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The facility failed to maintain the building type per code. Findings include:

During the survey, the following is an example of what was observed:
The facility is located on the first and second floors of a three story building. Type II (000) constuction type was observed in what appeared to be the "original" building's first and second floors, which is in the three story building. The original plaster ceiling had been removed and/or damaged in several areas.

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2000 NFPA 101, 19.1.6.2 Health care occupancies shall be limited to the types of building construction shown in Table 19.1.6.2. (See 8.2.1.)Table 19.1.6.2 Construction Type Limitations
Construction Stories
Type
1 2 3 4 or
More
I(443) X X X X
I(332) X X X X
II(222) X X X X
II(111) X X* X* NP
II(000) X* X* NP NP
III(211) X* X* NP NP
III(200) X* NP NP NP
IV(2HH) X* X* NP NP
V(111) X* X* NP NP
V(000) X* NP NP NP
X: Permitted type of construction.
NP: Not permitted.
*Building requires automatic sprinkler protection. (See 19.3.5.1.)
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The facility failed to maintain the construction type per code. Findings include:

During the survey, the following is an example of what was observed:
Second Floor E.R. Elevator Equipment Room had plywood at the ceiling/floor for decking, surveyor could not verify that this meets a type II (222) assembly

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2000 NFPA 101, 19.1.6.2 Health care occupancies shall be limited to the types of building construction shown in Table 19.1.6.2. (See 8.2.1.)Table 19.1.6.2 Construction Type Limitations
Construction Stories
Type
1 2 3 4 or
More
I(443) X X X X
I(332) X X X X
II(222) X X X X
II(111) X X* X* NP
II(000) X* X* NP NP
III(211) X* X* NP NP
III(200) X* NP NP NP
IV(2HH) X* X* NP NP
V(111) X* X* NP NP
V(000) X* NP NP NP
X: Permitted type of construction.
NP: Not permitted.
*Building requires automatic sprinkler protection. (See 19.3.5.1.)
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The facility failed to provide corridor doors that would close and resist the passage of smoke. Findings include: During the survey, the following are examples of what was observed:

1. Two doors from the ER which opens into the corridor failed to close tight as to resist the passage of smoke.

2. The door to Mechanical Room # 15 failed to close tight as to resist the passage of smoke this door opens into the corridor.

3. The door to Camera Room # 4 second floor failed to positive latch, this door opens into the corridor.


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The facility failed to maintain the corridor doors per code. Findings include:

During the survey, the following are examples of what was observed:
4. First Floor - Old One North Nurses' Station closet corridor door was not positive latching
5. Second Floor - Transcription Room in Radiology, corridor door had a broken roller latch

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2000 NFPA 101, 19.3.6.3.1 Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 13/4-in. (4.4-cm) thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke.

2000 NFPA 101, 19.3.6.3.2 Doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door. Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.2.
CMS - 2786R Fire Safety Survey Report 2000 Code - Healthcare Roller latches are prohibited by CMS regulations in all health care facilities.
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The facility failed to provide corridor doors that would close and resist the passage of smoke. Findings include: During the survey, the following are examples of what was observed:

1. Patient Room 3208 door failed to positive latch.

2. Patient Room 3206 door failed to positive latch.
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NFPA 101, 19.3.6.3.1 Exception No.2. In the smoke compartments protected throughout by an approved, supervised automatic sprinkler system, doors in corridor walls shall be constructed to resist the passage of smoke and be provided with suitable means of keeping the doors closed.
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The facility failed to maintain the corridor doors per code. Findings include:

During the survey, the following are examples of what was observed:
1. Second Floor - Recovery Room corridor door did not not have latching hardware
2. Second Floor - "Non Waiting Room" double corridor doors did not not have latching hardware

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2000 NFPA 101, 18.3.6.3.2 Doors shall be provided with positive latching hardware. Roller latches shall be prohibited. Exception: Doors to toilet rooms, bathrooms, shower rooms, sink closets, and similar auxiliary spaces that do not contain flammable or combustible materials.
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The facility failed to maintain the fire rated doors per code. Findings include:

During the survey, the following is an example of what was observed:
First Floor - the metal fire doors at POB I and the Main Hospital failed to close upon activation of the fire alarm on the Main Hospital side

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2000 NFPA 101, 19.2.2.2.6 Any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8.2. The automatic sprinkler system, if provided, and the fire alarm system, and the systems required by 7.2.1.8.2 shall be arranged to initiate the closing action of all such doors throughout the smoke compartment or throughout the entire facility.
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The facility failed to provide exit signs. Findings include: During the survey, the following is an example of what was observed:


The Exit by Dietary Office was not provided with an Exit Sign.
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7.10.1.4 Exit access shall be marked by signs.
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The facility failed to provide smoke barriers that would provide at least a half hour fire resistance rating. Findings include: During the survey, the following are examples of what was observed:


1. Unsealed penetrations at the end of two sleeve's, in the Smoke Barrier, by conference room one out patient surgery.

2. Unsealed penetrations at the end of a sleeve, in the Smoke Barrier, by Patient Room 239.


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First Floor - Materials Management Receiving - one hour fire/smoke barrier:
3. The right wall had several unsealed penetrations
4. The left wall did not continue above the ceiling to the deck above

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2000 NFPA 101, 8.2.4.4.1 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through smoke partitions shall be protected as follows: (1) The space between the penetrating item and the smoke partition shall meet one of the following conditions: a. It shall be filled with a material that is capable of limiting the transfer of smoke. b. It shall be protected by an approved device that is designed for the specific purpose. (2) Where the penetrating item uses a sleeve to penetrate the smoke partition, the sleeve shall be solidly set in the smoke partition, and the space between the item and the sleeve shall meet one of the following conditions: a. It shall be filled with a material that is capable of limiting the transfer of smoke. b. It shall be protected by an approved device that is designed for the specific purpose. (3) Where designs take transmission of vibrations into consideration, any vibration isolation shall meet one of the following conditions: a. It shall be made on either side of the smoke partitions. b. It shall be made by an approved device that is designed for the specific purpose.
2000 NFPA 101, 8.3.2 Smoke barriers required by this Code shall be continuous from an outside wall to an outside wall, from a floor to a floor, or from a smoke barrier to a smoke barrier or a combination thereof. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces.
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The facility failed to maintain the smoke barriers per code. Findings include:

During the survey, the following is an example of what was observed:
Second Floor - An unsealed penetration of a flex conduit at the corner of the Blood Supply Room in the hallway from the Front Lobby to the Surgery Waiting Room

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2000 NFPA 101, 8.2.4.4.1 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through smoke partitions shall be protected as follows: (1) The space between the penetrating item and the smoke partition shall meet one of the following conditions: a. It shall be filled with a material that is capable of limiting the transfer of smoke. b. It shall be protected by an approved device that is designed for the specific purpose. (2) Where the penetrating item uses a sleeve to penetrate the smoke partition, the sleeve shall be solidly set in the smoke partition, and the space between the item and the sleeve shall meet one of the following conditions: a. It shall be filled with a material that is capable of limiting the transfer of smoke. b. It shall be protected by an approved device that is designed for the specific purpose. (3) Where designs take transmission of vibrations into consideration, any vibration isolation shall meet one of the following conditions: a. It shall be made on either side of the smoke partitions. b. It shall be made by an approved device that is designed for the specific purpose.
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The facility failed to maintain the smoke barrier to restrict the passage of smoke. Findings include: During the survey, the following is an example of what was observed:

1. While testing the fire alarm system the doors in the barrier released, but failed to close tight as to resist the passage of smoke, by stairwell # 17 second floor.


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2. Third Floor - the corridor door to the Gift Shop is in an one hour fire/smoke barrier and did not have a self-closing device

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NFPA 101, 19.3.7.6., 8.3.4 Doors in smoke barriers to be self-closing. Doors in smoke barriers shall close the opening in the wall leaving only a minimum clearance to allow door(s) to function properly.

2000 NFPA 101, 19.3.7.6 Doors in smoke barriers shall comply with 8.3.4 and shall be self-closing or automatic-closing in accordance with 19.2.2.2.6. Such doors in smoke barriers shall not be required to swing with egress travel.

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The facility failed to maintain the hazardous area per code. Findings include:

During the survey, the following is an example of what was observed:
First Floor - Main Clean Linen Room - 576 sq. ft. with combustible storage, the door did not have a self-closing device

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2000 NFPA 101, 19.3.2.1 Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing.

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The facility failed to maintain the Gift Shop per code. Findings include:

During the survey, the following is an example of what was observed:
First Floor Gift Shop 196 sq. ft. with combustibles, the self-closing device had been removed from the door

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2000 NFPA 101, 18.3.2.5 Gift shops shall be protected as hazardous areas where used for the storage or display of combustibles in quantities considered hazardous.

2000 NFPA 101, 18.3.2.1* Hazardous Areas. Any hazardous area shall be protected in accordance with Section 8.4. The areas described in Table 18.3.2.1 shall be protected as indicated.

2000 NFPA 101, 8.4.1.1* Protection from any area having a degree of hazard greater than that normal to the general occupancy of the building or structure shall be provided by one of the following means: (1) Enclose the area with a fire barrier without windows that has a 1-hour fire resistance rating in accordance with Section 8.2. (2) Protect the area with automatic extinguishing systems in accordance with Section 9.7. (3) Apply both 8.4.1.1(1) and (2) where the hazard is severe or where otherwise specified by Chapters 12 through 42.

