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Based on observation and staff interview during the course of the survey, it was determined that the facility failed to install and maintain the two-hour fire rated separation to the clinic occupancy in accordance with Life Safety Code Section 18.1.2.1 and Section 8.2.3.2.4. This deficient practice could affect all 5 patients, staff and visitors within the health care building, smoke compartment B, should heat and smoke spread from a fire condition in the adjacent building. This was evidenced by the following:

Penetrations and miscellaneous openings in fire barriers were not filled with a material capable of maintaining the fire resistance rating of the barrier, as required.

The 2 hour rated occupancy separation wall (loading dock area) was observed to have the following deficiencies:
A) The top of wall fire stop system was incomplete and not installed to maintain the required two hour fire rating of the wall. The top of wall gap, at the roof deck, was sealed with a mineral wool backing (within the flutes) and covered with a fire stop caulk or spray. Numerous sections of exposed mineral wool were observed that did not have any coating of fire stop material.

B) One conduit penetration that had been fire caulked, was observed to have been pulled through the wall and no longer had fire rated caulk around the penetration at the wall. This penetration must also be re-installed to insure the conduit is anchored to the wall, as required.
The Facilities Manager acknowledged the fire stop system deficiencies during a tour of the facility.

Life Safety Code Section 18.1.2.1 requires, in part, that sections of health care facilities that are classified as other occupancies be separated by two hour rated construction.
Section 8.2.3.2.4 requires, in part, that penetrations and miscellaneous openings in fire barrier walls be filled with a material capable of maintaining the fire resistance rating of the barrier. Section 8.2.3.2.4.2(2) requires that penetrating sleeves be solidly set in the smoke barrier wall.

Based on observation, record review and staff interview during the survey, it was determined that the facility failed to install corridor doors in accordance with Life Safety Code Section 18.3.6.3. This deficient practice could affect all 5patients, staff and visitors within both smoke compartments should the egress corridor become untenable due to smoke and heat transfer via the deficient doors separating rooms from the egress corridor. This was evidenced by the following:

A) Corridor doors were not equipped with positive latching hardware, as required. Four emergency department exam/treatment rooms were not provided with latching hardware on the sliding corridor doors. The facility design plan, fire safety page A1.1, designated the walls throughout the emergency department as smoke partition corridor walls. There was no indication on the plan that the area was designed as a suite of rooms in accordance with Life Safety Code Section 18.2.5.

B) The latch bolt on the pharmacy corridor door was disabled preventing the door from positively latching into the door frame.

C) Corridor doors were not arranged to automatically latch into the door frame, as required. Three housekeeping closets and the O/R were equipped with double doors. One of two leafs was not equipped with automatic latching hardware, as required. The leaf equipped with the latchset was arranged to latch into the " fixed " door leaf that would not be automatically latched into the door frame.

D) Dutch doors were not equipped with latching hardware on both leafs and were not equipped with a rabbet, bevel or astragal, as required. The laboratory corridor dutch door was not equipped with latching hardware on the upper leaf and did not form a smoke resistive seal between the upper and lower leafs.
The Life Safety Code Section 19.3.6.3.6 requires that both the upper and lower leafs on dutch doors be equipped with a latching device, and the meeting edges of the upper and lower leaves be equipped with an astragal, a rabbet or a bevel.

E) Corridor doors were not arranged to be closed from the corridor side with a push or pull, as required. The kitchen area dish window roll down door could not be pulled closed from the corridor side.
The Facilities Manager acknowledged the door latching arrangements during a tour of the facility.

Life Safety Code Section 18.3.6.3.2: Doors shall be provided with positive latching hardware. Roller latches shall be prohibited. Section 18.3.6.3.6 requires that both the upper and lower leafs on dutch doors be equipped with a latching device, and the meeting edges of the upper and lower leaves be equipped with an astragal, a rabbet or a bevel.

Based on observation and staff interview during the survey, it was determined that the facility failed to mark access to exits in accordance with Life Safety Code Section 7.10. This deficient practice could affect all 5patients, staff and visitors within both smoke compartments should the way to reach an exit and adjoining smoke compartment not be readily apparent. This was evidenced by the following:

Illuminated exit signs must be installed and modified in the following areas:
1. Add an additional exit sign above the horizontal exit doors to the clinic building.
2. Add two additional exits signs above both sides of the double smoke barrier doors, main east/west corridor.
3. Add an additional exit sign above the corridor smoke barrier doors, near room S-5.
4. Add two additional exit signs in the corridor area outside of the procedure room.
5. Add two directional exit signs in the PREOP/PACU room.
6. Relocated the exit sign installed above the main entrance doors. The sign is obstructed by ceiling light fixtures.
The Facilities Manager acknowledged the exit sign installation during a tour of the facility.
The Life Safety Code Section 7.10.1.4 requires that access to exits be marked by approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent to the occupants.

Based on observation during the survey, it was determined that the fire resistance rating of smoke barrier walls were not maintained in accordance with Life Safety Code Section 18.3.7.3 and Section 8.2. This deficient practice could affect all 5 patients, staff and visitors within both smoke compartments by allowing the spread of fire and smoke between the compartments. This was evidenced by the following:

Penetrations and miscellaneous openings in fire barriers were not filled with a material capable of maintaining the fire resistance rating of the barrier, as required.
The 1 hour rated smoke barrier wall (above the corridor doors in the O/R corridor) was observed to have a deficient top of wall fire stop system. The fire barrier was incomplete and not installed to maintain the required one hour fire rating of the wall.
The top of wall gap, at the roof deck, was sealed with a mineral wool backing (within the flutes) and covered with a fire stop caulk or spray. Numerous sections of exposed mineral wool were observed that did not have any coating of fire stop material.

Life Safety Code Section 18.3.7.3 requires that the smoke barrier wall be constructed in accordance with Section 8.3, and shall have a fire resistance rating of not less than 1 hour. Section 8.2.3.2.4 requires, in part, that penetrations and miscellaneous openings in fire barrier walls be filled with a material capable of maintaining the fire resistance rating of the barrier.

Based on observation and staff interview during the survey, it was determined that the facility failed to provide and maintain hazardous area enclosures in accordance with the Life Safety Code Section 18.3.2.1 and Section 8.4. This deficient practice could affect all 5 patients, as well as staff and visitors within both smoke compartments, should there be smoke and heat transfer between the hazardous area and other portions of the building. This was evidenced by the following:

A) Storage rooms, larger than 100 square feet with combustible material storage, were not enclosed with one hour fire rated construction and door openings protected with 45 minute (minimum) fire rated doors equipped with self-closing devices.
1. The main boiler room one hour wall was not fire stopped at the roof deck and was not equipped with a minimum 45 minute fire rated corridor door.
2. The loading dock room was observed to be used for combustible storage that included kitchen supplies in cardboard boxes and wood furniture. The enclosure was not one hour fire rated and the doors were not fire rated and labeled.
3. The clean linen supply room (adjacent to the loading dock) was used for combustible materials in quantities deemed hazardous. The 3 of 4 enclosure walls were not one hour fire rated and the doors were not fire rated and labeled.
4. The recently created materials supply room (approximately 20 ft. x 24 ft.) was not a one hour fire rated enclosure and the doors were not fire rated and labeled. The Facilities Manger reported that the room had been converted from office space to storage approximately 6 months prior to the survey. The facility design plan, fire safety page A1.1, did not designate these rooms as having one-hour fire rated walls.

B) Hazardous area enclosure doors were not self-closing and positively latching, as required. The emergency department soiled linen room corridor door was observed to have a disabled latching mechanism.
The Facility Manager acknowledged the hazardous area arrangements during a tour of the facility.

The Life Safety Code requires that hazardous areas be separated from other spaces in accordance with Section 18.3.2.1 and Section 8.4. Section 8.4.1.3 requires that doors in fire rated barriers have a minimum ? hour fire resistance rating and that the doors be self-closing or automatic closing.

Based on observation and staff interview, it was determined that the facility failed to arrange and maintain the means of egress in accordance with Life Safety Code Section 18.2 and Chapter 7. This deficient practice could affect all 5 patients, as well as staff and visitors throughout the facility, if a continuous unobstructed means of egress to the public way not be provided. This was evidenced by the following:

A) Egress doors were not maintained to be readily opened from the egress side, as required. The break-away door feature (main entrance inner and outer door sets) was disabled due to a double-keyed deadbolt lock installed on each door set. The Facilities Manager reported that the outer doors were locked with the deadbolt at night for security purposes.

B) The ambulance entry breakaway sliding door (marked exit) was equipped with a double keyed deadbolt lock.

C) Powered egress doors were not equipped with readily visible signs that read " IN EMERGENCY, PUSH TO OPEN " , as required. Both inner and outer powered doors at the ambulance entrance were not equipped with the signage required in Life Safety Code Section 7.2.1.9.1.

