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Based on observation and interview, the facility failed to maintain corridor doors to resist the passage of smoke. This was evidenced by doors that failed to positive latch. This could result in the passage smoke and flames in the event of a fire, and affected one of two floors in the Main Building.


Findings:

During a tour of the facility with the Plant Operations Manager on 5/23/15, the corridor doors were observed.

1. At 10:23 a.m., the door to Room 158 was equipped with a self-closing device that failed to latch. The self-closing device was disconnected. When interviewed, the Plant Operations Manager confirmed the find and stated that they are currently working on replacing the self-closure device.

2. At 10:27 a.m., the door to the Kitchen was equipped with a self-closing device that failed to latch. The door remained open. The Plant Operations Manager stated that the self-closing device was not functioning.

Based on observation the facility failed to maintain the access/visibility to exits as evidenced by the failure to provide readily visible exit signs which indicate which way to exit. This affected all visitors in the OUTPATIENT CLINIC- CHEMICAL DEPENDENCY building and could lead to confusion in the event of an emergency evacuation.

Findings:

During a tour of the facility with the Plant Operations Manager and the Director of Accreditation on 5/24/16, access to exits was observed.

At 11:45 a.m., there was no readily visible exit sign observed at the courtyard after exiting Suite 2. The courtyard has a fenced gate that is locked at night since the building is only used during the day. Upon interview, the Plant Operations Manager stated that visitors may use either left or right exits, and confirmed there were no exit signs posted in the courtyard. Both the left and right exit ways lead to the parking lot.

Based on interview and document review, the facility failed to maintain the emergency battery backup lighting. This was evidenced by the lack of documentation for the testing of the emergency battery backup lighting unit. This could result in a failure to provide backup lighting in the event of evacuation and affected one of two floors in the OUTPATIENT SERVICE ADOLESCENT Building.


NFPA 101, Life Safety Code, 2000 Edition
7.9.3 Periodic Testing of Emergency Lighting Equipment. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 11/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests
shall be kept by the owner for inspection by the authority having jurisdiction.

Exception: Self-testing/self-diagnostic, battery-operated emergency lighting equipment that automatically performs a test for not less than 30 seconds and diagnostic routine not less than once every 30 days and indicates failures by a status indicator shall be exempt from the 30-day functional test, provided that a visual inspection is performed
at 30-day intervals.

7.10.9.2 Testing. Exit signs connected to or provided with a battery-operated emergency illumination source, where required in 7.10.4, shall be tested and maintained in accordance with 7.9.3.


Findings:

During interview and document review with the Stationary Engineer on 5/24/16, the emergency battery backup lighting system was observed.

At 1:39 p.m., there were no documents provided for the required monthly test of not less than 30 seconds, and an annual test of the emergency lighting system for not less than 1 1/2 hours for the battery powered emergency lighting system located above the main entrance door on the first floor. Upon interview, the Stationary Engineer stated that there is no testing documentation for the emergency lighting unit.

Based on observation, the facility failed to maintain the emergency exit signs. This was evidenced by two exit signs that were not illuminated. This could result in increased risk of patients, staff, and visitors inability to immediately find the exits in case of emergency. This affected one of two floors in the OUTPATIENT SERVICE ADOLESCENT Building.

NFPA 101, Life Safety Code, 2000 Edition
19.2.10 Marking of Means of Egress.
19.2.10.1 Means of egress shall have signs in accordance with Section 7.10.
Exception: Where the path of egress travel is obvious, signs shall not be required in one-story buildings with an occupant load of fewer than 30 persons.
7.8.1.2 Illumination of means of egress shall be continuous during the time that the conditions of occupancy require that the means of egress be available for use. Artificial lighting shall be employed at such locations and for such periods of time as required to maintain the illumination to the minimum criteria values herein specified.
Exception: Automatic, motion sensor-type lighting switches shall be permitted within the means of egress, provided that the switch controllers are equipped for fail-safe operation, the illumination timers are set for a minimum 15-minute duration, and the motion sensor is activated by any occupant movement in the area served by the lighting units.

7.8.1.3* The floors and other walking surfaces within an exit and within the portions of the exit access and exit discharge designated in 7.8.1.1 shall be illuminated to values of at least 1 ft-candle (10 lux) measured at the floor.
Exception No. 1: In assembly occupancies, the illumination of the floors of exit access shall be at least 0.2 ft-candle (2 lux) during periods of performances or projections involving directed light.
Exception No. 2:* This requirement shall not apply where operations or processes require low lighting levels.

7.8.1.4* Required illumination shall be arranged so that the failure of any single lighting unit does not result in an illumination level of less than 0.2 ft-candle (2 lux) in any designated area.

7.10.9.2 Exit signs connected to or provided with a battery-operated emergency illumination source, where required in 7.10.4, shall be tested and maintained in accordance with 7.9.3.

7.9.3 Periodic Testing of Emergency Lighting Equipment. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 1/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Findings:

During a tour of the facility with the Plant Operations Manager on 5/23/16, the exit signs were observed.

At 2:08 p.m., two exit signs on the second floor failed to illuminate. When interviewed, the Stationary Engineering confirmed the findings and stated that the bulbs were out.

Based observation and interview, the facility failed to ensure the evacuation plan was posted and readily accessible. This was evidenced by failure to have the evacuation plan posted. This could lead to the misguiding of evacuation in the event of an emergency. This affected the Outpatient Services Adolescent and Outpatient Clinic - Chemical Dependency.

NFPA 101, Life Safety Code, 2000 Edition
19.7.1 Evacuation and Relocation Plan and Fire Drills.
19.7.1.1 The administration of every health care occupancy shall have, in effect and available to all supervisory personnel, written copies of a plan for the protection of all persons in the
event of fire, for their evacuation to areas of refuge, and for their evacuation from the building when necessary. All employees shall be periodically instructed and kept informed
with respect to their duties under the plan. A copy of the plan shall be readily available at all times in the telephone operator ' s position or at the security center.

19.7.2.1* For health care occupancies, the proper protection of patients shall require the prompt and effective response of health care personnel. The basic response required of staff shall include the removal of all occupants directly involved with the fire emergency, transmission of an appropriate fire alarm signal to warn other building occupants and summon staff, confinement of the effects of the fire by closing doors to isolate the fire area, and the relocation of patients as detailed in the health care occupancy ' s fire safety plan.
19.7.2.2 A written health care occupancy fire safety plan shall provide for the following:
(1) Use of alarms
(2) Transmission of alarm to fire department
(3) Response to alarms
(4) Isolation of fire
(5) Evacuation of immediate area
(6) Evacuation of smoke compartment
(7) Preparation of floors and building for evacuation
(8) Extinguishment of fire


Findings:

During a tour of the facility with the Plant Operations Manager and Director Accreditation on 5/24/16, the exits were observed.

Outpatient Services Adolescent

1. At 8:37 a.m., there was no emergency evacuation plan on the second floor. When interviewed, the Plant Operations Manager stated that there was no emergency evacuation plan posted on the second floor, only on the first floor. There are two exits observed on the second floor.


Outpatient Clinic - Chemical Dependency

2. At 11:43 a.m., the facility failed to post an emergency evacuation plan in Suite 2. When interviewed, the finding was confirmed by the Plant Operations Manager and the Director of Accreditation.

Based on document review and interview, the facility failed to ensure that all staff were familiar with procedures during fire drills. This was evidenced by missing fire drills and by failure to document staff participation during each fire drill. This affected the Main Building, Outpatient Clinic - Chemical Dependency and Outpatient Services Adolescent. This could result in staff not being familiar with fire and emergency procedures in the event of an emergency.

