HospitalInspections.org

2005 Clinic Building (Aspen ID: A-3)
Based on observation and staff interview during the course of the survey, it was determined that the facility failed to maintain the two-hour fire rated separation to the attached healthcare occupancy in accordance with Life Safety Code Section 38.1.2.1 and 6.1.14. This deficient practice could affect all patients within the health care occupancy should heat and smoke spread from a fire condition in the adjacent building. This was evidenced by the following:

The 90 minute fire rated door, separating the Original Hospital building from the 2005 Clinic Building, was not maintained to be self-closing and positively latching, as required. When tested, the door was binding in the frame and not fully closing and latching. The door closer was not functional when the door was in a partially opened position.
The Maintenance Manager acknowledged the unprotected opening and door deficiency during a tour of the facility.

Life Safety Code Section 8.2.3.2.1 requires that fire doors be of a design that has been tested to meet the conditions of acceptance of NFPA 252, Standard Methods of Fire Tests of Door Assemblies, and that doors be installed in accordance with NFPA 80 Standard for Fire Doors and Fire Windows. Rated fire doors must self-close and positively latch into the door frame in accordance with NFPA 80.

Original Hospital Building (Aspen ID: A-1)
Based on observation and staff interview during the course of the survey, it was determined that the facility failed to maintain the two-hour fire rated separation to the attached non-healthcare occupancies in accordance with Life Safety Code Section 19.1.2.1. This deficient practice could affect all patients within the health care occupancy should heat and smoke spread from a fire condition in the adjacent building. This was evidenced by the following:

A) Openings in the two hour separation between the healthcare occupancy and the maintenance building were not protected, as required. The two hour wall (top of the former laundry stair enclosure) was observed to have an exhaust fan opening in the wall to the adjacent non-sprinklered wood frame maintenance building. The opening, approximately 20 " x 20 " was covered with sheet metal that does not maintain the fire rating of the wall.

B) The 90 minute fire rated door, separating the Original Hospital building from the 2005 Clinic Building, was not maintained to be self-closing and positively latching, as required. When tested, the door was binding in the frame and not fully closing and latching. The door closer was not functional when the door was in a partially opened position.
The Maintenance Manager acknowledged the unprotected opening and door deficiency during a tour of the facility.

Life Safety Code Section 19.1.2.1 requires that sections of health care facilities that are classified as other occupancies be separated by two hour rated construction. Section 8.2.3.2.1 requires that fire doors be of a design that has been tested to meet the conditions of acceptance of NFPA 252, Standard Methods of Fire Tests of Door Assemblies, and that doors be installed in accordance with NFPA 80 Standard for Fire Doors and Fire Windows. Rated fire doors must self-close and positively latch into the door frame in accordance with NFPA 80.

Original Hospital Building (Aspen ID: A-1)
Based on observation and staff interview during the survey, it was determined that the facility failed to install interior finish materials in accordance with Life Safety Code Section 19.3.3.2 and Section 10.2. This deficient practice could affect all patients within the CT trailer area should heat and smoke spread rapidly across non-rated wall and ceiling interior finish materials.
This was evidenced by the following:

A) Textile interior ceiling finish materials could not be confirmed as Class A rated, as required. The CT scanner trailer control room (approximately 8ft. x 20 ft.) and the scanner area (approximately 8 ft. x 10 ft.) were observed to have a textile material on the ceiling (carpet style). The Maintenance Manager was not aware of any facility records to document the flame spread rating of the exposed textile material.

Life Safety Code Section 10.2.4.1.1 requires that textile materials have a Class A rating when installed on walls or ceilings of rooms or areas protected by an approved automatic sprinkler system.

B) Non-code compliant foamed plastic insulation was installed as an interior finish material inside the CT scanner trailer. The blue foamed plastic insulation was installed over a former door opening, approximately 3 ft. x 7 ft. in size.
Life Safety Code Section 10.2.4.3: Cellular or foamed plastic materials shall not be used as interior wall and ceiling finish.

2005 Emergency Department Building (Aspen ID: A-2)
Based on observation and staff interview during the survey, it was determined that the facility failed to install corridor doors in accordance with Life Safety Code Section 18.3.6.3. This deficient practice could affect all patients within the emergency department should the egress corridor become untenable due to smoke and heat transfer via the deficient doors separating rooms from the egress corridor. This was evidenced by the following:

A) Corridor doors were not equipped with positive latching hardware, as required. Trauma Room #1 and #2 were not equipped with automatic positive latching hardware. Both leafs of the glass sliding doors were equipped with manual latch bolts. Manual latch bolts do allow for the door to be closed with a push or pull and automatically latch into the door frame.
Life Safety Code Section 18.3.6.3.2: Doors shall be provided with positive latching hardware. Roller latches shall be prohibited.

B) Use areas were not separated from the corridor by doors that could be closed with a push or a pull, as required. Rooms ER#1 and ER#2 (corridor doors) were equipped with a plunger style door hold open device that could not be released with a push or pull on the door. The Maintenance Manager acknowledged the door hold open devices during a tour of the facility.

Life Safety Code Section 18.3.6.3.3: Hold open devices that release when the door is pushed or pulled shall be permitted. The Life Safety Code Annex (explanatory material) explains that doors should not be blocked open by furniture, door stops, chocks, tie-backs, drop-down or plunger-type devices, or other devices that necessitate manual unlatching or releasing action to close. Examples of hold-open devices that release when the door is pushed or pulled are friction catches or magnetic catches.

Original Hospital Building (Aspen ID: A-1)
Based on observation and staff interview during the survey, it was determined that the facility failed to install corridor doors in accordance with Life Safety Code Section 19.3.6.3. This deficient practice could affect all patients within the central smoke compartment should the egress corridor become untenable due to smoke and heat transfer via the deficient doors separating rooms from the egress corridor. This was evidenced by the following:

Use areas were not separated from the corridor by doors that could be closed with a push or a pull, as required. The x-ray room and pharmacy corridor doors were equipped with a plunger style door hold open device that could not be released with a push or pull on the door. The Maintenance Manager acknowledged the door hold open devices during a tour of the facility.

Life Safety Code Section 19.3.6.3.3 permits hold-open devices that release when the door is pushed or pulled. The Life Safety Code Annex (explanatory material) explains that doors should not be blocked open by furniture, door stops, chocks, tie-backs, drop-down or plunger-type devices, or other devices that necessitate manual unlatching or releasing action to close. Examples of hold-open devices that release when the door is pushed or pulled are friction catches or magnetic catches.

Original Hospital Building (Aspen ID: A-1)
Based on observation and staff interview during the survey, it was determined that the facility failed to maintain vertical opening enclosures in accordance with Life Safety Code Section 19.3.1.2. This deficient practice could affect all patients within the facility by allowing the spread of fire and smoke between occupied rooms and the stair enclosure. This was evidenced by the following:

Doors protecting vertical openings were not self-closing, as required.

A) The one-hour fire rated door (first floor break room) was observed to have the self-closer disconnected.

B) The one-hour fire rated door (first floor materials storage room) was not equipped with a self-closer.
Life Safety Code Section 19.3.1.2: A door in a stair enclosure shall be self-closing and shall normally be kept in the closed position. Exception: doors in stair enclosures held open under the conditions specified by 19.2.2.2.6 and 19.2.2.2.7.

Original Hospital Building (Aspen ID: A-1)
Based on observation, it was determined that the facility failed to install smoke detectors to meet the minimum requirements for door release service in accordance with the Life Safety Code Section 19-2.2.2.6 and 7.2.1.8.2. This deficient practice could affect all patients within the facility by allowing the spread of fire and smoke between occupied rooms and the stair enclosure. This was evidenced by the following:

One-hour rated vertical opening protective doors were not held open by an automatic release device that complied with Life Safety Code Section 7.2.1.8.2, as required. The materials management one-hour rated door was held open with a magnetic latch that released upon activation of the fire alarm system. Smoke detection, in accordance with NFPA 72 for door release service, was not provided inside the room or in the corridor area outside the room.

Life Safety Code Section 19.2.2.2.6 requires that doors be held open only by an automatic release device that complies with Section 7.2.1.8.2. Section 7.2.1.8.2 requires, in part, that the automatic release mechanism be activated by the operation of an approved smoke detector installed in accordance with the requirements for smoke detectors for door release service in National Fire Protection Association (NFPA) Standard 72, National Fire Alarm Code.

Original Hospital Building (Aspen ID: A-1)
Based on observation and staff interview during the survey, it was determined that the fire resistance rating of smoke barrier walls were not maintained in accordance with Life Safety Code Section 19.3.7.3. This deficient practice could affect all patients within the north and south smoke compartments by allowing the spread of fire and smoke to the adjoining compartment. This was evidenced by the following:

Smoke barrier wall penetrations were not sealed to maintain the 30 minute fire resistance rating of the barrier, as required. The south smoke barrier wall was observed to have the following deficiencies:
A) An unsealed 1 " x 3 " hole.

B) An unsealed cable penetration.

C) An unsealed gap along the top of the wall ceiling intersection (ceiling tile should be removed prior to sealing the gap).

The Maintenance Manager acknowledged the penetrations during a tour of the facility.

Life Safety Code Section 19.3.7.3 requires that the smoke barrier wall be constructed in accordance with Section 8.3, and shall have a fire resistance rating of not less than ½ hour. Section 8.3.2 requires that the barrier be continuous through concealed spaces. Section 8-3.6.1 requires, in part, that the space between cable and pipe penetrations and the smoke barrier wall be filled with a material capable of maintaining the 30-minute fire resistance rating of the barrier.

Original Hospital Building (Aspen ID: A-1)
Based on observation and staff interview during the survey, it was determined that the facility failed to maintain sprinkler protected hazardous areas in accordance with Life Safety Code Section 19.3.2.1. This deficient practice could affect patients within the first floor smoke compartment, should there be smoke and heat transfer between the hazardous area and other portions of the building. This was evidenced by the following:

A) The main boiler room was observed to have an two unsealed holes (1 inch and 2 inch diameter) in the ceiling which voided the fire/smoke resistance rating of the plaster ceiling.
The Life Safety Code requires that sprinkler protected hazardous areas be separated from other spaces by smoke-resisting construction.

B) Hazardous area corridor doors were not equipped with self-closers, as required. Storage rooms # 6 and #10 did not have self-closers installed on the doors.
Life Safety Code Section 19.3.2.1 requires that sprinkler protected hazardous areas be separated from other spaces by smoke-resisting construction. Doors installed to protect hazardous areas must be self-closing or automatic closing.

The Maintenance Manager acknowledged the hazardous area deficiencies during a tour of the facility.

