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NFPA 101 (2000) LIFE SAFETY CODE SURVEY STANDARD - One hour fire rated construction (with 3/4 hour fire-rated doors) or an approved automatic fire extinguishing system in accordance with NFPA 101 (00), Chapter 8, Section 8.4.1 and Chapter 19, Section 19.3.5.4 protects hazardous areas. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors. Doors shall be self-closing and non-rated or field-applied protective plates that do not exceed 48 inches from the bottom of the door are permitted, in accordance with NFPA 101 (00), Chapter 19, Section 19.3.2.1.

This STANDARD is not met as evidenced by:

Based on observation, the facility failed to maintain hazardous area doors in accordance with NFPA 101 (00), Chapter 19, Section 19.3.2.1 and 19.3.6.3.2, and Chapter 8, Section 8.2.3.2.3.2. In a fire emergency, this deficient practice could adversely affect 25 of 25 patients, staff and visitors.

FINDINGS INCLUDE:

On 7/15/10 between 10:00 AM and 3:00 PM, observation revealed the corridor door to the Soiled Utility Room on the East Corridor did not positively latch into the frame when closed. The door was not equipped with a latching mechanism.

This finding was confirmed with the assistant building engineer (VM) at the time of discovery.

Based upon a review of available reports and records, it was determined the facility had failed to conduct one or more fire drills, on a quarterly basis for each shift, in accordance with NFPA 101 (2000) Life Safety Code, Chapter 19, Section 19.7.1.2.. In a fire emergency, this deficient practice could adversely affect the safety of 25 of 25 patients, staff and visitors throughout the facility.

FINDINGS INCLUDE:

On 7/15/10 between 10:00 AM and 3:00 PM, during a review of fire drill reports provided by the chief building engineer [GK], it was verified that the facility failed to conduct quarterly fie drills on each shift during the previous year. Specifically, no fire drills were conducted on the Overnight Shift during the previous year, and, only one fire drill was conducted on the PM-Shift during the previous year. This deficient practice was not in conformance with NFPA 101 (00), Chapter 19, Section 19.7.1.2.

NFPA 101 (2000) LIFE SAFETY CODE STANDARD - A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with NFPA 70 National Electrical Code (1999 edition) and NFPA 72 National Fire Alarm Code (1999 edition). The system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70 (99) and NFPA 72 (99) and NFPA 101 Life Safety Code (2000 edition), Chapter 9, Section 9.6.1.4.

FINDINGS INCLUDE:

On 7/15/10 between 10:00 AM and 3:00 PM, during an interview with the chief building engineer [GK], no documentation could be provided verifying the Digital Alarm Communicator Transmitter (DACT) was tested during the previous year in pursuant to NFPA 72 (1999) Table 7-3.2, nor monthly during the previous year in accordance with CMS requirements.

In a fire emergency, this deficient practice could adversely affect the safety of 25 of 25 patients, staff and visitors.

Based on interview and review of available documentation, the facility has not been conducting sensitivity testing of the smoke detectors on the fire alarm system, pursuant to NFPA 72 National Fire Alarm Code (1999 edition) and NFPA 101 Life Safety Code (2000 edition), Chapter 9, Section 9.6.1.3. In a fire emergency, this deficient practice could adversely affect 25 of 25 patients, staff and visitors.

FINDINGS INCLUDE:

On 7/15/10 between 10:00 AM and 3:00 PM, in a review of available documentation provided by the chief building engineer (GK), it was discovered that the required sensitivity testing of each smoke detector had not been performed within the past two years, as required by NFPA 72 (99), Chapter 7, Section 7-3.2.1.

NFPA 101 (2000) LIFE SAFETY CODE SURVEY STANDARD - Anesthetizing locations shall be protected in accordance with NFPA 99 (1999 edition) Standard for Health Care Facilities, pursuant to NFPA 101 (2000) Chapter 19, Section 19.3.2.3.