HCFA Transmittal 40-93 It is the intent of the code that (smoke-resisting) separation be provided even in a sprinklered hazardous area. "Where the sprinkler option is used, the (hazardous) areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be equipped with self- or automatic closers and be positive latching."

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The facility failed to provide protection of openings in fire barriers to limit the spread of fire and restrict the movement of smoke from one side of the fire barrier to the other. Findings include: During the survey, the following are examples of what was observed:

1. A hole apprximatley 12"x12" was observed in the two hour barrier, in LDR A/H room.

2. Unsealed penetrations around a air line,in the one hour barrier, Mechanical Room # 16 second floor.


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3. First Floor - three hour fire barrier at POB I and Old One North:
a. Unsealed penetration of a group of blue wires
b. Unsealed penetration of a sprinkler pipe and sleeve
4. Second Floor - fire barrier at Womens Center and Main Hospital (L and D) had an unsealed penetration
5. First Floor - the automatic fire door at Womens Center and Main Hospital failed to drop power while testing the fire alarm (it remained open)

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2000 NFPA 101, 8.2.3.2.4.2 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through fire barriers shall be protected as follows: (1) The space between the penetrating item and the fire barrier shall meet one of the following conditions: a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier. b. It shall be protected by an approved device that is designed for the specific purpose. (2) Where the penetrating item uses a sleeve to penetrate the fire barrier, the sleeve shall be solidly set in the fire barrier, and the space between the item and the sleeve shall meet one of the following conditions: a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier. b. It shall be protected by an approved device that is designed for the specific purpose. (3) * Insulation and coverings for pipes and ducts shall not pass through the fire barrier unless one of the following conditions is met: a. The material shall be capable of maintaining the fire resistance of the fire barrier. b. The material shall be protected by an approved device that is designed for the specific purpose. (4) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions: a. It shall be made on either side of the fire barrier. b. It shall be made by an approved device that is designed for the specific purpose.
2000 NFPA 101, 7.2.4.3.7 Doors in horizontal exits shall be designed and installed to minimize air leakage.
2000 NFPA 101, 7.2.4.3.8 All fire doors in horizontal exits shall be self-closing or automatic-closing in accordance with 7.2.1.8. Horizontal exit doors located across a corridor shall be automatic-closing in accordance with 7.2.1.8.
7.2.1.9.2 Where doors are required to be self-closing and (1) are operated by power upon the approach of a person or (2) are provided with power-assisted manual operation, they shall be permitted in the means of egress under the following conditions: (1) Doors can be opened manually in accordance with 7.2.1.9.1 to allow egress travel in the event of power failure. (2) New doors remain in the closed position unless actuated or opened manually. (3) When actuated, new doors remain open for not more than 30 seconds. (4) Doors held open for any period of time close - and the power-assist mechanism ceases to function - upon operation of approved smoke detectors installed in such a way as to detect smoke on either side of the door opening in accordance with the provisions of NFPA 72, National Fire Alarm Code. (5) Doors required to be self-latching are either self-latching or become self-latching upon operation of approved smoke detectors per 7.2.1.9.2(4). (6) New power-assisted swinging doors comply with BHMA/ANSI A156.19, American National Standard for Power Assist and Low Energy Power Operated Doors.

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The facility failed to conduct fire drills per code. Findings include: During the survey, the following are examples of what was observed:

1. Per documentation provided by maintenance staff, facility failed to illustrate that all facility personnel are familiar with the signals and emergency action required under varied conditions during fire drills. Per interview with facility maintenance staff, staff confirmed that documentation provided of fire drill participation did not include names of all staff in the facility at the time of the fire drills.

2. Per documentation not holding fire drills at unexpected times for the third shift

Third Shift
09/10/2012 - 5:38 am
06/22/2012 - 5:40 am
03/31/2012 - 6:00 am
12/29/2011 - 6:27 am

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2000 NFPA 101, 18.7.1.2 Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
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The facility failed to conduct fire drills per code. Findings include: During the survey, the following are examples of what was observed:

1. Per documentation provided by maintenance staff, facility failed to illustrate that all facility personnel are familiar with the signals and emergency action required under varied conditions during fire drills. Per interview with facility maintenance staff, staff confirmed that documentation provided of fire drill participation did not include names of all staff in the facility at the time of the fire drills.

2. Per documentation not holding fire drills at unexpected times for the third shift

Third Shift
09/10/2012 - 5:38 am
06/22/2012 - 5:40 am
03/31/2012 - 6:00 am
12/29/2011 - 6:27 am

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2000 NFPA 101, 18.7.1.2 Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
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The facility failed to conduct fire drills per code. Findings include: During the survey, the following are examples of what was observed:

1. Per documentation provided by maintenance staff, facility failed to illustrate that all facility personnel are familiar with the signals and emergency action required under varied conditions during fire drills. Per interview with facility maintenance staff, staff confirmed that documentation provided of fire drill participation did not include names of all staff in the facility at the time of the fire drills.

2. Per documentation not holding fire drills at unexpected times varying conditions for the third shift

Third Shift
09/10/2012 - 5:38 am
06/22/2012 - 5:40 am
03/31/2012 - 6:00 am
12/29/2011 - 6:27 am

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2000 NFPA 101, 19.7.1.2 Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
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The facility failed to provide a fire alarm system per code. Findings include:

During the survey, the following are examples of what was observed:
1. First Floor - the following locations had a visual fire alarm device only, the audible fire alarm could not be heard in these areas:
a. Loading Dock Corridor
b. Main Hallway
2. The fire alarm remote annunciator did not indicate separate troubles for the following:
a. Phone Line 1
b. Phone Line 2
c. Both Phone Lines
The only signal received at the fire alarm remote annunciator - "common trouble point for node 14"

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2000 NFPA 101, 9.6.3.6 Notification signals for occupants to evacuate shall be by audible and visible signals in accordance with NFPA 72, National Fire Alarm Code, and CABO/ANSI A117.1, American National Standard for Accessible and Usable Buildings and Facilities, or other means of notification acceptable to the authority having jurisdiction shall be provided.
1999 NFPA 72, Table 7-2.2

b. Digital Alarm Communicator
Transmitter (DACT)

The primary line from the DACT shall be disconnected. Indication of the DACT trouble signal at the premises shall be verified as well as transmission to the supervising station within 4 minutes of detection of the fault.

The secondary means of transmission from the DACT shall be disconnected. Indication of the DACT trouble signal at the premises shall be verified as well as transmission to the supervising station within 4 minutes of detection of the fault.

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The facility failed to maintain the fire alarm system in proper working order. Findings include: During the survey, the following are examples of what was observed:


1. The strobe was not operable in Dietary.

2. Several strobes were not operable in the corridor outside of Surgery Waiting Room.
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2000 NFPA 101, 9.6.3.2 Notification shall be provided by audible and visible signals in accordance with 9.6.3.3 through 9.6.3.12.

2000 NFPA 101, 9.6.3.6 Notification signals for occupants to evacuate shall be by audible and visible signals in accordance with NFPA 72, National Fire Alarm Code, and CABO/ANSI A117.1, American National Standard for Accessible and Usable Buildings and Facilities, or other means of notification acceptable to the authority having jurisdiction shall be provided.

The facility failed to maintain the fire alarm system per code. Findings include:

During the survey, the following is an example of what was observed:
First Floor - the audible fire alarm device by room 142 did not work when the fire alarm was tested

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2000 NFPA 101, 9.6.3.2 Notification shall be provided by audible and visible signals in accordance with 9.6.3.3 through 9.6.3.12.

2000 NFPA 101, 9.6.3.6 Notification signals for occupants to evacuate shall be by audible and visible signals in accordance with NFPA 72, National Fire Alarm Code, and CABO/ANSI A117.1, American National Standard for Accessible and Usable Buildings and Facilities, or other means of notification acceptable to the authority having jurisdiction shall be provided.
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The facility failed to provide a compete report of the sensitivity testing of the smoke detectors. Findings include: During the survey, the following is an example of what was observed:
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Documentation provided by the facility during the survey did not indicate the range of the sensitivity testing of the smoke detectors. Detector sensitivity shall be checked with one year after installation and every alternate year thereafter per 72, 7-3.2.1. (Up to 5 years permitted under certain circumstances. See 7-3.2.1).

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The facility failed to provide a compete report of the sensitivity testing of the smoke detectors. Findings include: During the survey, the following is an example of what was observed:
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Documentation provided by the facility during the survey did not indicate the range of the sensitivity testing of the smoke detectors. Detector sensitivity shall be checked with one year after installation and every alternate year thereafter per 72, 7-3.2.1. (Up to 5 years permitted under certain circumstances. See 7-3.2.1).

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Sprinkler coverage was observed during the survey not adequately provided. Findings include: During the survey, the following are examples of what was observed:

1. Several ceiling tiles missing in the Old CEP.

2. Sprinkler coverage was not provided in the Office of Old CEP.

3. A sprinkler in Biohazard was obstructed by an old exit sign, which is not in use at the present.

4. A sprinkler in Biohazard had a bend deflector.

5. Escutcheon plate missing on a sprinkler in the Out Patient Surgery Waiting Room.


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6. First Floor - Old One North Nurses' Station closet did not have sprinkler protection

7. Second Floor - excessive build up of foreign materials on the sprinkler head in the bathroom of room "W.S. 1"

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2000 NFPA 101, 19.3.5.1 Where required by 19.1.6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.
1998 NFPA 25, 2-2.1.1 Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.
2000 NFPA 101, 9.7.5 All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.
1999 NFPA 25, 2-2.1.1 and 2-4.1.2 Sprinklers that are painted, corroded or damaged shall be replaced with new listed sprinklers of the same characteristics, including orifice size, thermal response, and water distribution.

