HospitalInspections.org

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Based on observation on 3/30/2016, the facility failed to maintain corridor doors that would resist the passage of smoke. Findings include:


1. Mechanical room # 3, when doors were fully closed, and latched approximately 1/4" gap between the doors allowed this surveyor to be able to see into the room from the corridor.

2. Mechanical room # 4, when doors were fully closed, and latched approximately 1/4" gap between the doors allowed this surveyor to be able to see into the room from the corridor.

The deficiency impacted 2 of 5 smoke compartments.


NFPA 101, 19.3.6.3.1 Exception No. 2. In the smoke compartments protected throughout by an approved, supervised automatic sprinkler system, doors in corridor walls shall be constructed to resist the passage of smoke and be provided with suitable means of keeping the doors closed.

Based on the observation on 3/30/2016, the facility failed to maintain smoke barriers to restrict the movement of smoke from one side of the smoke barrier to the other. Findings include:

Unsealed penetrations around blue wiring, also an opening right bottom of a section of sheetrock, in the smoke barrier by the Pharmacy entrance.


The deficiency impacted 1 of 5 smoke compartments.


NFPA 101, 19.3.7.3 Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1/2 hour.

8.3.1* General. Where required by Chapters 12 through 42, smoke barriers shall be provided to subdivide building spaces for the purpose of restricting the movement of smoke.

NFPA 101, 8.3.6.1 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

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Based on observation on 3/30/2016, the facility to maintain combustible storage rooms with smoke resisting partitions and doors. Findings include:

Two combustible storage rooms, both over 50 sq. feet doors are equipped with self-closing devices. When the door was fully open, and released the doors failed to close and latch. These rooms are located by the locker room, by the entrance to Surgery.


This deficiency impacted 1 of 5 smoke compartments.


Review of 2000 NFPA 101, 8.4.1 and/or 19.3.5.4.

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Based on observation on 3/2-3/2016, the facility failed to maintain the automatic sprinkler system. Findings include:

1. Documentation was not provided for when the last 5 year internal inspection was conducted.
2. Date on sprinkler riser gauges was 2010.

The deficiency impacted 5 of 5 smoke compartments.


2000 NFPA 101, 19.7.6 Maintenance and Testing. (See 4.6.12.)

2000 NFPA 101, 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.

1998 NFPA 13, 12-1* General. A sprinkler system installed in accordance with this standard shall be properly inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, to provide at least the same level of performance and protection as designed.

1998 NFPA 25, 2-3.2* Gauges. Gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge. Gauges not accurate to within 3 percent of the full scale shall be recalibrated or replaced.

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Based on review of documentation on 3/30/2016, the facility failed to maintain smoke dampers. Findings include:

Per interview with the maintenance director, he was not aware of the 6-year damper maintenance interval requirements.

This deficiency impacted 5 of 5 smoke compartments.

1999 NFPA 90A, 3-4.7 At least every 6 years for hospitals (4 years for all other health care facilities), fusible links (where applicable) shall be removed; all dampers shall be operated to verify that they fully close; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary.

Per CMS Hospitals may apply a 6-year damper testing interval conforming to NFPA 80 & NFPA 105.

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Based on review of documentation on 3/30/2016, the facility failed to document the running of the generator for 30 minutes per month under load. Findings include:

Documentation reviewed by this surveyor was for Jan through Dec of 2015, and Jan, Feb, March of 2016. Exercise of generator under load for 30 minutes per month was not indicated. Maintenance director did advise this surveyor that the generator was always run under load each month.

This deficiency impacted 5 of 5 smoke compartments.


1999 NFPA 99, 3-4.4.1.1 Maintenance and Testing of Alternate Power Source and Transfer Switches.
(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, Chapter 6.
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.

1999 NFPA 99, 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.

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Based on observation on 3/30/2016, the facility failed to maintain corridor doors that would resist the passage of smoke. Findings include:


1. Mechanical room # 3, when doors were fully closed, and latched approximately 1/4" gap between the doors allowed this surveyor to be able to see into the room from the corridor.

2. Mechanical room # 4, when doors were fully closed, and latched approximately 1/4" gap between the doors allowed this surveyor to be able to see into the room from the corridor.

The deficiency impacted 2 of 5 smoke compartments.


NFPA 101, 19.3.6.3.1 Exception No. 2. In the smoke compartments protected throughout by an approved, supervised automatic sprinkler system, doors in corridor walls shall be constructed to resist the passage of smoke and be provided with suitable means of keeping the doors closed.

Based on the observation on 3/30/2016, the facility failed to maintain smoke barriers to restrict the movement of smoke from one side of the smoke barrier to the other. Findings include:

Unsealed penetrations around blue wiring, also an opening right bottom of a section of sheetrock, in the smoke barrier by the Pharmacy entrance.


The deficiency impacted 1 of 5 smoke compartments.


NFPA 101, 19.3.7.3 Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1/2 hour.

8.3.1* General. Where required by Chapters 12 through 42, smoke barriers shall be provided to subdivide building spaces for the purpose of restricting the movement of smoke.

NFPA 101, 8.3.6.1 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

.

Based on observation on 3/30/2016, the facility to maintain combustible storage rooms with smoke resisting partitions and doors. Findings include:

Two combustible storage rooms, both over 50 sq. feet doors are equipped with self-closing devices. When the door was fully open, and released the doors failed to close and latch. These rooms are located by the locker room, by the entrance to Surgery.


This deficiency impacted 1 of 5 smoke compartments.


Review of 2000 NFPA 101, 8.4.1 and/or 19.3.5.4.

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Based on observation on 3/2-3/2016, the facility failed to maintain the automatic sprinkler system. Findings include:

1. Documentation was not provided for when the last 5 year internal inspection was conducted.
2. Date on sprinkler riser gauges was 2010.

The deficiency impacted 5 of 5 smoke compartments.


2000 NFPA 101, 19.7.6 Maintenance and Testing. (See 4.6.12.)

2000 NFPA 101, 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.

1998 NFPA 13, 12-1* General. A sprinkler system installed in accordance with this standard shall be properly inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, to provide at least the same level of performance and protection as designed.

1998 NFPA 25, 2-3.2* Gauges. Gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge. Gauges not accurate to within 3 percent of the full scale shall be recalibrated or replaced.

.
Based on review of documentation on 3/30/2016, the facility failed to maintain smoke dampers. Findings include:

Per interview with the maintenance director, he was not aware of the 6-year damper maintenance interval requirements.

This deficiency impacted 5 of 5 smoke compartments.

1999 NFPA 90A, 3-4.7 At least every 6 years for hospitals (4 years for all other health care facilities), fusible links (where applicable) shall be removed; all dampers shall be operated to verify that they fully close; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary.

Per CMS Hospitals may apply a 6-year damper testing interval conforming to NFPA 80 & NFPA 105.

.
Based on review of documentation on 3/30/2016, the facility failed to document the running of the generator for 30 minutes per month under load. Findings include:

Documentation reviewed by this surveyor was for Jan through Dec of 2015, and Jan, Feb, March of 2016. Exercise of generator under load for 30 minutes per month was not indicated. Maintenance director did advise this surveyor that the generator was always run under load each month.

This deficiency impacted 5 of 5 smoke compartments.


1999 NFPA 99, 3-4.4.1.1 Maintenance and Testing of Alternate Power Source and Transfer Switches.
(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, Chapter 6.
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.

1999 NFPA 99, 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.