NFPA 101, Life Safety Code, 2000 Edition
19.7.1.3 Employees of health care occupancies shall be instructed in life safety procedures and devices.
19.7.2 Procedure in Case of Fire.
19.7.2.1* For health care occupancies, the proper protection of patients shall require the prompt and effective response of health care personnel. The basic response required of staff shall include the removal of all occupants directly involved with the fire emergency, transmission of an appropriate fire alarm signal to warn other building occupants and summon staff, confinement of the effects of the fire by closing doors to isolate the fire area, and the relocation of patients as detailed in the health care occupancy ' s fire safety plan.
19.7.2.2 A written health care occupancy fire safety plan shall provide for the following:
(1) Use of alarms
(2) Transmission of alarm to fire department
(3) Response to alarms
(4) Isolation of fire
(5) Evacuation of immediate area
(6) Evacuation of smoke compartment
(7) Preparation of floors and building for evacuation
(8) Extinguishment of fire
19.7.2.3 All health care occupancy personnel shall be instructed in the use of and response to fire alarms. In addition, they shall be instructed in the use of the code phrase to ensure transmission of an alarm under 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 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.

19.7.1.2* Fire drills in health care occupancies shall include the transmission of fire alarm signal and simulation of emergency fire conditions. 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. When drills are conducted between 9:00 p.m. (2100 hours)and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building.


Findings:

During document review and interview with the Plant Operations Manager and Director of Accreditation on 5/24/16 and 5/25/16, the fire drill records were reviewed.

Outpatient Clinic - Chemical Dependency

1. On 5/24/16 at 9:09 a.m., the facility failed to provide three of four quarterly fire drills during the first quarter of 2016, second quarter of 2015 or 2016, and third quarter of 2015. The facility provided the fourth quarter fire drill that was conducted on 11/4/2015. Upon interview, the Director of Accreditation stated there were no fire drills conducted during those quarters.

OUTPATIENT SERVICE ADOLESCENT

2. On 5/25/16 at 10:40 a.m., the facility failed to provide three of four quarterly fire drills during the first quarter of 2016, third quarter of 2015, and fourth quarter of 2015. The facility provided the second quarter fire drill that was conducted on 6/8/2015. Upon interview, the Director of Accreditation stated there were no fire drills conducted during those quarters.

Main Building

3. On 5/25/16 at 10:45 a.m., the facility failed to provide four of twelve quarterly fire drills. An AM and NOC shift fire drill was not conducted during the second quarter (April/May/June) 2015 or 2016 and an AM and PM shift fire drills during the third quarter (July/August/September) 2015.

4. On 5/25/16 at 10:48 a.m., the facility failed to provide documentation that all staff participated in the fire drills and practiced emergency response procedures. When interviewed, the Plant Operations Manager stated that they will fax the sign in sheet by 5/26/16 at 3 p.m.

5. On 5/27/16 at 1:57 p.m., an email was received from the Plant Operations Manager stating that they could not produce documentation reflecting staff participation during the drills conducted.


31203

Based on observation, document review, and interview, the facility failed to maintain their smoke detectors. This was evidenced by the failure to provide documentation for the maintenance of 5 single station smoke detectors in accordance with manufacturer's specifications, by the failure to correct the deficiency noted during the annual inspection and testing of the fire alarm system, and by the failure to provide a current smoke detector sensitivity testing report. This affected two of two floors in the MAIN BUILDING and OUTPATIENT SERVICE ADOLESCENT. This could result in a delay in patients and staff notification in the event of a fire.


NFPA 101, Life Safety Code, 2000 Edition
NFPA 101, Life Safety Code, 2000 Edition
9.6.1.3* The provisions of Section 9.6 cover the basic functions of a complete fire alarm system, including fire detection, alarm, and communications. These systems are primarily intended to provide the indication and warning of abnormal conditions, the summoning of appropriate aid, and the control of occupancy facilities to enhance protection of life.
9.6.1.4 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 Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.

9.6.2.10.1 Where required by another section of this Code, single-station smoke alarms shall be in accordance with the household fire-warning equipment requirements of NFPA 72, National Fire Alarm Code, unless they are system smoke detectors in accordance with NFPA 72, National Fire Alarm Code, and are arranged to function in the same manner.

NFPA 72, National Fire Alarm Code, 1999 Edition.
7-1.1.1 Inspection, testing, and maintenance programs shall satisfy the requirements of this code, shall conform to the equipment manufacturer's recommendations, and shall verify correct operation of the fire alarm system.

7-3.2.1* Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over
the previous year, calibration tests shall be performed. To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following
methods:
(1) Calibrated test method
(2) Manufacturer ' s calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the
detector causes a signal at the control unit where its sensitivity
is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the
authority having jurisdiction
Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.

Exception No. 1: Detectors listed as field adjustable shall be permitted
to be either adjusted within the listed and marked sensitivity range and
cleaned and recalibrated, or they shall be replaced.

Exception No. 2: This requirement shall not apply to single station detectors
referenced in 7-3.3 and Table 7-2.2.

The detector sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of smoke or other aerosol into the detector.


Findings:

During a tour of the facility, document review, and interview with the Plant Operations Manager and the Stationary Engineer on 5/24/16 and 5/25/16, the smoke detector sensitivity testing reports were requested, the single station smoke detectors were observed, and documentation reviewed.


OUTPATIENT SERVICE ADOLESCENT

1. On 5/24/16 at 8:22 a.m., the facility failed to provide documentation for the weekly testing of 5 single station smoke detectors. Upon interview, the Plant Operations Manager stated, the facility is aware of the weekly testing and will begin a maintenance program.

2. On 5/25/16 at 9:13 a.m., the document titled "2016 ANNUAL FIRE ALARM INITIATING DEVICES" dated 4/28/16 was reviewed. The document stated under "Summary List of any Deficiencies found in this section: SMOKE DETECTOR 10 YR LIFE EXPECTANCY IS PAST DUE- MFG DATE IS JULY 2005". Upon interview, the Stationary Engineer stated that the facility is aware of the deficiency.

MAIN BUILDING

3. On 5/25/16 at 2:20 p.m., there was no documentation provided for the smoke detector sensitivity testing upon request. Upon interview, the Plant Operations Manager stated that they will locate the smoke detector sensitivity documentation and fax it by 3:00 p.m. on 5/26/16. There were no document received as stated.

Based on interview and observation, the facility failed to ensure the valves for the automatic sprinkler were supervised. This was evidenced by the tamper valve that failed to sound a supervisory signal at a location within the building, and at an approved, remotely located receiving facility. This could lead to a failure to address problem with the water supply of the sprinkler system and result in an ineffective fire sprinkler system. This affected the Outpatient Clinic - Chemical Dependency.

NFPA 101, Life Safety Code, 2000 Edition
9.7.2.1* Supervisory Signals. Where supervised automatic sprinkler systems are required by another section of this Code, supervisory attachments shall be installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm Code, and a distinctive supervisory signal shall be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system of the sprinkler system. Monitoring shall include, but shall not be limited to, monitoring of control valves, fire pump power supplies and running conditions, water tank levels and temperatures, tank pressure, and air pressure on dry-pipe valves. Supervisory signals shall sound and shall be displayed either at a location within the protected building that is constantly attended by qualified personnel or at an approved, remotely located receiving facility.

Findings:

During fire alarm testing with the Plant Operations Manager, Director of Accreditation, Alliance Director and Stationary Engineer on 5/24/16, the tamper valve for the automatic sprinkler system was observed.

1. Between 9:02 a.m. and 9:05 a.m., the Post Indicator Valve (PIV) for the sprinkler system was tested. There were no audible or visual supervisory signal received at the key pad panel located at the Reception area on the first floor. The valve was turned at 13 revolutions by the Stationary Engineer and no alarm was transmitted.

