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Based upon observation and staff interview, the facility fails to assure that hazardous areas are protected in accordance with 8.4.1 and 19.3.5.4. The deficient practice increases the risk of fire or smoke spreading to other areas of the building, affecting approximately 5 patients, all staff and visitors in 3 of 19 smoke zones. The facility has a capacity of 69 with a census of 21 at the time of this survey.

Findings include:

During the tour conducted on 09/17/2013, at approximately 3:30 p.m., it was observed that in construction and remodeling areas in the 1st floor of the Hospital egress pathways have dust confinement walls constructed of wood and plastic. Egress pathways were not protected by one hour fire-rated construction. At least one patient (in a wheelchair), several visitors and hospital staff were observed traversing through the construction area. On 09/18/2013, at approximately 2:00 p.m., in a meeting with facility management personnel, maintenance staff, construction supervisors and the facility's architect, discussion was held regarding prohibition of egress through construction areas and the necessity for OSFM approved plans for temporary exiting during construction. On 09/19/2013, at 7:49 a.m., this surveyor placed a telephone call to the Chief of Fire Prevention for the Office of the State Fire Marshal, advising of the scope of construction and status of exiting at this facility. The information was then relayed to the CMS Regional Office Representative by the Chief of Fire Prevention. During a telephone conference between the CMS Regional Office Representative, the Chief of Fire Prevention and this surveyor, commencing at 10:16 a.m. on 09/19/2013, it was determined by the CMS Representative that the facility should be placed in an Immediate Jeopardy status. Notification of the Immediate Jeopardy status and the necessity for Fire Watch was provided to the facility staff by the Chief of Fire Prevention. On-site inspection on 09/19/2013 revealed that: 1.) Fire Watch tasks were being performed and documented; 2) Patients and Visitors were escorted by hospital staff and volunteers in pathways that avoided construction areas; 3) Exiting maps reflecting appropriate egress pathways were in place; 4) On-site contractors were in the process of constructing 1-hr rated walls/corridors to assure safe and protected passage through areas affected by the construction process. On 09/20/2013, after a tour of the facility and verification that affected areas were separated from use areas by 1-hr construction and that appropriate egress pathways were in place, the Immediate Jeopardy status was abated at 8:12 a.m.; at 8:44 a.m. The Fire Watch process was terminated at 8:44 a.m. by the Fire Protection Specialist with the Office of the State Fire Marshal after approval of temporary egress plans.

NFPA Standard: Hazardous areas shall be safeguarded by a fire barrier of one-hour fire resistance rating or provided with an automatic sprinkler system and doors shall have self-closing devices and positive latches. 2000 NFPA 101, 19.3.2.1 and 2000 NFPA 101, 8.4.1

Based upon observation and staff interview, the facility fails to assure that hazardous areas are protected in accordance with 8.4.1 and 19.3.5.4. The deficient practice increases the risk of fire or smoke spreading to other areas of the building, affecting approximately 5 patients, all staff and visitors in 3 of 19 smoke zones. The facility has a capacity of 69 with a census of 21 at the time of this survey.

Findings include:

During the tour conducted on 09/17/2013, at approximately 3:30 p.m., it was observed that in construction and remodeling areas in the 1st floor of the Hospital egress pathways have dust confinement walls constructed of wood and plastic. Egress pathways were not protected by one hour fire-rated construction. At least one patient (in a wheelchair), several visitors and hospital staff were observed traversing through the construction area. On 09/18/2013, at approximately 2:00 p.m., in a meeting with facility management personnel, maintenance staff, construction supervisors and the facility's architect, discussion was held regarding prohibition of egress through construction areas and the necessity for OSFM approved plans for temporary exiting during construction. On 09/19/2013, at 7:49 a.m., this surveyor placed a telephone call to the Chief of Fire Prevention for the Office of the State Fire Marshal, advising of the scope of construction and status of exiting at this facility. The information was then relayed to the CMS Regional Office Representative by the Chief of Fire Prevention. During a telephone conference between the CMS Regional Office Representative, the Chief of Fire Prevention and this surveyor, commencing at 10:16 a.m. on 09/19/2013, it was determined by the CMS Representative that the facility should be placed in an Immediate Jeopardy status. Notification of the Immediate Jeopardy status and the necessity for Fire Watch was provided to the facility staff by the Chief of Fire Prevention. On-site inspection on 09/19/2013 revealed that: 1.) Fire Watch tasks were being performed and documented; 2) Patients and Visitors were escorted by hospital staff and volunteers in pathways that avoided construction areas; 3) Exiting maps reflecting appropriate egress pathways were in place; 4) On-site contractors were in the process of constructing 1-hr rated walls/corridors to assure safe and protected passage through areas affected by the construction process. On 09/20/2013, after a tour of the facility and verification that affected areas were separated from use areas by 1-hr construction and that appropriate egress pathways were in place, the Immediate Jeopardy status was abated at 8:12 a.m.; at 8:44 a.m. The Fire Watch process was terminated at 8:44 a.m. by the Fire Protection Specialist with the Office of the State Fire Marshal after approval of temporary egress plans.

NFPA Standard: Hazardous areas shall be safeguarded by a fire barrier of one-hour fire resistance rating or provided with an automatic sprinkler system and doors shall have self-closing devices and positive latches. 2000 NFPA 101, 19.3.2.1 and 2000 NFPA 101, 8.4.1