2005 Clinic Building (Aspen ID: A-3)
Based on observation and staff interview, it was determined that the facility failed to arrange the means of egress in accordance with Life Safety Code Section 38.2 and Chapter 7. This deficient practice could affect the building occupants if a code compliant exit is not provided. This was evidenced by the following:

A) The power operated egress doors (main entrance) were not arranged in accordance with Life Safety Code Sections 7.2.1.5, as required. The sliding doors were equipped with a thumb style deadbolt lock that requires special knowledge and effort to unlock. When locked, the deadbolt voids the breakaway feature of the door.

B) The center courtyard area exit door was not arranged to be readily opened from the courtyard side, as required. The double doors that serve as the single means of egress from the courtyard were equipped with a dead bolt lock that prevented the doors from being opened from the courtyard side.

The Maintenance Manager acknowledged the door arrangements during a tour of the facility.
Life Safety Code Section 7.2.1.5.1 requires that a door shall be so arranged as to be readily opened from the egress side whenever the building is occupied. Locks, if provided, shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side.

2005 Emergency Department Building (Aspen ID: A-2)
Based on observation and staff interview, it was determined that the facility failed to arrange the means of egress in accordance with Life Safety Code Section 18.2 and Chapter 7. This deficient practice could affect the building occupants if a code compliant exterior exit is not provided. This was evidenced by the following:

The power operated egress doors from the emergency department were not arranged in accordance with Life Safety Code Sections 7.2.1.5 and 7.2.1.9.1.

A) The sliding doors were equipped with a thumb style deadbolt lock that requires special knowledge and effort to unlock. When locked, the deadbolt voids the breakaway feature of the door.

B) The sliding glass breakaway style doors were not equipped with door signage that reads " IN EMERGENCY, PUSH TO OPEN " .

The Maintenance Manager acknowledged the door arrangement during a tour of the facility.

Life Safety Code Section 7.2.1.5.1 requires that a door shall be so arranged as to be readily opened from the egress side whenever the building is occupied. Locks, if provided, shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side. Section 7.2.1.9.1 requires, in part: On the egress side of each door, there shall be a readily visible, durable sign that reads as follows: " IN EMERGENCY, PUSH TO OPEN " . The sign shall be in letters not less than 1 inch high on a contrasting background.

Original Hospital Building (Aspen ID: A-1)
Based on observation and staff interview, it was determined that the facility failed to arrange and maintain the means of egress in accordance with Life Safety Code Section 19.2 and Chapter 7. This deficient practice could affect the occupants of Room #9 if an unobstructed room exit is not provided. This was evidenced by the following:

Doors in the means of egress were not maintained to be readily opened from the egress side, as required. Patient room #9 was observed to have a locking hasp on the corridor side of the door. When locked, the door would no longer be readily opened from inside the room.

The Maintenance Manager acknowledged the door arrangement during a tour of the facility.

Life Safety Code Section 7-2.1.5.1 requires that a door shall be so arranged as to be readily opened from the egress side whenever the building is occupied. Locks, if provided, shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side.

2005 Emergency Department Building (Aspen ID: A-2)
Based on record review, observation and staff interview during the survey, it was determined that the facility failed to install and maintain emergency lighting systems in accordance with Life Safety Code Section 7.9 and the referenced NFPA 110. This deficient practice could affect all patients should the emergency lighting and emergency power systems fail to operate due to non-standard installation or maintenance. This was evidenced by the following:

A) Records were not available to document the monthly and annual testing of the battery powered emergency lighting units, as required. The Maintenance Manager reported that the battery units were tested monthly, but documentation of the testing was not maintained.
Life Safety Code Section 7.9.3, Periodic Testing of Emergency Lighting Equipment:
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 1½ 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.

B) Emergency illumination of the exit discharge areas throughout the facility was not provided, as required. Maintenance staff verified during the survey that the hospital building exterior lighting was not powered by emergency generator supplied panelboard branch circuits. Illumination of the means of egress should be supplied by the Life Safety Branch of the Essential Electrical System.
Life Safety Code Section 7.9.1 requires emergency lighting facilities for the means of egress which includes the exit discharge walkways leading to a public way.

C) The emergency generator was not equipped with a remote manual stop station, located outside of the generator enclosure, as required. The Maintenance Manager reported that the emergency generator was installed as part of the 2005 building addition project.
NFPA 110 Section 3-5.5.6: All Level 1 and Level 2 installations shall have a remote manual stop station of a type similar to a break-glass station located outside of the room housing the prime mover, where so installed, or located elsewhere on the premises where the prime mover is located outside of the building.

D) The outside generator area and automatic transfer switch electrical room were not provided with battery operated emergency lighting, as required.
NFPA Standard 110 Section 5-3.1 requires that EPS equipment locations be provided with battery-powered emergency lighting. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch.

E) The diesel powered emergency generator was not being load tested monthly at a minimum of 30% of nameplate rating, as required. Generator monthly load test records did not document current readings on each phase of the generator while under normal building load. The Maintenance Manager confirmed that there was no annual load bank testing of the emergency generator.
NFPA 110 Section 6-4.2 requires that generator sets in Level 1 and Level 2 service be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
The date and time of day for required testing shall be decided by the owner, based on facility operations.
Section 6-4.2.2: Diesel-powered EPS installations that do not meet the requirements of 6-4.2 shall be exercised monthly with the available EPSS load and exercised annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of 2 continuous hours.

Original Hospital Building (Aspen ID: A-1)
Based on record review, observation and staff interview during the survey, it was determined that the facility failed to install and maintain emergency lighting systems in accordance with Life Safety Code Section 7.9 and the referenced NFPA 110. This deficient practice could affect all patients should the emergency lighting and emergency power systems fail to operate due to non-standard installation or maintenance. This was evidenced by the following:

A) Records were not available to document the monthly and annual testing of the battery powered emergency lighting units, as required. The Maintenance Manager reported that the battery units were tested monthly, but documentation of the testing was not maintained.
Life Safety Code Section 7.9.3, Periodic Testing of Emergency Lighting Equipment:
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 1½ 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.

B) Emergency illumination of the exit discharge areas throughout the facility was not provided, as required. Maintenance staff verified during the survey that the hospital building exterior lighting was not powered by emergency generator supplied panelboard branch circuits. Illumination of the means of egress should be supplied by the Life Safety Branch of the Essential Electrical System.
Life Safety Code Section 7.9.1 requires emergency lighting facilities for the means of egress which includes the exit discharge walkways leading to a public way.

C) The emergency generator was not equipped with a remote manual stop station, located outside of the generator enclosure, as required. The Maintenance Manager reported that the emergency generator was installed as part of the 2005 building addition.
NFPA 110 Section 3-5.5.6: All Level 1 and Level 2 installations shall have a remote manual stop station of a type similar to a break-glass station located outside of the room housing the prime mover, where so installed, or located elsewhere on the premises where the prime mover is located outside of the building.

D) The outside generator area and automatic transfer switch electrical room were not provided with battery operated emergency lighting, as required.
NFPA Standard 110 Section 5-3.1 requires that EPS equipment locations be provided with battery-powered emergency lighting. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch.

E) The diesel powered emergency generator was not being load tested monthly at a minimum of 30% of nameplate rating, as required. Generator monthly load test records did not document current readings on each phase of the generator while under normal building load. The Maintenance Manager confirmed that there was no annual load bank testing of the emergency generator.
NFPA 110 Section 6-4.2 requires that generator sets in Level 1 and Level 2 service be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
The date and time of day for required testing shall be decided by the owner, based on facility operations.
Section 6-4.2.2: Diesel-powered EPS installations that do not meet the requirements of 6-4.2 shall be exercised monthly with the available EPSS load and exercised annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of 2 continuous hours.

2005 Emergency Department Building (Aspen ID: A-2)
Based on record review during the survey, it was determined that the facility failed to maintain a complete plan for the protection of all persons in the event of fire in accordance with Life Safety Code Section 18.7.1 and 18.7.2. This deficient practice could affect all patients if staff response during a fire situation does not include knowledge and training in evacuation of the hospital smoke compartments. This was evidenced by the following:

The fire emergency plan did not specifically discuss the evacuation of a hospital smoke compartment, as required. The facility fire emergency plan titled "Sedgwick County Health Center Emergency Operations Plan" Section II titled "Concept of Operations, Functional Response-Item 1E (Evacuate beyond the first smoke/fire barrier doors away from the fire)" did not address evacuation of a hospital smoke compartment. The remainder of the section specifically addresses smoke compartments and evacuation of the nursing home to the adjacent living center. The nursing home and living center are separate buildings located across the street from the hospital buildings. The plan did not specifically discuss the hospital smoke compartments and the 2 hour rated separation between the two hospital buildings and the 2 hour separation to the adjoining Clinic Building.

Life Safety Code Section 18.7.1.1 requires that the administration of all health care facilities develop a plan for the protection of all persons in the event of fire, including a plan for their evacuation to an area of refuge and from the building when necessary. The plan must include all components and requirements outlined in Life Safety Code Section 18.7.1 and 18.7.2.
Life Safety Code Section 18.7.2.2 requires that a written health care occupancy fire safety plan provide for the following:
1. Use of alarms
2. Transmission of alarms to the fire department
3. Response to alarms
4. Isolation of fire
5. Evacuation of immediate area
6. Evacuation of smoke compartment
7. Preparation of floors and building for evacuation
8. Extinguishment of fire

Original Hospital Building (Aspen ID: A-1)
Based on record review during the survey, it was determined that the facility failed to maintain a complete plan for the protection of all persons in the event of fire in accordance with Life Safety Code Section 19.7.1 and 19.7.2. This deficient practice could affect all patients if staff response during a fire situation does not include knowledge and training in evacuation of the hospital smoke compartments. This was evidenced by the following:

The fire emergency plan did not specifically discuss the evacuation of a hospital smoke compartment, as required. The facility fire emergency plan titled "Sedgwick County Health Center Emergency Operations Plan" Section II titled "Concept of Operations, Functional Response-Item 1E (Evacuate beyond the first smoke/fire barrier doors away from the fire)" did not address evacuation of a hospital smoke compartment. The remainder of the section specifically addresses smoke compartments and evacuation of the nursing home to the adjacent living center. The nursing home and living center are separate buildings located across the street from the hospital buildings. The plan did not specifically discuss the hospital smoke compartments and the 2 hour rated separation between the two hospital buildings and the 2 hour separation to the adjoining Clinic Building.