2. At 9:09 a.m., the monitoring company was called by the Plant Operations Manager to confirm that the signal was received. The monitoring company stated no signal was received for the trouble signal for the PIV.

3. At 9:19 a.m., the Plant Operations Manager stated the facility will implement a fire watch at 9:20 a.m. The facility will fax a daily fire watch log to the Department of Public Health.

4. At 10 a.m., the PIV was retested and the valve was turned at 14 revolutions and no audible or visual supervisory signal received at the key pad panel.

5. At 10:01 a.m., the Alliance Director stated the vendor was contacted and will be at the facility to troubleshoot the problem by 10:30 a.m.

6. An email was received from the Alliance Director at 6:07 p.m., stating the issues with the PIV. The vendor indicated that the PIV switch was not mechanically functioning, need to replace PIV switch (Potter), open/close indicator does not move when valve is closed (valve does close all the way) needs adjustment by fitter.

7. On 5/26/16 at 11:38 a.m., an email was received from the Alliance Director for the proposal of repairs that will be done on 5/27/16. The Alliance Director and Plant Operations Manager were instructed to email/fax the signal from the monitoring company and service description of the repairs.

8. On 5/27/16 at 3:37 p.m., a fax of the work order and verification of signal from the monitoring company was received regarding fixing the PIV.

31203


Based on observation, document review, and interview, the facility failed to maintain their automatic sprinkler system. This was evidenced by an escutcheon ring that was not flush with ceiling, by sprinklers not free from foreign material, by bell to the waterflow that failed to sound, by failure to provide current five year certification sticker on the riser, and by the failure of the waterflow device to initiate an alarm within 90 seconds when tested. This could result in the failure of the automatic sprinkler system in the event of a fire and could result in failure of the sprinkler system to extinguish a fire in the event of a fire. This affected two of two floors in the MAIN BUILDING and two of two floors in the OUTPATIENT SERVICE ADOLESCENT.

NFPA 101, Life Safety Code, 2000 Edition
4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction
.
SECTION 9.6 FIRE DETECTION, ALARM, AND COMMUNICATIONS SYSTEMS
9.6.1.4 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 Code, unless an existing installation, which shall be permitted to be continued in use, subject to the authority having jurisdiction.

9.6.1.8* Where a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction is notified, and the building is evacuated or an approved fire watch is provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service.

SECTION 9.7 AUTOMATIC SPRINKLERS AND OTHER EXTINGUISHING EQUIPMENT

9.7.1.1 Each automatic sprinkler system required by another section of this Code shall be in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.

9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

9.7.6* Sprinkler System Shutdown.

9.7.6.1 Where a required automatic sprinkler system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the sprinkler system has been returned to service.

NFPA 13, Installation of Sprinkler Systems, 1999 Edition
3-8.3* Identification of Valves. All control, drain and test connection valves shall be provided with permanently marked weatherproof metal or rigid plastic identification signs. The sign shall be secured with corrosion-resistant wire, chain or other approved means.

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 Edition

1-8.1 Records shall indicate the procedure performed (e.g., inspection, test, or maintenance), the organization that performed the work, the results, and the date.

1-8.2 Records shall be maintained by the owner. Original records shall be retained for the life of the system. Subsequent records shall be retained for a period of one year after the next inspection, test, or maintenance required by the standard.

2-2.1.1 Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.

2-2.1.2 Unacceptable obstructions to spray patterns shall be corrected.

2-4.1.8 Sprinklers shall not be altered in any respect or have any type of ornamentation, paint, or coatings applied after shipment from the place of manufacture.

2-2.6 Alarm Devices. Alarm devices shall be inspected quarterly to verify that they are free of physical damage.

2-2.7 Hydraulic Nameplate. The hydraulic nameplate, if provided, shall be inspected quarterly to verify that it is attached securely to the sprinkler riser and is legible.

2-3.3 Alarm Devices. Waterflow alarm devices including, but not limited to, mechanical water motor gongs, vane-type waterflow devices, and pressure switches that provide audible or visual signals shall be tested quarterly.

9-2.7 Waterflow Alarm. All waterflow alarms shall be tested quarterly in accordance with the manufacturer's instructions.

9-3.4.3 Valve supervisory switches shall be tested semiannually. A distinctive signal shall indicate movement from the valve ' s normal position during either the first two revolutions of a hand wheel or when the stem of the valve has moved one-fifth of the distance from its normal position. The signal shall not be restored at any valve position except the normal position.

9-5.1.1 All valves shall be inspected quarterly. The inspection shall verify that the valves are in the following condition:
(a) In the open position
(b) Not leaking
(c) Maintaining downstream pressures in accordance with the design criteria
(d) In good condition, with handwheels installed and unbroken
9-5.2.1 All valves shall be inspected quarterly. The inspection shall verify the following:
(a) The handwheel is not broken or missing.
(b) The outlet hose threads are not damaged.
(c) There are no leaks.
(d) The reducer and the cap are not missing.
9-7.1 Fire department connections shall be inspected quarterly. The inspection shall verify the following:
(a) The fire department connections are visible and accessible.
(b) Couplings or swivels are not damaged and rotate smoothly.
(c) Plugs or caps are in place and undamaged.
(d) Gaskets are in place and in good condition.
(e) Identification signs are in place.
(f) The check valve is not leaking.
(g) The automatic drain valve is in place and operating properly.

NFPA 72, National Fire Alarm Code, 1999 Edition
2-6 Sprinkler Waterflow Alarm -Initiating Devices.

2-6.1 The provisions of Section 2-6 shall apply to devices that initiate an alarm indicating a flow of water in a sprinkler system.

2-6.2* Initiation of the alarm signal shall occur within 90 seconds of waterflow at the alarm-initiating device when flow occurs that is equal to or greater than that from a single sprinkler of the smallest orifice size installed in the system. Movement of water due to waste, surges, or variable pressure shall not be indicated.

Findings:

During a tour of the facility, interview, and document review with the Plant Operations Manager, Stationary Engineer, and the Director of Accreditation on 5/23/16 through 5/25/16, the automatic sprinkler systems were observed and document reviewed.

MAIN BUILDING

5/23/16

1. On 5/23/16 at 10:35 a.m., the sprinkler in Room 237 on the second floor had foreign material around the sprinkler. This finding was confirmed by the Director of Accreditation.

2. On 5/23/16 at 10:41 a.m., there was a bent sprinkler head in the Breakroom located on the second floor. The finding was confirmed by the Plant Operations Manager.

3. On 5/23/16 at 10:43 a.m., the sprinkler in the Shower room near Room 237 on the second floor had foreign materials around the sprinkler. This finding was confirmed by the Director of Accreditation.

4. On 5/23/16 at 10:43 a.m., the sprinkler in Room 212 on the second floor had foreign materials around the sprinkler. This finding was confirmed by the Director of Accreditation.

5. On 5/23/16 at 10:45 a.m., the sprinkler in the Supply closet near Room 214 on the second floor had foreign material hanging on the deflector. This finding was confirmed by the Director Accreditation.

OUTPATIENT SERVICE ADOLESCENT

6. On 5/24/16 at 8:12 a.m., the side wall sprinkler head on the second floor was not flush to the wall and exposed an approximately 1 1/2 penetration. The finding was confirmed the Plant Operations Manager.


7. On 5/24/16 at 8:59 a.m., during fire alarm testing of the automatic sprinkler system, the Inspector's Test Valve (ITV) was opened. The fire alarm failed to emit an audible alarm and failed to show a trouble signal on the fire alarm key pad located near the Reception area on the first floor. The ITV was opened for approximately four minutes.