D) Access-controlled egress doors were not equipped with a manual release device that was installed in accordance with Section 7.2.1.6.2(c), as required. The MRI area exit door, the pharmacy exit door and the med room exit door were all equipped with magnetic locking devices that unlocked with a motion sensor installed above the door and with fire alarm activation. The required manual release device was not installed within 5 ft. of each door, as required. Note: see special manual release wiring arrangements in Section 7.2.1.6.2.

E) The exit discharge area (south exit door adjacent to the lab) was not continuous to the public way, as required. The exit discharge area was a small concrete pad and a landscaped garden area. There was no continuous paved walk to the public way.

Life Safety Code Section 18.2.1 requires that means of egress components be arranged in accordance with Chapter 7. Section 18.2.2.2.4: doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side.
Exception No. 2: Delayed-egress locks complying with 7.2.1.6.1 shall be permitted, provided that not more than one such device is located in any egress path.
Exception No. 3: Access-controlled egress doors complying with 7.2.1.6.2 shall be permitted.
Section 7-2.1.5.1 requires that a door shall be so arranged as to be readily opened from the egress side whenever the building is occupied. Section 7.2.1.9.1 requires, in part, that powered doors be designed and installed so that when a force is applied to the door on the side from which egress is made, it shall be capable of swinging from any position to the full use of the required width of the opening in which it is installed (see 7.2.1.4). On the egress side of each door, there shall be a readily visible, durable sign that reads as follows: IN EMERGENCY, PUSH TO OPEN.
The sign shall be in letters not less than 1 in. (2.5 cm) high on a contrasting background.
Section 7.7 requires that all exits terminate directly at a public way or at an exterior exit discharge. Yards, courts, open spaces or other portions of the exit discharge shall be of required width and size to provide all occupants with a safe access to a public way.
Section 7.1.10.1 requires that the means of egress be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. This would include any type of barrier that is an impediment to free movement in the means of egress, such as the accumulation of snow or ice.
Life Safety Code Section 7.2.1.6.2 Access-Controlled Egress Doors:
Where permitted in Chapters 11 through 42, doors in the means of egress shall be permitted to be equipped with an approved entrance and egress access control system, provided that the following criteria are met.
(a) A sensor shall be provided on the egress side and arranged to detect an occupant approaching the doors, and the doors shall be arranged to unlock in the direction of egress upon detection of an approaching occupant or loss of power to the sensor.
(b) Loss of power to the part of the access control system that locks the doors shall automatically unlock the doors in the direction of egress.
(c) The doors shall be arranged to unlock in the direction of egress from a manual release device located 40 inches to 48 inches vertically above the floor and within 5 ft of the secured doors. The manual release device shall be readily accessible and clearly identified by a sign that reads as follows: PUSH TO EXIT
When operated, the manual release device shall result in direct interruption of power to the lock - independent of the access control system electronics - and the doors shall remain unlocked for not less than 30 seconds.
(d) Activation of the building fire-protective signaling system, if provided, shall automatically unlock the doors in the direction of egress, and the doors shall remain unlocked until the fire-protective signaling system has been manually reset.
(e) Activation of the building automatic sprinkler or fire detection system, if provided, shall automatically unlock the doors in the direction of egress and the doors shall remain unlocked until the fire-protective signaling system has been manually reset.

Based on observation and record review, it was determined that the facility failed to install horizontal exits in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code Section 18.2.2.5. This deficient practice could affect all building occupants attempting to use the exit if visibility is not provided between compartments. This was evidenced by the following:

Cross-corridor horizontal exit doors were not equipped with vision panels, as required. The clinic entrance cross-corridor horizontal exit doors were not equipped with vision panels. The facility design plan, fire safety page A1.1, designated these doors as a horizontal exit.
Life Safety Code Section 18.2.2.5.6: An approved vision panel shall be required in each horizontal exit. Center mullions shall be prohibited.

Based on record review and staff interview during the survey, it was determined that the facility failed to install emergency lighting for the entire means of egress and maintain battery powered emergency lighting systems in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code. This deficient practice could affect patients and staff within the operating rooms should the battery emergency lighting fail and occupants evacuating the building to the public way.
This was evidenced by the following:


A) It could not be determined during the survey if the exit discharge areas, on the exterior of the building, were provided with emergency lighting, as required. The Facilities Manager was not aware of any exterior emergency illumination.
Life Safety Code Section 7.9.1 requires emergency lighting facilities for the means of egress which includes the exit discharge walkways leading to a public way.

B) There were no records on premises that documented the routine testing of the battery powered emergency lighting units installed in the O/R. The Facilities Manager reported that there was no test program in place.
Life Safety Code Section 7.9.3, Periodic Testing of Emergency Lighting Equipment, states: "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? 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.

Based on record review during the survey, it was determined that the facility failed to maintain a complete plan for the protection of all persons in the event of fire in accordance with Life Safety Code Section 18.7.1 and 18.7.2. This deficient practice could affect all 5 patients if staff response during a fire situation does not include knowledge and training in evacuation of the smoke compartment.
This was evidenced by the following:

The fire emergency plan did not specifically discuss the evacuation of a smoke compartment, as required. The facility fire emergency plan titled "Plant Operations & Safety Policy & Procedures Manual" Section 820-0013 titled "Fire Safety and Evacuation" did not address evacuation of a smoke compartment.

Life Safety Code Section 18.7.1.1 requires that the administration of all health care facilities develop a plan for the protection of all persons in the event of fire, including a plan for their evacuation to an area of refuge and from the building when necessary. The plan must include all components and requirements outlined in Life Safety Code Section 18.7.1 and 18.7.2.
Life Safety Code Section 18.7.2.2 requires that a written health care occupancy fire safety plan provide for the following:
1. Use of alarms
2. Transmission of alarms to the 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

Based on record review and staff interview during the survey, it was determined that the facility failed to conduct fire drills in accordance with Life Safety Code Sections 18.7.1.2 and 4.7. This deficient practice could affect all 5 patients if staff are not trained in the emergency actions required during the unusual conditions that can occur in an actual emergency. This was evidenced by the following:

A review of fire drill records determined that the facility failed to:
1. conduct fire drills at least quarterly on each shift,
2. conduct fire drills at varied times under varying conditions,
3. sound the fire alarm system during fire drills,
4. familiarize personnel with the signals and emergency action required under varied conditions.
5. assign the responsibility for planning and conduct of the drills to staff knowledgeable and trained in drill conduct and objectives.

Fire drill records provided minimal documentation and did not include specific dates or specific time of day. The drills were conducted every 4 months and were documented only with the Facilities Manager's initials in a grid chart by month and year. The Facilities Manager reported that most drills did not activate the fire alarm system or alternate coded announcement and often consisted of a discussion of fire procedures with staff.

Life Safety Code, Section 18.7.1.2 requires, in part, that fire drills be conducted quarterly on each shift to familiarize 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 pm and 6:00 am, a coded announcement shall be permitted to be used instead of audible alarms. Section 4.7.5 requires that drills be held at unexpected times and under varying conditions to simulate the unusual conditions that can occur in an actual emergency. Section 4.7.3: Responsibility for the planning and conduct of drills shall be assigned only to competent persons qualified to exercise leadership.

Based on observation and record review during the survey, it was determined that the facility failed to install and maintain the fire alarm system in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code, and NFPA 72, National Fire Alarm Code. This deficient practice could affect all 5 patients, staff and visitors should the fire alarm system fail to function as designed and fail to notify staff in all areas of the building. This was evidenced by the following:

A) Fire alarm system secondary power supply sealed lead-acid batteries were not load voltage tested semiannually, as required. The Facilities Manager reported that the fire alarm system was subject to annual inspections only. The last load voltage test was conducted on 05-29-12 during the annual inspection of the fire alarm system.
NFPA 72, Section 7.3.2 subsection 6d requires that sealed lead-acid type fire alarm system batteries be subject to a load voltage test semiannually.

B) Fire alarm system visual notification appliances were not installed to alert occupants in all building areas, as required. The O/R and Procedure Room were not equipped with visual notification appliances. The O/R did not have windows to the corridor area where audible/visual appliances were installed.
Life Safety Code Section 18.3.4.3.1 allows visible alarm indicating appliances to be used in lieu of audible alarm signals in critical care areas. Section 9.6.3.7 requires that the general evacuation alarm signal operate throughout the entire building.

Based on observation and record review during the survey, it was determined that the facility failed to install and maintain the automatic fire sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 13 and Standard 25. This deficient practice could affect all 5 patients, staff and visitors should the automatic sprinkler system fail to operate in a timely and effective manner due to non-code compliant installation and maintenance. This was evidenced by the following:

A) Sprinkler system control valves were not equipped with signs indicating system or area served, as required. Control valves in the pump room were equipped with signage stating "Control Valve" but the signs did not specify the system or portion of the system served by the valve. One sign was observed to be detached from the valve on the floor.
NFPA 25 Section 9-3.2 requires that each control valve have a sign indicating the system or portion of the system it controls.

B) Sidewall sprinklers, installed in the walk-in cooler and freezer, were subject to damage by stock storage on the top shelf. The sprinkler heads were not protected by listed guards.
NFPA 13 Section 3-2.8 requires that sprinklers subject to mechanical damage be protected with listed guards.