2000 NFPA 13, 3-2.7.2 Escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly..

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The facility failed to perform the required maintenance of the facility sprinkler system. Findings include: During the survey, the following is an example of what was observed:

Inoperable gauge on riser in stairwell 5th. floor.
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NFPA 101, 4.6.12, and NFPA 25, 2-2 and Table 2-1 Requires an inspection every quarter (three months).
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The facility failed to provide metal self-closing containers for disposing of cigarette butts and ashes from ashtrays. Findings include: During the survey, the following are examples of what was observed:

The facility has five designated smoking areas located at differ locations around the outside, none of these areas were provided with noncombustible ashtrays or metal self-closing containers for disposing of cigarette butts.
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NFPA 101, 19.7.4 Ashtrays of noncombustible material and safe design, and metal self-closing containers for disposing of cigarette butts and ashes from ashtrays, shall be provided.

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The facility failed to provide metal self-closing containers for disposing of cigarette butts and ashes from ashtrays. Findings include: During the survey, the following are examples of what was observed:

The facility has five designated smoking areas located at differ locations around the outside, none of these areas were provided with noncombustible ashtrays or metal self-closing containers for disposing of cigarette butts.
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NFPA 101, 19.7.4 Ashtrays of noncombustible material and safe design, and metal self-closing containers for disposing of cigarette butts and ashes from ashtrays, shall be provided.

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The facility failed to provide metal self-closing containers for disposing of cigarette butts and ashes from ashtrays. Findings include: During the survey, the following are examples of what was observed:

The facility has five designated smoking areas located at differ locations around the outside, none of these areas were provided with noncombustible ashtrays or metal self-closing containers for disposing of cigarette butts.
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NFPA 101, 19.7.4 Ashtrays of noncombustible material and safe design, and metal self-closing containers for disposing of cigarette butts and ashes from ashtrays, shall be provided.

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A. The facility failed to maintain the dietary hood. Findings include: During the survey, the following are examples of what was observed:

One damaged filter observed not to be tight fitting or firming held in place, another set of filters had approximatley a 1/4" gap between them.
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NFPA 96, 3-2.3 Grease filters shall be listed and constructed of steel or listed equivalent material and shall be of rigid construction that will not distort or crush under normal operation, handling, and cleaning conditions. Filters shall be tight fitting and firmly held in place.



B. The facility failed to adequately perform testing and inspection of the dietary hood extinguishment system. Findings include:

During survey, the provided documentation for the monthly inspection of the hood system was the inspection card attached to the pull station of the hood extinguishing system. This card was observed with space on the reverse side to date and initial each month an inspection was conducted by facility staff. This side of the inspection card was blank.
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NFPA 17, 9-2.1- On a monthly basis, inspection shall be conducted in accordance with the manufacturer 's listed installation and maintenance manual or owner 's manual. As a minimum, this "quick check " or inspection shall include verification of the following:

(a) The extinguishing system is in its proper location.
(b) The manual actuators are unobstructed.
(c) The tamper indicators and seals are intact.
(d) The maintenance tag or certificate is in place.
(e) The system shows no physical damage or condition that might prevent operation.
(f) The pressure gauge(s), if provided, is in operable range.
(g) The nozzle blow-off caps, where provided, are intact and undamaged.
(h) Neither the protected equipment nor the hazard has been replaced, modified, or relocated.

A. The facility failed to maintain the dietary hood. Findings include: During the survey, the following are examples of what was observed:

One damaged filter observed not to be tight fitting or firming held in place, another set of filters had approximatley a 1/4" gap between them.
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NFPA 96, 3-2.3 Grease filters shall be listed and constructed of steel or listed equivalent material and shall be of rigid construction that will not distort or crush under normal operation, handling, and cleaning conditions. Filters shall be tight fitting and firmly held in place.




B. The facility failed to adequately perform testing and inspection of the dietary hood extinguishment system. Findings include:

During survey, the provided documentation for the monthly inspection of the hood system was the inspection card attached to the pull station of the hood extinguishing system. This card was observed with space on the reverse side to date and initial each month an inspection was conducted by facility staff. This side of the inspection card was blank.

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NFPA 17, 9-2.1- On a monthly basis, inspection shall be conducted in accordance with the manufacturer 's listed installation and maintenance manual or owner 's manual. As a minimum, this "quick check " or inspection shall include verification of the following: (a) The extinguishing system is in its proper location.
(b) The manual actuators are unobstructed. (c) The tamper indicators and seals are intact. (d) The maintenance tag or certificate is in place. (e) The system shows no physical damage or condition that might prevent operation. (f) The pressure gauge(s), if provided, is in operable range. (g) The nozzle blow-off caps, where provided, are intact and undamaged. (h) Neither the protected equipment nor the hazard has been replaced, modified, or relocated.

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A. The facility failed to maintain the dietary hood. Findings include: During the survey, the following are examples of what was observed:

A. One damaged filter observed not to be tight fitting or firming held in place, another set of filters had approximatley a 1/4" gap between them.
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NFPA 96, 3-2.3 Grease filters shall be listed and constructed of steel or listed equivalent material and shall be of rigid construction that will not distort or crush under normal operation, handling, and cleaning conditions. Filters shall be tight fitting and firmly held in place.




B. The facility failed to adequately perform testing and inspection of the dietary hood extinguishment system. Findings include:

During survey, the provided documentation for the monthly inspection of the hood system was the inspection card attached to the pull station of the hood extinguishing system. This card was observed with space on the reverse side to date and initial each month an inspection was conducted by facility staff. This side of the inspection card was blank.
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NFPA 17, 9-2.1- On a monthly basis, inspection shall be conducted in accordance with the manufacturer 's listed installation and maintenance manual or owner 's manual. As a minimum, this "quick check " or inspection shall include verification of the following: (a) The extinguishing system is in its proper location.
(b) The manual actuators are unobstructed.
(c) The tamper indicators and seals are intact.
(d) The maintenance tag or certificate is in place.
(e) The system shows no physical damage or condition that might prevent operation.
(f) The pressure gauge(s), if provided, is in operable range.
(g) The nozzle blow-off caps, where provided, are intact and undamaged.
(h) Neither the protected equipment nor the hazard has been replaced, modified, or relocated.

The facility failed to prohibit portable space heating devices per code. Findings include:

During the survey, the following is an example of what was observed;
Second Floor - Nurse Practioner's Sleep Room had a portable space heating device by the bed

_____________

2000 NFPA 101, 18.7.8 Portable space-heating devices shall be prohibited in all health care occupancies. Exception: Portable space-heating devices shall be permitted to be used in nonsleeping staff and employee areas where the heating elements of such devices do not exceed 212°F (100°C).
.

.
The facility failed to prohibit space heating devices per code. Findings include:

During the survey, the following are examples of what was observed:
Portable space heating devices were observed in the following locations:
1. First Floor - Volunteers' Office, plugged in, nonsleeping compartment
2. First Floor - Director of Quality's Office, was found under desk with combustibles touching the heater, not plugged in, nonsleeping compartment
3. First Floor - Pastorial Office, plugged in, nonsleeping compartment
4. Second Floor - Clinical Information Office across from patient room 209, sleeping compartment
5. Second Floor - Patient Assesment Office (Radiology), nonsleeping compartment
6. Second Floor - Transcription Room (Radiology), nonsleeping compartment

_________________

2000 NFPA 101, 19.7.8 Portable space-heating devices shall be prohibited in all health care occupancies. Exception: Portable space-heating devices shall be permitted to be used in nonsleeping staff and employee areas where the heating elements of such devices do not exceed 212°F (100°C).
.

.
The facility failed to provide a readily accessible means of egress pathway at all times. Findings include: During the survey, the following are examples of what was observed:


1. The means of egress was blocked with boxes, carts, hand trucks, in Materials Management.

2. Boxes being stored in the corridor in Receiving Department.

3. Boxes, carts, being stored in the corridor obstructing the means of egress to the Exit from Dietary.
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NFPA 101, 7.1.10.1 Means of egress shall be continuously maintained free of all obstructions or impediments for full instant use in case of fire or other emergencies.

Corridors must be maintained free of all furniture and other items. Items are considered stored in the corridor if they are not both used and moved at least once every half hour. Transmittal #99-94.

The facility failed to provide proper storage of oxygen cylinders. Findings include: During the survey, the following is an example of what was observed:

1. Unsecured oxygen cylinder in Trauma # 3.


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The facility failed to maintain the medical gas storage per code. Findings include:

During the survey, the following is an example of what was observed:
2. Second Floor - Medication Supply Room at CVU an unsecured oxygen cylinder was observed in this room

___________

1999 NFPA 99, 4-3.1.1.1 and 4-5.1.1.1 Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over.

1999 NFPA 99, 4-3.5.2.1 Gases in Cylinders and Liquefied Gases in Containers - Level 1. (a) * Handling of Gases. Administrative authorities shall provide regulations to ensure that standards for safe practice in the specifications for cylinders; marking of cylinders, regulators, and valves; and cylinder connections have been met by vendors of cylinders containing compressed gases supplied to the facility. (b) Special Precautions - Oxygen Cylinders and Manifolds. Great care shall be exercised in handling oxygen to prevent contact of oxygen under pressure with oils, greases, organic lubricants, rubber, or other materials of an organic nature. The following regulations, based on those of the CGA Pamphlet G-4, Oxygen, shall be observed:

27. Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.