Life Safety Code Section 19.7.1.1 requires that the administration of all health care facilities develop a plan for the protection of all persons in the event of fire, including a plan for their evacuation to an area of refuge and from the building when necessary. The plan must include all components and requirements outlined in Life Safety Code Section 19.7.1 and 19.7.2.
Life Safety Code Section 19.7.2.2 requires that a written health care occupancy fire safety plan provide for the following:
1. Use of alarms
2. Transmission of alarms to the fire department
3. Response to alarms
4. Isolation of fire
5. Evacuation of immediate area
6. Evacuation of smoke compartment
7. Preparation of floors and building for evacuation
8. Extinguishment of fire

2005 Emergency Department Building (Aspen ID: A-2)
Based on observation, staff interview and record review during the survey, it was determined that the facility failed to install the fire alarm system in accordance with National Fire Protection Association (NFPA) 101- Life Safety Code, and NFPA 72- National Fire Alarm Code. This deficient practice could affect all patients should the fire alarm system fail to notify the local fire department, via code compliant notification methods. This was evidenced by the following:

The fire alarm control unit (installed in 2005) was not arranged to transmit fire alarms automatically, to notify emergency forces, via a code compliant transmission method. The Maintenance Manager reported that the fire alarm control unit was arranged to send a signal to the local county emergency dispatch center. The transmission method was believed to be a single telephone line, but could not be confirmed during the survey. The Maintenance Manager also reported that upon receipt of an alarm signal, the emergency operations center would call the facility to verify the alarm, prior to dispatching emergency forces. Alarm transmission to the county emergency dispatch center does not comply with Life Safety Code Section 9.6.4.

Life Safety Code Section 18.3.4.3.2 requires that fire department notification be accomplished in accordance with Section 9.6.4. Section 9.6.4 (Emergency Forces Notification): Where required by another section of this Code, emergency forces notification shall be provided to alert the municipal fire department and fire brigade (if provided) of fire or other emergency.
Where fire department notification is required by another section of this Code, the fire alarm system shall be arranged to transmit the alarm automatically via any of the following means acceptable to the authority having jurisdiction and shall be in accordance with NFPA 72, National Fire Alarm Code:
(1) Auxiliary alarm system
(2) Central station connection
(3) Proprietary system
(4) Remote station connection
Equipment, power supply and transmission methods must be in accordance with NFPA 72, National Fire Alarm Code.

Original Hospital Building (Aspen ID: A-1)
Based on observation, staff interview and record review during the survey, it was determined that the facility failed to install the fire alarm system in accordance with National Fire Protection Association (NFPA) 101- Life Safety Code, and NFPA 72- National Fire Alarm Code. This deficient practice could affect all patients should the fire alarm system fail to notify building occupants, and the local fire department, via code compliant notification methods. This was evidenced by the following:

A) The fire alarm control unit (installed in 2005) was not arranged to transmit fire alarms automatically, to notify emergency forces, via a code compliant transmission method. The Maintenance Manager reported that the fire alarm control unit was arranged to send a signal to the local county emergency dispatch center. The transmission method was believed to be a single telephone line, but could not be confirmed during the survey. The Maintenance Manager also reported that upon receipt of an alarm signal, the emergency operations center would call the facility to verify the alarm, prior to dispatching emergency forces. Alarm transmission to the county emergency dispatch center does not comply with Life Safety Code Section 9.6.4.

Life Safety Code Section 19.3.4.3.2 requires that fire department notification be accomplished in accordance with Section 9.6.4. Section 9.6.4 (Emergency Forces Notification): Where required by another section of this Code, emergency forces notification shall be provided to alert the municipal fire department and fire brigade (if provided) of fire or other emergency.
Where fire department notification is required by another section of this Code, the fire alarm system shall be arranged to transmit the alarm automatically via any of the following means acceptable to the authority having jurisdiction and shall be in accordance with NFPA 72, National Fire Alarm Code:
(1) Auxiliary alarm system
(2) Central station connection
(3) Proprietary system
(4) Remote station connection
Equipment, power supply and transmission methods must be in accordance with NFPA 72, National Fire Alarm Code.

B) Fire alarm system visible notification appliances did not flash in synchronization, as required. During a test of the fire alarm system, visible notification appliances (strobes) were observed as follows:
1. From the one hour smoke compartment doors looking north: 4 strobes were in the field of view that were not synchronized.
2. From the nurses station: 3 strobes were in the field of view, one of three strobes was not synchronized with the other two.
The appliances were spaced less than 55 feet from each other.

NFPA 72 Section 4-4.4.2.3: In corridors where there are more than two visible notification appliances in any field of view, they shall be spaced a minimum of 55 feet from each other, or they shall flash in synchronization.

2005 Emergency Department Building (Aspen ID: A-2)
Based on observation during the survey, it was determined that the facility failed to the automatic fire sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 13. This deficient practice could affect all patients should the automatic sprinkler system fail to operate as intended due to non-code compliant installation. This was evidenced by the following:

The attic dry-pipe sprinkler system was not equipped with a listed air maintenance device, as required. NFPA 13 Section 4-2.6.6: Where a dry pipe system is supplied by an automatic air compressor or plant air system, any device or apparatus used for automatic maintenance of air pressure shall be of a type specifically listed for such service and capable of maintaining the required air pressure on, and maximum air flow to, the dry pipe system.

Original Hospital Building (Aspen ID: A-1)
Based on observation and staff interview, it was determined that the facility failed to install the automatic fire sprinkler system in accordance with National Fire Protection Association (NFPA) 101-Life Safety Code and the referenced NFPA 13. This deficient practice could affect all patients should a fire occur in an area not protected by the automatic sprinkler system or not operate as designed due to non-code compliant installation. This was evidenced by the following:

A) Automatic sprinkler protection was not installed in all building areas, as required. The following areas were not protected by the automatic sprinkler system:
1. The enclosed former laundry room stair.

2. Areas of the loading dock (northwest corner of building) where the combustible roof overhang exceeded 4 ft. in width.

3. The 6 ft. x 7 ft. bio-hazard storage room (adjacent to the loading dock).

4. Areas above the suspended ceiling that may be combustible concealed spaces due to the original ceiling tiles installed on the lath and plaster ceiling. If the original ceiling tiles are documented as being combustible, the area will have to be sprinkler protected or the tiles removed.

B) Sprinkler piping was not installed in accordance with the manufacture ' s installation instructions, as required. The CPVC branch line, installed in the CT trailer control room, did not have a sprinkler hanger installed within 12 inches of the end of the branch line. The end of line was equipped with a 90 degree elbow and a pendant sprinkler head. The hanger, when installed, must also be equipped with an approved vertical restraint method. The all-thread cannot be installed with direct contact on the CPVC piping.

Life Safety Code Section 19.1.6 requires automatic sprinkler protection for all buildings of Type III construction in accordance with Section 19.3.5.1. NFPA 13, Installation of Sprinkler Systems, Section 1-6.1 states: "A building, where protected by an automatic sprinkler system installation, shall be provided with sprinklers in all areas." Section 5-13.1.1 requires that all concealed spaces enclosed wholly or partly by exposed combustible construction be sprinkler protected.
Section 5-13.8.1: Sprinklers shall be installed under exterior roofs or canopies exceeding 4 ft. in width. Exception: Sprinklers are permitted to be omitted where the canopy or roof is of noncombustible or limited combustible construction.

2005 Emergency Department Building (Aspen ID: A-2)
Based on observation and record review during the survey, it was determined that the facility failed to maintain the automatic fire sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 25. This deficient practice could affect all patients should the automatic sprinkler system fail to operate in a timely and effective manner due to non-code compliant maintenance. This was evidenced by the following:

A) Automatic sprinkler system waterflow alarms were not tested quarterly, as required. Records on premises documented testing of the wet system waterflow alarm in September 2013 and March 2014. Dry system waterflow alarm testing was not documented.
NFPA 25 Section 9-2.7 requires that waterflow alarms be tested quarterly in accordance with manufacturer's instructions.

B) Sprinkler system tamper switches were not documented to be tested semi-annually as required. The fire alarm inspection report, dated 03-21-14, documented testing of one waterflow alarm (two installed) and 3 supervisory devices (6 installed).
NFPA 25 Section 9-3.4.3 requires that valve supervisory switches be tested semi-annually in accordance with manufacturer's instructions.

C) Records on premises did not adequately document that sprinkler system pressure gauges were calibrated every 5 years, as required. The sprinkler pressure gauges, installed at the main system riser, were dated 2004. The gauges had stickers attached to the face with handwritten " calibrated 09-2011 " . The Maintenance Manager was not aware of any test/calibration report that documented the gauge calibration in 2011.
NFPA 25 Section 9-2.8.2: Gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge. Gauges not accurate to within 3 percent of the full scale shall be recalibrated or replaced.

D) Dry sprinkler system low air alarms were not tested quarterly, as required. Inspection records did not specifically document testing of the dry pipe system low air alarm.
NFPA 25 Section 9-4.4.2.6 requires that low air pressure alarms be tested quarterly in accordance with manufacturer's instructions.

Original Hospital Building (Aspen ID: A-1)
Based on observation and record review during the survey, it was determined that the facility failed to maintain the automatic fire sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 25. This deficient practice could affect all patients should the automatic sprinkler system fail to operate in a timely and effective manner due to non-code compliant maintenance. This was evidenced by the following:

A) Sidewall sprinkler heads were not maintained free of obstructions to spray distribution patterns, as required. The closet sidewall sprinkler (Room #1) was obstructed by storage.

NFPA 25, Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems, Section 2-2.1.2 states "Unacceptable obstructions to spray patterns shall be corrected."

B) The automatic sprinkler system waterflow alarm was not tested quarterly as required. Records on premises documented testing of the waterflow alarm in September 2013 and March 2014. NFPA 25 Section 9-2.7 requires that waterflow alarms be tested quarterly in accordance with manufacturer's instructions.

C) Sprinkler system tamper switches were not documented to be tested semi-annually as required. The fire alarm inspection report, dated 03-21-14, documented testing of one waterflow alarm (two installed) and 3 supervisory devices (6 installed).
NFPA 25 Section 9-3.4.3 requires that valve supervisory switches be tested semi-annually in accordance with manufacturer's instructions.

D) Records on premises did not adequately document that sprinkler system pressure gauges were calibrated every 5 years, as required. The sprinkler pressure gauges, installed at the main system riser, were dated 2004. The gauges had stickers attached to the face with handwritten " calibrated 09-2011 " . The Maintenance Manager was not aware of any test/calibration report that documented the gauge calibration in 2011.
NFPA 25 Section 9-2.8.2: Gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge. Gauges not accurate to within 3 percent of the full scale shall be recalibrated or replaced.

2005 Clinic Building (Aspen ID: A-3)
Based on record review during the survey, it was determined that the facility failed to maintain mechanical equipment in accordance with Life Safety Code Section 9.2 and the referenced NFPA 90A. This deficient practice could affect all patients should the mechanical equipment malfunction due to inadequate maintenance. This was evidenced by the following:

Records were not available to document the inspection and test operation of fire/smoke dampers, as required.
NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, Section 3-4.7 states "At least every 4 years, fusible links shall be removed; all dampers shall be operated to verify that they fully close; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary." Centers for Medicare and Medicaid Services (CMS) S&C-10-04-LSC allows hospitals to apply the NFPA 6-year damper testing interval provided that the testing conforms to the requirements of the 2007 edition of NFPA 80 and NFPA 105.