C) Standard pendant sprinkler heads were not installed with unobstructed water spray patterns, as required. Two pendant sprinkler heads, installed in the x-ray room, were obstructed by a ceiling mounted equipment track.
NFPA 25, Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems Section 2-2.1.2 states:"Unacceptable obstructions to spray patterns shall be corrected."

D) The automatic sprinkler system waterflow alarm was not tested quarterly, as required. Records on premises documented testing of the waterflow alarm in August and May 2012. NFPA 25 Section 9-2.7 requires that waterflow alarms be tested quarterly in accordance with manufacturer's instructions.

E) The central supply storage room had two 3" x 3" holes in the suspended ceiling from electrical raceway posts that had been removed. Prompt sprinkler operation is dependent upon a continuous ceiling when sprinklers are installed below the suspended ceiling.

Based on record review and staff interview during the survey, it was determined that the facility failed to insure that the automatic sprinkler system has an adequate and reliable water supply in accordance with NFPA 20 and NFPA 25. This deficient practice could affect all 5 patients, staff and visitors should the automatic fire pump fail to operate as designed due to inadequate maintenance and testing. This was evidenced by the following:

A) Weekly churn tests were not conducted for a 10 minute (minimum) duration, as required. Records documenting the weekly churn test were incomplete and did not include a specific date, suction and discharge pressures, pump starting pressure, and pump run time. The required recordings were not documented during the weekly tests. The test record on premises did not include any entries since February 2013.
The Facilities Manager reported that the weekly test consisted of opening the main drain valve until the pump started and allowing water to flow for approximately 10 seconds before shutting the main drain valve. The pump was manually shut down without running for the minimum 10 minute duration.

NFPA 25 Section 5-3.2.1 requires that the weekly test of electric motor-driven pump be conducted by starting the pump automatically with a minimum run time of 10 minutes.
A weekly test of electric motor-driven pump assemblies shall be conducted without flowing water. Section 5-3.2.4.1 Pump System Procedure:
(a) Record the system suction and discharge pressure gauge readings.
(b) Check the pump packing glands for slight discharge.
(c) Adjust gland nuts if necessary.
(d) Check for unusual noise or vibration.
(e) Check packing boxes, bearings, or pump casing for overheating.
(f) Record the pump starting pressure.

B) It could not be determined during the survey if fire pump supervisory signals transmit to a location within the protected building that was constantly attended by qualified personnel or at an approved, remotely located receiving facility. The Facility Manager believed the pump was supervised by the fire alarm system but could not verify what functions were supervised. There were no records of periodic testing of the supervisory equipment NFPA 72 Section 7.3.2 requires that supervisory equipment be tested quarterly.

NFPA 20 Section 7-4.7 Alarm and Signal Devices Remote from Controller.
Where the pump room is not constantly attended, audible or visible alarms powered by a source not exceeding 125 V shall be provided at a point of constant attendance. These alarms shall indicate the following.
(a) Pump or Motor Running. The alarm shall actuate whenever the controller has operated into a motor-running condition. This alarm circuit shall be energized by a separate reliable supervised power source or from the pump motor power, reduced to not more than 125 V.
(b) Loss of Phase. The loss of any phase at the line terminals of the motor contactor shall be monitored. All phases shall be monitored.
Exception: When power is supplied from multiple power sources, monitoring of each power source for phase loss shall be permitted at any point electrically upstream of the line terminals of the contactor provided all sources are monitored.
(c) Phase Reversal. (See 7-4.6.2.) This alarm circuit shall be energized by a separate reliable supervised power source or from the pump motor power, reduced to not more than 125 V.
(d) Controller Connected to Alternate Source. Where two sources of power are supplied to meet the requirements of 6-2.3, this alarm circuit shall indicate whenever the alternate source is the source supplying power to the controller. This alarm circuit shall be energized by a separate reliable, supervised power source, reduced to not more than 125 volts.

C) Fire pump casing relief valves, pressure relief valves and pump/electrical conditions were not inspected weekly, as required. Records were not available to document weekly inspections in accordance with NFPA 25 Section 9-5.5and Section 5-2.

Based on observation and staff interview during the survey, it was determined that the facility failed to maintain egress corridors that were clear and unobstructed in accordance with Life Safety Code Sections 7.1.10, 7.2 and 7.3.2. This deficient practice could affect all 5 patients, staff and visitors throughout the facility by obstructing and impeding the egress corridor for full instant use during an emergency evacuation. This was evidenced by the following:

A) Egress corridors throughout the facility were not maintained free of obstructions or impediments to full instant use, as required.
1. A large convex mirror (wall mounted across from the nurse's station) with the body of the mirror (angled) located 2-12 inches from the wall and 69 inches above the finished floor.
2. Two stainless steel wheeled tables were stored in the egress corridor outside of the O/R.
3. The C-arm was stored in the egress corridor outside of the Procedure Room. Red tape was installed on the floor to mark the proper storage location for the unit.

B) Corridor doors were not installed to project 7 inches or less into the required corridor width when in the fully opened position, as required. Housekeeping closets #1 and #2 each were arranged such that 1 of 2 door leafs, when fully opened, projected greater than 7 inches from the corridor wall.
The Facilities Manager acknowledged the corridor obstructions during a tour of the facility.
The Life Safety Code Section 7.1.10.1 requires that the means of egress be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. Section 7.1.10.2.1 requires that no furnishings, decorations, or other objects obstruct exits, access thereto, egress therefrom, or visibility thereof. Section 7.3.2 limits projections into the egress corridor of not more than 3? inches at a height of 38 inches or below. Section 7.1.5 requires, in part, that projections from the ceiling be not less than 6 ft. 8 inches nominal height above the finished floor. Section 7.2.1.4.4: During its swing, any door in a means of egress shall leave not less than one-half of the required width of an aisle, corridor, passageway, or landing unobstructed and shall not project more than 7 inches into the required width of an aisle, corridor, passageway, or landing, when fully open.

Based on observation and staff interview during the survey, it was determined that the facility failed to document that wall hangings were flame resistant in accordance with the provisions of Life Safety Code Section 10.3.1. This deficient practice could affect all staff and visitors in the east smoke compartment should the hanging materials ignite and contribute to rapid fire extension. This was evidenced by the following:

Wall mounted, loosely hanging decorations were not documented to be flame resistant, as required. The main entrance corridor had a 5 ft. x 8ft.antique blanket wall hanging and the corridor outside of the Foundation Office had a hanging rug on the corridor wall. The Facilities Manager was not aware of any records that would document the wall hangings as being flame resistant.
Life Safety Code Section 18.7.5.1 requires that draperies, curtains (including cubicle curtains) and other loosely hanging fabrics and films serving as furnishings or decorations in health care occupancies shall be in accordance with the provisions of 10.3.1. Section 10.3.1 requires that draperies, curtains, and other similar loosely hanging furnishings and decorations be flame resistant as demonstrated by testing in accordance with NFPA 701, Standard Methods of Fire Tests for Flame Propagation of Textiles and Films.

Based on observation, staff interview and record review during the course of the survey, it was determined that the facility failed to install and maintain the piped medical gas system in accordance with National Fire Protection Association Standard 99, Health Care Facilities. This deficient practice could affect all 5 patients should the medical gas system not function as designed. This was evidenced by the following:

A) The original high pressure oxygen manifold system has been altered and now uses cryogenic liquid vessels that are not arranged in accordance with NFPA 99 Section 4-3.1.1.6, as required. The altered system is deficient as follows:
1. The existing manifold is not designed for use with low pressure cryogenic liquid vessels.
2. The system is no longer arranged for automatic changeover from the primary to secondary supply.
3. The system is not arranged with an emergency reserve supply, as required.
4. Alarm signals to the master alarm panel no longer function as originally designed.

The Facilities Manager reported that the original high pressure system was altered due to high oxygen demand and consequent cylinder change frequency. The system is now arranged with 2 cryogenic liquid vessels installed on the original primary (right) bank that are manually changed from vessel #1 to #2 by the Facilities Manager, as needed. The original secondary supply now has 5 high pressure cylinders connected. The cylinders are normally kept shut off and would have to be manually turned on by the Facilities Manager if needed. The master alarm panel was observed to have a red alarm indicator (alarm silenced) for oxygen reserve in use.

B) The nitrous oxide secondary supply was not maintained operational, as required. The Facilities Manager reported that the secondary supply was normally kept valved off due to lack of demand. The master alarm panel had a red alarm indicator for nitrous oxide reserve in use. The secondary supply valves were opened by the Facilities Manager during a tour of the medical gas manifold room.

C) The nitrogen secondary supply was not maintained operational, as required. The Facilities Manager reported that the secondary supply was normally kept valved off due to lack of demand. The master alarm panel had a red alarm indicator for nitrogen reserve in use. The secondary supply valves were opened by the Facilities Manager during a tour of the medical gas manifold room.

