tested and maintained in accordance with NFPA 25 as required. No reference to regular inspection, testing, service, and maintenance of the standpipe system as required was located. A five year full flow test report (dated 8/1/2012) was reviewed. Several maintenance items were identified from this test in the " MAIN " building that have not been addressed as of this date. Ongoing inspection, testing, and service of the standpipe system shall be included in the facility's future maintenance plan and contracts.

2) it was determined through a review of the facility's records, observation of the physical environment, and confirmed through interview with the Director of Facilities and the Manager of Facilities that the private hydrants and underground water mains at the facility are not documented as having been inspected, serviced, tested and maintained in accordance with NFPA 25 as required. No additional reference to full system inspection was made other than a flush and inspection performed on 7/23/2012 by ARK Services.

3.) sprinkler heads in two locations appeared to have plastic caught on the arm and deflector of at least one sprinkler head - soiled linen room #6204 and soiled linen room #0209 in the emergency department - it appeared that this plastic was from soiled linen bags that were thrown into the rooms and came into contact with the sprinkler heads;

2.) tamper/flow switch covers were not secured with their tamper resistant screws in multiple location including, but not limited to: Stairwell B, Floor 2; Stairwell F, Floor 2 South - Devices - M2-61, M2-63, M2-58; and the ED CT scan sprinkler closet;

3.) the spare sprinkler head box in the Tower Building sprinkler riser room was not mounted on the wall in an easy to access location, and it was missing a sprinkler wrench.

4.) one sprinkler head in the Xerox room was missing its escutcheon ring; the main kitchen dishwashing room had one sprinkler head missing its escutcheon ring, and multiple heads appeared to have moderate to severe corrosion (greenish discoloration of the metal); one sprinkler head in the main walk-in refrigerator was loaded (buildup of lint and dirt); two sprinkler heads in the entry foyer to the shop area were too recessed into the ceiling to properly distribute water and they were missing their escutcheon rings; other sprinkler heads in the facility that were located close to ventilation discharges appeared to have lint and dirt loading.

The system shall be maintained in a fully compliant manner and condition. The failure to maintain the entire water based fire suppression systems as well as the private hydrants and underground water main systems as required could lead to improper operation of the systems in the event of an emergency thereby promoting harm to occupants of the facility.

Reference - NFPA 25, Standard for Inspection, Testing, and Maintenance of Water Based Fire Protection Systems, 1998 edition.

Based on observation of the physical environment, it was determined that the facility staff failed to provide a safe and hazard free environment by failing to address the following miscellaneous safety issues.

Each of the following NFPA Standards, NFPA 13, NFPA 14, NFPA 20, NFPA 72, and NFPA 110, requires Acceptance Testing as a required portion of initial installation, start-up, and use of the system(s) prior to occupying the structure.

Based on review of the facility's records and interview with facility staff it was determined that the facility staff failed to provide a safe and hazard free environment by not performing or obtaining and maintaining records of the Acceptance Test for the listed systems as required.

The findings include:

(1) Systems Acceptance Tests- New Tower: As part of the on-site LSC survey process on November 13, 14, and 19, 2012 this inspector requested from the Director of Facilities and the Manager of Facilities to review the acceptance test reports for all NFPA 13 (automatic sprinkler), NFPA 14 (standpipe), NFPA 20 (stationary fire pump), NFPA 72 (fire alarm), and NFPA 110 (emergency electrical) systems.

The following reports were produced for review:

NFPA 13- Baltimore County Fire Department Investigative Services Fire Inspection Reports showing that hydrostatic tests were completed and OK to occupy various portions of the building between 11/2009 and 2/2010;
NFPA 14- 5 year flow test only performed on 8/1/2012;
NFPA 20-Factory bench test record dated 5/13/2010 by Hydro-Tec;
NFPA 72- No reports specifically related to fire alarm system acceptance test produced for review;
NFPA 110- Functional Performance Test Checklist dated 6/7 & 6/23/2010.

None of the reports produced as listed above satisfies the full requirements of the respective NFPA Standards for Acceptance Testing. Each of these systems has been maintained during the most recent intervals required by NFPA standards except as may be noted within the attached Statement of Deficiencies.

The failure to obtain complete acceptance testing of the facility's life safety systems as required and maintain records of such tests could lead to improper operation of the systems in the event of an emergency thereby promoting harm to occupants of the facility.

Based on observation of the physical environment, it was determined that the facility staff failed to provide a safe and hazard free environment by not maintaining proper signs at oxygen storage locations.

The findings include:

During the initial survey on November 13 and 14, 2012 with the Safety Manager, it was observed between 9:00 am and 2:00 pm on both days that numerous areas in the facility with oxygen storage had no signs indicating "Caution - Oxygen Stored Within - No Smoking." Oxygen storage signs must be conspicuously displayed on each door of a storage room and must be readable from a distance of 5 feet. Note - since this is a non-smoking campus and is clearly marked as such at all entrances, the "No Smoking" portion of the sign can be deleted.

