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Based on the E.P.P. (Emergency Preparedness Plan) review and interview the facility failed to ensure that a community based risk assessment was included in the planning process of the E.P.P.

Findings include:

Review of the E.P.P. during tour on 01/30/19 between 1:30 p.m. and 3:00 p.m. with Staff A (Director of Facilities) revealed that the plan was developed with a facility based risk assessment only and failed to take into account the larger community based risk assessment in the development process of the E.P.P.

Interview with Staff A confirmed the findings and available documentation.

NFPA 101 (2012 edition) LIFE SAFETY CODE
19.2.2.2.1 Doors complying with 7.2.1 shall be permitted

7.2.1.15 Inspection of Door Openings
7.2.1.15.1 Where required by Chapters 11 through 43, the following door assemblies shall be inspected and tested not less than annually in accordance with 7.2.1.15.2 through 7.2.1.15.8:
(1) Door leaves equipped with panic hardware or fire exit hardware in accordance with 7.2.1.7.
(2) Door assemblies in exit enclosures.
(3) Electrically controlled egress doors.
(4) Door assemblies with special locking arrangements subject to 7.2.1.6.

7.2.1.15.2 Fire-rated door assemblies shall be inspected and tested in accordance with NFPA 80 STANDARD for FIRE DOORS and other OPENING PROTECTIVE'S.

NFPA 80 STANDARD for FIRE DOORS and other OPENING PROTECTIVE'S
5.1.3 Operability
5.1.3.1 Doors, shutters and windows shall be operable at all times.
5.1.3.2 Doors, shutters, and windows shall be kept closed and latched or arranged for automatic closing and latching.
5.2 Inspections
5.2.1 Fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for inspection by the AHJ.


Based on observations and interview the facility failed to ensure that 4 (45 minute fire rated door assemblies) sets of double doors would automatically close to a latched position.

Findings include:

Observations during tour on 01/31/19 between 9:00 a.m. and 10:45 a.m. with Staff A (Director of Facilities) revealed that 4 fire rated door assemblies failed to fully close to a latched and secured position when released from the magnetic hold open device's.
The 4 fire door assemblies and locations are as follows:
1. Door assembly # 004 B, located in the basement level utility corridor, between the Kitchen and the main hospital supply room, failed to close to a latched position when released from the magnetic hold open device.
2. Door assembly # GO-0278, located on the lower level, between the MOB (Medical Office Building) and the main Hospital, failed to close to a latched position when released from the magnetic hold open device.
3. Door assembly # 2100, located on the upper level, between the MOB and the main Hospital, failed to close to a latched position when released from the magnetic hold open device.
4. The fire door assembly located on the 2nd floor, between the Sleep Lab wing and the Elevator lobby, failed to close to a latched position when released from the magnetic hold open device.

Interview with Staff A on 1/31/2019 confirmed the above findings and fire door locations.

Based on observations and interviews the facility failed to maintain the continuity of at least 7 smoke/fire barrier walls to resist the passage of smoke or the effects from fire.

Findings include:

Observations during tour on 01/31/19 between 9:40 a.m. and 1:30 p.m. with Staff A (Director of Facilities) revealed at least 6 locations where unprotected penetrations pass through the 1 hour rated smoke/fire barrier walls.
These locations and conditions are as follows:
1. The Main Electrical room, located in the basement, has 3 electrical conduit pipes penetrating through the 1 hour smoke/fire barrier wall. approximately 1-4" and 2-3" unused metal conduit tubes that are open through the wall, and ready for future use.
2. Above the suspended ceiling, over the (facility identified) barrier door # IN 004 has 2 unsealed electrical conduits, approximately 1-1/2" metal conduit tubes that are open through the barrier wall, and ready for future use.
3. Above the suspended ceiling, over the (facility identified) barrier door # SDR 001 B has 2 unsealed electrical conduits, approximately 1-1/2" metal conduit tubes that are open through the barrier wall and ready for future use.
4. Above the suspended ceiling, over the (facility identified) barrier door # CIA 4A has 1 unsealed electrical conduit, approximately a 2" metal conduit tube that is open through the barrier wall and ready for future use.
5. Above the suspended ceiling, over the (facility identified) barrier door # C 101 has 1 unsealed electrical conduit, approximately a 1" metal conduit tube that is open through the barrier wall and ready for future use.
6. Above the suspended ceiling, over the (facility identified) barrier door # SDRG 003 B has a 1" unsealed penetration through the barrier wall.
7. Above the suspended ceiling, over the (facility identified) barrier door # SDRG 001 B has a 1" unsealed penetration through the barrier wall.

Interview with Staff A and Staff B (Facilities Staff) confirmed the above findings and locations.