D) The master alarm panel had a red alarm indicator for medical air reserve in use. The Facilities Manager reported that both primary and secondary medical air supply cylinder valves were kept open at all times.

The complete facility medical gas system must be evaluated and modified in order to comply with the applicable requirements in NFPA 99. All medical gas alarm systems must also be evaluated to insure correct alarming operation.

Based on staff interview and record review during the course of the survey, it was determined that the facility failed to install and test environmental systems in accordance with National Fire Protection Association Standard 99, Health Care Facilities. This deficient practice could affect patients and staff within the O/R during a fire/smoke condition should the system not automatically detect smoke and exhaust smoke while preventing recirculation. This was evidenced by the following:

It could not be determined during the survey if the O/R (anesthetizing location) was arranged with a functioning smoke evacuation system, installed in accordance with NFPA 99 Section 5-4.1.2 and 5-4.1.3, as required. The facility records consisted of a single page schematic plan for Roof Top Unit RTU-02, dated 03-14-07. The sequence of operation noted a "smoke purge mode" and described the operation as: When fire alarm system is in purge mode, supply fan is stopped, return fan runs, outside and return dampers are closed, and exhaust damper is open. Specific details on automatic initiation of the purge mode were not provided. The Facilities Manager was not familiar with the smoke purge mode operation and could not confirm if the system had ever been tested.
NFPA 99 Section 5-4.1.2: Supply and exhaust systems for windowless anesthetizing locations shall be arranged to automatically vent smoke and products of combustion. Section 5-4.1.3: Ventilating systems for anesthetizing locations shall be provided that automatically (a) prevent recirculation of smoke originating within the surgical suite and (b) prevent the circulation of smoke entering the system intake, without in either case interfering with the exhaust function of the system.

Based on record review, observation and staff interview during the survey, it was determined that the facility failed to maintain emergency power systems in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code and the referenced NFPA 110, Standard for Emergency and Standby Power Systems. This deficient practice could affect all 5 patients should the essential electrical system not function as designed due to lack of maintenance and testing. This was evidenced by the following:

A) Automatic transfer switches were not exercised monthly, as required. The Facilities Manager did not maintain transfer switch test records and was not aware of any testing of the fire pump automatic transfer switch.
NFPA 110 Section 6-4.5: Level 1 and Level 2 transfer switches shall be operated monthly. The monthly test of a transfer switch shall consist of electrically operating the transfer switch from the standard position to the alternate position and then a return to the standard position.

B) The emergency generator was not exercised under load for a minimum of 30 minutes per month, as required. Test records did not document run times, voltage/amperage readings or specific dates for the monthly load tests. The Facilities Manager reported that the generator was exercised weekly for 60 minutes without load.
NFPA 110 Section 6-4.2: Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a 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

C) The outdoor generator enclosure was not adequately protected from environmental conditions that could affect the performance of the emergency power supply system, as required. The outdoor generator enclosure was a complete manufactured unit including a base diesel fuel tank. The generator enclosure was installed on a concrete pad adjacent to the facility parking area. There were no protective bollards installed around the generator unit to protect it from damage by moving vehicles. During the survey, a parked vehicle was observed with the rear bumper/trailer hitch to be approximately 30 inches from the diesel fuel tank. The Facilities Manager reported that protective bollards were planned to protect the unit, but not yet installed.
NFPA 110 Section 5-1.2: Consideration shall be given to the installation requirements and the environmental conditions that could affect the performance of the EPSS such as geographic location, building type, classification of occupancy, and hazard of contents.

D) Routine operational testing program was not overseen by a properly trained individual, as required. During an attempted load test of the generator, the Facilities Manager reported the test sequence could be initiated by opening the main circuit breaker on any one of the three emergency distribution panels. Attempted tests utilizing EMDP3 (critical branch) and EMDP2 (life safety branch) were not successful in starting the generator and transferring building electrical loads.
NFPA 110 Section 6-4.7: The routine maintenance and operational testing program shall be overseen by a properly instructed individual.

E) Automatic transfer switch test and annunciation indicators were not maintained in operational condition, as required. The LCD displays, installed on the exterior of all three transfer switches, were no longer visible and could not be read by the operator. The display information was required to perform testing and to indicate the position of the transfer switch. The exterior transfer switch installation subjected the displays to direct sunlight that apparently destroyed the visible display readout. The Facilities Director reported that replacements had been ordered, but had not yet been delivered.
NFPA 110 4-2.4.10 Test Switch:
A test shall be provided on each automatic transfer switch (ATS) that simulates failure of the primary power source. An ATS then shall transfer the load to the EPS.
Section 4-2.4.11 Indication of Switch Position:
Two pilot lights with identification nameplates or other approved position indicators shall be provided to indicate the transfer switch position.

Based on observation and record review during the course of the survey, it was determined that the facility failed to install the Type I essential electrical system in accordance with NFPA 99-Health Care Facilities. This deficient practice could affect all 5 patients should the essential electrical system malfunction or fail due to non-compliant loads on the designated branch circuits. This was evidenced by the following:

A) It could not be determined if the Life Safety Branch of the essential electrical system was supplying branch circuits that were not considered essential to life safety nor specifically allowed on the Life Safety Branch in accordance with Section 3-4.2.2.2 (b).
The facility one-line electrical drawing indicated PE-3 as a Life Safety Branch panelboard. Panelboard PE-3 was not located and reviewed for compliance during the survey. The facility must locate PE-3 and confirm compliance with Section 3-4.2.2.2(b).

B) Branch circuits specifically required to be supplied by the Life Safety Branch were not connected, as required. The fire alarm system and medical gas alarm branch circuits were noted to be supplied by Critical Branch panelboard PE-1and PE-1 Section 2.

NFPA 99 Section 3-4.2.2.2 (b) Life Safety Branch: The life safety branch of the emergency system shall supply power for the following lighting, receptacles, and equipment:
1. Illumination of means of egress as required in NFPA 101,? Life Safety Code?
2. Exit signs and exit direction signs required in NFPA 101, Life Safety Code
3. Alarm and alerting systems including the following:
a. Fire alarms
b. Alarms required for systems used for the piping of nonflammable medical gases as
specified in Chapter 4, " Gas and Vacuum Systems "
4. * Hospital communication systems, where used for issuing instruction during emergency conditions
5. Task illumination, battery charger for emergency battery-powered lighting unit(s), and selected receptacles at the generator set location
6. Elevator cab lighting, control, communication, and signal systems
7. Automatically operated doors used for building egress.
No function other than those listed above in items 1 through 7 shall be connected to the life safety branch.
Exception: The auxiliary functions of fire alarm combination systems complying with NFPA 72, National Fire Alarm Code, shall be permitted to be connected to the life safety branch.

C) The Critical Branch of the essential electrical system was supplying branch circuits that were not related to patient care in accordance with Section 3-4.2.2.2 (c) and specifically allowed on the Critical Branch.

1) Panelboard PE-1, circuit #37 was powering unit heater/exhaust fan 16.

2) Panelboard PE-1Section 2, circuit #43 was powering the boiler #1.

3) Panelboard PE-1Section 2, circuit #45 and #47 were powering boiler pump 4 & 3.

4) Panelboard PE-1Section 2, circuit #44 was powering the DDC panel (unidentified load).

5) Panelboard PE-1Section 2, circuit #46 was powering the boiler #2.

6) Distribution Panel EMDP3 had a circuit breaker labeled "jockey pump". Note: the one-line diagram listed the jockey pump on the fire pump controller which is believed to be incorrect.

7) Distribution Panel EMDP3 had a circuit breakers labeled for the heating system circulation pump variable speed drives.

NFPA 99 Section 3-4.2.2.2 (c) Critical Branch.: The critical branch of the emergency system shall supply power for task illumination, fixed equipment, selected receptacles, and selected power circuits serving the following areas and functions related to patient care. It shall be permitted to subdivide the critical branch into two or more branches.
1. Critical care areas that utilize anesthetizing gases, task illumination, selected receptacles, and fixed equipment
2. The isolated power systems in special environments
3. Patient care areas - task illumination and selected receptacles in the following:
a. Infant nurseries
b. Medication preparation areas
c. Pharmacy dispensing areas
d. Selected acute nursing areas
e. Psychiatric bed areas (omit receptacles)
f. Ward treatment rooms
g. Nurses ' stations (unless adequately lighted by corridor luminaires)
4. Additional specialized patient care task illumination and receptacles, where needed
5. Nurse call systems
6. Blood, bone, and tissue banks
7. * Telephone equipment rooms and closets
8. Task illumination, selected receptacles, and selected power circuits for the following:
a. General care beds (at least one duplex receptacle per patient bedroom)
b. Angiographic labs
c. Cardiac catheterization labs
d. Coronary care units
e. Hemodialysis rooms or areas
f. Emergency room treatment areas (selected)
g. Human physiology labs
h. Intensive care units
i. Postoperative recovery rooms (selected)
9. Additional task illumination, receptacles, and selected power circuits needed for effective facility operation. Single-phase fractional horsepower motors shall be permitted to be connected to the critical branch.