8. On 5/24/16 at 9:09 a.m., the Plant Operations Manager called the monitoring service to confirm signal. The monitoring service stated there were no signal received for the waterflow.

9. On 5/24/16 at 9:57 a.m., the ITV was retested by the Stationary Engineer after resetting the fire alarm key pad. The ITV was opened and activated the alarm at 43 seconds. The bell located outside for the waterlfow did not sound, but the alarm box inside the facility sounded. This signal was confirmed by the monitoring service at 10:06 a.m. Upon interview, the Plant Operations Manager stated that the bell near the riser does not work and was noted during the annual testing and inspections by the vendor on 4/28/16.

OUTPATIENT SERVICE ADOLESCENT
10. On 5/25/16 at 9:15 a.m., the document titled "VISUAL AND AUDIBLE FIRE ALARM DEVICES TESTS AND INSPECTIONS" dated 4/28/16 was reviewed. The document stated "OUTSIDE HORN/BELL DID NOT SOUND WHEN TESTED BY FLOW SWITCH. FURTHER INVESTIGATION REQUIRED". This finding was confirmed by Plant Operations Manager and was mentioned during the waterflow testing that was conducted on 5/24/16.

11. On 5/25/16 at 10:00 a.m., there was no five (5) year certification sticker posted on the riser located in back of the building. Upon document review, the document titled "5 year Inspection, Testing, and Maintenance Fire Sprinkler System" dated 4/15/15 stated "PASS". When interviewed, the Plant Operations Manager stated that they will follow up with the vendor as to why is wasn't provided on the riser.

Based on interview and document review, the facility failed to maintain their emergency generator. This was evidenced by the failure to record transfer time during monthly generator load test, and not performing the required 30 minute full load test monthly. This affected the Main Building, and could result in failure of the generator in the event of a power outage.

NFPA 99, Standard for Health Care Facilities, 1999 edition
3-4.4.1 Maintenance and Testing of Essential Electrical System.
3-4.4.1.1 Maintenance and Testing of Alternate Power Source and Transfer Switches.
(a) Maintenance of Alternate Power Source. The generator set or other alternate power source and associated equipment, including all appurtenant parts, shall be so maintained as to be capable of supplying service within the shortest time practicable and within the 10-second interval specified in 3-4.1.1.8 and 3-4.3.1. Maintenance shall be performed in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6.
(b) Inspection and Testing.
1.* Test Criteria. Generator sets shall be tested twelve (12) times a year with testing intervals between not less than 20 days or exceeding 40 days. Generator sets serving emergency and equipment systems shall be in accordance with NFPA 110, Standard for Emergency and Standby Power Systems,
2. Test Conditions. The scheduled test under load conditions shall include a complete simulated cold start and appropriate automatic and manual transfer of all essential electrical system loads.
3. Test Personnel. The scheduled tests shall be conducted by competent personnel. The tests are needed to keep the machines ready to function and, in addition, serve to detect causes of malfunction and to train personnel in operating procedures.
3-4.4.2 Recordkeeping. A written record of inspection, performance, exercising period, and repairs shall be regularly maintained and available for inspection by the authority having jurisdiction.

NFPA 110, Standard for Emergency and Standby Power Systems, 1999 Edition
6-3 Maintenance and Operational Testing.
6-3.1* The EPSS shall be maintained to ensure to a reasonable degree that the system is capable of supplying service within the time specified for the type and for the time duration specified for the class.
6-3.2 A routine maintenance and operational testing program shall be initiated immediately after the EPSS has passed acceptance tests or after completion of repairs that impact the operational reliability of the system.
6-3.3 A written schedule for routine maintenance and operational testing of the EPSS shall be established.
6-3.4 A written record of the EPSS inspections, tests, exercising, operation, and repairs shall be maintained on the premises.
The written record shall include the following:
(a) The date of the maintenance report
(b) Identification of the servicing personnel
(c) Notation of any unsatisfactory condition and the corrective action taken, including parts replaced
(d) Testing of any repair for the appropriate time as recommended by the manufacturer

6-4.2* Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly , for minimum of 30 minutes, using one of the following methods:
(a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating.
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer.
The date and time of day for required testing shall be decided by the owner, based on facility operations.
6-4.2.2 Diesel-powered EPS installations that do not meet the requirements of 6-4.2 shall be exercised monthly with the available EPSS load and exercised annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of 2 continuous hours.

Findings:

During document review and interview with the Plant Operations Manager and Director of Accreditation on 5/25/16, the emergency generator maintenance documents were requested.

1. At 10:10 a.m., the documents for the monthly load tests for the diesel emergency generator were requested. The August 2015 monthly load test indicated that the generator was tested 6 minutes. The generator was not tested for the required full 30 minutes.

2. At 9:35 a.m., there was no transfer time recorded during the monthly generator load test for August 2015. The finding was confirmed by the Plant Operations Manager.

Based on observation and interview, the facility failed to maintain the electrical wiring, as evidenced by the use of power strips as substitute for fixed wiring. This could result in the ignition of an electrical fire. This affected two of two floors in the Main Building, Outpatient Clinic - Chemical Dependency and Outpatient Clinic Adolescent.

NFPA 101, Life Safety Code, 2000 Edition
9.1.2 Electric. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

NFPA 70, National Electrical Code, 1999 Edition
400-7 Uses Permitted
(a) Uses. Flexible cords shall be used only for the following:
1) Pendants
2) Wiring of fixtures
3) Connection of portable lamps, portable and mobile signs or appliances
4) Elevator cables
5) Wiring of cranes and hoists
6) Connection of stationary equipment to facilitate their frequent interchange
7) Prevention of the transmission of noise or vibration
8) Appliances where the fastening means and mechanical connections are specifically designed to permit ready removal for maintenance and repair, and the appliance is intended or identified for flexible cord connection
9) Data processing cables as permitted by Section 645-5
10) Connection of moving parts
11) Temporary wiring as permitted in Sections 305-4 b) & 305-4 c)

400-8. Uses not Permitted. Unless specifically permitted in Section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
Exception: Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of Section 364-8.

Findings:

During a tour of the facility with the Plant Operations Manager and Director of Accreditation on 5/23/16, the electrical wiring in the facility was observed.

Main Building

1. At 10:18 a.m., there was a microwave and electric fan plugged into a power strip instead of directly in to an electrical outlet in the Pharmacy office located on the first floor. This finding was confirmed by the Director Accreditation.

2. At 10:40 a.m., there microwave and coffee maker plugged into a power strip instead of directly in to an electrical outlet in the Staff Lounge located on the second floor. This finding was confirmed by the Director Accreditation.

3. At 10:41 a.m., a water dispenser and a refrigerator were plugged into a mounted power strip instead of directly in to an electrical outlet in the Breakroom located on the second floor. This finding was confirmed by the Plant Operations Manager.

Outpatient - Chemical Dependency

4. At 1:31 p.m., a water dispenser and a microwave were plugged into a power strip instead of directly in to an electrical outlet in the Pulmonary Rehabilitation Room.

Outpatient Services Adolescent

5. At 2:24 p.m., there were two fans that were plugged into two power strips instead of directly in to an electrical outlet in the Staff Office B located on the second floor. When interviewed, the Plant Operations Manager confirmed the findings and removed the fans from the power strips.



31203

Based on observation, the facility failed to maintain their use of Alcohol Based Hand Rub dispenser (ABHR). This was evidenced by an alcohol based hand rub dispensers installed adjacent to an ignition source. This affected one of one smoke compartment in the OUTPATIENT CLINIC- CHEMICAL DEPENDENCY and could result in an electrical fire.

