HospitalInspections.org

Based on observation by the surveyor 16732 on June th, 2010 the following doors open to corridor did not work properly with evidence as follows:

1) Laude room 3/4 hour fire rated door does not self close and positive latch

2) Storage room 1 1/2 hour fire rated doors near OR area has foot hold on door so door will not self close and positive latch.

3) Storage room fire rated door across from nurses station on med surg floor will not self close and positive latch due to the closing devices not properly secured to door.

4) Patient room door number 307 does not close properly.

5) Patient room door number 326 does not close properly

Based on observation of the surveyor on June 9th, 2010 the following hazardous area is not properly protected with evidence as follows:

1 1/2 hour fire rated door protecting the repair shop that is open to the corridor has glazing in door that is not fire rated.

Based on observation of the surveyor on June 9th, 2010 the following exit access area was not totally accessible with the evidence as follows:

In the exit corridor at the operation room area there were 5 "e" cylinder oxygen tanks and one CO2 tank chained to the wall in the exit corridor.

Based on record review by the surveyor on June 9th, 2010 the evacuation plan in the event of an emergency was not correct with evidence as follows:

1) In the mutual aid agreement with other facilities, the emergency call personal University of Maine at Fort Kent is no longer working at the facility after the surveyor made some random calls from the list.

2) The emergency water supply number is listed for Maine Public Service. Upon calling Maine Public Service the person answering the phone advised they are not a water facility and the personal listed on the emergency call list are no longer employed at Maine Public Service.

Based on observation of the surveyor on June th, 2010 an appliance in kitchen was no properly protected with evidence as follows:


The deep fryer was not properly aligned under the commercial cooking hood. The kitchen manager advises item was moved for cleaning and not put back to the appropriate space.

Based on observation of the surveyor on June 11th, 2010 the following violation of the Life Safety Code were noted:

Wellness Building at 82 West Main St:

1) 39.3.3.2 Interior Wall and Ceiling Finish
Interior wall and ceiling finish complying with 10.2.3 shall be Class A or Class B in exits and in enclosed corridors furnishing access to exits; and Class A, Class B, or Class C in office areas. Evidence: There is OSB board on the walls of the boiler room and storage room on 2nd floor.

2) 39.3.2.2*
High hazard contents areas, as classified in Section 6.2, shall meet the following criteria:
(1) The area shall be separated from other parts of the building by fire barriers having a fire resistance rating of not less than 1 hour, with all openings therein protected by 3/4-hour fire protection-rated self-closing fire doors.
(2) The area shall be protected by an automatic extinguishing system in accordance with Section 9.7.
Evidence: The boiler room is allowed to be smoke tight in accordance with Section 9.7 There are penetrations in the walls that would allow the penetration of smoke.

3) NFPA 1 10.19.5 Equipment Rooms.
10.19.5.1 Combustible material shall not be stored in boiler rooms, mechanical rooms, or electrical equipment rooms.
10.19.5.2 Materials and supplies for the operation and maintenance of the equipment in the room shall be permitted. Evidence: Several empty containers of clorox bleach are being stored in the boiler room

4) Maine Law Title 25 Section ?2447-B. Foam plastic insulation standards
1. Prohibition. No individual, partnership or corporation shall install in this State any type of foam plastic insulation unless that product complies with and is installed in accordance with the following requirements.
A. Unless otherwise excepted in the following subparagraphs, all foam plastic or foam plastic cores of manufactured assemblies shall have a flame-spread rating of not more than 75 and a smoke-developed rating of not more than 450 when tested in the maximum thickness intended for use in accordance with ASTM E-84. For all such installations, the foam plastic shall be separated from habitable or occupiable spaces by an approved thermal barrier of 1/2 inch gypsum wallboard or equivalent thermal barrier material which will limit the average temperature rise of the unexposed surface to not more than 250` F. after 15 minutes of fire exposure complying with the ASTM E-119 standard time-temperature curve. Thermal barriers shall be installed in a manner that assures they will stay in place for a minimum of 15 minutes under the same test exposure conditions. Evidence: Foam insulation board on ceiling of storage room on 2nd floor with no thermal barrier.

Based on observation of the surveyor on June 9th, 2010 the following electrical equipment was no correct with evidence as follows:

In the operating recovery rooms, there were two power relocation tap devices attached to the wall of at the top part of the patients beds. The devices are not U.N. listed for healthcare.