Based on observation and staff interview during the course of the survey, it was determined that the facility failed to install and maintain the two-hour fire rated separation to the clinic occupancy in accordance with Life Safety Code Section 18.1.2.1 and Section 8.2.3.2.4. This deficient practice could affect all 5 patients, staff and visitors within the health care building, smoke compartment B, should heat and smoke spread from a fire condition in the adjacent building. This was evidenced by the following:

Penetrations and miscellaneous openings in fire barriers were not filled with a material capable of maintaining the fire resistance rating of the barrier, as required.

The 2 hour rated occupancy separation wall (loading dock area) was observed to have the following deficiencies:
A) The top of wall fire stop system was incomplete and not installed to maintain the required two hour fire rating of the wall. The top of wall gap, at the roof deck, was sealed with a mineral wool backing (within the flutes) and covered with a fire stop caulk or spray. Numerous sections of exposed mineral wool were observed that did not have any coating of fire stop material.

B) One conduit penetration that had been fire caulked, was observed to have been pulled through the wall and no longer had fire rated caulk around the penetration at the wall. This penetration must also be re-installed to insure the conduit is anchored to the wall, as required.
The Facilities Manager acknowledged the fire stop system deficiencies during a tour of the facility.

Life Safety Code Section 18.1.2.1 requires, in part, that sections of health care facilities that are classified as other occupancies be separated by two hour rated construction.
Section 8.2.3.2.4 requires, in part, that penetrations and miscellaneous openings in fire barrier walls be filled with a material capable of maintaining the fire resistance rating of the barrier. Section 8.2.3.2.4.2(2) requires that penetrating sleeves be solidly set in the smoke barrier wall.

Based on observation, record review and staff interview during the survey, it was determined that the facility failed to install corridor doors in accordance with Life Safety Code Section 18.3.6.3. This deficient practice could affect all 5patients, staff and visitors within both smoke compartments should the egress corridor become untenable due to smoke and heat transfer via the deficient doors separating rooms from the egress corridor. This was evidenced by the following:

A) Corridor doors were not equipped with positive latching hardware, as required. Four emergency department exam/treatment rooms were not provided with latching hardware on the sliding corridor doors. The facility design plan, fire safety page A1.1, designated the walls throughout the emergency department as smoke partition corridor walls. There was no indication on the plan that the area was designed as a suite of rooms in accordance with Life Safety Code Section 18.2.5.

B) The latch bolt on the pharmacy corridor door was disabled preventing the door from positively latching into the door frame.

C) Corridor doors were not arranged to automatically latch into the door frame, as required. Three housekeeping closets and the O/R were equipped with double doors. One of two leafs was not equipped with automatic latching hardware, as required. The leaf equipped with the latchset was arranged to latch into the " fixed " door leaf that would not be automatically latched into the door frame.

D) Dutch doors were not equipped with latching hardware on both leafs and were not equipped with a rabbet, bevel or astragal, as required. The laboratory corridor dutch door was not equipped with latching hardware on the upper leaf and did not form a smoke resistive seal between the upper and lower leafs.
The Life Safety Code Section 19.3.6.3.6 requires that both the upper and lower leafs on dutch doors be equipped with a latching device, and the meeting edges of the upper and lower leaves be equipped with an astragal, a rabbet or a bevel.

E) Corridor doors were not arranged to be closed from the corridor side with a push or pull, as required. The kitchen area dish window roll down door could not be pulled closed from the corridor side.
The Facilities Manager acknowledged the door latching arrangements during a tour of the facility.

Life Safety Code Section 18.3.6.3.2: Doors shall be provided with positive latching hardware. Roller latches shall be prohibited. Section 18.3.6.3.6 requires that both the upper and lower leafs on dutch doors be equipped with a latching device, and the meeting edges of the upper and lower leaves be equipped with an astragal, a rabbet or a bevel.

Based on observation and staff interview during the survey, it was determined that the facility failed to mark access to exits in accordance with Life Safety Code Section 7.10. This deficient practice could affect all 5patients, staff and visitors within both smoke compartments should the way to reach an exit and adjoining smoke compartment not be readily apparent. This was evidenced by the following:

Illuminated exit signs must be installed and modified in the following areas:
1. Add an additional exit sign above the horizontal exit doors to the clinic building.
2. Add two additional exits signs above both sides of the double smoke barrier doors, main east/west corridor.
3. Add an additional exit sign above the corridor smoke barrier doors, near room S-5.
4. Add two additional exit signs in the corridor area outside of the procedure room.
5. Add two directional exit signs in the PREOP/PACU room.
6. Relocated the exit sign installed above the main entrance doors. The sign is obstructed by ceiling light fixtures.
The Facilities Manager acknowledged the exit sign installation during a tour of the facility.
The Life Safety Code Section 7.10.1.4 requires that access to exits be marked by approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent to the occupants.

Based on observation during the survey, it was determined that the fire resistance rating of smoke barrier walls were not maintained in accordance with Life Safety Code Section 18.3.7.3 and Section 8.2. This deficient practice could affect all 5 patients, staff and visitors within both smoke compartments by allowing the spread of fire and smoke between the compartments. This was evidenced by the following:

Penetrations and miscellaneous openings in fire barriers were not filled with a material capable of maintaining the fire resistance rating of the barrier, as required.
The 1 hour rated smoke barrier wall (above the corridor doors in the O/R corridor) was observed to have a deficient top of wall fire stop system. The fire barrier was incomplete and not installed to maintain the required one hour fire rating of the wall.
The top of wall gap, at the roof deck, was sealed with a mineral wool backing (within the flutes) and covered with a fire stop caulk or spray. Numerous sections of exposed mineral wool were observed that did not have any coating of fire stop material.

Life Safety Code Section 18.3.7.3 requires that the smoke barrier wall be constructed in accordance with Section 8.3, and shall have a fire resistance rating of not less than 1 hour. Section 8.2.3.2.4 requires, in part, that penetrations and miscellaneous openings in fire barrier walls be filled with a material capable of maintaining the fire resistance rating of the barrier.

Based on observation and staff interview during the survey, it was determined that the facility failed to provide and maintain hazardous area enclosures in accordance with the Life Safety Code Section 18.3.2.1 and Section 8.4. This deficient practice could affect all 5 patients, as well as staff and visitors within both smoke compartments, should there be smoke and heat transfer between the hazardous area and other portions of the building. This was evidenced by the following:

A) Storage rooms, larger than 100 square feet with combustible material storage, were not enclosed with one hour fire rated construction and door openings protected with 45 minute (minimum) fire rated doors equipped with self-closing devices.
1. The main boiler room one hour wall was not fire stopped at the roof deck and was not equipped with a minimum 45 minute fire rated corridor door.
2. The loading dock room was observed to be used for combustible storage that included kitchen supplies in cardboard boxes and wood furniture. The enclosure was not one hour fire rated and the doors were not fire rated and labeled.
3. The clean linen supply room (adjacent to the loading dock) was used for combustible materials in quantities deemed hazardous. The 3 of 4 enclosure walls were not one hour fire rated and the doors were not fire rated and labeled.
4. The recently created materials supply room (approximately 20 ft. x 24 ft.) was not a one hour fire rated enclosure and the doors were not fire rated and labeled. The Facilities Manger reported that the room had been converted from office space to storage approximately 6 months prior to the survey. The facility design plan, fire safety page A1.1, did not designate these rooms as having one-hour fire rated walls.

B) Hazardous area enclosure doors were not self-closing and positively latching, as required. The emergency department soiled linen room corridor door was observed to have a disabled latching mechanism.
The Facility Manager acknowledged the hazardous area arrangements during a tour of the facility.

The Life Safety Code requires that hazardous areas be separated from other spaces in accordance with Section 18.3.2.1 and Section 8.4. Section 8.4.1.3 requires that doors in fire rated barriers have a minimum ? hour fire resistance rating and that the doors be self-closing or automatic closing.

Based on observation and staff interview, it was determined that the facility failed to arrange and maintain the means of egress in accordance with Life Safety Code Section 18.2 and Chapter 7. This deficient practice could affect all 5 patients, as well as staff and visitors throughout the facility, if a continuous unobstructed means of egress to the public way not be provided. This was evidenced by the following:

A) Egress doors were not maintained to be readily opened from the egress side, as required. The break-away door feature (main entrance inner and outer door sets) was disabled due to a double-keyed deadbolt lock installed on each door set. The Facilities Manager reported that the outer doors were locked with the deadbolt at night for security purposes.

B) The ambulance entry breakaway sliding door (marked exit) was equipped with a double keyed deadbolt lock.

C) Powered egress doors were not equipped with readily visible signs that read " IN EMERGENCY, PUSH TO OPEN " , as required. Both inner and outer powered doors at the ambulance entrance were not equipped with the signage required in Life Safety Code Section 7.2.1.9.1.