Findings:

During a tour of the facility with the Plant Operations Manager and the Director of Accreditation on 5/23/16, the alcohol based hand rub dispensers were observed.

At 1:26 p.m., the ABHR dispenser in the Pulmonary Rehab Program office was installed approximately 2 inches adjacent a light ignition source. The ABHR contained 70% Ethyl Alcohol with a volume of 1L. This finding was confirmed by the Plant Operations Manager and the Director Accreditation.

Based on observation and interview, the facility failed to maintain corridor doors to resist the passage of smoke. This was evidenced by doors that failed to positive latch. This could result in the passage smoke and flames in the event of a fire, and affected one of two floors in the Main Building.


Findings:

During a tour of the facility with the Plant Operations Manager on 5/23/15, the corridor doors were observed.

1. At 10:23 a.m., the door to Room 158 was equipped with a self-closing device that failed to latch. The self-closing device was disconnected. When interviewed, the Plant Operations Manager confirmed the find and stated that they are currently working on replacing the self-closure device.

2. At 10:27 a.m., the door to the Kitchen was equipped with a self-closing device that failed to latch. The door remained open. The Plant Operations Manager stated that the self-closing device was not functioning.

Based on observation the facility failed to maintain the access/visibility to exits as evidenced by the failure to provide readily visible exit signs which indicate which way to exit. This affected all visitors in the OUTPATIENT CLINIC- CHEMICAL DEPENDENCY building and could lead to confusion in the event of an emergency evacuation.

Findings:

During a tour of the facility with the Plant Operations Manager and the Director of Accreditation on 5/24/16, access to exits was observed.

At 11:45 a.m., there was no readily visible exit sign observed at the courtyard after exiting Suite 2. The courtyard has a fenced gate that is locked at night since the building is only used during the day. Upon interview, the Plant Operations Manager stated that visitors may use either left or right exits, and confirmed there were no exit signs posted in the courtyard. Both the left and right exit ways lead to the parking lot.

Based on interview and document review, the facility failed to maintain the emergency battery backup lighting. This was evidenced by the lack of documentation for the testing of the emergency battery backup lighting unit. This could result in a failure to provide backup lighting in the event of evacuation and affected one of two floors in the OUTPATIENT SERVICE ADOLESCENT Building.


NFPA 101, Life Safety Code, 2000 Edition
7.9.3 Periodic Testing of Emergency Lighting Equipment. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 11/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests
shall be kept by the owner for inspection by the authority having jurisdiction.

Exception: Self-testing/self-diagnostic, battery-operated emergency lighting equipment that automatically performs a test for not less than 30 seconds and diagnostic routine not less than once every 30 days and indicates failures by a status indicator shall be exempt from the 30-day functional test, provided that a visual inspection is performed
at 30-day intervals.

7.10.9.2 Testing. Exit signs connected to or provided with a battery-operated emergency illumination source, where required in 7.10.4, shall be tested and maintained in accordance with 7.9.3.


Findings:

During interview and document review with the Stationary Engineer on 5/24/16, the emergency battery backup lighting system was observed.

At 1:39 p.m., there were no documents provided for the required monthly test of not less than 30 seconds, and an annual test of the emergency lighting system for not less than 1 1/2 hours for the battery powered emergency lighting system located above the main entrance door on the first floor. Upon interview, the Stationary Engineer stated that there is no testing documentation for the emergency lighting unit.

Based on observation, the facility failed to maintain the emergency exit signs. This was evidenced by two exit signs that were not illuminated. This could result in increased risk of patients, staff, and visitors inability to immediately find the exits in case of emergency. This affected one of two floors in the OUTPATIENT SERVICE ADOLESCENT Building.

NFPA 101, Life Safety Code, 2000 Edition
19.2.10 Marking of Means of Egress.
19.2.10.1 Means of egress shall have signs in accordance with Section 7.10.
Exception: Where the path of egress travel is obvious, signs shall not be required in one-story buildings with an occupant load of fewer than 30 persons.
7.8.1.2 Illumination of means of egress shall be continuous during the time that the conditions of occupancy require that the means of egress be available for use. Artificial lighting shall be employed at such locations and for such periods of time as required to maintain the illumination to the minimum criteria values herein specified.
Exception: Automatic, motion sensor-type lighting switches shall be permitted within the means of egress, provided that the switch controllers are equipped for fail-safe operation, the illumination timers are set for a minimum 15-minute duration, and the motion sensor is activated by any occupant movement in the area served by the lighting units.

7.8.1.3* The floors and other walking surfaces within an exit and within the portions of the exit access and exit discharge designated in 7.8.1.1 shall be illuminated to values of at least 1 ft-candle (10 lux) measured at the floor.
Exception No. 1: In assembly occupancies, the illumination of the floors of exit access shall be at least 0.2 ft-candle (2 lux) during periods of performances or projections involving directed light.
Exception No. 2:* This requirement shall not apply where operations or processes require low lighting levels.

7.8.1.4* Required illumination shall be arranged so that the failure of any single lighting unit does not result in an illumination level of less than 0.2 ft-candle (2 lux) in any designated area.

7.10.9.2 Exit signs connected to or provided with a battery-operated emergency illumination source, where required in 7.10.4, shall be tested and maintained in accordance with 7.9.3.

7.9.3 Periodic Testing of Emergency Lighting Equipment. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 1/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Findings:

During a tour of the facility with the Plant Operations Manager on 5/23/16, the exit signs were observed.

At 2:08 p.m., two exit signs on the second floor failed to illuminate. When interviewed, the Stationary Engineering confirmed the findings and stated that the bulbs were out.

Based observation and interview, the facility failed to ensure the evacuation plan was posted and readily accessible. This was evidenced by failure to have the evacuation plan posted. This could lead to the misguiding of evacuation in the event of an emergency. This affected the Outpatient Services Adolescent and Outpatient Clinic - Chemical Dependency.

NFPA 101, Life Safety Code, 2000 Edition
19.7.1 Evacuation and Relocation Plan and Fire Drills.
19.7.1.1 The administration of every health care occupancy shall have, in effect and available to all supervisory personnel, written copies of a plan for the protection of all persons in the
event of fire, for their evacuation to areas of refuge, and for their evacuation from the building when necessary. All employees shall be periodically instructed and kept informed
with respect to their duties under the plan. A copy of the plan shall be readily available at all times in the telephone operator ' s position or at the security center.

19.7.2.1* For health care occupancies, the proper protection of patients shall require the prompt and effective response of health care personnel. The basic response required of staff shall include the removal of all occupants directly involved with the fire emergency, transmission of an appropriate fire alarm signal to warn other building occupants and summon staff, confinement of the effects of the fire by closing doors to isolate the fire area, and the relocation of patients as detailed in the health care occupancy ' s fire safety plan.
19.7.2.2 A written health care occupancy fire safety plan shall provide for the following:
(1) Use of alarms
(2) Transmission of alarm to fire department
(3) Response to alarms
(4) Isolation of fire
(5) Evacuation of immediate area
(6) Evacuation of smoke compartment
(7) Preparation of floors and building for evacuation
(8) Extinguishment of fire


Findings:

During a tour of the facility with the Plant Operations Manager and Director Accreditation on 5/24/16, the exits were observed.

Outpatient Services Adolescent

1. At 8:37 a.m., there was no emergency evacuation plan on the second floor. When interviewed, the Plant Operations Manager stated that there was no emergency evacuation plan posted on the second floor, only on the first floor. There are two exits observed on the second floor.


Outpatient Clinic - Chemical Dependency

2. At 11:43 a.m., the facility failed to post an emergency evacuation plan in Suite 2. When interviewed, the finding was confirmed by the Plant Operations Manager and the Director of Accreditation.