2005 Emergency Department Building (Aspen ID: A-2)
Based on record review during the survey, it was determined that the facility failed to maintain mechanical equipment in accordance with Life Safety Code Section 9.2 and the referenced NFPA 90A. This deficient practice could affect all patients should the mechanical equipment malfunction due to inadequate maintenance. This was evidenced by the following:

Records were not available to document the inspection and test operation of fire/smoke dampers, as required.
NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, Section 3-4.7 states "At least every 4 years, fusible links shall be removed; all dampers shall be operated to verify that they fully close; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary." Centers for Medicare and Medicaid Services (CMS) S&C-10-04-LSC allows hospitals to apply the NFPA 6-year damper testing interval provided that the testing conforms to the requirements of the 2007 edition of NFPA 80 and NFPA 105.

Original Hospital Building (Aspen ID: A-1)
Based on record review during the survey, it was determined that the facility failed to maintain mechanical equipment in accordance with Life Safety Code Section 9.2 and the referenced NFPA 90A. This deficient practice could affect all patients should the mechanical equipment malfunction due to inadequate maintenance. This was evidenced by the following:

Records were not available to document the inspection and test operation of fire/smoke dampers, as required.
NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, Section 3-4.7 states "At least every 4 years, fusible links shall be removed; all dampers shall be operated to verify that they fully close; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary." Centers for Medicare and Medicaid Services (CMS) S&C-10-04-LSC allows hospitals to apply the NFPA 6-year damper testing interval provided that the testing conforms to the requirements of the 2007 edition of NFPA 80 and NFPA 105.

2005 Emergency Department Building (Aspen ID: A-2)
Based on observation and record review during the survey, it was determined that the facility failed to document that window loosely hanging fabrics were flame resistant in accordance with the provisions of the Life Safety Code Section 10.3.1. This deficient practice could affect all patients should the hanging materials ignite and contribute to rapid fire extension. This was evidenced by the following:

Loosely hanging curtains were not documented to be flame resistant, as required. Records were not available to document that cubicle curtains were flame resistant. The cubicle curtains did not have tags attached to document compliance with NFPA 701.

Life Safety Code Section 18.7.5.1 requires that draperies, curtains (including cubicle curtains) and other loosely hanging fabrics and films serving as furnishings or decorations in health care occupancies shall be in accordance with the provisions of 10.3.1. Section 10.3.1 requires that draperies, curtains, and other similar loosely hanging furnishings and decorations be flame resistant as demonstrated by testing in accordance with NFPA 701, Standard Methods of Fire Tests for Flame Propagation of Textiles and Films.

Original Hospital Building (Aspen ID: A-1)
Based on observation, record review and staff interview during the survey, it was determined that the facility failed to document that window loosely hanging fabrics were flame resistant in accordance with the provisions of the Life Safety Code Section 10.3.1. This deficient practice could affect all patients should the hanging materials ignite and contribute to rapid fire extension. This was evidenced by the following:

Loosely hanging curtains were not documented to be flame resistant, as required.

A) The mammography room window curtains were not documented to be flame resistant. The Maintenance Manager confirmed that the facility had not provided the window curtains.

B) Records were not available to document that cubicle curtains were flame resistant. The cubicle curtains did not have tags attached to document compliance with NFPA 701.

Life Safety Code Section 19.7.5.1 requires that draperies, curtains (including cubicle curtains) and other loosely hanging fabrics and films serving as furnishings or decorations in health care occupancies shall be in accordance with the provisions of 10.3.1. Section 10.3.1 requires that draperies, curtains, and other similar loosely hanging furnishings and decorations be flame resistant as demonstrated by testing in accordance with NFPA 701, Standard Methods of Fire Tests for Flame Propagation of Textiles and Films.

2005 Emergency Department Building (Aspen ID: A-2)
Based on observation and record review during the survey, it was determined that the facility failed to maintain the piped medical gas system in accordance with National Fire Protection Association Standard 99, Health Care Facilities. This deficient practice could affect all patients should the medical gas system not function as designed. This was evidenced by the following:

A) The oxygen system source valve was not located to permit the entire source of supply to be isolated from the piping system. The source valve was installed prior to pressure regulators and regulator isolation ball valves.
NFPA 99 Section 4-3.1.2.3(a): Source Valve. A shutoff valve shall be placed at the immediate outlet of the source of supply to permit the entire source of supply, including all accessory devices (such as air dryers, final line regulators, etc.), to be isolated from the piping system. The source valve shall be located in the immediate vicinity of the source equipment. It shall be labeled " SOURCE VALVE FOR THE (SOURCE NAME). "

B) There were no records available to document the periodic testing of the medical gas alarm system, as required. The Maintenance Manager confirmed that there were no records documenting the periodic testing of the alarm system.
NFPA 99 Section 4-3.5.2.3(g) requires that a periodic testing procedure for nonflammable medical gas and related alarm systems be implemented. Section 4-3.5.2.3(i) requires that periodic retesting of audible and visual alarm indicators shall be performed to determine that they are functioning properly and records of the test shall be maintained until the next test.

C) Medical gas master alarm panels were not arranged to monitor oxygen or medical air high and low line pressure signals, as required.
NFPA 99 Section 4-3.1.1.2(b)3e requires, in part, that the master alarm panel include visual indicators for each medical gas piping system when the pressure in the main line increases 20 percent or decreases 20 percent from the normal operating pressure.

D) The manifold/supply system room was not ventilated to the outside by a dedicated mechanical ventilation system or provided with natural ventilation, as required. The supply system room was not provided with natural ventilation openings to the outside or mechanical ventilation.
NFPA 99 Section 4-3.1.1.2 (b) 4 requires, in part, that locations for supply systems of more than 3000 cubic feet total capacity (connected and in storage) be vented to the outside by a dedicated mechanical ventilation system or by natural venting. If natural venting is used, the vent opening or openings shall be a minimum of 72 square inches in total free area.

E) There were no records available to document the required periodic tests for detecting leaks in the vacuum system, as required. NFPA 99 Section 4-3.5.6.1 (b) Leakage Tests: " The facility shall perform periodic tests for detecting leaks in the system in accordance with Section 4-3.4.2.2.

F) Records were not available to document vacuum system station inlet performance tests, as required. NFPA 99 Section 4-3.5.6.1(c) requires, in part, that inlet performance be tested on a regular preventive maintenance schedule as determined by the facility maintenance staff. Section 4-3.5.7 requires that a written record of tests be maintained in the permanent records of the facility.

Original Hospital Building (Aspen ID: A-1)
Based on observation and record review during the survey, it was determined that the facility failed to maintain the piped medical gas system in accordance with National Fire Protection Association Standard 99, Health Care Facilities. This deficient practice could affect all patients should the medical gas system not function as designed. This was evidenced by the following:


A) The oxygen system source valve was not located to permit the entire source of supply to be isolated from the piping system. The source valve was installed prior to pressure regulators and regulator isolation ball valves.
NFPA 99 Section 4-3.1.2.3(a): Source Valve. A shutoff valve shall be placed at the immediate outlet of the source of supply to permit the entire source of supply, including all accessory devices (such as air dryers, final line regulators, etc.), to be isolated from the piping system. The source valve shall be located in the immediate vicinity of the source equipment. It shall be labeled " SOURCE VALVE FOR THE (SOURCE NAME). "

B) There were no records available to document the periodic testing of the medical gas alarm system, as required. The Maintenance Manager confirmed that there were no records documenting the periodic testing of the alarm system.
NFPA 99 Section 4-3.5.2.3(g) requires that a periodic testing procedure for nonflammable medical gas and related alarm systems be implemented. Section 4-3.5.2.3(i) requires that periodic retesting of audible and visual alarm indicators shall be performed to determine that they are functioning properly and records of the test shall be maintained until the next test.

C) Medical gas master alarm panels were not arranged to monitor oxygen or medical air high and low line pressure signals, as required.
NFPA 99 Section 4-3.1.1.2(b)3e requires, in part, that the master alarm panel include visual indicators for each medical gas piping system when the pressure in the main line increases 20 percent or decreases 20 percent from the normal operating pressure.

D) The manifold/supply system room was not ventilated to the outside by a dedicated mechanical ventilation system or provided with natural ventilation, as required. The supply system room was not provided with natural ventilation openings to the outside or mechanical ventilation.
NFPA 99 Section 4-3.1.1.2 (b) 4 requires, in part, that locations for supply systems of more than 3000 cubic feet total capacity (connected and in storage) be vented to the outside by a dedicated mechanical ventilation system or by natural venting. If natural venting is used, the vent opening or openings shall be a minimum of 72 square inches in total free area.

E) There were no records available to document the required periodic tests for detecting leaks in the vacuum system, as required. NFPA 99 Section 4-3.5.6.1 (b) Leakage Tests: " The facility shall perform periodic tests for detecting leaks in the system in accordance with Section 4-3.4.2.2.

F) Records were not available to document vacuum system station inlet performance tests, as required. NFPA 99 Section 4-3.5.6.1(c) requires, in part, that inlet performance be tested on a regular preventive maintenance schedule as determined by the facility maintenance staff. Section 4-3.5.7 requires that a written record of tests be maintained in the permanent records of the facility.

Original Hospital Building (Aspen ID: A-1)
Based on staff interview during the course of the survey, it was determined that the facility failed to protect anesthetizing locations in accordance with National Fire Protection Association Standard 99, Health Care Facilities. This deficient practice could affect patients in the procedure room should a fire or smoke condition occur without proper automatic ventilation to remove the products of combustion. This was evidenced by the following:

Anesthetizing locations (first floor procedure room) were not arranged to automatically vent smoke and products of combustion in accordance with NFPA 99 Section 5-4.1.2, as required. The CEO confirmed that inhalation anesthetics are used in the room and that an automatic system to vent smoke was not installed.
NFPA 99 Section 5-4.1.2: Supply and exhaust systems for windowless anesthetizing locations shall be arranged to automatically vent smoke and products of combustion. Section 5-4.1.3: Ventilating systems for anesthetizing locations shall be provided that automatically (a) prevent recirculation of smoke originating within the surgical suite and (b) prevent the circulation of smoke entering the system intake, without in either case interfering with the exhaust function of the system.

Original Hospital Building (Aspen ID: A-1)
Based on record review and staff interview during the course of the survey, it was determined that the facility failed to establish emergency spill procedures in accordance with NFPA 99 Health Care Facilities. This deficient practice could affect patients and staff in the laboratory should a chemical spill occur without a knowledgeable response by laboratory staff. This was evidenced by the following:

Facility records did not include an emergency spill procedure for the laboratory, as required. The laboratory manager acknowledged the absence of a written emergency spill procedure.
NFPA 99 Section 10-2.1.3.2 requires that emergency procedures be established for controlling chemical spills.

