HospitalInspections.org

Through document review during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101. This was evidenced by:

1) Emergency Lighting (Monthly & Annual)(101 7.9.3.1.1): Not Done

NFPA 101 7.9.3.1.1 Testing of required emergency lighting systems shall be permitted to be conducted as follows:
(1) Functional testing shall be conducted monthly, with a minimum of 3 weeks and a maximum of 5 weeks between tests, for not less than 30 seconds, except as otherwise
permitted by 7.9.3.1.1(2).
(2)*The test interval shall be permitted to be extended beyond 30 days with the approval of the authority having jurisdiction.
(3) Functional testing shall be conducted annually for a minimum of 11/2 hours if the emergency lighting system is battery-powered.
(4) The emergency lighting equipment shall be fully operational for the duration of the tests required by 7.9.3.1.1(1)and (3).
(5) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. The deficient item was discussed with the maintenance team at the exit conference.

Through observation during the survey, it was determined that the facility failed to meet the healthcare facilities code requirements in accordance with NFPA 101 and 54. This was evidenced by:

1) missing gas cable on kitchen appliance

NFPA 101, 9.1.1 Gas.
Equipment using gas and related gas piping shall be in accordance with NFPA 54, National Fuel Gas Code, or NFPA 58, Liquefied Petroleum Gas Code, unless such installations are approved existing installations, which shall be permitted to be continued in service.

NFPA 54
9.6.1.1 Commercial Cooking Appliances. Commercial cooking appliances that are moved for cleaning and sanitation purposes shall be connected in accordance with the connector manufacturer ' s installation instructions using a listed appliance connector complying with ANSI Z21.69/CSA 6.16, Connectors for Movable Gas Appliances. The commercial cooking appliance connection installation shall be configured in accordance with the manufacturer ' s installation instructions.
9.6.1.2 Restraint. Movement of appliances with casters shall be limited by a restraining device installed in accordance with the connector and appliance manufacturer ' s installation instructions.

This deficiency could affect occupants, who might include residents, staff, and visitors within the smoke compartment. The deficient item was discussed with the facility maintenance director during the exit conference.

Through document review during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101 and 72. This was evidenced by:

1) Fire alarm Annual: 2.6.24 Microtek, Report not adequate information per NFPA 72 requirements. The report shows smoke, heat, and elevator recall not tested. The strobes were not Synchronized, and the Pharmacy strobe did not activate
2) Fire alarm Semi-Annual: Not Provided
3) Fire alarm Sensitivity test (2 Years) (72 14.4.5.3.2): Not Provided

Based on a record review, it was determined that the facility failed to maintain the fire alarm system components and devices in accordance with the Life Safety Code Section 9.6 and NFPA 72.

NFPA 101, Section 9.6.1.5* To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code.

NFPA 101 19.3.4.1 to comply with section 9.6. Section 9.6.1.3, fire alarm system testing and maintenance to comply with NFPA 72.

NFPA 72 14.2.1.2.2 System defects and malfunctions shall be corrected.

NFPA 72 Table14.4.5 Testing Frequencies

This deficiency could affect occupants, who might include residents, staff, and visitors within the entire facility. The deficient item was discussed with the maintenance team at the exit conference.

Through document review during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101, and 25. This was evidenced by:

1) Fire Sprinkler Weekly/Monthly: Not Provided
2) Fire Sprinkler Annual: 5.18.2024 Cooper Fire. Dry barrel heads need replacement per report heads dated 2006
3) Fire Sprinkler Semi-Annual: Not Provided
4) Need inspection reports for Chemical system in MRI trailer
5) remove the grounding cable from the fire sprinkler system

Based on a record review, it was determined that the facility failed to maintain the fire sprinkler system components and devices in accordance with the Life Safety Code Section 9.6 and NFPA 72.

NFPA 101, 9.7.5 Maintenance and Testing.
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.

NFPA 25, Chapter 5 Sprinkler Systems
Table 5.1.1.2 shall be used to determine the minimum required frequencies for inspection, testing, and maintenance.

NFPA 25, Chapter 13 Common Components and Valves
Table 13.1.1.2 shall be used to determine the minimum required frequencies for inspection, testing, and maintenance.