D) Access-controlled egress doors were not equipped with a manual release device that was installed in accordance with Section 7.2.1.6.2(c), as required. The MRI area exit door, the pharmacy exit door and the med room exit door were all equipped with magnetic locking devices that unlocked with a motion sensor installed above the door and with fire alarm activation. The required manual release device was not installed within 5 ft. of each door, as required. Note: see special manual release wiring arrangements in Section 7.2.1.6.2.

E) The exit discharge area (south exit door adjacent to the lab) was not continuous to the public way, as required. The exit discharge area was a small concrete pad and a landscaped garden area. There was no continuous paved walk to the public way.

Life Safety Code Section 18.2.1 requires that means of egress components be arranged in accordance with Chapter 7. Section 18.2.2.2.4: doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side.
Exception No. 2: Delayed-egress locks complying with 7.2.1.6.1 shall be permitted, provided that not more than one such device is located in any egress path.
Exception No. 3: Access-controlled egress doors complying with 7.2.1.6.2 shall be permitted.
Section 7-2.1.5.1 requires that a door shall be so arranged as to be readily opened from the egress side whenever the building is occupied. Section 7.2.1.9.1 requires, in part, that powered doors be designed and installed so that when a force is applied to the door on the side from which egress is made, it shall be capable of swinging from any position to the full use of the required width of the opening in which it is installed (see 7.2.1.4). On the egress side of each door, there shall be a readily visible, durable sign that reads as follows: IN EMERGENCY, PUSH TO OPEN.
The sign shall be in letters not less than 1 in. (2.5 cm) high on a contrasting background.
Section 7.7 requires that all exits terminate directly at a public way or at an exterior exit discharge. Yards, courts, open spaces or other portions of the exit discharge shall be of required width and size to provide all occupants with a safe access to a public way.
Section 7.1.10.1 requires that the means of egress be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. This would include any type of barrier that is an impediment to free movement in the means of egress, such as the accumulation of snow or ice.
Life Safety Code Section 7.2.1.6.2 Access-Controlled Egress Doors:
Where permitted in Chapters 11 through 42, doors in the means of egress shall be permitted to be equipped with an approved entrance and egress access control system, provided that the following criteria are met.
(a) A sensor shall be provided on the egress side and arranged to detect an occupant approaching the doors, and the doors shall be arranged to unlock in the direction of egress upon detection of an approaching occupant or loss of power to the sensor.
(b) Loss of power to the part of the access control system that locks the doors shall automatically unlock the doors in the direction of egress.
(c) The doors shall be arranged to unlock in the direction of egress from a manual release device located 40 inches to 48 inches vertically above the floor and within 5 ft of the secured doors. The manual release device shall be readily accessible and clearly identified by a sign that reads as follows: PUSH TO EXIT
When operated, the manual release device shall result in direct interruption of power to the lock - independent of the access control system electronics - and the doors shall remain unlocked for not less than 30 seconds.
(d) Activation of the building fire-protective signaling system, if provided, shall automatically unlock the doors in the direction of egress, and the doors shall remain unlocked until the fire-protective signaling system has been manually reset.
(e) Activation of the building automatic sprinkler or fire detection system, if provided, shall automatically unlock the doors in the direction of egress and the doors shall remain unlocked until the fire-protective signaling system has been manually reset.

Based on observation and record review, it was determined that the facility failed to install horizontal exits in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code Section 18.2.2.5. This deficient practice could affect all building occupants attempting to use the exit if visibility is not provided between compartments. This was evidenced by the following:

Cross-corridor horizontal exit doors were not equipped with vision panels, as required. The clinic entrance cross-corridor horizontal exit doors were not equipped with vision panels. The facility design plan, fire safety page A1.1, designated these doors as a horizontal exit.
Life Safety Code Section 18.2.2.5.6: An approved vision panel shall be required in each horizontal exit. Center mullions shall be prohibited.

Based on record review and staff interview during the survey, it was determined that the facility failed to install emergency lighting for the entire means of egress and maintain battery powered emergency lighting systems in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code. This deficient practice could affect patients and staff within the operating rooms should the battery emergency lighting fail and occupants evacuating the building to the public way.
This was evidenced by the following:


A) It could not be determined during the survey if the exit discharge areas, on the exterior of the building, were provided with emergency lighting, as required. The Facilities Manager was not aware of any exterior emergency illumination.
Life Safety Code Section 7.9.1 requires emergency lighting facilities for the means of egress which includes the exit discharge walkways leading to a public way.

B) There were no records on premises that documented the routine testing of the battery powered emergency lighting units installed in the O/R. The Facilities Manager reported that there was no test program in place.
Life Safety Code Section 7.9.3, Periodic Testing of Emergency Lighting Equipment, states: "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? 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.

Based on record review during the survey, it was determined that the facility failed to maintain a complete plan for the protection of all persons in the event of fire in accordance with Life Safety Code Section 18.7.1 and 18.7.2. This deficient practice could affect all 5 patients if staff response during a fire situation does not include knowledge and training in evacuation of the smoke compartment.
This was evidenced by the following:

The fire emergency plan did not specifically discuss the evacuation of a smoke compartment, as required. The facility fire emergency plan titled "Plant Operations & Safety Policy & Procedures Manual" Section 820-0013 titled "Fire Safety and Evacuation" did not address evacuation of a smoke compartment.

Life Safety Code Section 18.7.1.1 requires that the administration of all health care facilities develop a plan for the protection of all persons in the event of fire, including a plan for their evacuation to an area of refuge and from the building when necessary. The plan must include all components and requirements outlined in Life Safety Code Section 18.7.1 and 18.7.2.
Life Safety Code Section 18.7.2.2 requires that a written health care occupancy fire safety plan provide for the following:
1. Use of alarms
2. Transmission of alarms to the 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

Based on record review and staff interview during the survey, it was determined that the facility failed to conduct fire drills in accordance with Life Safety Code Sections 18.7.1.2 and 4.7. This deficient practice could affect all 5 patients if staff are not trained in the emergency actions required during the unusual conditions that can occur in an actual emergency. This was evidenced by the following:

A review of fire drill records determined that the facility failed to:
1. conduct fire drills at least quarterly on each shift,
2. conduct fire drills at varied times under varying conditions,
3. sound the fire alarm system during fire drills,
4. familiarize personnel with the signals and emergency action required under varied conditions.
5. assign the responsibility for planning and conduct of the drills to staff knowledgeable and trained in drill conduct and objectives.

Fire drill records provided minimal documentation and did not include specific dates or specific time of day. The drills were conducted every 4 months and were documented only with the Facilities Manager's initials in a grid chart by month and year. The Facilities Manager reported that most drills did not activate the fire alarm system or alternate coded announcement and often consisted of a discussion of fire procedures with staff.

Life Safety Code, Section 18.7.1.2 requires, in part, that fire drills be conducted quarterly on each shift to familiarize 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 pm and 6:00 am, a coded announcement shall be permitted to be used instead of audible alarms. Section 4.7.5 requires that drills be held at unexpected times and under varying conditions to simulate the unusual conditions that can occur in an actual emergency. Section 4.7.3: Responsibility for the planning and conduct of drills shall be assigned only to competent persons qualified to exercise leadership.

Based on observation and record review during the survey, it was determined that the facility failed to install and maintain the fire alarm system in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code, and NFPA 72, National Fire Alarm Code. This deficient practice could affect all 5 patients, staff and visitors should the fire alarm system fail to function as designed and fail to notify staff in all areas of the building. This was evidenced by the following:

A) Fire alarm system secondary power supply sealed lead-acid batteries were not load voltage tested semiannually, as required. The Facilities Manager reported that the fire alarm system was subject to annual inspections only. The last load voltage test was conducted on 05-29-12 during the annual inspection of the fire alarm system.
NFPA 72, Section 7.3.2 subsection 6d requires that sealed lead-acid type fire alarm system batteries be subject to a load voltage test semiannually.

B) Fire alarm system visual notification appliances were not installed to alert occupants in all building areas, as required. The O/R and Procedure Room were not equipped with visual notification appliances. The O/R did not have windows to the corridor area where audible/visual appliances were installed.
Life Safety Code Section 18.3.4.3.1 allows visible alarm indicating appliances to be used in lieu of audible alarm signals in critical care areas. Section 9.6.3.7 requires that the general evacuation alarm signal operate throughout the entire building.

Based on observation and record review during the survey, it was determined that the facility failed to install and maintain the automatic fire sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 13 and Standard 25. This deficient practice could affect all 5 patients, staff and visitors should the automatic sprinkler system fail to operate in a timely and effective manner due to non-code compliant installation and maintenance. This was evidenced by the following:

A) Sprinkler system control valves were not equipped with signs indicating system or area served, as required. Control valves in the pump room were equipped with signage stating "Control Valve" but the signs did not specify the system or portion of the system served by the valve. One sign was observed to be detached from the valve on the floor.
NFPA 25 Section 9-3.2 requires that each control valve have a sign indicating the system or portion of the system it controls.

B) Sidewall sprinklers, installed in the walk-in cooler and freezer, were subject to damage by stock storage on the top shelf. The sprinkler heads were not protected by listed guards.
NFPA 13 Section 3-2.8 requires that sprinklers subject to mechanical damage be protected with listed guards.