Original Hospital Building (Aspen ID: A-1)
Based on record review and staff interview during the course of the survey, it was determined that the facility failed to establish procedures for laboratory emergencies in accordance with NFPA 99 Health Care Facilities. This deficient practice could affect patients and staff in the laboratory should a laboratory emergency occur without a knowledgeable response by laboratory staff. This was evidenced by the following:

The laboratory did not have established written procedures for laboratory emergencies, as required. The laboratory manager confirmed there were no written procedures for laboratory emergencies.

NFPA 99 Section 10-2.1.2 requires that fire prevention procedures be established in accordance with Section 10-8. Section 10-2.1.3.1 Emergency Procedures:
Procedures for laboratory emergencies shall be developed. Such procedures shall include alarm actuation, evacuation, and equipment shutdown procedures, and provisions for control of emergencies that could occur in the laboratory, including specific detailed plans for control operations by an emergency control group within the organization or a public fire department.
Section 10-2.1.3.3: Emergency procedures shall be established for extinguishing clothing fires.

2005 Emergency Department Building (Aspen ID: A-2)
Based on observation and staff interview during the course of the survey, it was determined that the facility failed to maintain the Type I essential electrical system in accordance with NFPA 99-Health Care Facilities. This deficient practice could affect patients throughout the facility if the critical branch of the essential electrical system were to have a failure due to non-allowed branch circuits on the system. This was evidenced by the following:

The Critical Branch of the essential electrical system was supplying a branch circuit that was not related to patient care in accordance with Section 3-4.2.2.2 (c). Panelboard "CR " circuit breaker #59 was labeled " sump pump " . The Maintenance Manager confirmed that the sump pump was part of the courtyard drainage system.

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

Original Hospital Building (Aspen ID: A-1)
Based on observation and staff interview during the course of the survey, it was determined that the facility failed to maintain the Type I essential electrical system in accordance with NFPA 99-Health Care Facilities. This deficient practice could affect patients throughout the facility if the critical branch of the essential electrical system were to have a failure due to non-allowed branch circuits on the system. This was evidenced by the following:

The Critical Branch of the essential electrical system was supplying a branch circuit that was not related to patient care in accordance with Section 3-4.2.2.2 (c). Panelboard "CR " circuit breaker #59 was labeled " sump pump " . The Maintenance Manager confirmed that the sump pump was part of the courtyard drainage system.

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

Original Hospital Building (Aspen ID: A-1)
Based on observation and staff interview, it was determined that the facility failed to install electrical equipment in accordance with National Fire Protection Association (NFPA) 70, National Electric Code. This deficient practice could affect all residents, staff and visitors in the 500-700 smoke compartment due to the increased potential hazard of electrical a fire ignited by a non-code compliant electrical source. This was evidenced by the following:

A) Flexible electric cords were being used as a substitute for permanent wiring in the basement boiler room. Three extension cords were plugged into a multi-outlet adapter that was supplied by a ceiling incandescent light bulb fixture. The extension cords were supplying power to ceiling mounted fluorescent light fixtures.

B) A flexible cord was routed through the suspended ceiling in room 7.

The Maintenance Manager acknowledged the flexible cords during a tour of the facility.

NFPA 70 National Electric Code Section 400-8. (Uses Not Permitted)
Unless specifically permitted in Section 400-7, flexible cords and cables shall not be used for the following:
1. As a substitute for the fixed wiring of a structure
2. Where run through holes in walls, structural ceilings suspended ceilings, dropped ceilings, or floors
3. Where run through doorways, windows, or similar openings
4. Where attached to building surfaces
Exception: Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of Section 364-8.
5. Where concealed behind building walls, structural ceilings, suspended ceilings, dropped ceilings, or floors

2005 Clinic Building (Aspen ID: A-3)
Based on observation and staff interview during the course of the survey, it was determined that the facility failed to maintain the two-hour fire rated separation to the attached healthcare occupancy in accordance with Life Safety Code Section 38.1.2.1 and 6.1.14. This deficient practice could affect all patients within the health care occupancy should heat and smoke spread from a fire condition in the adjacent building. This was evidenced by the following:

The 90 minute fire rated door, separating the Original Hospital building from the 2005 Clinic Building, was not maintained to be self-closing and positively latching, as required. When tested, the door was binding in the frame and not fully closing and latching. The door closer was not functional when the door was in a partially opened position.
The Maintenance Manager acknowledged the unprotected opening and door deficiency during a tour of the facility.

Life Safety Code Section 8.2.3.2.1 requires that fire doors be of a design that has been tested to meet the conditions of acceptance of NFPA 252, Standard Methods of Fire Tests of Door Assemblies, and that doors be installed in accordance with NFPA 80 Standard for Fire Doors and Fire Windows. Rated fire doors must self-close and positively latch into the door frame in accordance with NFPA 80.

Original Hospital Building (Aspen ID: A-1)
Based on observation and staff interview during the course of the survey, it was determined that the facility failed to maintain the two-hour fire rated separation to the attached non-healthcare occupancies in accordance with Life Safety Code Section 19.1.2.1. This deficient practice could affect all patients within the health care occupancy should heat and smoke spread from a fire condition in the adjacent building. This was evidenced by the following:

A) Openings in the two hour separation between the healthcare occupancy and the maintenance building were not protected, as required. The two hour wall (top of the former laundry stair enclosure) was observed to have an exhaust fan opening in the wall to the adjacent non-sprinklered wood frame maintenance building. The opening, approximately 20 " x 20 " was covered with sheet metal that does not maintain the fire rating of the wall.

B) The 90 minute fire rated door, separating the Original Hospital building from the 2005 Clinic Building, was not maintained to be self-closing and positively latching, as required. When tested, the door was binding in the frame and not fully closing and latching. The door closer was not functional when the door was in a partially opened position.
The Maintenance Manager acknowledged the unprotected opening and door deficiency during a tour of the facility.

Life Safety Code Section 19.1.2.1 requires that sections of health care facilities that are classified as other occupancies be separated by two hour rated construction. Section 8.2.3.2.1 requires that fire doors be of a design that has been tested to meet the conditions of acceptance of NFPA 252, Standard Methods of Fire Tests of Door Assemblies, and that doors be installed in accordance with NFPA 80 Standard for Fire Doors and Fire Windows. Rated fire doors must self-close and positively latch into the door frame in accordance with NFPA 80.

Original Hospital Building (Aspen ID: A-1)
Based on observation and staff interview during the survey, it was determined that the facility failed to install interior finish materials in accordance with Life Safety Code Section 19.3.3.2 and Section 10.2. This deficient practice could affect all patients within the CT trailer area should heat and smoke spread rapidly across non-rated wall and ceiling interior finish materials.
This was evidenced by the following:

A) Textile interior ceiling finish materials could not be confirmed as Class A rated, as required. The CT scanner trailer control room (approximately 8ft. x 20 ft.) and the scanner area (approximately 8 ft. x 10 ft.) were observed to have a textile material on the ceiling (carpet style). The Maintenance Manager was not aware of any facility records to document the flame spread rating of the exposed textile material.

Life Safety Code Section 10.2.4.1.1 requires that textile materials have a Class A rating when installed on walls or ceilings of rooms or areas protected by an approved automatic sprinkler system.

B) Non-code compliant foamed plastic insulation was installed as an interior finish material inside the CT scanner trailer. The blue foamed plastic insulation was installed over a former door opening, approximately 3 ft. x 7 ft. in size.
Life Safety Code Section 10.2.4.3: Cellular or foamed plastic materials shall not be used as interior wall and ceiling finish.

2005 Emergency Department Building (Aspen ID: A-2)
Based on observation and staff interview during the survey, it was determined that the facility failed to install corridor doors in accordance with Life Safety Code Section 18.3.6.3. This deficient practice could affect all patients within the emergency department should the egress corridor become untenable due to smoke and heat transfer via the deficient doors separating rooms from the egress corridor. This was evidenced by the following:

A) Corridor doors were not equipped with positive latching hardware, as required. Trauma Room #1 and #2 were not equipped with automatic positive latching hardware. Both leafs of the glass sliding doors were equipped with manual latch bolts. Manual latch bolts do allow for the door to be closed with a push or pull and automatically latch into the door frame.
Life Safety Code Section 18.3.6.3.2: Doors shall be provided with positive latching hardware. Roller latches shall be prohibited.

B) Use areas were not separated from the corridor by doors that could be closed with a push or a pull, as required. Rooms ER#1 and ER#2 (corridor doors) were equipped with a plunger style door hold open device that could not be released with a push or pull on the door. The Maintenance Manager acknowledged the door hold open devices during a tour of the facility.

Life Safety Code Section 18.3.6.3.3: Hold open devices that release when the door is pushed or pulled shall be permitted. The Life Safety Code Annex (explanatory material) explains that doors should not be blocked open by furniture, door stops, chocks, tie-backs, drop-down or plunger-type devices, or other devices that necessitate manual unlatching or releasing action to close. Examples of hold-open devices that release when the door is pushed or pulled are friction catches or magnetic catches.

Original Hospital Building (Aspen ID: A-1)
Based on observation and staff interview during the survey, it was determined that the facility failed to install corridor doors in accordance with Life Safety Code Section 19.3.6.3. This deficient practice could affect all patients within the central smoke compartment should the egress corridor become untenable due to smoke and heat transfer via the deficient doors separating rooms from the egress corridor. This was evidenced by the following:

Use areas were not separated from the corridor by doors that could be closed with a push or a pull, as required. The x-ray room and pharmacy corridor doors were equipped with a plunger style door hold open device that could not be released with a push or pull on the door. The Maintenance Manager acknowledged the door hold open devices during a tour of the facility.

Life Safety Code Section 19.3.6.3.3 permits hold-open devices that release when the door is pushed or pulled. The Life Safety Code Annex (explanatory material) explains that doors should not be blocked open by furniture, door stops, chocks, tie-backs, drop-down or plunger-type devices, or other devices that necessitate manual unlatching or releasing action to close. Examples of hold-open devices that release when the door is pushed or pulled are friction catches or magnetic catches.

Original Hospital Building (Aspen ID: A-1)
Based on observation and staff interview during the survey, it was determined that the facility failed to maintain vertical opening enclosures in accordance with Life Safety Code Section 19.3.1.2. This deficient practice could affect all patients within the facility by allowing the spread of fire and smoke between occupied rooms and the stair enclosure. This was evidenced by the following:

Doors protecting vertical openings were not self-closing, as required.

A) The one-hour fire rated door (first floor break room) was observed to have the self-closer disconnected.

B) The one-hour fire rated door (first floor materials storage room) was not equipped with a self-closer.
Life Safety Code Section 19.3.1.2: A door in a stair enclosure shall be self-closing and shall normally be kept in the closed position. Exception: doors in stair enclosures held open under the conditions specified by 19.2.2.2.6 and 19.2.2.2.7.