.

.
The facility failed to maintain the anesthetizing locations per code. Findings include:

During the survey, the following are examples of what was observed:
Per interview with the staff the ten windowless ORs did not have automatic smoke venting

_____________

1999 NFPA 99, 5-4.1.2 Supply and exhaust systems for windowless anesthetizing locations shall be arranged to automatically vent smoke and products of combustion.
1999 NFPA 99, 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.
1999 NFPA 99, 5-4.1.4 The electric supply to the ventilating system shall be served by the equipment system of the essential electrical system specified in Chapter 3, " Electrical Systems. "
1999 NFPA 99, 5-6.1.1 Ventilating and humidifying equipment for anesthetizing locations shall be kept in operable condition and be continually operating during surgical procedures (see A-5-4.1).
.

1. The facility failed to provide the annual fire alarm system inspection report. Findings include: During the survey, the following is an example of what was observed:

During the review of the Life Safety Documentation, the facility could not provide the inspection report for the annual inspection of the fire alarm system.
------------------------------------------
NFPA 101, 9.6.1.4 The fire alarm system to be installed, tested, and maintained in accordance with the requirements of NFPA 70 and NFPA 72.



2. The facility failed to provide the required the quarterly inspection reports for the facility sprinkler system. Findings include During the survey, the following is an example of what was oberved:

During the review of the Life Safety Code Documentation, the facility could not provide the quarterly inspection reports for the sprinkler system.
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NFPA 101, 4.6.12, and NFPA 25, 2-2 and Table 2-1 Requires an inspection every quarter (three months).






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3. The facility failed to maintain the following systems per code. Findings include:

During the survey, the following are examples of what was observed:
Sleep Center Suite 501
a. The Main Office (file/storage room) approximately 240 sq. ft. with combustible storage did not have a self-closing device on the door
b. The emergency battery lighting in the Waiting Room in suite 501did not illuminate when tested
Sleep Center Suite 304
c. Storage Room, with combustible storage did not have a self-closing device on the door
For the entire building:
d. Could not verify if the building had emergency lighting through out
e. The facility failed to provide documentation of monthly and annual testing of the emergency lighting
___________
2000 NFPA 101, 39.3.2.1* Hazardous areas including, but not limited to, areas used for general storage, boiler or furnace rooms, and maintenance shops that include woodworking and painting areas shall be protected in accordance with Section 8.4.

HCFA Transmittal 40-93 It is the intent of the code that (smoke-resisting) separation be provided even in a sprinklered hazardous area. "Where the sprinkler option is used, the (hazardous) areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be equipped with self- or automatic closers and be positive latching."

2000 NFPA 101, 39.2.9.1 Emergency lighting shall be provided in accordance with Section 7.9 in any building where any one of the following conditions exists: (1) The building is two or more stories in height above the level of exit discharge. (2) The occupancy is subject to 100 or more occupants above or below the level of exit discharge. (3) The occupancy is subject to 1000 or more total occupants.

2000 NFPA 101, 7.9.3 A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 1/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

A. The facility failed to maintain proper emergency lighting at the generator set and controls. Findings include: During the survey, the following is an example of what was observed:

The battery-powered light in generator set and control room number three was inoperable.
---------------------------------------------
1999 NFPA 99, 3-6.1.1 and 3-4.1.1.4, and 1999 NFPA 110, 5-3.1 The Level 1 or Level 2 EPS equipment location shall be provided with battery-powered emergency lighting.




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B. The facility failed to maintain the generator remote annunciator per code. Findings include:

During the survey, the following are examples of what was observed:
1. "Generator #1 CEP" and "Generator #2 CEP" remote annunciators did not give an audible alarm when these generators were taken out of the auto position. The remote annunciators did give a visual "control switch not in auto"
2. "Generator #3" remote annunciator:
a. No audible or visual alarm when the generator was taken out of the auto position
b. No visual indication when the generator was supplying the load, the remote annunciator had an indicating light for this - "generator on"

_______________

1999 NFPA 99, 3-4.1.1.15 A remote annunciator, storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station (see NFPA 70, National Electrical Code, Section 700-12.) The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows: (a) Individual visual signals shall indicate the following: 1. When the emergency or auxiliary power source is operating to supply power to load 2. When the battery charger is malfunctioning (b) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following: 1. Low lubricating oil pressure 2. Low water temperature (below those required in 3-4.1.1.9) 3. Excessive water temperature 4. Low fuel - when the main fuel storage tank contains less than a 3-hour operating supply 5. Overcrank (failed to start) 6. Overspeed
Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions in 3-4.1.1.15(a) and (b) occur, but need not display these conditions individually. [110: 3-5.5.2]
.

The facility failed to provide the required the quarterly inspection reports for the facility sprinkler system. Findings include During the survey, the following is an example of what was oberved:

During the review of the Life Safety Code Documentation, the facility could not provide the quarterly inspection reports for the sprinkler system.
--------------------------------------------------

NFPA 101, 4.6.12, and NFPA 25, 2-2 and Table 2-1 Requires an inspection every quarter (three months).

.
The facility failed to provide the annual fire alarm system inspection report. Findings include: During the survey, the following is an example of what was observed:

During the review of the Life Safety Documentation, the facility could not provide the inspection report for the annual inspection of the fire alarm system.
------------------------------------------------

NFPA 101, 9.6.1.4 The fire alarm system to be installed, tested, and maintained in accordance with the requirements of NFPA 70 and NFPA 72.

.

.
The facility failed to provide the required the quarterly inspection reports for the facility sprinkler system. Findings include During the survey, the following is an example of what was oberved:

During the review of the Life Safety Code Documentation, the facility could not provide the quarterly inspection reports for the sprinkler system.
-------------------------------------------------

NFPA 101, 4.6.12, and NFPA 25, 2-2 and Table 2-1 Requires an inspection every quarter (three months).

.

A. The facility failed to provide the annual fire alarm system inspection report. Findings include: During the survey, the following is an example of what was observed:

During the review of the Life Safety Documentation, the facility could not provide the inspection report for the annual inspection of the fire alarm system.
-------------------------------------------------
NFPA 101, 9.6.1.4 The fire alarm system to be installed, tested, and maintained in accordance with the requirements of NFPA 70 and NFPA 72.




B. The facility failed to provide the required the quarterly inspection reports for the facility sprinkler system. Findings include During the survey, the following is an example of what was oberved:

During the review of the Life Safety Code Documentation, the facility could not provide the quarterly inspection reports for the sprinkler system.
------------------------------------------------
NFPA 101, 4.6.12, and NFPA 25, 2-2 and Table 2-1 Requires an inspection every quarter (three months).

The facility failed to maintain the electrical wiring and equipment per code. Findings include:

During the survey, the following are examples of what was observed:
1. First Floor - "Outakes" had a microwave plugged into an extension cord
2. Second Floor - Nurse Practioner's Sleep Room had a microwave plugged into a surge protector

________________

1999 NFPA 70, 400-7 and 400-8, and HCFA Transmittal Notice 22-99 The 1984 edition of the National Electric Code restricts the use of extension cords to temporary short term uses. It is the policy of HCFA to prohibit non-circuit breaker protected extension cords in health care. The limited use of circuit breaker protected power strips is acceptable, provided the current is limited to 15 amps or less, and no major appliances such as air conditioners, refrigerators, or heating units are connected to the power strip.

The facility failed to maintain the electrical wiring and equipment per code. Findings include:

During the survey, the following is an example of what was observed:
First Floor - Old Security Office at Old One North - refrigerator plugged into a surge protector

____________

1999 NFPA 70, 400-7 and 400-8, and HCFA Transmittal Notice 22-99 The 1984 edition of the National Electric Code restricts the use of extension cords to temporary short term uses. It is the policy of HCFA to prohibit non-circuit breaker protected extension cords in health care. The limited use of circuit breaker protected power strips is acceptable, provided the current is limited to 15 amps or less, and no major appliances such as air conditioners, refrigerators, or heating units are connected to the power strip.

The facility failed to maintain the electrical wiring and equipment per code. Findings include:

During the survey, the following is an example of what was observed:
Second Floor South Tower Mechanical Room, the bed repair area had a refrigerator plugged into a surge protector
______________

1999 NFPA 70, 400-7 and 400-8, and HCFA Transmittal Notice 22-99 The 1984 edition of the National Electric Code restricts the use of extension cords to temporary short term uses. It is the policy of HCFA to prohibit non-circuit breaker protected extension cords in health care. The limited use of circuit breaker protected power strips is acceptable, provided the current is limited to 15 amps or less, and no major appliances such as air conditioners, refrigerators, or heating units are connected to the power strip.

The facility failed to maintain the building type per code. Findings include:

During the survey, the following is an example of what was observed:
The facility is located on the first and second floors of a three story building. Type II (000) constuction type was observed in what appeared to be the "original" building's first and second floors, which is in the three story building. The original plaster ceiling had been removed and/or damaged in several areas.