This could result in staff, visitors, or firefighters not knowing where oxygen was in use and/or stored and could impact up to 20% of the patients in the event of an emergency or fire.

Based on observation of the physical environment, it was determined that the facility staff failed to provide a safe and hazard free environment by having locations where there were non-compliant electrical applications.

The findings include:

During the initial survey on November 13 and 14, 2012 with the Safety Manager, it was observed between 9:00 am and 2:00 pm on both days that:

1.) one electrical junction box located in the old boiler room had no protective cover plate;

2.) one wall-mounted electrical junction box in the rooftop HVAC room had no protective cover plate.

These cause overheating or electrical short circuits resulting in fire or could increase the potential for electrical shock to employees.

Based on observation of the physical environment, it was determined that the facility staff failed to provide a safe and hazard free environment by not sealing holes and gaps in the ceilings of corridors or exit ways.

The findings include:

During the initial survey on November 13, 2012 with the Safety Manager, it was observed between 9:00 am and 2:00 pm that there was a 4" x 4" hole in the ceiling above the sprinkler riser piping in Stairwell B, ground floor level.

This penetration could have the possibility of affecting 20 % of occupants of the facility and could allow smoke to travel above the ceiling or from one section to another in the event of an emergency and could delay egress through this stairwell.

Based on observation of the physical environment, it was determined that the facility staff failed to provide a safe and hazard free environment by not sealing holes and gaps in the ceilings.

The findings include:

During the initial survey on November 14, 2012 with the Safety Manager, it was observed between 9:00 am and 2:00 pm that the main fire alarm control panel room had one missing ceiling tile (small) and several gaps and holes around pipes and conduits that penetrated the ceiling tiles.

These penetrations could have the possibility of affecting 25 % of occupants of the facility and could allow smoke to travel above the ceiling or from one section to another in the event of an emergency.

Based on observation of the physical environment, it was determined that the facility staff failed to provide a safe and hazard free environment by not having all doors protecting corridor openings closing tightly in their frames or ready to close without impediments

The findings include:

During the initial survey on November 13 and 14, 2012 with the Safety Manager, it was observed between 9:00 am and 2:00 pm on both days that:

1.) the door to patient room #273 had a large gap between the face of the door and the frame (larger than 1");

2.) the door to patient room # 3139 was held open with a trash can - when the can was removed the door drifted shut.

Item #1 could allow smoke to pass between the corridor and the room and could effect the patients of the listed room and up to 20% of the patients in the corridor. Item #2 could delay the closing of the door by staff in the event of an emergency.

Based on review of facility documents and interview with facility staff it was determined that the facility staff failed to provide a safe and hazard free environment by not fulfilling all fire alarm system testing and maintenance requirements of NFPA 72 and NFPA 101.
The findings include:
During the initial survey on November 13 & 14, 2012 it was determined through observation of the physical environment, review of the facility's documents, and confirmed through interview with the Director of Facilities and the Manager of Facilities, that the building fire alarm system was not documented as having been maintained as required by NFPA 72.
Specifically, there are duct detectors in both the Tower (approximately 6) and Main Building (approximately 50) that have not been tested as required. In addition, on November 13, 14, and 19, 2012 the main fire alarm annunciators at the lobby indicated an ongoing " TROUBLE " condition which was not corrected.
The fire alarm system was last documented as being tested in July through September of 2012 by ARK Services.
Failure to properly maintain all components of the building fire alarm system has the potential to promote harm to occupants of the facility in the event of a fire. This has the possibility of affecting 100 % of the occupants of the facility
Notes- The Tower and Main building fire alarm systems are not interconnected. Both systems are monitored off site as well as at the Security Office on site. All indicating devices should be listed and addressed individually on the inspection reports.

Based on observation of the physical environment, review of the facility's records, and interviews with facility staff, it was determined that the facility staff failed to provide a safe and hazard free environment by not maintaining the water based fire suppression systems as required.

The findings include:

During the initial survey on November 13 and 14, 2012, it was observed between 9:00 am and 2:00 pm on both days, and a follow-up visit on November 19, that:

1.) it was determined through a review of the facility's records, observation of the physical environment, and confirmed through interview with the Director of Facilities and the Manager of Facilities that the standpipe system in the facility was not documented as having been inspected, serviced, tested and maintained in accordance with NFPA 25 as required. No reference to regular inspection, testing, service, and maintenance of the standpipe system as required was located. A five year full flow test report (dated 8/1/2012) was reviewed. Several maintenance items were identified from this test in the " MAIN " building that have not been addressed as of this date. Ongoing inspection, testing, and service of the standpipe system shall be included in the facility's future maintenance plan and contracts.

2) it was determined through a review of the facility's records, observation of the physical environment, and confirmed through interview with the Director of Facilities and the Manager of Facilities that the private hydrants and underground water mains at the facility are not documented as having been inspected, serviced, tested and maintained in accordance with NFPA 25 as required. No additional reference to full system inspection was made other than a flush and inspection performed on 7/23/2012 by ARK Services.