Original Hospital Building (Aspen ID: A-1)
Based on observation, it was determined that the facility failed to install smoke detectors to meet the minimum requirements for door release service in accordance with the Life Safety Code Section 19-2.2.2.6 and 7.2.1.8.2. This deficient practice could affect all patients within the facility by allowing the spread of fire and smoke between occupied rooms and the stair enclosure. This was evidenced by the following:

One-hour rated vertical opening protective doors were not held open by an automatic release device that complied with Life Safety Code Section 7.2.1.8.2, as required. The materials management one-hour rated door was held open with a magnetic latch that released upon activation of the fire alarm system. Smoke detection, in accordance with NFPA 72 for door release service, was not provided inside the room or in the corridor area outside the room.

Life Safety Code Section 19.2.2.2.6 requires that doors be held open only by an automatic release device that complies with Section 7.2.1.8.2. Section 7.2.1.8.2 requires, in part, that the automatic release mechanism be activated by the operation of an approved smoke detector installed in accordance with the requirements for smoke detectors for door release service in National Fire Protection Association (NFPA) Standard 72, National Fire Alarm Code.

Original Hospital Building (Aspen ID: A-1)
Based on observation and staff interview during the survey, it was determined that the fire resistance rating of smoke barrier walls were not maintained in accordance with Life Safety Code Section 19.3.7.3. This deficient practice could affect all patients within the north and south smoke compartments by allowing the spread of fire and smoke to the adjoining compartment. This was evidenced by the following:

Smoke barrier wall penetrations were not sealed to maintain the 30 minute fire resistance rating of the barrier, as required. The south smoke barrier wall was observed to have the following deficiencies:
A) An unsealed 1 " x 3 " hole.

B) An unsealed cable penetration.

C) An unsealed gap along the top of the wall ceiling intersection (ceiling tile should be removed prior to sealing the gap).

The Maintenance Manager acknowledged the penetrations during a tour of the facility.

Life Safety Code Section 19.3.7.3 requires that the smoke barrier wall be constructed in accordance with Section 8.3, and shall have a fire resistance rating of not less than ½ hour. Section 8.3.2 requires that the barrier be continuous through concealed spaces. Section 8-3.6.1 requires, in part, that the space between cable and pipe penetrations and the smoke barrier wall be filled with a material capable of maintaining the 30-minute fire resistance rating of the barrier.

Original Hospital Building (Aspen ID: A-1)
Based on observation and staff interview during the survey, it was determined that the facility failed to maintain sprinkler protected hazardous areas in accordance with Life Safety Code Section 19.3.2.1. This deficient practice could affect patients within the first floor smoke compartment, should there be smoke and heat transfer between the hazardous area and other portions of the building. This was evidenced by the following:

A) The main boiler room was observed to have an two unsealed holes (1 inch and 2 inch diameter) in the ceiling which voided the fire/smoke resistance rating of the plaster ceiling.
The Life Safety Code requires that sprinkler protected hazardous areas be separated from other spaces by smoke-resisting construction.

B) Hazardous area corridor doors were not equipped with self-closers, as required. Storage rooms # 6 and #10 did not have self-closers installed on the doors.
Life Safety Code Section 19.3.2.1 requires that sprinkler protected hazardous areas be separated from other spaces by smoke-resisting construction. Doors installed to protect hazardous areas must be self-closing or automatic closing.

The Maintenance Manager acknowledged the hazardous area deficiencies during a tour of the facility.

2005 Clinic Building (Aspen ID: A-3)
Based on observation and staff interview, it was determined that the facility failed to arrange the means of egress in accordance with Life Safety Code Section 38.2 and Chapter 7. This deficient practice could affect the building occupants if a code compliant exit is not provided. This was evidenced by the following:

A) The power operated egress doors (main entrance) were not arranged in accordance with Life Safety Code Sections 7.2.1.5, as required. The sliding doors were equipped with a thumb style deadbolt lock that requires special knowledge and effort to unlock. When locked, the deadbolt voids the breakaway feature of the door.

B) The center courtyard area exit door was not arranged to be readily opened from the courtyard side, as required. The double doors that serve as the single means of egress from the courtyard were equipped with a dead bolt lock that prevented the doors from being opened from the courtyard side.

The Maintenance Manager acknowledged the door arrangements during a tour of the facility.
Life Safety Code Section 7.2.1.5.1 requires that a door shall be so arranged as to be readily opened from the egress side whenever the building is occupied. Locks, if provided, shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side.

2005 Emergency Department Building (Aspen ID: A-2)
Based on observation and staff interview, it was determined that the facility failed to arrange the means of egress in accordance with Life Safety Code Section 18.2 and Chapter 7. This deficient practice could affect the building occupants if a code compliant exterior exit is not provided. This was evidenced by the following:

The power operated egress doors from the emergency department were not arranged in accordance with Life Safety Code Sections 7.2.1.5 and 7.2.1.9.1.

A) The sliding doors were equipped with a thumb style deadbolt lock that requires special knowledge and effort to unlock. When locked, the deadbolt voids the breakaway feature of the door.

B) The sliding glass breakaway style doors were not equipped with door signage that reads " IN EMERGENCY, PUSH TO OPEN " .

The Maintenance Manager acknowledged the door arrangement during a tour of the facility.

Life Safety Code Section 7.2.1.5.1 requires that a door shall be so arranged as to be readily opened from the egress side whenever the building is occupied. Locks, if provided, shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side. Section 7.2.1.9.1 requires, in part: On the egress side of each door, there shall be a readily visible, durable sign that reads as follows: " IN EMERGENCY, PUSH TO OPEN " . The sign shall be in letters not less than 1 inch high on a contrasting background.

Original Hospital Building (Aspen ID: A-1)
Based on observation and staff interview, it was determined that the facility failed to arrange and maintain the means of egress in accordance with Life Safety Code Section 19.2 and Chapter 7. This deficient practice could affect the occupants of Room #9 if an unobstructed room exit is not provided. This was evidenced by the following:

Doors in the means of egress were not maintained to be readily opened from the egress side, as required. Patient room #9 was observed to have a locking hasp on the corridor side of the door. When locked, the door would no longer be readily opened from inside the room.

The Maintenance Manager acknowledged the door arrangement during a tour of the facility.

Life Safety Code Section 7-2.1.5.1 requires that a door shall be so arranged as to be readily opened from the egress side whenever the building is occupied. Locks, if provided, shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side.

2005 Emergency Department Building (Aspen ID: A-2)
Based on record review, observation and staff interview during the survey, it was determined that the facility failed to install and maintain emergency lighting systems in accordance with Life Safety Code Section 7.9 and the referenced NFPA 110. This deficient practice could affect all patients should the emergency lighting and emergency power systems fail to operate due to non-standard installation or maintenance. This was evidenced by the following:

A) Records were not available to document the monthly and annual testing of the battery powered emergency lighting units, as required. The Maintenance Manager reported that the battery units were tested monthly, but documentation of the testing was not maintained.
Life Safety Code Section 7.9.3, Periodic Testing of Emergency Lighting Equipment:
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 1½ 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.

B) Emergency illumination of the exit discharge areas throughout the facility was not provided, as required. Maintenance staff verified during the survey that the hospital building exterior lighting was not powered by emergency generator supplied panelboard branch circuits. Illumination of the means of egress should be supplied by the Life Safety Branch of the Essential Electrical System.
Life Safety Code Section 7.9.1 requires emergency lighting facilities for the means of egress which includes the exit discharge walkways leading to a public way.

C) The emergency generator was not equipped with a remote manual stop station, located outside of the generator enclosure, as required. The Maintenance Manager reported that the emergency generator was installed as part of the 2005 building addition project.
NFPA 110 Section 3-5.5.6: All Level 1 and Level 2 installations shall have a remote manual stop station of a type similar to a break-glass station located outside of the room housing the prime mover, where so installed, or located elsewhere on the premises where the prime mover is located outside of the building.

D) The outside generator area and automatic transfer switch electrical room were not provided with battery operated emergency lighting, as required.
NFPA Standard 110 Section 5-3.1 requires that EPS equipment locations be provided with battery-powered emergency lighting. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch.

E) The diesel powered emergency generator was not being load tested monthly at a minimum of 30% of nameplate rating, as required. Generator monthly load test records did not document current readings on each phase of the generator while under normal building load. The Maintenance Manager confirmed that there was no annual load bank testing of the emergency generator.
NFPA 110 Section 6-4.2 requires that generator sets in Level 1 and Level 2 service be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
The date and time of day for required testing shall be decided by the owner, based on facility operations.
Section 6-4.2.2: Diesel-powered EPS installations that do not meet the requirements of 6-4.2 shall be exercised monthly with the available EPSS load and exercised annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of 2 continuous hours.

Original Hospital Building (Aspen ID: A-1)
Based on record review, observation and staff interview during the survey, it was determined that the facility failed to install and maintain emergency lighting systems in accordance with Life Safety Code Section 7.9 and the referenced NFPA 110. This deficient practice could affect all patients should the emergency lighting and emergency power systems fail to operate due to non-standard installation or maintenance. This was evidenced by the following:

A) Records were not available to document the monthly and annual testing of the battery powered emergency lighting units, as required. The Maintenance Manager reported that the battery units were tested monthly, but documentation of the testing was not maintained.
Life Safety Code Section 7.9.3, Periodic Testing of Emergency Lighting Equipment:
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 1½ 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.

B) Emergency illumination of the exit discharge areas throughout the facility was not provided, as required. Maintenance staff verified during the survey that the hospital building exterior lighting was not powered by emergency generator supplied panelboard branch circuits. Illumination of the means of egress should be supplied by the Life Safety Branch of the Essential Electrical System.
Life Safety Code Section 7.9.1 requires emergency lighting facilities for the means of egress which includes the exit discharge walkways leading to a public way.

C) The emergency generator was not equipped with a remote manual stop station, located outside of the generator enclosure, as required. The Maintenance Manager reported that the emergency generator was installed as part of the 2005 building addition.
NFPA 110 Section 3-5.5.6: All Level 1 and Level 2 installations shall have a remote manual stop station of a type similar to a break-glass station located outside of the room housing the prime mover, where so installed, or located elsewhere on the premises where the prime mover is located outside of the building.

D) The outside generator area and automatic transfer switch electrical room were not provided with battery operated emergency lighting, as required.
NFPA Standard 110 Section 5-3.1 requires that EPS equipment locations be provided with battery-powered emergency lighting. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch.