_____________

2000 NFPA 101, 19.1.6.2 Health care occupancies shall be limited to the types of building construction shown in Table 19.1.6.2. (See 8.2.1.)Table 19.1.6.2 Construction Type Limitations
Construction Stories
Type
1 2 3 4 or
More
I(443) X X X X
I(332) X X X X
II(222) X X X X
II(111) X X* X* NP
II(000) X* X* NP NP
III(211) X* X* NP NP
III(200) X* NP NP NP
IV(2HH) X* X* NP NP
V(111) X* X* NP NP
V(000) X* NP NP NP
X: Permitted type of construction.
NP: Not permitted.
*Building requires automatic sprinkler protection. (See 19.3.5.1.)
.

The facility failed to maintain the construction type per code. Findings include:

During the survey, the following is an example of what was observed:
Second Floor E.R. Elevator Equipment Room had plywood at the ceiling/floor for decking, surveyor could not verify that this meets a type II (222) assembly

_______________

2000 NFPA 101, 19.1.6.2 Health care occupancies shall be limited to the types of building construction shown in Table 19.1.6.2. (See 8.2.1.)Table 19.1.6.2 Construction Type Limitations
Construction Stories
Type
1 2 3 4 or
More
I(443) X X X X
I(332) X X X X
II(222) X X X X
II(111) X X* X* NP
II(000) X* X* NP NP
III(211) X* X* NP NP
III(200) X* NP NP NP
IV(2HH) X* X* NP NP
V(111) X* X* NP NP
V(000) X* NP NP NP
X: Permitted type of construction.
NP: Not permitted.
*Building requires automatic sprinkler protection. (See 19.3.5.1.)
.

The facility failed to provide corridor doors that would close and resist the passage of smoke. Findings include: During the survey, the following are examples of what was observed:

1. Two doors from the ER which opens into the corridor failed to close tight as to resist the passage of smoke.

2. The door to Mechanical Room # 15 failed to close tight as to resist the passage of smoke this door opens into the corridor.

3. The door to Camera Room # 4 second floor failed to positive latch, this door opens into the corridor.


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The facility failed to maintain the corridor doors per code. Findings include:

During the survey, the following are examples of what was observed:
4. First Floor - Old One North Nurses' Station closet corridor door was not positive latching
5. Second Floor - Transcription Room in Radiology, corridor door had a broken roller latch

_____________

2000 NFPA 101, 19.3.6.3.1 Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 13/4-in. (4.4-cm) thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke.

2000 NFPA 101, 19.3.6.3.2 Doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door. Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.2.
CMS - 2786R Fire Safety Survey Report 2000 Code - Healthcare Roller latches are prohibited by CMS regulations in all health care facilities.
.

.
The facility failed to provide corridor doors that would close and resist the passage of smoke. Findings include: During the survey, the following are examples of what was observed:

1. Patient Room 3208 door failed to positive latch.

2. Patient Room 3206 door failed to positive latch.
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NFPA 101, 19.3.6.3.1 Exception No.2. In the smoke compartments protected throughout by an approved, supervised automatic sprinkler system, doors in corridor walls shall be constructed to resist the passage of smoke and be provided with suitable means of keeping the doors closed.
.

.
The facility failed to maintain the corridor doors per code. Findings include:

During the survey, the following are examples of what was observed:
1. Second Floor - Recovery Room corridor door did not not have latching hardware
2. Second Floor - "Non Waiting Room" double corridor doors did not not have latching hardware

_______________

2000 NFPA 101, 18.3.6.3.2 Doors shall be provided with positive latching hardware. Roller latches shall be prohibited. Exception: Doors to toilet rooms, bathrooms, shower rooms, sink closets, and similar auxiliary spaces that do not contain flammable or combustible materials.
.

The facility failed to maintain the fire rated doors per code. Findings include:

During the survey, the following is an example of what was observed:
First Floor - the metal fire doors at POB I and the Main Hospital failed to close upon activation of the fire alarm on the Main Hospital side

______________

2000 NFPA 101, 19.2.2.2.6 Any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8.2. The automatic sprinkler system, if provided, and the fire alarm system, and the systems required by 7.2.1.8.2 shall be arranged to initiate the closing action of all such doors throughout the smoke compartment or throughout the entire facility.
.

.
The facility failed to provide exit signs. Findings include: During the survey, the following is an example of what was observed:


The Exit by Dietary Office was not provided with an Exit Sign.
___________________________

7.10.1.4 Exit access shall be marked by signs.
.

The facility failed to provide smoke barriers that would provide at least a half hour fire resistance rating. Findings include: During the survey, the following are examples of what was observed:


1. Unsealed penetrations at the end of two sleeve's, in the Smoke Barrier, by conference room one out patient surgery.

2. Unsealed penetrations at the end of a sleeve, in the Smoke Barrier, by Patient Room 239.


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First Floor - Materials Management Receiving - one hour fire/smoke barrier:
3. The right wall had several unsealed penetrations
4. The left wall did not continue above the ceiling to the deck above

_________________
2000 NFPA 101, 8.2.4.4.1 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through smoke partitions shall be protected as follows: (1) The space between the penetrating item and the smoke partition shall meet one of the following conditions: a. It shall be filled with a material that is capable of limiting the transfer of smoke. b. It shall be protected by an approved device that is designed for the specific purpose. (2) Where the penetrating item uses a sleeve to penetrate the smoke partition, the sleeve shall be solidly set in the smoke partition, and the space between the item and the sleeve shall meet one of the following conditions: a. It shall be filled with a material that is capable of limiting the transfer of smoke. b. It shall be protected by an approved device that is designed for the specific purpose. (3) Where designs take transmission of vibrations into consideration, any vibration isolation shall meet one of the following conditions: a. It shall be made on either side of the smoke partitions. b. It shall be made by an approved device that is designed for the specific purpose.
2000 NFPA 101, 8.3.2 Smoke barriers required by this Code shall be continuous from an outside wall to an outside wall, from a floor to a floor, or from a smoke barrier to a smoke barrier or a combination thereof. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces.
.

The facility failed to maintain the smoke barriers per code. Findings include:

During the survey, the following is an example of what was observed:
Second Floor - An unsealed penetration of a flex conduit at the corner of the Blood Supply Room in the hallway from the Front Lobby to the Surgery Waiting Room

_______________

2000 NFPA 101, 8.2.4.4.1 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through smoke partitions shall be protected as follows: (1) The space between the penetrating item and the smoke partition shall meet one of the following conditions: a. It shall be filled with a material that is capable of limiting the transfer of smoke. b. It shall be protected by an approved device that is designed for the specific purpose. (2) Where the penetrating item uses a sleeve to penetrate the smoke partition, the sleeve shall be solidly set in the smoke partition, and the space between the item and the sleeve shall meet one of the following conditions: a. It shall be filled with a material that is capable of limiting the transfer of smoke. b. It shall be protected by an approved device that is designed for the specific purpose. (3) Where designs take transmission of vibrations into consideration, any vibration isolation shall meet one of the following conditions: a. It shall be made on either side of the smoke partitions. b. It shall be made by an approved device that is designed for the specific purpose.
.

.
The facility failed to maintain the smoke barrier to restrict the passage of smoke. Findings include: During the survey, the following is an example of what was observed:

1. While testing the fire alarm system the doors in the barrier released, but failed to close tight as to resist the passage of smoke, by stairwell # 17 second floor.


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2. Third Floor - the corridor door to the Gift Shop is in an one hour fire/smoke barrier and did not have a self-closing device

__________________
NFPA 101, 19.3.7.6., 8.3.4 Doors in smoke barriers to be self-closing. Doors in smoke barriers shall close the opening in the wall leaving only a minimum clearance to allow door(s) to function properly.

2000 NFPA 101, 19.3.7.6 Doors in smoke barriers shall comply with 8.3.4 and shall be self-closing or automatic-closing in accordance with 19.2.2.2.6. Such doors in smoke barriers shall not be required to swing with egress travel.

.

The facility failed to maintain the hazardous area per code. Findings include:

During the survey, the following is an example of what was observed:
First Floor - Main Clean Linen Room - 576 sq. ft. with combustible storage, the door did not have a self-closing device

_________________

2000 NFPA 101, 19.3.2.1 Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing.

.

The facility failed to maintain the Gift Shop per code. Findings include:

During the survey, the following is an example of what was observed:
First Floor Gift Shop 196 sq. ft. with combustibles, the self-closing device had been removed from the door

__________________

2000 NFPA 101, 18.3.2.5 Gift shops shall be protected as hazardous areas where used for the storage or display of combustibles in quantities considered hazardous.

2000 NFPA 101, 18.3.2.1* Hazardous Areas. Any hazardous area shall be protected in accordance with Section 8.4. The areas described in Table 18.3.2.1 shall be protected as indicated.

2000 NFPA 101, 8.4.1.1* Protection from any area having a degree of hazard greater than that normal to the general occupancy of the building or structure shall be provided by one of the following means: (1) Enclose the area with a fire barrier without windows that has a 1-hour fire resistance rating in accordance with Section 8.2. (2) Protect the area with automatic extinguishing systems in accordance with Section 9.7. (3) Apply both 8.4.1.1(1) and (2) where the hazard is severe or where otherwise specified by Chapters 12 through 42.