3.) sprinkler heads in two locations appeared to have plastic caught on the arm and deflector of at least one sprinkler head - soiled linen room #6204 and soiled linen room #0209 in the emergency department - it appeared that this plastic was from soiled linen bags that were thrown into the rooms and came into contact with the sprinkler heads;

2.) tamper/flow switch covers were not secured with their tamper resistant screws in multiple location including, but not limited to: Stairwell B, Floor 2; Stairwell F, Floor 2 South - Devices - M2-61, M2-63, M2-58; and the ED CT scan sprinkler closet;

3.) the spare sprinkler head box in the Tower Building sprinkler riser room was not mounted on the wall in an easy to access location, and it was missing a sprinkler wrench.

4.) one sprinkler head in the Xerox room was missing its escutcheon ring; the main kitchen dishwashing room had one sprinkler head missing its escutcheon ring, and multiple heads appeared to have moderate to severe corrosion (greenish discoloration of the metal); one sprinkler head in the main walk-in refrigerator was loaded (buildup of lint and dirt); two sprinkler heads in the entry foyer to the shop area were too recessed into the ceiling to properly distribute water and they were missing their escutcheon rings; other sprinkler heads in the facility that were located close to ventilation discharges appeared to have lint and dirt loading.

The system shall be maintained in a fully compliant manner and condition. The failure to maintain the entire water based fire suppression systems as well as the private hydrants and underground water main systems as required could lead to improper operation of the systems in the event of an emergency thereby promoting harm to occupants of the facility.

Reference - NFPA 25, Standard for Inspection, Testing, and Maintenance of Water Based Fire Protection Systems, 1998 edition.

Based on observation of the physical environment, it was determined that the facility staff failed to provide a safe and hazard free environment by failing to address the following miscellaneous safety issues.

Each of the following NFPA Standards, NFPA 13, NFPA 14, NFPA 20, NFPA 72, and NFPA 110, requires Acceptance Testing as a required portion of initial installation, start-up, and use of the system(s) prior to occupying the structure.

Based on review of the facility's records and interview with facility staff it was determined that the facility staff failed to provide a safe and hazard free environment by not performing or obtaining and maintaining records of the Acceptance Test for the listed systems as required.

The findings include:

(1) Systems Acceptance Tests- New Tower: As part of the on-site LSC survey process on November 13, 14, and 19, 2012 this inspector requested from the Director of Facilities and the Manager of Facilities to review the acceptance test reports for all NFPA 13 (automatic sprinkler), NFPA 14 (standpipe), NFPA 20 (stationary fire pump), NFPA 72 (fire alarm), and NFPA 110 (emergency electrical) systems.

The following reports were produced for review:

NFPA 13- Baltimore County Fire Department Investigative Services Fire Inspection Reports showing that hydrostatic tests were completed and OK to occupy various portions of the building between 11/2009 and 2/2010;
NFPA 14- 5 year flow test only performed on 8/1/2012;
NFPA 20-Factory bench test record dated 5/13/2010 by Hydro-Tec;
NFPA 72- No reports specifically related to fire alarm system acceptance test produced for review;
NFPA 110- Functional Performance Test Checklist dated 6/7 & 6/23/2010.

None of the reports produced as listed above satisfies the full requirements of the respective NFPA Standards for Acceptance Testing. Each of these systems has been maintained during the most recent intervals required by NFPA standards except as may be noted within the attached Statement of Deficiencies.

The failure to obtain complete acceptance testing of the facility's life safety systems as required and maintain records of such tests could lead to improper operation of the systems in the event of an emergency thereby promoting harm to occupants of the facility.

Based on observation of the physical environment, it was determined that the facility staff failed to provide a safe and hazard free environment by not maintaining proper signs at oxygen storage locations.

The findings include:

During the initial survey on November 13 and 14, 2012 with the Safety Manager, it was observed between 9:00 am and 2:00 pm on both days that numerous areas in the facility with oxygen storage had no signs indicating "Caution - Oxygen Stored Within - No Smoking." Oxygen storage signs must be conspicuously displayed on each door of a storage room and must be readable from a distance of 5 feet. Note - since this is a non-smoking campus and is clearly marked as such at all entrances, the "No Smoking" portion of the sign can be deleted.

This could result in staff, visitors, or firefighters not knowing where oxygen was in use and/or stored and could impact up to 20% of the patients in the event of an emergency or fire.

Based on observation of the physical environment, it was determined that the facility staff failed to provide a safe and hazard free environment by having locations where there were non-compliant electrical applications.

The findings include:

During the initial survey on November 13 and 14, 2012 with the Safety Manager, it was observed between 9:00 am and 2:00 pm on both days that:

1.) one electrical junction box located in the old boiler room had no protective cover plate;

2.) one wall-mounted electrical junction box in the rooftop HVAC room had no protective cover plate.

These cause overheating or electrical short circuits resulting in fire or could increase the potential for electrical shock to employees.