Based on document review and interview, the facility failed to ensure that all staff were familiar with procedures during fire drills. This was evidenced by missing fire drills and by failure to document staff participation during each fire drill. This affected the Main Building, Outpatient Clinic - Chemical Dependency and Outpatient Services Adolescent. This could result in staff not being familiar with fire and emergency procedures in the event of an emergency.

NFPA 101, Life Safety Code, 2000 Edition
19.7.1.3 Employees of health care occupancies shall be instructed in life safety procedures and devices.
19.7.2 Procedure in Case of Fire.
19.7.2.1* For health care occupancies, the proper protection of patients shall require the prompt and effective response of health care personnel. The basic response required of staff shall include the removal of all occupants directly involved with the fire emergency, transmission of an appropriate fire alarm signal to warn other building occupants and summon staff, confinement of the effects of the fire by closing doors to isolate the fire area, and the relocation of patients as detailed in the health care occupancy ' s fire safety plan.
19.7.2.2 A written health care occupancy fire safety plan shall provide for the following:
(1) Use of alarms
(2) Transmission of alarm to fire department
(3) Response to alarms
(4) Isolation of fire
(5) Evacuation of immediate area
(6) Evacuation of smoke compartment
(7) Preparation of floors and building for evacuation
(8) Extinguishment of fire
19.7.2.3 All health care occupancy personnel shall be instructed in the use of and response to fire alarms. In addition, they shall be instructed in the use of the code phrase to ensure transmission of an alarm under 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 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.

19.7.1.2* Fire drills in health care occupancies shall include the transmission of fire alarm signal and simulation of emergency fire conditions. 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. When drills are conducted between 9:00 p.m. (2100 hours)and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building.


Findings:

During document review and interview with the Plant Operations Manager and Director of Accreditation on 5/24/16 and 5/25/16, the fire drill records were reviewed.

Outpatient Clinic - Chemical Dependency

1. On 5/24/16 at 9:09 a.m., the facility failed to provide three of four quarterly fire drills during the first quarter of 2016, second quarter of 2015 or 2016, and third quarter of 2015. The facility provided the fourth quarter fire drill that was conducted on 11/4/2015. Upon interview, the Director of Accreditation stated there were no fire drills conducted during those quarters.

OUTPATIENT SERVICE ADOLESCENT

2. On 5/25/16 at 10:40 a.m., the facility failed to provide three of four quarterly fire drills during the first quarter of 2016, third quarter of 2015, and fourth quarter of 2015. The facility provided the second quarter fire drill that was conducted on 6/8/2015. Upon interview, the Director of Accreditation stated there were no fire drills conducted during those quarters.

Main Building

3. On 5/25/16 at 10:45 a.m., the facility failed to provide four of twelve quarterly fire drills. An AM and NOC shift fire drill was not conducted during the second quarter (April/May/June) 2015 or 2016 and an AM and PM shift fire drills during the third quarter (July/August/September) 2015.

4. On 5/25/16 at 10:48 a.m., the facility failed to provide documentation that all staff participated in the fire drills and practiced emergency response procedures. When interviewed, the Plant Operations Manager stated that they will fax the sign in sheet by 5/26/16 at 3 p.m.

5. On 5/27/16 at 1:57 p.m., an email was received from the Plant Operations Manager stating that they could not produce documentation reflecting staff participation during the drills conducted.


31203

Based on observation, document review, and interview, the facility failed to maintain their smoke detectors. This was evidenced by the failure to provide documentation for the maintenance of 5 single station smoke detectors in accordance with manufacturer's specifications, by the failure to correct the deficiency noted during the annual inspection and testing of the fire alarm system, and by the failure to provide a current smoke detector sensitivity testing report. This affected two of two floors in the MAIN BUILDING and OUTPATIENT SERVICE ADOLESCENT. This could result in a delay in patients and staff notification in the event of a fire.


NFPA 101, Life Safety Code, 2000 Edition
NFPA 101, Life Safety Code, 2000 Edition
9.6.1.3* The provisions of Section 9.6 cover the basic functions of a complete fire alarm system, including fire detection, alarm, and communications. These systems are primarily intended to provide the indication and warning of abnormal conditions, the summoning of appropriate aid, and the control of occupancy facilities to enhance protection of life.
9.6.1.4 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 Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.

9.6.2.10.1 Where required by another section of this Code, single-station smoke alarms shall be in accordance with the household fire-warning equipment requirements of NFPA 72, National Fire Alarm Code, unless they are system smoke detectors in accordance with NFPA 72, National Fire Alarm Code, and are arranged to function in the same manner.

NFPA 72, National Fire Alarm Code, 1999 Edition.
7-1.1.1 Inspection, testing, and maintenance programs shall satisfy the requirements of this code, shall conform to the equipment manufacturer's recommendations, and shall verify correct operation of the fire alarm system.

7-3.2.1* Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over
the previous year, calibration tests shall be performed. To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following
methods:
(1) Calibrated test method
(2) Manufacturer ' s calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the
detector causes a signal at the control unit where its sensitivity
is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the
authority having jurisdiction
Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.

Exception No. 1: Detectors listed as field adjustable shall be permitted
to be either adjusted within the listed and marked sensitivity range and
cleaned and recalibrated, or they shall be replaced.

Exception No. 2: This requirement shall not apply to single station detectors
referenced in 7-3.3 and Table 7-2.2.

The detector sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of smoke or other aerosol into the detector.


Findings:

During a tour of the facility, document review, and interview with the Plant Operations Manager and the Stationary Engineer on 5/24/16 and 5/25/16, the smoke detector sensitivity testing reports were requested, the single station smoke detectors were observed, and documentation reviewed.


OUTPATIENT SERVICE ADOLESCENT

1. On 5/24/16 at 8:22 a.m., the facility failed to provide documentation for the weekly testing of 5 single station smoke detectors. Upon interview, the Plant Operations Manager stated, the facility is aware of the weekly testing and will begin a maintenance program.

2. On 5/25/16 at 9:13 a.m., the document titled "2016 ANNUAL FIRE ALARM INITIATING DEVICES" dated 4/28/16 was reviewed. The document stated under "Summary List of any Deficiencies found in this section: SMOKE DETECTOR 10 YR LIFE EXPECTANCY IS PAST DUE- MFG DATE IS JULY 2005". Upon interview, the Stationary Engineer stated that the facility is aware of the deficiency.

MAIN BUILDING

3. On 5/25/16 at 2:20 p.m., there was no documentation provided for the smoke detector sensitivity testing upon request. Upon interview, the Plant Operations Manager stated that they will locate the smoke detector sensitivity documentation and fax it by 3:00 p.m. on 5/26/16. There were no document received as stated.

Based on interview and observation, the facility failed to ensure the valves for the automatic sprinkler were supervised. This was evidenced by the tamper valve that failed to sound a supervisory signal at a location within the building, and at an approved, remotely located receiving facility. This could lead to a failure to address problem with the water supply of the sprinkler system and result in an ineffective fire sprinkler system. This affected the Outpatient Clinic - Chemical Dependency.

NFPA 101, Life Safety Code, 2000 Edition
9.7.2.1* Supervisory Signals. Where supervised automatic sprinkler systems are required by another section of this Code, supervisory attachments shall be installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm Code, and a distinctive supervisory signal shall be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system of the sprinkler system. Monitoring shall include, but shall not be limited to, monitoring of control valves, fire pump power supplies and running conditions, water tank levels and temperatures, tank pressure, and air pressure on dry-pipe valves. Supervisory signals shall sound and shall be displayed either at a location within the protected building that is constantly attended by qualified personnel or at an approved, remotely located receiving facility.