HCFA Transmittal 40-93 It is the intent of the code that (smoke-resisting) separation be provided even in a sprinklered hazardous area. "Where the sprinkler option is used, the (hazardous) areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be equipped with self- or automatic closers and be positive latching."

.

The facility failed to provide protection of openings in fire barriers to limit the spread of fire and restrict the movement of smoke from one side of the fire barrier to the other. Findings include: During the survey, the following are examples of what was observed:

1. A hole apprximatley 12"x12" was observed in the two hour barrier, in LDR A/H room.

2. Unsealed penetrations around a air line,in the one hour barrier, Mechanical Room # 16 second floor.


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3. First Floor - three hour fire barrier at POB I and Old One North:
a. Unsealed penetration of a group of blue wires
b. Unsealed penetration of a sprinkler pipe and sleeve
4. Second Floor - fire barrier at Womens Center and Main Hospital (L and D) had an unsealed penetration
5. First Floor - the automatic fire door at Womens Center and Main Hospital failed to drop power while testing the fire alarm (it remained open)

______________

2000 NFPA 101, 8.2.3.2.4.2 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through fire barriers shall be protected as follows: (1) The space between the penetrating item and the fire barrier shall meet one of the following conditions: a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier. b. It shall be protected by an approved device that is designed for the specific purpose. (2) Where the penetrating item uses a sleeve to penetrate the fire barrier, the sleeve shall be solidly set in the fire barrier, and the space between the item and the sleeve shall meet one of the following conditions: a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier. b. It shall be protected by an approved device that is designed for the specific purpose. (3) * Insulation and coverings for pipes and ducts shall not pass through the fire barrier unless one of the following conditions is met: a. The material shall be capable of maintaining the fire resistance of the fire barrier. b. The material shall be protected by an approved device that is designed for the specific purpose. (4) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions: a. It shall be made on either side of the fire barrier. b. It shall be made by an approved device that is designed for the specific purpose.
2000 NFPA 101, 7.2.4.3.7 Doors in horizontal exits shall be designed and installed to minimize air leakage.
2000 NFPA 101, 7.2.4.3.8 All fire doors in horizontal exits shall be self-closing or automatic-closing in accordance with 7.2.1.8. Horizontal exit doors located across a corridor shall be automatic-closing in accordance with 7.2.1.8.
7.2.1.9.2 Where doors are required to be self-closing and (1) are operated by power upon the approach of a person or (2) are provided with power-assisted manual operation, they shall be permitted in the means of egress under the following conditions: (1) Doors can be opened manually in accordance with 7.2.1.9.1 to allow egress travel in the event of power failure. (2) New doors remain in the closed position unless actuated or opened manually. (3) When actuated, new doors remain open for not more than 30 seconds. (4) Doors held open for any period of time close - and the power-assist mechanism ceases to function - upon operation of approved smoke detectors installed in such a way as to detect smoke on either side of the door opening in accordance with the provisions of NFPA 72, National Fire Alarm Code. (5) Doors required to be self-latching are either self-latching or become self-latching upon operation of approved smoke detectors per 7.2.1.9.2(4). (6) New power-assisted swinging doors comply with BHMA/ANSI A156.19, American National Standard for Power Assist and Low Energy Power Operated Doors.

.

The facility failed to conduct fire drills per code. Findings include: During the survey, the following are examples of what was observed:

1. Per documentation provided by maintenance staff, facility failed to illustrate that all facility personnel are familiar with the signals and emergency action required under varied conditions during fire drills. Per interview with facility maintenance staff, staff confirmed that documentation provided of fire drill participation did not include names of all staff in the facility at the time of the fire drills.

2. Per documentation not holding fire drills at unexpected times for the third shift

Third Shift
09/10/2012 - 5:38 am
06/22/2012 - 5:40 am
03/31/2012 - 6:00 am
12/29/2011 - 6:27 am

_________________

2000 NFPA 101, 18.7.1.2 Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
.

The facility failed to conduct fire drills per code. Findings include: During the survey, the following are examples of what was observed:

1. Per documentation provided by maintenance staff, facility failed to illustrate that all facility personnel are familiar with the signals and emergency action required under varied conditions during fire drills. Per interview with facility maintenance staff, staff confirmed that documentation provided of fire drill participation did not include names of all staff in the facility at the time of the fire drills.

2. Per documentation not holding fire drills at unexpected times for the third shift

Third Shift
09/10/2012 - 5:38 am
06/22/2012 - 5:40 am
03/31/2012 - 6:00 am
12/29/2011 - 6:27 am

_________________

2000 NFPA 101, 18.7.1.2 Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
.

The facility failed to conduct fire drills per code. Findings include: During the survey, the following are examples of what was observed:

1. Per documentation provided by maintenance staff, facility failed to illustrate that all facility personnel are familiar with the signals and emergency action required under varied conditions during fire drills. Per interview with facility maintenance staff, staff confirmed that documentation provided of fire drill participation did not include names of all staff in the facility at the time of the fire drills.

2. Per documentation not holding fire drills at unexpected times varying conditions for the third shift

Third Shift
09/10/2012 - 5:38 am
06/22/2012 - 5:40 am
03/31/2012 - 6:00 am
12/29/2011 - 6:27 am

_________________

2000 NFPA 101, 19.7.1.2 Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
.

The facility failed to provide a fire alarm system per code. Findings include:

During the survey, the following are examples of what was observed:
1. First Floor - the following locations had a visual fire alarm device only, the audible fire alarm could not be heard in these areas:
a. Loading Dock Corridor
b. Main Hallway
2. The fire alarm remote annunciator did not indicate separate troubles for the following:
a. Phone Line 1
b. Phone Line 2
c. Both Phone Lines
The only signal received at the fire alarm remote annunciator - "common trouble point for node 14"

_______________

2000 NFPA 101, 9.6.3.6 Notification signals for occupants to evacuate shall be by audible and visible signals in accordance with NFPA 72, National Fire Alarm Code, and CABO/ANSI A117.1, American National Standard for Accessible and Usable Buildings and Facilities, or other means of notification acceptable to the authority having jurisdiction shall be provided.
1999 NFPA 72, Table 7-2.2

b. Digital Alarm Communicator
Transmitter (DACT)

The primary line from the DACT shall be disconnected. Indication of the DACT trouble signal at the premises shall be verified as well as transmission to the supervising station within 4 minutes of detection of the fault.

The secondary means of transmission from the DACT shall be disconnected. Indication of the DACT trouble signal at the premises shall be verified as well as transmission to the supervising station within 4 minutes of detection of the fault.

.

The facility failed to maintain the fire alarm system in proper working order. Findings include: During the survey, the following are examples of what was observed:


1. The strobe was not operable in Dietary.

2. Several strobes were not operable in the corridor outside of Surgery Waiting Room.
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2000 NFPA 101, 9.6.3.2 Notification shall be provided by audible and visible signals in accordance with 9.6.3.3 through 9.6.3.12.

2000 NFPA 101, 9.6.3.6 Notification signals for occupants to evacuate shall be by audible and visible signals in accordance with NFPA 72, National Fire Alarm Code, and CABO/ANSI A117.1, American National Standard for Accessible and Usable Buildings and Facilities, or other means of notification acceptable to the authority having jurisdiction shall be provided.

The facility failed to maintain the fire alarm system per code. Findings include:

During the survey, the following is an example of what was observed:
First Floor - the audible fire alarm device by room 142 did not work when the fire alarm was tested

___________________

2000 NFPA 101, 9.6.3.2 Notification shall be provided by audible and visible signals in accordance with 9.6.3.3 through 9.6.3.12.

2000 NFPA 101, 9.6.3.6 Notification signals for occupants to evacuate shall be by audible and visible signals in accordance with NFPA 72, National Fire Alarm Code, and CABO/ANSI A117.1, American National Standard for Accessible and Usable Buildings and Facilities, or other means of notification acceptable to the authority having jurisdiction shall be provided.
.

.
The facility failed to provide a compete report of the sensitivity testing of the smoke detectors. Findings include: During the survey, the following is an example of what was observed:
------------------------------------------------

Documentation provided by the facility during the survey did not indicate the range of the sensitivity testing of the smoke detectors. Detector sensitivity shall be checked with one year after installation and every alternate year thereafter per 72, 7-3.2.1. (Up to 5 years permitted under certain circumstances. See 7-3.2.1).

.

.
The facility failed to provide a compete report of the sensitivity testing of the smoke detectors. Findings include: During the survey, the following is an example of what was observed:
___________________________

Documentation provided by the facility during the survey did not indicate the range of the sensitivity testing of the smoke detectors. Detector sensitivity shall be checked with one year after installation and every alternate year thereafter per 72, 7-3.2.1. (Up to 5 years permitted under certain circumstances. See 7-3.2.1).

.

Sprinkler coverage was observed during the survey not adequately provided. Findings include: During the survey, the following are examples of what was observed:

1. Several ceiling tiles missing in the Old CEP.

2. Sprinkler coverage was not provided in the Office of Old CEP.

3. A sprinkler in Biohazard was obstructed by an old exit sign, which is not in use at the present.

4. A sprinkler in Biohazard had a bend deflector.

5. Escutcheon plate missing on a sprinkler in the Out Patient Surgery Waiting Room.


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6. First Floor - Old One North Nurses' Station closet did not have sprinkler protection

7. Second Floor - excessive build up of foreign materials on the sprinkler head in the bathroom of room "W.S. 1"

_______________

2000 NFPA 101, 19.3.5.1 Where required by 19.1.6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.
1998 NFPA 25, 2-2.1.1 Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.
2000 NFPA 101, 9.7.5 All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.
1999 NFPA 25, 2-2.1.1 and 2-4.1.2 Sprinklers that are painted, corroded or damaged shall be replaced with new listed sprinklers of the same characteristics, including orifice size, thermal response, and water distribution.