Based on observation by the surveyor 16732 on June th, 2010 the following doors open to corridor did not work properly with evidence as follows:

1) Laude room 3/4 hour fire rated door does not self close and positive latch

2) Storage room 1 1/2 hour fire rated doors near OR area has foot hold on door so door will not self close and positive latch.

3) Storage room fire rated door across from nurses station on med surg floor will not self close and positive latch due to the closing devices not properly secured to door.

4) Patient room door number 307 does not close properly.

5) Patient room door number 326 does not close properly

Based on observation of the surveyor on June 9th, 2010 the following hazardous area is not properly protected with evidence as follows:

1 1/2 hour fire rated door protecting the repair shop that is open to the corridor has glazing in door that is not fire rated.

Based on observation of the surveyor on June 9th, 2010 the following exit access area was not totally accessible with the evidence as follows:

In the exit corridor at the operation room area there were 5 "e" cylinder oxygen tanks and one CO2 tank chained to the wall in the exit corridor.

Based on record review by the surveyor on June 9th, 2010 the evacuation plan in the event of an emergency was not correct with evidence as follows:

1) In the mutual aid agreement with other facilities, the emergency call personal University of Maine at Fort Kent is no longer working at the facility after the surveyor made some random calls from the list.

2) The emergency water supply number is listed for Maine Public Service. Upon calling Maine Public Service the person answering the phone advised they are not a water facility and the personal listed on the emergency call list are no longer employed at Maine Public Service.

Based on observation of the surveyor on June th, 2010 an appliance in kitchen was no properly protected with evidence as follows:


The deep fryer was not properly aligned under the commercial cooking hood. The kitchen manager advises item was moved for cleaning and not put back to the appropriate space.

Based on observation of the surveyor on June 11th, 2010 the following violation of the Life Safety Code were noted:

Wellness Building at 82 West Main St:

1) 39.3.3.2 Interior Wall and Ceiling Finish
Interior wall and ceiling finish complying with 10.2.3 shall be Class A or Class B in exits and in enclosed corridors furnishing access to exits; and Class A, Class B, or Class C in office areas. Evidence: There is OSB board on the walls of the boiler room and storage room on 2nd floor.

2) 39.3.2.2*
High hazard contents areas, as classified in Section 6.2, shall meet the following criteria:
(1) The area shall be separated from other parts of the building by fire barriers having a fire resistance rating of not less than 1 hour, with all openings therein protected by 3/4-hour fire protection-rated self-closing fire doors.
(2) The area shall be protected by an automatic extinguishing system in accordance with Section 9.7.
Evidence: The boiler room is allowed to be smoke tight in accordance with Section 9.7 There are penetrations in the walls that would allow the penetration of smoke.

3) NFPA 1 10.19.5 Equipment Rooms.
10.19.5.1 Combustible material shall not be stored in boiler rooms, mechanical rooms, or electrical equipment rooms.
10.19.5.2 Materials and supplies for the operation and maintenance of the equipment in the room shall be permitted. Evidence: Several empty containers of clorox bleach are being stored in the boiler room

4) Maine Law Title 25 Section ?2447-B. Foam plastic insulation standards
1. Prohibition. No individual, partnership or corporation shall install in this State any type of foam plastic insulation unless that product complies with and is installed in accordance with the following requirements.
A. Unless otherwise excepted in the following subparagraphs, all foam plastic or foam plastic cores of manufactured assemblies shall have a flame-spread rating of not more than 75 and a smoke-developed rating of not more than 450 when tested in the maximum thickness intended for use in accordance with ASTM E-84. For all such installations, the foam plastic shall be separated from habitable or occupiable spaces by an approved thermal barrier of 1/2 inch gypsum wallboard or equivalent thermal barrier material which will limit the average temperature rise of the unexposed surface to not more than 250` F. after 15 minutes of fire exposure complying with the ASTM E-119 standard time-temperature curve. Thermal barriers shall be installed in a manner that assures they will stay in place for a minimum of 15 minutes under the same test exposure conditions. Evidence: Foam insulation board on ceiling of storage room on 2nd floor with no thermal barrier.

Based on observation of the surveyor on June 9th, 2010 the following electrical equipment was no correct with evidence as follows:

In the operating recovery rooms, there were two power relocation tap devices attached to the wall of at the top part of the patients beds. The devices are not U.N. listed for healthcare.