NFPA 25
4.3.1* Records shall be made for all inspections, tests, and maintenance of the system and its components and shall be made available to the authority having jurisdiction upon request.
4.3.2 Records shall indicate the procedure performed (e.g., inspection, test, or maintenance), the organization that performed the work, the results, and the date.

NFPA 25
5.3.1.1.1.6* Dry sprinklers that have been in service for 10 years shall be replaced, or representative samples shall be tested and then retested at 10-year intervals.

NFPA 101
9.7.3.1 In any occupancy where the character of the fuel for fire is such that extinguishment or control of fire is accomplished by a type of automatic extinguishing system in lieu of an automatic sprinkler system, such system shall be installed in accordance with the appropriate standard, as determined in accordance with Table 9.7.3.1.

NFPA 101, 9.7.1.1*
Each automatic sprinkler system required by another section of this Code shall be in accordance with one of the following:
(1) NFPA 13, Standard for the Installation of Sprinkler Systems

NFPA 13 10.6.8*
In no case shall the underground piping be used as a grounding electrode for electrical systems.

This deficiency could affect occupants, who might include residents, staff, and visitors within the entire facility. The deficient item was discussed with the maintenance team at the exit conference.

Through observation during the survey, it was determined that the facility failed to maintain hazardous areas in accordance with NFPA 101. This was evidenced by:

1) The receiving dock wall is not smoke-tight, has multiple penetrations, and transfer grill
2) The waste room firewall needs to be patched
3) The sterile humidifier room is not smoke-tight needs ceiling or wall patched

NFPA 101
19.3.6.2.3* Corridor walls shall form a barrier to limit the transfer of smoke.

NFPA 101
4.5.8 Maintenance.
Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be maintained, unless the Code exempts such maintenance.

This deficiency could affect occupants, including residents, staff, and visitors within the entire building. Deficient items were discussed with the facility maintenance director during the exit conference.

Through observation during the survey, it was determined that the facility failed to maintain hazardous areas in accordance with NFPA 101 and 70. This was evidenced by:

1) remove storage from the waste room near electrical panels

NFPA 101
9.1.2 Electrical Systems. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless such installations are approved existing installations, which shall be permitted to be continued in service.

NFPA 70
110.26 Spaces About Electrical Equipment
(A) Working Space. Working space for equipment operating at 600 volts, nominal, or less to ground and likely to require examination, adjustment, servicing, or maintenance while energized shall comply with the dimensions of 110.26(A)(1), (A)(2), and (A)(3) or as required or permitted elsewhere in this Code.
(B) Clear Spaces. Working space required by this section shall not be used for storage. When normally enclosed live parts are exposed for inspection or servicing, the working space, if in a passageway or general open space, shall be suitably guarded.

This deficiency could affect occupants, including residents, staff, and visitors within the smoke compartment. Deficient items were discussed with the facility maintenance director during the exit conference.

Through document review during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101, 80, 90A, and 105. This was evidenced by:

1) Fire Dampers report (4-6 years)(101 8.5.5.4.1 & 80 19.4): Not Done

NFPA 101 8.5.5.4.1 Air-conditioning, heating, ventilating ductwork, and related equipment, including smoke dampers and combination fire and smoke dampers, shall be installed in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, and NFPA 105, Standard for Smoke Door Assemblies and Other Opening Protectives.

NFPA 80 19.4* Periodic Inspection and Testing.
19.4.1 Each damper shall be tested and inspected 1 year after installation.
19.4.1.1 The test and inspection frequency shall then be every 4 years, except in hospitals, where the frequency shall be every 6 years.

NFPA 105 6.5 Periodic inspection and testing.
6.5.1 Smoke dampers for dedicated and non-dedicated smoke control systems shall be inspected and tested in accordance with NFPA92A, Standard for Smoke-Control Systems Utilizing Barriers and Pressure Differences.
6.5.2* Each damper shall be tested and inspected one year after installation. The test and inspection frequency shall then be every 4 years, except in hospitals, where the frequency shall be every 6 years.

This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the facility maintenance director during the exit conference.

Through document review during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 10. This was evidenced by:

1) Fire Drills not provided for 2nd shift, 2nd and 3rd quarter. 1st and 2nd shift drills are not varied.

NFPA 101
19.7.1.6 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.

This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. The deficient item was discussed with the maintenance team at the exit conference.