C) Standard pendant sprinkler heads were not installed with unobstructed water spray patterns, as required. Two pendant sprinkler heads, installed in the x-ray room, were obstructed by a ceiling mounted equipment track.
NFPA 25, Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems Section 2-2.1.2 states:"Unacceptable obstructions to spray patterns shall be corrected."

D) The automatic sprinkler system waterflow alarm was not tested quarterly, as required. Records on premises documented testing of the waterflow alarm in August and May 2012. NFPA 25 Section 9-2.7 requires that waterflow alarms be tested quarterly in accordance with manufacturer's instructions.

E) The central supply storage room had two 3" x 3" holes in the suspended ceiling from electrical raceway posts that had been removed. Prompt sprinkler operation is dependent upon a continuous ceiling when sprinklers are installed below the suspended ceiling.

Based on record review and staff interview during the survey, it was determined that the facility failed to insure that the automatic sprinkler system has an adequate and reliable water supply in accordance with NFPA 20 and NFPA 25. This deficient practice could affect all 5 patients, staff and visitors should the automatic fire pump fail to operate as designed due to inadequate maintenance and testing. This was evidenced by the following:

A) Weekly churn tests were not conducted for a 10 minute (minimum) duration, as required. Records documenting the weekly churn test were incomplete and did not include a specific date, suction and discharge pressures, pump starting pressure, and pump run time. The required recordings were not documented during the weekly tests. The test record on premises did not include any entries since February 2013.
The Facilities Manager reported that the weekly test consisted of opening the main drain valve until the pump started and allowing water to flow for approximately 10 seconds before shutting the main drain valve. The pump was manually shut down without running for the minimum 10 minute duration.

NFPA 25 Section 5-3.2.1 requires that the weekly test of electric motor-driven pump be conducted by starting the pump automatically with a minimum run time of 10 minutes.
A weekly test of electric motor-driven pump assemblies shall be conducted without flowing water. Section 5-3.2.4.1 Pump System Procedure:
(a) Record the system suction and discharge pressure gauge readings.
(b) Check the pump packing glands for slight discharge.
(c) Adjust gland nuts if necessary.
(d) Check for unusual noise or vibration.
(e) Check packing boxes, bearings, or pump casing for overheating.
(f) Record the pump starting pressure.

B) It could not be determined during the survey if fire pump supervisory signals transmit to a location within the protected building that was constantly attended by qualified personnel or at an approved, remotely located receiving facility. The Facility Manager believed the pump was supervised by the fire alarm system but could not verify what functions were supervised. There were no records of periodic testing of the supervisory equipment NFPA 72 Section 7.3.2 requires that supervisory equipment be tested quarterly.

NFPA 20 Section 7-4.7 Alarm and Signal Devices Remote from Controller.
Where the pump room is not constantly attended, audible or visible alarms powered by a source not exceeding 125 V shall be provided at a point of constant attendance. These alarms shall indicate the following.
(a) Pump or Motor Running. The alarm shall actuate whenever the controller has operated into a motor-running condition. This alarm circuit shall be energized by a separate reliable supervised power source or from the pump motor power, reduced to not more than 125 V.
(b) Loss of Phase. The loss of any phase at the line terminals of the motor contactor shall be monitored. All phases shall be monitored.
Exception: When power is supplied from multiple power sources, monitoring of each power source for phase loss shall be permitted at any point electrically upstream of the line terminals of the contactor provided all sources are monitored.
(c) Phase Reversal. (See 7-4.6.2.) This alarm circuit shall be energized by a separate reliable supervised power source or from the pump motor power, reduced to not more than 125 V.
(d) Controller Connected to Alternate Source. Where two sources of power are supplied to meet the requirements of 6-2.3, this alarm circuit shall indicate whenever the alternate source is the source supplying power to the controller. This alarm circuit shall be energized by a separate reliable, supervised power source, reduced to not more than 125 volts.

C) Fire pump casing relief valves, pressure relief valves and pump/electrical conditions were not inspected weekly, as required. Records were not available to document weekly inspections in accordance with NFPA 25 Section 9-5.5and Section 5-2.

Based on observation and staff interview during the survey, it was determined that the facility failed to maintain egress corridors that were clear and unobstructed in accordance with Life Safety Code Sections 7.1.10, 7.2 and 7.3.2. This deficient practice could affect all 5 patients, staff and visitors throughout the facility by obstructing and impeding the egress corridor for full instant use during an emergency evacuation. This was evidenced by the following:

A) Egress corridors throughout the facility were not maintained free of obstructions or impediments to full instant use, as required.
1. A large convex mirror (wall mounted across from the nurse's station) with the body of the mirror (angled) located 2-12 inches from the wall and 69 inches above the finished floor.
2. Two stainless steel wheeled tables were stored in the egress corridor outside of the O/R.
3. The C-arm was stored in the egress corridor outside of the Procedure Room. Red tape was installed on the floor to mark the proper storage location for the unit.

B) Corridor doors were not installed to project 7 inches or less into the required corridor width when in the fully opened position, as required. Housekeeping closets #1 and #2 each were arranged such that 1 of 2 door leafs, when fully opened, projected greater than 7 inches from the corridor wall.
The Facilities Manager acknowledged the corridor obstructions during a tour of the facility.
The Life Safety Code Section 7.1.10.1 requires that the means of egress be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. Section 7.1.10.2.1 requires that no furnishings, decorations, or other objects obstruct exits, access thereto, egress therefrom, or visibility thereof. Section 7.3.2 limits projections into the egress corridor of not more than 3? inches at a height of 38 inches or below. Section 7.1.5 requires, in part, that projections from the ceiling be not less than 6 ft. 8 inches nominal height above the finished floor. Section 7.2.1.4.4: During its swing, any door in a means of egress shall leave not less than one-half of the required width of an aisle, corridor, passageway, or landing unobstructed and shall not project more than 7 inches into the required width of an aisle, corridor, passageway, or landing, when fully open.

Based on observation and staff interview during the survey, it was determined that the facility failed to document that wall hangings were flame resistant in accordance with the provisions of Life Safety Code Section 10.3.1. This deficient practice could affect all staff and visitors in the east smoke compartment should the hanging materials ignite and contribute to rapid fire extension. This was evidenced by the following:

Wall mounted, loosely hanging decorations were not documented to be flame resistant, as required. The main entrance corridor had a 5 ft. x 8ft.antique blanket wall hanging and the corridor outside of the Foundation Office had a hanging rug on the corridor wall. The Facilities Manager was not aware of any records that would document the wall hangings as being flame resistant.
Life Safety Code Section 18.7.5.1 requires that draperies, curtains (including cubicle curtains) and other loosely hanging fabrics and films serving as furnishings or decorations in health care occupancies shall be in accordance with the provisions of 10.3.1. Section 10.3.1 requires that draperies, curtains, and other similar loosely hanging furnishings and decorations be flame resistant as demonstrated by testing in accordance with NFPA 701, Standard Methods of Fire Tests for Flame Propagation of Textiles and Films.

Based on observation, staff interview and record review during the course of the survey, it was determined that the facility failed to install and maintain the piped medical gas system in accordance with National Fire Protection Association Standard 99, Health Care Facilities. This deficient practice could affect all 5 patients should the medical gas system not function as designed. This was evidenced by the following:

A) The original high pressure oxygen manifold system has been altered and now uses cryogenic liquid vessels that are not arranged in accordance with NFPA 99 Section 4-3.1.1.6, as required. The altered system is deficient as follows:
1. The existing manifold is not designed for use with low pressure cryogenic liquid vessels.
2. The system is no longer arranged for automatic changeover from the primary to secondary supply.
3. The system is not arranged with an emergency reserve supply, as required.
4. Alarm signals to the master alarm panel no longer function as originally designed.

The Facilities Manager reported that the original high pressure system was altered due to high oxygen demand and consequent cylinder change frequency. The system is now arranged with 2 cryogenic liquid vessels installed on the original primary (right) bank that are manually changed from vessel #1 to #2 by the Facilities Manager, as needed. The original secondary supply now has 5 high pressure cylinders connected. The cylinders are normally kept shut off and would have to be manually turned on by the Facilities Manager if needed. The master alarm panel was observed to have a red alarm indicator (alarm silenced) for oxygen reserve in use.

B) The nitrous oxide secondary supply was not maintained operational, as required. The Facilities Manager reported that the secondary supply was normally kept valved off due to lack of demand. The master alarm panel had a red alarm indicator for nitrous oxide reserve in use. The secondary supply valves were opened by the Facilities Manager during a tour of the medical gas manifold room.

C) The nitrogen secondary supply was not maintained operational, as required. The Facilities Manager reported that the secondary supply was normally kept valved off due to lack of demand. The master alarm panel had a red alarm indicator for nitrogen reserve in use. The secondary supply valves were opened by the Facilities Manager during a tour of the medical gas manifold room.