E) The diesel powered emergency generator was not being load tested monthly at a minimum of 30% of nameplate rating, as required. Generator monthly load test records did not document current readings on each phase of the generator while under normal building load. The Maintenance Manager confirmed that there was no annual load bank testing of the emergency generator.
NFPA 110 Section 6-4.2 requires that generator sets in Level 1 and Level 2 service be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
The date and time of day for required testing shall be decided by the owner, based on facility operations.
Section 6-4.2.2: Diesel-powered EPS installations that do not meet the requirements of 6-4.2 shall be exercised monthly with the available EPSS load and exercised annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of 2 continuous hours.

2005 Emergency Department Building (Aspen ID: A-2)
Based on record review during the survey, it was determined that the facility failed to maintain a complete plan for the protection of all persons in the event of fire in accordance with Life Safety Code Section 18.7.1 and 18.7.2. This deficient practice could affect all patients if staff response during a fire situation does not include knowledge and training in evacuation of the hospital smoke compartments. This was evidenced by the following:

The fire emergency plan did not specifically discuss the evacuation of a hospital smoke compartment, as required. The facility fire emergency plan titled "Sedgwick County Health Center Emergency Operations Plan" Section II titled "Concept of Operations, Functional Response-Item 1E (Evacuate beyond the first smoke/fire barrier doors away from the fire)" did not address evacuation of a hospital smoke compartment. The remainder of the section specifically addresses smoke compartments and evacuation of the nursing home to the adjacent living center. The nursing home and living center are separate buildings located across the street from the hospital buildings. The plan did not specifically discuss the hospital smoke compartments and the 2 hour rated separation between the two hospital buildings and the 2 hour separation to the adjoining Clinic Building.

Life Safety Code Section 18.7.1.1 requires that the administration of all health care facilities develop a plan for the protection of all persons in the event of fire, including a plan for their evacuation to an area of refuge and from the building when necessary. The plan must include all components and requirements outlined in Life Safety Code Section 18.7.1 and 18.7.2.
Life Safety Code Section 18.7.2.2 requires that a written health care occupancy fire safety plan provide for the following:
1. Use of alarms
2. Transmission of alarms to the fire department
3. Response to alarms
4. Isolation of fire
5. Evacuation of immediate area
6. Evacuation of smoke compartment
7. Preparation of floors and building for evacuation
8. Extinguishment of fire

Original Hospital Building (Aspen ID: A-1)
Based on record review during the survey, it was determined that the facility failed to maintain a complete plan for the protection of all persons in the event of fire in accordance with Life Safety Code Section 19.7.1 and 19.7.2. This deficient practice could affect all patients if staff response during a fire situation does not include knowledge and training in evacuation of the hospital smoke compartments. This was evidenced by the following:

The fire emergency plan did not specifically discuss the evacuation of a hospital smoke compartment, as required. The facility fire emergency plan titled "Sedgwick County Health Center Emergency Operations Plan" Section II titled "Concept of Operations, Functional Response-Item 1E (Evacuate beyond the first smoke/fire barrier doors away from the fire)" did not address evacuation of a hospital smoke compartment. The remainder of the section specifically addresses smoke compartments and evacuation of the nursing home to the adjacent living center. The nursing home and living center are separate buildings located across the street from the hospital buildings. The plan did not specifically discuss the hospital smoke compartments and the 2 hour rated separation between the two hospital buildings and the 2 hour separation to the adjoining Clinic Building.

Life Safety Code Section 19.7.1.1 requires that the administration of all health care facilities develop a plan for the protection of all persons in the event of fire, including a plan for their evacuation to an area of refuge and from the building when necessary. The plan must include all components and requirements outlined in Life Safety Code Section 19.7.1 and 19.7.2.
Life Safety Code Section 19.7.2.2 requires that a written health care occupancy fire safety plan provide for the following:
1. Use of alarms
2. Transmission of alarms to the fire department
3. Response to alarms
4. Isolation of fire
5. Evacuation of immediate area
6. Evacuation of smoke compartment
7. Preparation of floors and building for evacuation
8. Extinguishment of fire

2005 Emergency Department Building (Aspen ID: A-2)
Based on observation, staff interview and record review during the survey, it was determined that the facility failed to install the fire alarm system in accordance with National Fire Protection Association (NFPA) 101- Life Safety Code, and NFPA 72- National Fire Alarm Code. This deficient practice could affect all patients should the fire alarm system fail to notify the local fire department, via code compliant notification methods. This was evidenced by the following:

The fire alarm control unit (installed in 2005) was not arranged to transmit fire alarms automatically, to notify emergency forces, via a code compliant transmission method. The Maintenance Manager reported that the fire alarm control unit was arranged to send a signal to the local county emergency dispatch center. The transmission method was believed to be a single telephone line, but could not be confirmed during the survey. The Maintenance Manager also reported that upon receipt of an alarm signal, the emergency operations center would call the facility to verify the alarm, prior to dispatching emergency forces. Alarm transmission to the county emergency dispatch center does not comply with Life Safety Code Section 9.6.4.

Life Safety Code Section 18.3.4.3.2 requires that fire department notification be accomplished in accordance with Section 9.6.4. Section 9.6.4 (Emergency Forces Notification): Where required by another section of this Code, emergency forces notification shall be provided to alert the municipal fire department and fire brigade (if provided) of fire or other emergency.
Where fire department notification is required by another section of this Code, the fire alarm system shall be arranged to transmit the alarm automatically via any of the following means acceptable to the authority having jurisdiction and shall be in accordance with NFPA 72, National Fire Alarm Code:
(1) Auxiliary alarm system
(2) Central station connection
(3) Proprietary system
(4) Remote station connection
Equipment, power supply and transmission methods must be in accordance with NFPA 72, National Fire Alarm Code.

Original Hospital Building (Aspen ID: A-1)
Based on observation, staff interview and record review during the survey, it was determined that the facility failed to install the fire alarm system in accordance with National Fire Protection Association (NFPA) 101- Life Safety Code, and NFPA 72- National Fire Alarm Code. This deficient practice could affect all patients should the fire alarm system fail to notify building occupants, and the local fire department, via code compliant notification methods. This was evidenced by the following:

A) The fire alarm control unit (installed in 2005) was not arranged to transmit fire alarms automatically, to notify emergency forces, via a code compliant transmission method. The Maintenance Manager reported that the fire alarm control unit was arranged to send a signal to the local county emergency dispatch center. The transmission method was believed to be a single telephone line, but could not be confirmed during the survey. The Maintenance Manager also reported that upon receipt of an alarm signal, the emergency operations center would call the facility to verify the alarm, prior to dispatching emergency forces. Alarm transmission to the county emergency dispatch center does not comply with Life Safety Code Section 9.6.4.

Life Safety Code Section 19.3.4.3.2 requires that fire department notification be accomplished in accordance with Section 9.6.4. Section 9.6.4 (Emergency Forces Notification): Where required by another section of this Code, emergency forces notification shall be provided to alert the municipal fire department and fire brigade (if provided) of fire or other emergency.
Where fire department notification is required by another section of this Code, the fire alarm system shall be arranged to transmit the alarm automatically via any of the following means acceptable to the authority having jurisdiction and shall be in accordance with NFPA 72, National Fire Alarm Code:
(1) Auxiliary alarm system
(2) Central station connection
(3) Proprietary system
(4) Remote station connection
Equipment, power supply and transmission methods must be in accordance with NFPA 72, National Fire Alarm Code.

B) Fire alarm system visible notification appliances did not flash in synchronization, as required. During a test of the fire alarm system, visible notification appliances (strobes) were observed as follows:
1. From the one hour smoke compartment doors looking north: 4 strobes were in the field of view that were not synchronized.
2. From the nurses station: 3 strobes were in the field of view, one of three strobes was not synchronized with the other two.
The appliances were spaced less than 55 feet from each other.

NFPA 72 Section 4-4.4.2.3: In corridors where there are more than two visible notification appliances in any field of view, they shall be spaced a minimum of 55 feet from each other, or they shall flash in synchronization.

2005 Emergency Department Building (Aspen ID: A-2)
Based on observation during the survey, it was determined that the facility failed to the automatic fire sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 13. This deficient practice could affect all patients should the automatic sprinkler system fail to operate as intended due to non-code compliant installation. This was evidenced by the following:

The attic dry-pipe sprinkler system was not equipped with a listed air maintenance device, as required. NFPA 13 Section 4-2.6.6: Where a dry pipe system is supplied by an automatic air compressor or plant air system, any device or apparatus used for automatic maintenance of air pressure shall be of a type specifically listed for such service and capable of maintaining the required air pressure on, and maximum air flow to, the dry pipe system.

Original Hospital Building (Aspen ID: A-1)
Based on observation and staff interview, it was determined that the facility failed to install the automatic fire sprinkler system in accordance with National Fire Protection Association (NFPA) 101-Life Safety Code and the referenced NFPA 13. This deficient practice could affect all patients should a fire occur in an area not protected by the automatic sprinkler system or not operate as designed due to non-code compliant installation. This was evidenced by the following:

A) Automatic sprinkler protection was not installed in all building areas, as required. The following areas were not protected by the automatic sprinkler system:
1. The enclosed former laundry room stair.

2. Areas of the loading dock (northwest corner of building) where the combustible roof overhang exceeded 4 ft. in width.

3. The 6 ft. x 7 ft. bio-hazard storage room (adjacent to the loading dock).

4. Areas above the suspended ceiling that may be combustible concealed spaces due to the original ceiling tiles installed on the lath and plaster ceiling. If the original ceiling tiles are documented as being combustible, the area will have to be sprinkler protected or the tiles removed.

B) Sprinkler piping was not installed in accordance with the manufacture ' s installation instructions, as required. The CPVC branch line, installed in the CT trailer control room, did not have a sprinkler hanger installed within 12 inches of the end of the branch line. The end of line was equipped with a 90 degree elbow and a pendant sprinkler head. The hanger, when installed, must also be equipped with an approved vertical restraint method. The all-thread cannot be installed with direct contact on the CPVC piping.

Life Safety Code Section 19.1.6 requires automatic sprinkler protection for all buildings of Type III construction in accordance with Section 19.3.5.1. NFPA 13, Installation of Sprinkler Systems, Section 1-6.1 states: "A building, where protected by an automatic sprinkler system installation, shall be provided with sprinklers in all areas." Section 5-13.1.1 requires that all concealed spaces enclosed wholly or partly by exposed combustible construction be sprinkler protected.
Section 5-13.8.1: Sprinklers shall be installed under exterior roofs or canopies exceeding 4 ft. in width. Exception: Sprinklers are permitted to be omitted where the canopy or roof is of noncombustible or limited combustible construction.

2005 Emergency Department Building (Aspen ID: A-2)
Based on observation and record review during the survey, it was determined that the facility failed to maintain the automatic fire sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 25. This deficient practice could affect all patients should the automatic sprinkler system fail to operate in a timely and effective manner due to non-code compliant maintenance. This was evidenced by the following:

A) Automatic sprinkler system waterflow alarms were not tested quarterly, as required. Records on premises documented testing of the wet system waterflow alarm in September 2013 and March 2014. Dry system waterflow alarm testing was not documented.
NFPA 25 Section 9-2.7 requires that waterflow alarms be tested quarterly in accordance with manufacturer's instructions.