Through observation during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101 and NFPA 80. This was evidenced by:

1) exam room 7 requires a fire closure on the fire door
2) The drop fire window for the kitchen needs to be inspected

NFPA 101, 8.3.3.1
Openings required to have a fire protection rating by Table 8.3.4.2 shall be protected by approved, listed, labeled fire door assemblies and fire window assemblies and their accompanying hardware, including all frames, closing devices, anchorage, and sills in accordance with the requirements of NFPA 80, Standard for Fire Doors and Other Opening Protectives, except as otherwise specified in this Code.

NFPA 80, 5.2 Inspections.
5.2.1 Fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for inspection by the AHJ.

5.2.15.3 Where a fire door, frame, or any part of its appurtenances is damaged to the extent that it could impair the door ' s proper emergency function, the following actions shall be performed:

(1)The fire door, frame, door assembly, or any part of its appurtenances shall be repaired with labeled parts or parts obtained from the original manufacturer.
(2)The door shall be tested to ensure emergency operation and closing upon completion of the repairs.

These deficiencies can potentially affect occupants, including residents, staff, and visitors throughout the facility. The deficient item was discussed with the maintenance team at the exit conference.

Through document review during the survey, it was determined that the facility failed to maintain the electrical systems in accordance with NFPA 99. This was evidenced by:

1) The facility does not inspect wet locations every 6 months as required by NFPA 99 6.3.2.2.8.5.
2) The facility does not meet the record-keeping requirements per NFPA 99 6.3.4.2
3) Receptacle Testing (99 6.3.4.1): Not Provided

NFPA 99 6.3.2.2.8.5(B)(4)
(B) Fixed receptacles, equipment connected by cord and plug, and fixed electrical equipment shall be tested as follows:
(1) When first installed
(2) Where there is evidence of damage
(3) After any repairs
(4) At intervals not exceeding 6 months

NFPA 99
6.3.4.2 Record Keeping.
6.3.4.2.1* General.
6.3.4.2.1.1 A record shall be maintained of the tests required by this chapter and associated repairs or modification.
6.3.4.2.1.2 At a minimum, the record shall contain the date, the rooms or areas tested, and an indication of which items have met, or have failed to meet, the performance requirements of this chapter.

NFPA 99
6.3.4.1.1
Where hospital-grade receptacles are required at patient bed locations and in locations where deep sedation or general anesthesia is administered, testing shall be performed after initial installation, replacement, or servicing of the device.
6.3.4.1.2
Additional testing of receptacles in patient care rooms shall be performed at intervals defined by documented performance data.
6.3.4.1.3
Receptacles not listed as hospital-grade at patient bed locations and in locations where deep sedation or general anesthesia is administered shall be tested at intervals not exceeding 12 months.

This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. The deficient item was discussed with the maintenance team at the exit conference.

Through document review during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101, 99, and 110. This was evidenced by:

1) Generator fuel quality (annually) (110 8.3.8): Not Provided

NFPA 99
15.5.1.3 Emergency Generators and Standby Power Systems. Emergency generators and standby power systems, where required for compliance with this code, shall be installed, tested, and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems.

NFPA 110
8.3.8 A fuel quality test shall be performed at least annually
Using tests approved by ASTM standards.

This deficiency could affect occupants, including residents, staff, and visitors within the entire facility. The deficient item was discussed with the maintenance team at the exit conference.

Through observation during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 99. This was evidenced by:

1) Defend in Place strategy is being utilized for patient care, fire sprinkler and fire alarm systems do not meet NFPA 99 requirements for Defend in Place.

NFPA 99
15.7.4.3 Defend in Place. For new and existing facilities, where the response to a fire is to defend in place within a safe place in the building, occupant notification shall be in accordance with the facility fire plan.

15.7.4.3.1* Where buildings are required to be subdivided into smoke compartments, fire alarm notification zones shall coincide with one or more smoke compartment boundaries or shall be in accordance with the facility fire plan.

15.8.1.2* Defend in Place. For new and existing facilities, where the response to a fire is to defend in place within a safe place in the building and not to automatically evacuate the building, sprinkler system zones shall coincide with smoke compartment boundaries or shall be in accordance with the facility fire plan.

This deficiency could affect occupants, who might include residents, staff, and visitors within all smoke compartments. Deficient items were discussed with the facility maintenance director during the exit conference.