2000 NFPA 13, 3-2.7.2 Escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly..

.
The facility failed to perform the required maintenance of the facility sprinkler system. Findings include: During the survey, the following is an example of what was observed:

Inoperable gauge on riser in stairwell 5th. floor.
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NFPA 101, 4.6.12, and NFPA 25, 2-2 and Table 2-1 Requires an inspection every quarter (three months).
.

.
The facility failed to provide metal self-closing containers for disposing of cigarette butts and ashes from ashtrays. Findings include: During the survey, the following are examples of what was observed:

The facility has five designated smoking areas located at differ locations around the outside, none of these areas were provided with noncombustible ashtrays or metal self-closing containers for disposing of cigarette butts.
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NFPA 101, 19.7.4 Ashtrays of noncombustible material and safe design, and metal self-closing containers for disposing of cigarette butts and ashes from ashtrays, shall be provided.

.
The facility failed to provide metal self-closing containers for disposing of cigarette butts and ashes from ashtrays. Findings include: During the survey, the following are examples of what was observed:

The facility has five designated smoking areas located at differ locations around the outside, none of these areas were provided with noncombustible ashtrays or metal self-closing containers for disposing of cigarette butts.
------------------------------------------------

NFPA 101, 19.7.4 Ashtrays of noncombustible material and safe design, and metal self-closing containers for disposing of cigarette butts and ashes from ashtrays, shall be provided.

.
The facility failed to provide metal self-closing containers for disposing of cigarette butts and ashes from ashtrays. Findings include: During the survey, the following are examples of what was observed:

The facility has five designated smoking areas located at differ locations around the outside, none of these areas were provided with noncombustible ashtrays or metal self-closing containers for disposing of cigarette butts.
____________________________

NFPA 101, 19.7.4 Ashtrays of noncombustible material and safe design, and metal self-closing containers for disposing of cigarette butts and ashes from ashtrays, shall be provided.

.

A. The facility failed to maintain the dietary hood. Findings include: During the survey, the following are examples of what was observed:

One damaged filter observed not to be tight fitting or firming held in place, another set of filters had approximatley a 1/4" gap between them.
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NFPA 96, 3-2.3 Grease filters shall be listed and constructed of steel or listed equivalent material and shall be of rigid construction that will not distort or crush under normal operation, handling, and cleaning conditions. Filters shall be tight fitting and firmly held in place.



B. The facility failed to adequately perform testing and inspection of the dietary hood extinguishment system. Findings include:

During survey, the provided documentation for the monthly inspection of the hood system was the inspection card attached to the pull station of the hood extinguishing system. This card was observed with space on the reverse side to date and initial each month an inspection was conducted by facility staff. This side of the inspection card was blank.
------------------------------------------------
NFPA 17, 9-2.1- On a monthly basis, inspection shall be conducted in accordance with the manufacturer 's listed installation and maintenance manual or owner 's manual. As a minimum, this "quick check " or inspection shall include verification of the following:

(a) The extinguishing system is in its proper location.
(b) The manual actuators are unobstructed.
(c) The tamper indicators and seals are intact.
(d) The maintenance tag or certificate is in place.
(e) The system shows no physical damage or condition that might prevent operation.
(f) The pressure gauge(s), if provided, is in operable range.
(g) The nozzle blow-off caps, where provided, are intact and undamaged.
(h) Neither the protected equipment nor the hazard has been replaced, modified, or relocated.

A. The facility failed to maintain the dietary hood. Findings include: During the survey, the following are examples of what was observed:

One damaged filter observed not to be tight fitting or firming held in place, another set of filters had approximatley a 1/4" gap between them.
------------------------------------------------
NFPA 96, 3-2.3 Grease filters shall be listed and constructed of steel or listed equivalent material and shall be of rigid construction that will not distort or crush under normal operation, handling, and cleaning conditions. Filters shall be tight fitting and firmly held in place.




B. The facility failed to adequately perform testing and inspection of the dietary hood extinguishment system. Findings include:

During survey, the provided documentation for the monthly inspection of the hood system was the inspection card attached to the pull station of the hood extinguishing system. This card was observed with space on the reverse side to date and initial each month an inspection was conducted by facility staff. This side of the inspection card was blank.

------------------------------------------------
NFPA 17, 9-2.1- On a monthly basis, inspection shall be conducted in accordance with the manufacturer 's listed installation and maintenance manual or owner 's manual. As a minimum, this "quick check " or inspection shall include verification of the following: (a) The extinguishing system is in its proper location.
(b) The manual actuators are unobstructed. (c) The tamper indicators and seals are intact. (d) The maintenance tag or certificate is in place. (e) The system shows no physical damage or condition that might prevent operation. (f) The pressure gauge(s), if provided, is in operable range. (g) The nozzle blow-off caps, where provided, are intact and undamaged. (h) Neither the protected equipment nor the hazard has been replaced, modified, or relocated.

.
A. The facility failed to maintain the dietary hood. Findings include: During the survey, the following are examples of what was observed:

A. One damaged filter observed not to be tight fitting or firming held in place, another set of filters had approximatley a 1/4" gap between them.
-------------------------------------------------
NFPA 96, 3-2.3 Grease filters shall be listed and constructed of steel or listed equivalent material and shall be of rigid construction that will not distort or crush under normal operation, handling, and cleaning conditions. Filters shall be tight fitting and firmly held in place.




B. The facility failed to adequately perform testing and inspection of the dietary hood extinguishment system. Findings include:

During survey, the provided documentation for the monthly inspection of the hood system was the inspection card attached to the pull station of the hood extinguishing system. This card was observed with space on the reverse side to date and initial each month an inspection was conducted by facility staff. This side of the inspection card was blank.
------------------------------------------------
NFPA 17, 9-2.1- On a monthly basis, inspection shall be conducted in accordance with the manufacturer 's listed installation and maintenance manual or owner 's manual. As a minimum, this "quick check " or inspection shall include verification of the following: (a) The extinguishing system is in its proper location.
(b) The manual actuators are unobstructed.
(c) The tamper indicators and seals are intact.
(d) The maintenance tag or certificate is in place.
(e) The system shows no physical damage or condition that might prevent operation.
(f) The pressure gauge(s), if provided, is in operable range.
(g) The nozzle blow-off caps, where provided, are intact and undamaged.
(h) Neither the protected equipment nor the hazard has been replaced, modified, or relocated.

The facility failed to prohibit portable space heating devices per code. Findings include:

During the survey, the following is an example of what was observed;
Second Floor - Nurse Practioner's Sleep Room had a portable space heating device by the bed

_____________

2000 NFPA 101, 18.7.8 Portable space-heating devices shall be prohibited in all health care occupancies. Exception: Portable space-heating devices shall be permitted to be used in nonsleeping staff and employee areas where the heating elements of such devices do not exceed 212°F (100°C).
.

.
The facility failed to prohibit space heating devices per code. Findings include:

During the survey, the following are examples of what was observed:
Portable space heating devices were observed in the following locations:
1. First Floor - Volunteers' Office, plugged in, nonsleeping compartment
2. First Floor - Director of Quality's Office, was found under desk with combustibles touching the heater, not plugged in, nonsleeping compartment
3. First Floor - Pastorial Office, plugged in, nonsleeping compartment
4. Second Floor - Clinical Information Office across from patient room 209, sleeping compartment
5. Second Floor - Patient Assesment Office (Radiology), nonsleeping compartment
6. Second Floor - Transcription Room (Radiology), nonsleeping compartment

_________________

2000 NFPA 101, 19.7.8 Portable space-heating devices shall be prohibited in all health care occupancies. Exception: Portable space-heating devices shall be permitted to be used in nonsleeping staff and employee areas where the heating elements of such devices do not exceed 212°F (100°C).
.

.
The facility failed to provide a readily accessible means of egress pathway at all times. Findings include: During the survey, the following are examples of what was observed:


1. The means of egress was blocked with boxes, carts, hand trucks, in Materials Management.

2. Boxes being stored in the corridor in Receiving Department.

3. Boxes, carts, being stored in the corridor obstructing the means of egress to the Exit from Dietary.
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NFPA 101, 7.1.10.1 Means of egress shall be continuously maintained free of all obstructions or impediments for full instant use in case of fire or other emergencies.

Corridors must be maintained free of all furniture and other items. Items are considered stored in the corridor if they are not both used and moved at least once every half hour. Transmittal #99-94.