D) The master alarm panel had a red alarm indicator for medical air reserve in use. The Facilities Manager reported that both primary and secondary medical air supply cylinder valves were kept open at all times.

The complete facility medical gas system must be evaluated and modified in order to comply with the applicable requirements in NFPA 99. All medical gas alarm systems must also be evaluated to insure correct alarming operation.

Based on staff interview and record review during the course of the survey, it was determined that the facility failed to install and test environmental systems in accordance with National Fire Protection Association Standard 99, Health Care Facilities. This deficient practice could affect patients and staff within the O/R during a fire/smoke condition should the system not automatically detect smoke and exhaust smoke while preventing recirculation. This was evidenced by the following:

It could not be determined during the survey if the O/R (anesthetizing location) was arranged with a functioning smoke evacuation system, installed in accordance with NFPA 99 Section 5-4.1.2 and 5-4.1.3, as required. The facility records consisted of a single page schematic plan for Roof Top Unit RTU-02, dated 03-14-07. The sequence of operation noted a "smoke purge mode" and described the operation as: When fire alarm system is in purge mode, supply fan is stopped, return fan runs, outside and return dampers are closed, and exhaust damper is open. Specific details on automatic initiation of the purge mode were not provided. The Facilities Manager was not familiar with the smoke purge mode operation and could not confirm if the system had ever been tested.
NFPA 99 Section 5-4.1.2: Supply and exhaust systems for windowless anesthetizing locations shall be arranged to automatically vent smoke and products of combustion. Section 5-4.1.3: Ventilating systems for anesthetizing locations shall be provided that automatically (a) prevent recirculation of smoke originating within the surgical suite and (b) prevent the circulation of smoke entering the system intake, without in either case interfering with the exhaust function of the system.

Based on record review, observation and staff interview during the survey, it was determined that the facility failed to maintain emergency power systems in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code and the referenced NFPA 110, Standard for Emergency and Standby Power Systems. This deficient practice could affect all 5 patients should the essential electrical system not function as designed due to lack of maintenance and testing. This was evidenced by the following:

A) Automatic transfer switches were not exercised monthly, as required. The Facilities Manager did not maintain transfer switch test records and was not aware of any testing of the fire pump automatic transfer switch.
NFPA 110 Section 6-4.5: Level 1 and Level 2 transfer switches shall be operated monthly. The monthly test of a transfer switch shall consist of electrically operating the transfer switch from the standard position to the alternate position and then a return to the standard position.

B) The emergency generator was not exercised under load for a minimum of 30 minutes per month, as required. Test records did not document run times, voltage/amperage readings or specific dates for the monthly load tests. The Facilities Manager reported that the generator was exercised weekly for 60 minutes without load.
NFPA 110 Section 6-4.2: Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a 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

C) The outdoor generator enclosure was not adequately protected from environmental conditions that could affect the performance of the emergency power supply system, as required. The outdoor generator enclosure was a complete manufactured unit including a base diesel fuel tank. The generator enclosure was installed on a concrete pad adjacent to the facility parking area. There were no protective bollards installed around the generator unit to protect it from damage by moving vehicles. During the survey, a parked vehicle was observed with the rear bumper/trailer hitch to be approximately 30 inches from the diesel fuel tank. The Facilities Manager reported that protective bollards were planned to protect the unit, but not yet installed.
NFPA 110 Section 5-1.2: Consideration shall be given to the installation requirements and the environmental conditions that could affect the performance of the EPSS such as geographic location, building type, classification of occupancy, and hazard of contents.

D) Routine operational testing program was not overseen by a properly trained individual, as required. During an attempted load test of the generator, the Facilities Manager reported the test sequence could be initiated by opening the main circuit breaker on any one of the three emergency distribution panels. Attempted tests utilizing EMDP3 (critical branch) and EMDP2 (life safety branch) were not successful in starting the generator and transferring building electrical loads.
NFPA 110 Section 6-4.7: The routine maintenance and operational testing program shall be overseen by a properly instructed individual.

E) Automatic transfer switch test and annunciation indicators were not maintained in operational condition, as required. The LCD displays, installed on the exterior of all three transfer switches, were no longer visible and could not be read by the operator. The display information was required to perform testing and to indicate the position of the transfer switch. The exterior transfer switch installation subjected the displays to direct sunlight that apparently destroyed the visible display readout. The Facilities Director reported that replacements had been ordered, but had not yet been delivered.
NFPA 110 4-2.4.10 Test Switch:
A test shall be provided on each automatic transfer switch (ATS) that simulates failure of the primary power source. An ATS then shall transfer the load to the EPS.
Section 4-2.4.11 Indication of Switch Position:
Two pilot lights with identification nameplates or other approved position indicators shall be provided to indicate the transfer switch position.

Based on observation and record review during the course of the survey, it was determined that the facility failed to install the Type I essential electrical system in accordance with NFPA 99-Health Care Facilities. This deficient practice could affect all 5 patients should the essential electrical system malfunction or fail due to non-compliant loads on the designated branch circuits. This was evidenced by the following:

A) It could not be determined if the Life Safety Branch of the essential electrical system was supplying branch circuits that were not considered essential to life safety nor specifically allowed on the Life Safety Branch in accordance with Section 3-4.2.2.2 (b).
The facility one-line electrical drawing indicated PE-3 as a Life Safety Branch panelboard. Panelboard PE-3 was not located and reviewed for compliance during the survey. The facility must locate PE-3 and confirm compliance with Section 3-4.2.2.2(b).

B) Branch circuits specifically required to be supplied by the Life Safety Branch were not connected, as required. The fire alarm system and medical gas alarm branch circuits were noted to be supplied by Critical Branch panelboard PE-1and PE-1 Section 2.

NFPA 99 Section 3-4.2.2.2 (b) Life Safety Branch: The life safety branch of the emergency system shall supply power for the following lighting, receptacles, and equipment:
1. Illumination of means of egress as required in NFPA 101,? Life Safety Code?
2. Exit signs and exit direction signs required in NFPA 101, Life Safety Code
3. Alarm and alerting systems including the following:
a. Fire alarms
b. Alarms required for systems used for the piping of nonflammable medical gases as
specified in Chapter 4, " Gas and Vacuum Systems "
4. * Hospital communication systems, where used for issuing instruction during emergency conditions
5. Task illumination, battery charger for emergency battery-powered lighting unit(s), and selected receptacles at the generator set location
6. Elevator cab lighting, control, communication, and signal systems
7. Automatically operated doors used for building egress.
No function other than those listed above in items 1 through 7 shall be connected to the life safety branch.
Exception: The auxiliary functions of fire alarm combination systems complying with NFPA 72, National Fire Alarm Code, shall be permitted to be connected to the life safety branch.

C) The Critical Branch of the essential electrical system was supplying branch circuits that were not related to patient care in accordance with Section 3-4.2.2.2 (c) and specifically allowed on the Critical Branch.

1) Panelboard PE-1, circuit #37 was powering unit heater/exhaust fan 16.

2) Panelboard PE-1Section 2, circuit #43 was powering the boiler #1.

3) Panelboard PE-1Section 2, circuit #45 and #47 were powering boiler pump 4 & 3.

4) Panelboard PE-1Section 2, circuit #44 was powering the DDC panel (unidentified load).

5) Panelboard PE-1Section 2, circuit #46 was powering the boiler #2.

6) Distribution Panel EMDP3 had a circuit breaker labeled "jockey pump". Note: the one-line diagram listed the jockey pump on the fire pump controller which is believed to be incorrect.

7) Distribution Panel EMDP3 had a circuit breakers labeled for the heating system circulation pump variable speed drives.

NFPA 99 Section 3-4.2.2.2 (c) Critical Branch.: The critical branch of the emergency system shall supply power for task illumination, fixed equipment, selected receptacles, and selected power circuits serving the following areas and functions related to patient care. It shall be permitted to subdivide the critical branch into two or more branches.
1. Critical care areas that utilize anesthetizing gases, task illumination, selected receptacles, and fixed equipment
2. The isolated power systems in special environments
3. Patient care areas - task illumination and selected receptacles in the following:
a. Infant nurseries
b. Medication preparation areas
c. Pharmacy dispensing areas
d. Selected acute nursing areas
e. Psychiatric bed areas (omit receptacles)
f. Ward treatment rooms
g. Nurses ' stations (unless adequately lighted by corridor luminaires)
4. Additional specialized patient care task illumination and receptacles, where needed
5. Nurse call systems
6. Blood, bone, and tissue banks
7. * Telephone equipment rooms and closets
8. Task illumination, selected receptacles, and selected power circuits for the following:
a. General care beds (at least one duplex receptacle per patient bedroom)
b. Angiographic labs
c. Cardiac catheterization labs
d. Coronary care units
e. Hemodialysis rooms or areas
f. Emergency room treatment areas (selected)
g. Human physiology labs
h. Intensive care units
i. Postoperative recovery rooms (selected)
9. Additional task illumination, receptacles, and selected power circuits needed for effective facility operation. Single-phase fractional horsepower motors shall be permitted to be connected to the critical branch.