FINDINGS INCLUDE:

On 7/15/10 between 10:00 AM and 3:00 PM while inspecting the sole Operating Room [a wet location where general anesthesia is administered], a line isolation monitor could not be located. Further, GFCI circuitry could not be visually confirmed. In a discussion with the assistant building engineer [VM], it could not be verified that a circuit interruption could be tolerated [See NFPA 70 (99) article 517-20(a)]. If an interruption can be tolerated, GFCI protection may be permitted. If an interruption cannot be tolerated, an isolated power system is required [See NFPA 70 (99), article 517-20(a)]. Based upon observation, it could not be determined whether the electrical system within the Operating Room would properly protect patients and staff from an electrical shock, or that this existing arrangement complies with the requirements at NFPA 99 (1999) Chapter 3, Section 3-3.

NFPA 101 (2000) LIFE SAFETY CODE SURVEY STANDARD - Generators must be inspected weekly and exercised under load for 30 minutes per month and shall be in accordance with NFPA 99 (1999 edition) and NFPA 110 (1999 edition).

NFPA 110 (1999 edition) Chapter 3, Section 3-5.5.6 requires the following: All Level 1 and Level 2 installations shall have a remote manual stop station of a type similar to a break-glass station located outside the room housing the prime mover, where so installed, or located elsewhere on the premises where the prime mover is located outside the building.

NFPA 110 (1999 edition) Chapter 3, Section 3-5.6.1 requires the following: A remote, common audible alarm powered by the storage battery shall be provided as specified in 3-5.5.2(d). This remote alarm shall be located outside of the EPS service room at a work site readily observable by personnel.

FINDINGS INCLUDE:

On 7/15/10 between 10:00 AM and 3:00 PM, during a review of available records provided by the chief building engineer [GK], no documentation could be provided verifying the emergency generator was exercised monthly for at least 30 minutes at not less than 30% of the EPS nameplate rating, during the previous year, in accordance with NFPA 110 (1999), Chapter 6, Section 6-4.2 and NFPA 99 (1999), Chapter 3, Section 3-4.4.1.1.

In a fire or other emergency, this deficient practice could adversely affect the safety of 25 of 25 patients, staff and visitors.

NFPA 101 (2000) LIFE SAFETY CODE SURVEY STANDARD - One hour fire rated construction (with 3/4 hour fire-rated doors) or an approved automatic fire extinguishing system in accordance with NFPA 101 (00), Chapter 8, Section 8.4.1 and Chapter 19, Section 19.3.5.4 protects hazardous areas. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors. Doors shall be self-closing and non-rated or field-applied protective plates that do not exceed 48 inches from the bottom of the door are permitted, in accordance with NFPA 101 (00), Chapter 19, Section 19.3.2.1.

This STANDARD is not met as evidenced by:

Based on observation, the facility failed to maintain hazardous area doors in accordance with NFPA 101 (00), Chapter 19, Section 19.3.2.1 and 19.3.6.3.2, and Chapter 8, Section 8.2.3.2.3.2. In a fire emergency, this deficient practice could adversely affect 25 of 25 patients, staff and visitors.

FINDINGS INCLUDE:

On 7/15/10 between 10:00 AM and 3:00 PM, observation revealed the corridor door to the Soiled Utility Room on the East Corridor did not positively latch into the frame when closed. The door was not equipped with a latching mechanism.

This finding was confirmed with the assistant building engineer (VM) at the time of discovery.

Based upon a review of available reports and records, it was determined the facility had failed to conduct one or more fire drills, on a quarterly basis for each shift, in accordance with NFPA 101 (2000) Life Safety Code, Chapter 19, Section 19.7.1.2.. In a fire emergency, this deficient practice could adversely affect the safety of 25 of 25 patients, staff and visitors throughout the facility.

FINDINGS INCLUDE:

On 7/15/10 between 10:00 AM and 3:00 PM, during a review of fire drill reports provided by the chief building engineer [GK], it was verified that the facility failed to conduct quarterly fie drills on each shift during the previous year. Specifically, no fire drills were conducted on the Overnight Shift during the previous year, and, only one fire drill was conducted on the PM-Shift during the previous year. This deficient practice was not in conformance with NFPA 101 (00), Chapter 19, Section 19.7.1.2.