The facility failed to provide proper storage of oxygen cylinders. Findings include: During the survey, the following is an example of what was observed:

1. Unsecured oxygen cylinder in Trauma # 3.


27382


The facility failed to maintain the medical gas storage per code. Findings include:

During the survey, the following is an example of what was observed:
2. Second Floor - Medication Supply Room at CVU an unsecured oxygen cylinder was observed in this room

___________

1999 NFPA 99, 4-3.1.1.1 and 4-5.1.1.1 Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over.

1999 NFPA 99, 4-3.5.2.1 Gases in Cylinders and Liquefied Gases in Containers - Level 1. (a) * Handling of Gases. Administrative authorities shall provide regulations to ensure that standards for safe practice in the specifications for cylinders; marking of cylinders, regulators, and valves; and cylinder connections have been met by vendors of cylinders containing compressed gases supplied to the facility. (b) Special Precautions - Oxygen Cylinders and Manifolds. Great care shall be exercised in handling oxygen to prevent contact of oxygen under pressure with oils, greases, organic lubricants, rubber, or other materials of an organic nature. The following regulations, based on those of the CGA Pamphlet G-4, Oxygen, shall be observed:

27. Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.

.

.
The facility failed to maintain the anesthetizing locations per code. Findings include:

During the survey, the following are examples of what was observed:
Per interview with the staff the ten windowless ORs did not have automatic smoke venting

_____________

1999 NFPA 99, 5-4.1.2 Supply and exhaust systems for windowless anesthetizing locations shall be arranged to automatically vent smoke and products of combustion.
1999 NFPA 99, 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.
1999 NFPA 99, 5-4.1.4 The electric supply to the ventilating system shall be served by the equipment system of the essential electrical system specified in Chapter 3, " Electrical Systems. "
1999 NFPA 99, 5-6.1.1 Ventilating and humidifying equipment for anesthetizing locations shall be kept in operable condition and be continually operating during surgical procedures (see A-5-4.1).
.

1. The facility failed to provide the annual fire alarm system inspection report. Findings include: During the survey, the following is an example of what was observed:

During the review of the Life Safety Documentation, the facility could not provide the inspection report for the annual inspection of the fire alarm system.
------------------------------------------
NFPA 101, 9.6.1.4 The fire alarm system to be installed, tested, and maintained in accordance with the requirements of NFPA 70 and NFPA 72.



2. The facility failed to provide the required the quarterly inspection reports for the facility sprinkler system. Findings include During the survey, the following is an example of what was oberved:

During the review of the Life Safety Code Documentation, the facility could not provide the quarterly inspection reports for the sprinkler system.
-------------------------------------------------
NFPA 101, 4.6.12, and NFPA 25, 2-2 and Table 2-1 Requires an inspection every quarter (three months).






27382


3. The facility failed to maintain the following systems per code. Findings include:

During the survey, the following are examples of what was observed:
Sleep Center Suite 501
a. The Main Office (file/storage room) approximately 240 sq. ft. with combustible storage did not have a self-closing device on the door
b. The emergency battery lighting in the Waiting Room in suite 501did not illuminate when tested
Sleep Center Suite 304
c. Storage Room, with combustible storage did not have a self-closing device on the door
For the entire building:
d. Could not verify if the building had emergency lighting through out
e. The facility failed to provide documentation of monthly and annual testing of the emergency lighting
___________
2000 NFPA 101, 39.3.2.1* Hazardous areas including, but not limited to, areas used for general storage, boiler or furnace rooms, and maintenance shops that include woodworking and painting areas shall be protected in accordance with Section 8.4.

HCFA Transmittal 40-93 It is the intent of the code that (smoke-resisting) separation be provided even in a sprinklered hazardous area. "Where the sprinkler option is used, the (hazardous) areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be equipped with self- or automatic closers and be positive latching."

2000 NFPA 101, 39.2.9.1 Emergency lighting shall be provided in accordance with Section 7.9 in any building where any one of the following conditions exists: (1) The building is two or more stories in height above the level of exit discharge. (2) The occupancy is subject to 100 or more occupants above or below the level of exit discharge. (3) The occupancy is subject to 1000 or more total occupants.

2000 NFPA 101, 7.9.3 A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 1/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

A. The facility failed to maintain proper emergency lighting at the generator set and controls. Findings include: During the survey, the following is an example of what was observed:

The battery-powered light in generator set and control room number three was inoperable.
---------------------------------------------
1999 NFPA 99, 3-6.1.1 and 3-4.1.1.4, and 1999 NFPA 110, 5-3.1 The Level 1 or Level 2 EPS equipment location shall be provided with battery-powered emergency lighting.




27382


B. The facility failed to maintain the generator remote annunciator per code. Findings include:

During the survey, the following are examples of what was observed:
1. "Generator #1 CEP" and "Generator #2 CEP" remote annunciators did not give an audible alarm when these generators were taken out of the auto position. The remote annunciators did give a visual "control switch not in auto"
2. "Generator #3" remote annunciator:
a. No audible or visual alarm when the generator was taken out of the auto position
b. No visual indication when the generator was supplying the load, the remote annunciator had an indicating light for this - "generator on"

_______________

1999 NFPA 99, 3-4.1.1.15 A remote annunciator, storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station (see NFPA 70, National Electrical Code, Section 700-12.) The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows: (a) Individual visual signals shall indicate the following: 1. When the emergency or auxiliary power source is operating to supply power to load 2. When the battery charger is malfunctioning (b) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following: 1. Low lubricating oil pressure 2. Low water temperature (below those required in 3-4.1.1.9) 3. Excessive water temperature 4. Low fuel - when the main fuel storage tank contains less than a 3-hour operating supply 5. Overcrank (failed to start) 6. Overspeed
Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions in 3-4.1.1.15(a) and (b) occur, but need not display these conditions individually. [110: 3-5.5.2]
.

The facility failed to provide the required the quarterly inspection reports for the facility sprinkler system. Findings include During the survey, the following is an example of what was oberved:

During the review of the Life Safety Code Documentation, the facility could not provide the quarterly inspection reports for the sprinkler system.
--------------------------------------------------

NFPA 101, 4.6.12, and NFPA 25, 2-2 and Table 2-1 Requires an inspection every quarter (three months).

.
The facility failed to provide the annual fire alarm system inspection report. Findings include: During the survey, the following is an example of what was observed:

During the review of the Life Safety Documentation, the facility could not provide the inspection report for the annual inspection of the fire alarm system.
------------------------------------------------

NFPA 101, 9.6.1.4 The fire alarm system to be installed, tested, and maintained in accordance with the requirements of NFPA 70 and NFPA 72.

.

.
The facility failed to provide the required the quarterly inspection reports for the facility sprinkler system. Findings include During the survey, the following is an example of what was oberved:

During the review of the Life Safety Code Documentation, the facility could not provide the quarterly inspection reports for the sprinkler system.
-------------------------------------------------

NFPA 101, 4.6.12, and NFPA 25, 2-2 and Table 2-1 Requires an inspection every quarter (three months).

.

A. The facility failed to provide the annual fire alarm system inspection report. Findings include: During the survey, the following is an example of what was observed:

During the review of the Life Safety Documentation, the facility could not provide the inspection report for the annual inspection of the fire alarm system.
-------------------------------------------------
NFPA 101, 9.6.1.4 The fire alarm system to be installed, tested, and maintained in accordance with the requirements of NFPA 70 and NFPA 72.




B. The facility failed to provide the required the quarterly inspection reports for the facility sprinkler system. Findings include During the survey, the following is an example of what was oberved:

During the review of the Life Safety Code Documentation, the facility could not provide the quarterly inspection reports for the sprinkler system.
------------------------------------------------
NFPA 101, 4.6.12, and NFPA 25, 2-2 and Table 2-1 Requires an inspection every quarter (three months).

The facility failed to maintain the electrical wiring and equipment per code. Findings include:

During the survey, the following are examples of what was observed:
1. First Floor - "Outakes" had a microwave plugged into an extension cord
2. Second Floor - Nurse Practioner's Sleep Room had a microwave plugged into a surge protector

________________

1999 NFPA 70, 400-7 and 400-8, and HCFA Transmittal Notice 22-99 The 1984 edition of the National Electric Code restricts the use of extension cords to temporary short term uses. It is the policy of HCFA to prohibit non-circuit breaker protected extension cords in health care. The limited use of circuit breaker protected power strips is acceptable, provided the current is limited to 15 amps or less, and no major appliances such as air conditioners, refrigerators, or heating units are connected to the power strip.

The facility failed to maintain the electrical wiring and equipment per code. Findings include:

During the survey, the following is an example of what was observed:
First Floor - Old Security Office at Old One North - refrigerator plugged into a surge protector

____________

1999 NFPA 70, 400-7 and 400-8, and HCFA Transmittal Notice 22-99 The 1984 edition of the National Electric Code restricts the use of extension cords to temporary short term uses. It is the policy of HCFA to prohibit non-circuit breaker protected extension cords in health care. The limited use of circuit breaker protected power strips is acceptable, provided the current is limited to 15 amps or less, and no major appliances such as air conditioners, refrigerators, or heating units are connected to the power strip.

The facility failed to maintain the electrical wiring and equipment per code. Findings include:

During the survey, the following is an example of what was observed:
Second Floor South Tower Mechanical Room, the bed repair area had a refrigerator plugged into a surge protector
______________

1999 NFPA 70, 400-7 and 400-8, and HCFA Transmittal Notice 22-99 The 1984 edition of the National Electric Code restricts the use of extension cords to temporary short term uses. It is the policy of HCFA to prohibit non-circuit breaker protected extension cords in health care. The limited use of circuit breaker protected power strips is acceptable, provided the current is limited to 15 amps or less, and no major appliances such as air conditioners, refrigerators, or heating units are connected to the power strip.