Findings:

During fire alarm testing with the Plant Operations Manager, Director of Accreditation, Alliance Director and Stationary Engineer on 5/24/16, the tamper valve for the automatic sprinkler system was observed.

1. Between 9:02 a.m. and 9:05 a.m., the Post Indicator Valve (PIV) for the sprinkler system was tested. There were no audible or visual supervisory signal received at the key pad panel located at the Reception area on the first floor. The valve was turned at 13 revolutions by the Stationary Engineer and no alarm was transmitted.

2. At 9:09 a.m., the monitoring company was called by the Plant Operations Manager to confirm that the signal was received. The monitoring company stated no signal was received for the trouble signal for the PIV.

3. At 9:19 a.m., the Plant Operations Manager stated the facility will implement a fire watch at 9:20 a.m. The facility will fax a daily fire watch log to the Department of Public Health.

4. At 10 a.m., the PIV was retested and the valve was turned at 14 revolutions and no audible or visual supervisory signal received at the key pad panel.

5. At 10:01 a.m., the Alliance Director stated the vendor was contacted and will be at the facility to troubleshoot the problem by 10:30 a.m.

6. An email was received from the Alliance Director at 6:07 p.m., stating the issues with the PIV. The vendor indicated that the PIV switch was not mechanically functioning, need to replace PIV switch (Potter), open/close indicator does not move when valve is closed (valve does close all the way) needs adjustment by fitter.

7. On 5/26/16 at 11:38 a.m., an email was received from the Alliance Director for the proposal of repairs that will be done on 5/27/16. The Alliance Director and Plant Operations Manager were instructed to email/fax the signal from the monitoring company and service description of the repairs.

8. On 5/27/16 at 3:37 p.m., a fax of the work order and verification of signal from the monitoring company was received regarding fixing the PIV.

31203


Based on observation, document review, and interview, the facility failed to maintain their automatic sprinkler system. This was evidenced by an escutcheon ring that was not flush with ceiling, by sprinklers not free from foreign material, by bell to the waterflow that failed to sound, by failure to provide current five year certification sticker on the riser, and by the failure of the waterflow device to initiate an alarm within 90 seconds when tested. This could result in the failure of the automatic sprinkler system in the event of a fire and could result in failure of the sprinkler system to extinguish a fire in the event of a fire. This affected two of two floors in the MAIN BUILDING and two of two floors in the OUTPATIENT SERVICE ADOLESCENT.

NFPA 101, Life Safety Code, 2000 Edition
4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction
.
SECTION 9.6 FIRE DETECTION, ALARM, AND COMMUNICATIONS SYSTEMS
9.6.1.4 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 Code, unless an existing installation, which shall be permitted to be continued in use, subject to the authority having jurisdiction.

9.6.1.8* Where a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction is notified, and the building is evacuated or an approved fire watch is provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service.

SECTION 9.7 AUTOMATIC SPRINKLERS AND OTHER EXTINGUISHING EQUIPMENT

9.7.1.1 Each automatic sprinkler system required by another section of this Code shall be in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.

9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

9.7.6* Sprinkler System Shutdown.

9.7.6.1 Where a required automatic sprinkler system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the sprinkler system has been returned to service.

NFPA 13, Installation of Sprinkler Systems, 1999 Edition
3-8.3* Identification of Valves. All control, drain and test connection valves shall be provided with permanently marked weatherproof metal or rigid plastic identification signs. The sign shall be secured with corrosion-resistant wire, chain or other approved means.

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 Edition

1-8.1 Records shall indicate the procedure performed (e.g., inspection, test, or maintenance), the organization that performed the work, the results, and the date.

1-8.2 Records shall be maintained by the owner. Original records shall be retained for the life of the system. Subsequent records shall be retained for a period of one year after the next inspection, test, or maintenance required by the standard.

2-2.1.1 Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.

2-2.1.2 Unacceptable obstructions to spray patterns shall be corrected.

2-4.1.8 Sprinklers shall not be altered in any respect or have any type of ornamentation, paint, or coatings applied after shipment from the place of manufacture.

2-2.6 Alarm Devices. Alarm devices shall be inspected quarterly to verify that they are free of physical damage.

2-2.7 Hydraulic Nameplate. The hydraulic nameplate, if provided, shall be inspected quarterly to verify that it is attached securely to the sprinkler riser and is legible.

2-3.3 Alarm Devices. Waterflow alarm devices including, but not limited to, mechanical water motor gongs, vane-type waterflow devices, and pressure switches that provide audible or visual signals shall be tested quarterly.

9-2.7 Waterflow Alarm. All waterflow alarms shall be tested quarterly in accordance with the manufacturer's instructions.

9-3.4.3 Valve supervisory switches shall be tested semiannually. A distinctive signal shall indicate movement from the valve ' s normal position during either the first two revolutions of a hand wheel or when the stem of the valve has moved one-fifth of the distance from its normal position. The signal shall not be restored at any valve position except the normal position.

9-5.1.1 All valves shall be inspected quarterly. The inspection shall verify that the valves are in the following condition:
(a) In the open position
(b) Not leaking
(c) Maintaining downstream pressures in accordance with the design criteria
(d) In good condition, with handwheels installed and unbroken
9-5.2.1 All valves shall be inspected quarterly. The inspection shall verify the following:
(a) The handwheel is not broken or missing.
(b) The outlet hose threads are not damaged.
(c) There are no leaks.
(d) The reducer and the cap are not missing.
9-7.1 Fire department connections shall be inspected quarterly. The inspection shall verify the following:
(a) The fire department connections are visible and accessible.
(b) Couplings or swivels are not damaged and rotate smoothly.
(c) Plugs or caps are in place and undamaged.
(d) Gaskets are in place and in good condition.
(e) Identification signs are in place.
(f) The check valve is not leaking.
(g) The automatic drain valve is in place and operating properly.

NFPA 72, National Fire Alarm Code, 1999 Edition
2-6 Sprinkler Waterflow Alarm -Initiating Devices.

2-6.1 The provisions of Section 2-6 shall apply to devices that initiate an alarm indicating a flow of water in a sprinkler system.

2-6.2* Initiation of the alarm signal shall occur within 90 seconds of waterflow at the alarm-initiating device when flow occurs that is equal to or greater than that from a single sprinkler of the smallest orifice size installed in the system. Movement of water due to waste, surges, or variable pressure shall not be indicated.

Findings:

During a tour of the facility, interview, and document review with the Plant Operations Manager, Stationary Engineer, and the Director of Accreditation on 5/23/16 through 5/25/16, the automatic sprinkler systems were observed and document reviewed.

MAIN BUILDING

5/23/16

1. On 5/23/16 at 10:35 a.m., the sprinkler in Room 237 on the second floor had foreign material around the sprinkler. This finding was confirmed by the Director of Accreditation.

2. On 5/23/16 at 10:41 a.m., there was a bent sprinkler head in the Breakroom located on the second floor. The finding was confirmed by the Plant Operations Manager.

3. On 5/23/16 at 10:43 a.m., the sprinkler in the Shower room near Room 237 on the second floor had foreign materials around the sprinkler. This finding was confirmed by the Director of Accreditation.

4. On 5/23/16 at 10:43 a.m., the sprinkler in Room 212 on the second floor had foreign materials around the sprinkler. This finding was confirmed by the Director of Accreditation.

5. On 5/23/16 at 10:45 a.m., the sprinkler in the Supply closet near Room 214 on the second floor had foreign material hanging on the deflector. This finding was confirmed by the Director Accreditation.

OUTPATIENT SERVICE ADOLESCENT

6. On 5/24/16 at 8:12 a.m., the side wall sprinkler head on the second floor was not flush to the wall and exposed an approximately 1 1/2 penetration. The finding was confirmed the Plant Operations Manager.