NFPA 101 (2000) LIFE SAFETY CODE STANDARD - A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with NFPA 70 National Electrical Code (1999 edition) and NFPA 72 National Fire Alarm Code (1999 edition). The system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70 (99) and NFPA 72 (99) and NFPA 101 Life Safety Code (2000 edition), Chapter 9, Section 9.6.1.4.

FINDINGS INCLUDE:

On 7/15/10 between 10:00 AM and 3:00 PM, during an interview with the chief building engineer [GK], no documentation could be provided verifying the Digital Alarm Communicator Transmitter (DACT) was tested during the previous year in pursuant to NFPA 72 (1999) Table 7-3.2, nor monthly during the previous year in accordance with CMS requirements.

In a fire emergency, this deficient practice could adversely affect the safety of 25 of 25 patients, staff and visitors.

Based on interview and review of available documentation, the facility has not been conducting sensitivity testing of the smoke detectors on the fire alarm system, pursuant to NFPA 72 National Fire Alarm Code (1999 edition) and NFPA 101 Life Safety Code (2000 edition), Chapter 9, Section 9.6.1.3. In a fire emergency, this deficient practice could adversely affect 25 of 25 patients, staff and visitors.

FINDINGS INCLUDE:

On 7/15/10 between 10:00 AM and 3:00 PM, in a review of available documentation provided by the chief building engineer (GK), it was discovered that the required sensitivity testing of each smoke detector had not been performed within the past two years, as required by NFPA 72 (99), Chapter 7, Section 7-3.2.1.

NFPA 101 (2000) LIFE SAFETY CODE SURVEY STANDARD - Anesthetizing locations shall be protected in accordance with NFPA 99 (1999 edition) Standard for Health Care Facilities, pursuant to NFPA 101 (2000) Chapter 19, Section 19.3.2.3.

FINDINGS INCLUDE:

On 7/15/10 between 10:00 AM and 3:00 PM while inspecting the sole Operating Room [a wet location where general anesthesia is administered], a line isolation monitor could not be located. Further, GFCI circuitry could not be visually confirmed. In a discussion with the assistant building engineer [VM], it could not be verified that a circuit interruption could be tolerated [See NFPA 70 (99) article 517-20(a)]. If an interruption can be tolerated, GFCI protection may be permitted. If an interruption cannot be tolerated, an isolated power system is required [See NFPA 70 (99), article 517-20(a)]. Based upon observation, it could not be determined whether the electrical system within the Operating Room would properly protect patients and staff from an electrical shock, or that this existing arrangement complies with the requirements at NFPA 99 (1999) Chapter 3, Section 3-3.

NFPA 101 (2000) LIFE SAFETY CODE SURVEY STANDARD - Generators must be inspected weekly and exercised under load for 30 minutes per month and shall be in accordance with NFPA 99 (1999 edition) and NFPA 110 (1999 edition).

NFPA 110 (1999 edition) Chapter 3, Section 3-5.5.6 requires the following: All Level 1 and Level 2 installations shall have a remote manual stop station of a type similar to a break-glass station located outside the room housing the prime mover, where so installed, or located elsewhere on the premises where the prime mover is located outside the building.

NFPA 110 (1999 edition) Chapter 3, Section 3-5.6.1 requires the following: A remote, common audible alarm powered by the storage battery shall be provided as specified in 3-5.5.2(d). This remote alarm shall be located outside of the EPS service room at a work site readily observable by personnel.

FINDINGS INCLUDE:

On 7/15/10 between 10:00 AM and 3:00 PM, during a review of available records provided by the chief building engineer [GK], no documentation could be provided verifying the emergency generator was exercised monthly for at least 30 minutes at not less than 30% of the EPS nameplate rating, during the previous year, in accordance with NFPA 110 (1999), Chapter 6, Section 6-4.2 and NFPA 99 (1999), Chapter 3, Section 3-4.4.1.1.

In a fire or other emergency, this deficient practice could adversely affect the safety of 25 of 25 patients, staff and visitors.