7. On 5/24/16 at 8:59 a.m., during fire alarm testing of the automatic sprinkler system, the Inspector's Test Valve (ITV) was opened. The fire alarm failed to emit an audible alarm and failed to show a trouble signal on the fire alarm key pad located near the Reception area on the first floor. The ITV was opened for approximately four minutes.

8. On 5/24/16 at 9:09 a.m., the Plant Operations Manager called the monitoring service to confirm signal. The monitoring service stated there were no signal received for the waterflow.

9. On 5/24/16 at 9:57 a.m., the ITV was retested by the Stationary Engineer after resetting the fire alarm key pad. The ITV was opened and activated the alarm at 43 seconds. The bell located outside for the waterlfow did not sound, but the alarm box inside the facility sounded. This signal was confirmed by the monitoring service at 10:06 a.m. Upon interview, the Plant Operations Manager stated that the bell near the riser does not work and was noted during the annual testing and inspections by the vendor on 4/28/16.

OUTPATIENT SERVICE ADOLESCENT
10. On 5/25/16 at 9:15 a.m., the document titled "VISUAL AND AUDIBLE FIRE ALARM DEVICES TESTS AND INSPECTIONS" dated 4/28/16 was reviewed. The document stated "OUTSIDE HORN/BELL DID NOT SOUND WHEN TESTED BY FLOW SWITCH. FURTHER INVESTIGATION REQUIRED". This finding was confirmed by Plant Operations Manager and was mentioned during the waterflow testing that was conducted on 5/24/16.

11. On 5/25/16 at 10:00 a.m., there was no five (5) year certification sticker posted on the riser located in back of the building. Upon document review, the document titled "5 year Inspection, Testing, and Maintenance Fire Sprinkler System" dated 4/15/15 stated "PASS". When interviewed, the Plant Operations Manager stated that they will follow up with the vendor as to why is wasn't provided on the riser.

Based on interview and document review, the facility failed to maintain their emergency generator. This was evidenced by the failure to record transfer time during monthly generator load test, and not performing the required 30 minute full load test monthly. This affected the Main Building, and could result in failure of the generator in the event of a power outage.

NFPA 99, Standard for Health Care Facilities, 1999 edition
3-4.4.1 Maintenance and Testing of Essential Electrical System.
3-4.4.1.1 Maintenance and Testing of Alternate Power Source and Transfer Switches.
(a) Maintenance of Alternate Power Source. The generator set or other alternate power source and associated equipment, including all appurtenant parts, shall be so maintained as to be capable of supplying service within the shortest time practicable and within the 10-second interval specified in 3-4.1.1.8 and 3-4.3.1. Maintenance shall be performed in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6.
(b) Inspection and Testing.
1.* Test Criteria. Generator sets shall be tested twelve (12) times a year with testing intervals between not less than 20 days or exceeding 40 days. Generator sets serving emergency and equipment systems shall be in accordance with NFPA 110, Standard for Emergency and Standby Power Systems,
2. Test Conditions. The scheduled test under load conditions shall include a complete simulated cold start and appropriate automatic and manual transfer of all essential electrical system loads.
3. Test Personnel. The scheduled tests shall be conducted by competent personnel. The tests are needed to keep the machines ready to function and, in addition, serve to detect causes of malfunction and to train personnel in operating procedures.
3-4.4.2 Recordkeeping. A written record of inspection, performance, exercising period, and repairs shall be regularly maintained and available for inspection by the authority having jurisdiction.

NFPA 110, Standard for Emergency and Standby Power Systems, 1999 Edition
6-3 Maintenance and Operational Testing.
6-3.1* The EPSS shall be maintained to ensure to a reasonable degree that the system is capable of supplying service within the time specified for the type and for the time duration specified for the class.
6-3.2 A routine maintenance and operational testing program shall be initiated immediately after the EPSS has passed acceptance tests or after completion of repairs that impact the operational reliability of the system.
6-3.3 A written schedule for routine maintenance and operational testing of the EPSS shall be established.
6-3.4 A written record of the EPSS inspections, tests, exercising, operation, and repairs shall be maintained on the premises.
The written record shall include the following:
(a) The date of the maintenance report
(b) Identification of the servicing personnel
(c) Notation of any unsatisfactory condition and the corrective action taken, including parts replaced
(d) Testing of any repair for the appropriate time as recommended by the manufacturer

6-4.2* Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly , for minimum of 30 minutes, using one of the following methods:
(a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating.
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer.
The date and time of day for required testing shall be decided by the owner, based on facility operations.
6-4.2.2 Diesel-powered EPS installations that do not meet the requirements of 6-4.2 shall be exercised monthly with the available EPSS load and exercised annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of 2 continuous hours.

Findings:

During document review and interview with the Plant Operations Manager and Director of Accreditation on 5/25/16, the emergency generator maintenance documents were requested.

1. At 10:10 a.m., the documents for the monthly load tests for the diesel emergency generator were requested. The August 2015 monthly load test indicated that the generator was tested 6 minutes. The generator was not tested for the required full 30 minutes.

2. At 9:35 a.m., there was no transfer time recorded during the monthly generator load test for August 2015. The finding was confirmed by the Plant Operations Manager.

Based on observation and interview, the facility failed to maintain the electrical wiring, as evidenced by the use of power strips as substitute for fixed wiring. This could result in the ignition of an electrical fire. This affected two of two floors in the Main Building, Outpatient Clinic - Chemical Dependency and Outpatient Clinic Adolescent.

NFPA 101, Life Safety Code, 2000 Edition
9.1.2 Electric. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

NFPA 70, National Electrical Code, 1999 Edition
400-7 Uses Permitted
(a) Uses. Flexible cords shall be used only for the following:
1) Pendants
2) Wiring of fixtures
3) Connection of portable lamps, portable and mobile signs or appliances
4) Elevator cables
5) Wiring of cranes and hoists
6) Connection of stationary equipment to facilitate their frequent interchange
7) Prevention of the transmission of noise or vibration
8) Appliances where the fastening means and mechanical connections are specifically designed to permit ready removal for maintenance and repair, and the appliance is intended or identified for flexible cord connection
9) Data processing cables as permitted by Section 645-5
10) Connection of moving parts
11) Temporary wiring as permitted in Sections 305-4 b) & 305-4 c)

400-8. Uses not Permitted. Unless specifically permitted in Section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
Exception: Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of Section 364-8.

Findings:

During a tour of the facility with the Plant Operations Manager and Director of Accreditation on 5/23/16, the electrical wiring in the facility was observed.

Main Building

1. At 10:18 a.m., there was a microwave and electric fan plugged into a power strip instead of directly in to an electrical outlet in the Pharmacy office located on the first floor. This finding was confirmed by the Director Accreditation.

2. At 10:40 a.m., there microwave and coffee maker plugged into a power strip instead of directly in to an electrical outlet in the Staff Lounge located on the second floor. This finding was confirmed by the Director Accreditation.

3. At 10:41 a.m., a water dispenser and a refrigerator were plugged into a mounted power strip instead of directly in to an electrical outlet in the Breakroom located on the second floor. This finding was confirmed by the Plant Operations Manager.

Outpatient - Chemical Dependency

4. At 1:31 p.m., a water dispenser and a microwave were plugged into a power strip instead of directly in to an electrical outlet in the Pulmonary Rehabilitation Room.

Outpatient Services Adolescent

5. At 2:24 p.m., there were two fans that were plugged into two power strips instead of directly in to an electrical outlet in the Staff Office B located on the second floor. When interviewed, the Plant Operations Manager confirmed the findings and removed the fans from the power strips.



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