B) Sprinkler system tamper switches were not documented to be tested semi-annually as required. The fire alarm inspection report, dated 03-21-14, documented testing of one waterflow alarm (two installed) and 3 supervisory devices (6 installed).
NFPA 25 Section 9-3.4.3 requires that valve supervisory switches be tested semi-annually in accordance with manufacturer's instructions.

C) Records on premises did not adequately document that sprinkler system pressure gauges were calibrated every 5 years, as required. The sprinkler pressure gauges, installed at the main system riser, were dated 2004. The gauges had stickers attached to the face with handwritten " calibrated 09-2011 " . The Maintenance Manager was not aware of any test/calibration report that documented the gauge calibration in 2011.
NFPA 25 Section 9-2.8.2: Gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge. Gauges not accurate to within 3 percent of the full scale shall be recalibrated or replaced.

D) Dry sprinkler system low air alarms were not tested quarterly, as required. Inspection records did not specifically document testing of the dry pipe system low air alarm.
NFPA 25 Section 9-4.4.2.6 requires that low air pressure alarms be tested quarterly in accordance with manufacturer's instructions.

Original Hospital Building (Aspen ID: A-1)
Based on observation and record review during the survey, it was determined that the facility failed to maintain the automatic fire sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 25. This deficient practice could affect all patients should the automatic sprinkler system fail to operate in a timely and effective manner due to non-code compliant maintenance. This was evidenced by the following:

A) Sidewall sprinkler heads were not maintained free of obstructions to spray distribution patterns, as required. The closet sidewall sprinkler (Room #1) was obstructed by storage.

NFPA 25, Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems, Section 2-2.1.2 states "Unacceptable obstructions to spray patterns shall be corrected."

B) The automatic sprinkler system waterflow alarm was not tested quarterly as required. Records on premises documented testing of the waterflow alarm in September 2013 and March 2014. NFPA 25 Section 9-2.7 requires that waterflow alarms be tested quarterly in accordance with manufacturer's instructions.

C) Sprinkler system tamper switches were not documented to be tested semi-annually as required. The fire alarm inspection report, dated 03-21-14, documented testing of one waterflow alarm (two installed) and 3 supervisory devices (6 installed).
NFPA 25 Section 9-3.4.3 requires that valve supervisory switches be tested semi-annually in accordance with manufacturer's instructions.

D) Records on premises did not adequately document that sprinkler system pressure gauges were calibrated every 5 years, as required. The sprinkler pressure gauges, installed at the main system riser, were dated 2004. The gauges had stickers attached to the face with handwritten " calibrated 09-2011 " . The Maintenance Manager was not aware of any test/calibration report that documented the gauge calibration in 2011.
NFPA 25 Section 9-2.8.2: Gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge. Gauges not accurate to within 3 percent of the full scale shall be recalibrated or replaced.

2005 Clinic Building (Aspen ID: A-3)
Based on record review during the survey, it was determined that the facility failed to maintain mechanical equipment in accordance with Life Safety Code Section 9.2 and the referenced NFPA 90A. This deficient practice could affect all patients should the mechanical equipment malfunction due to inadequate maintenance. This was evidenced by the following:

Records were not available to document the inspection and test operation of fire/smoke dampers, as required.
NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, Section 3-4.7 states "At least every 4 years, fusible links shall be removed; all dampers shall be operated to verify that they fully close; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary." Centers for Medicare and Medicaid Services (CMS) S&C-10-04-LSC allows hospitals to apply the NFPA 6-year damper testing interval provided that the testing conforms to the requirements of the 2007 edition of NFPA 80 and NFPA 105.

2005 Emergency Department Building (Aspen ID: A-2)
Based on record review during the survey, it was determined that the facility failed to maintain mechanical equipment in accordance with Life Safety Code Section 9.2 and the referenced NFPA 90A. This deficient practice could affect all patients should the mechanical equipment malfunction due to inadequate maintenance. This was evidenced by the following:

Records were not available to document the inspection and test operation of fire/smoke dampers, as required.
NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, Section 3-4.7 states "At least every 4 years, fusible links shall be removed; all dampers shall be operated to verify that they fully close; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary." Centers for Medicare and Medicaid Services (CMS) S&C-10-04-LSC allows hospitals to apply the NFPA 6-year damper testing interval provided that the testing conforms to the requirements of the 2007 edition of NFPA 80 and NFPA 105.

Original Hospital Building (Aspen ID: A-1)
Based on record review during the survey, it was determined that the facility failed to maintain mechanical equipment in accordance with Life Safety Code Section 9.2 and the referenced NFPA 90A. This deficient practice could affect all patients should the mechanical equipment malfunction due to inadequate maintenance. This was evidenced by the following:

Records were not available to document the inspection and test operation of fire/smoke dampers, as required.
NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, Section 3-4.7 states "At least every 4 years, fusible links shall be removed; all dampers shall be operated to verify that they fully close; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary." Centers for Medicare and Medicaid Services (CMS) S&C-10-04-LSC allows hospitals to apply the NFPA 6-year damper testing interval provided that the testing conforms to the requirements of the 2007 edition of NFPA 80 and NFPA 105.

2005 Emergency Department Building (Aspen ID: A-2)
Based on observation and record review during the survey, it was determined that the facility failed to document that window loosely hanging fabrics were flame resistant in accordance with the provisions of the Life Safety Code Section 10.3.1. This deficient practice could affect all patients should the hanging materials ignite and contribute to rapid fire extension. This was evidenced by the following:

Loosely hanging curtains were not documented to be flame resistant, as required. Records were not available to document that cubicle curtains were flame resistant. The cubicle curtains did not have tags attached to document compliance with NFPA 701.

Life Safety Code Section 18.7.5.1 requires that draperies, curtains (including cubicle curtains) and other loosely hanging fabrics and films serving as furnishings or decorations in health care occupancies shall be in accordance with the provisions of 10.3.1. Section 10.3.1 requires that draperies, curtains, and other similar loosely hanging furnishings and decorations be flame resistant as demonstrated by testing in accordance with NFPA 701, Standard Methods of Fire Tests for Flame Propagation of Textiles and Films.

Original Hospital Building (Aspen ID: A-1)
Based on observation, record review and staff interview during the survey, it was determined that the facility failed to document that window loosely hanging fabrics were flame resistant in accordance with the provisions of the Life Safety Code Section 10.3.1. This deficient practice could affect all patients should the hanging materials ignite and contribute to rapid fire extension. This was evidenced by the following:

Loosely hanging curtains were not documented to be flame resistant, as required.

A) The mammography room window curtains were not documented to be flame resistant. The Maintenance Manager confirmed that the facility had not provided the window curtains.

B) Records were not available to document that cubicle curtains were flame resistant. The cubicle curtains did not have tags attached to document compliance with NFPA 701.

Life Safety Code Section 19.7.5.1 requires that draperies, curtains (including cubicle curtains) and other loosely hanging fabrics and films serving as furnishings or decorations in health care occupancies shall be in accordance with the provisions of 10.3.1. Section 10.3.1 requires that draperies, curtains, and other similar loosely hanging furnishings and decorations be flame resistant as demonstrated by testing in accordance with NFPA 701, Standard Methods of Fire Tests for Flame Propagation of Textiles and Films.

2005 Emergency Department Building (Aspen ID: A-2)
Based on observation and record review during the survey, it was determined that the facility failed to maintain the piped medical gas system in accordance with National Fire Protection Association Standard 99, Health Care Facilities. This deficient practice could affect all patients should the medical gas system not function as designed. This was evidenced by the following:

A) The oxygen system source valve was not located to permit the entire source of supply to be isolated from the piping system. The source valve was installed prior to pressure regulators and regulator isolation ball valves.
NFPA 99 Section 4-3.1.2.3(a): Source Valve. A shutoff valve shall be placed at the immediate outlet of the source of supply to permit the entire source of supply, including all accessory devices (such as air dryers, final line regulators, etc.), to be isolated from the piping system. The source valve shall be located in the immediate vicinity of the source equipment. It shall be labeled " SOURCE VALVE FOR THE (SOURCE NAME). "

B) There were no records available to document the periodic testing of the medical gas alarm system, as required. The Maintenance Manager confirmed that there were no records documenting the periodic testing of the alarm system.
NFPA 99 Section 4-3.5.2.3(g) requires that a periodic testing procedure for nonflammable medical gas and related alarm systems be implemented. Section 4-3.5.2.3(i) requires that periodic retesting of audible and visual alarm indicators shall be performed to determine that they are functioning properly and records of the test shall be maintained until the next test.

C) Medical gas master alarm panels were not arranged to monitor oxygen or medical air high and low line pressure signals, as required.
NFPA 99 Section 4-3.1.1.2(b)3e requires, in part, that the master alarm panel include visual indicators for each medical gas piping system when the pressure in the main line increases 20 percent or decreases 20 percent from the normal operating pressure.

D) The manifold/supply system room was not ventilated to the outside by a dedicated mechanical ventilation system or provided with natural ventilation, as required. The supply system room was not provided with natural ventilation openings to the outside or mechanical ventilation.
NFPA 99 Section 4-3.1.1.2 (b) 4 requires, in part, that locations for supply systems of more than 3000 cubic feet total capacity (connected and in storage) be vented to the outside by a dedicated mechanical ventilation system or by natural venting. If natural venting is used, the vent opening or openings shall be a minimum of 72 square inches in total free area.

E) There were no records available to document the required periodic tests for detecting leaks in the vacuum system, as required. NFPA 99 Section 4-3.5.6.1 (b) Leakage Tests: " The facility shall perform periodic tests for detecting leaks in the system in accordance with Section 4-3.4.2.2.

F) Records were not available to document vacuum system station inlet performance tests, as required. NFPA 99 Section 4-3.5.6.1(c) requires, in part, that inlet performance be tested on a regular preventive maintenance schedule as determined by the facility maintenance staff. Section 4-3.5.7 requires that a written record of tests be maintained in the permanent records of the facility.

Original Hospital Building (Aspen ID: A-1)
Based on observation and record review during the survey, it was determined that the facility failed to maintain the piped medical gas system in accordance with National Fire Protection Association Standard 99, Health Care Facilities. This deficient practice could affect all patients should the medical gas system not function as designed. This was evidenced by the following:


A) The oxygen system source valve was not located to permit the entire source of supply to be isolated from the piping system. The source valve was installed prior to pressure regulators and regulator isolation ball valves.
NFPA 99 Section 4-3.1.2.3(a): Source Valve. A shutoff valve shall be placed at the immediate outlet of the source of supply to permit the entire source of supply, including all accessory devices (such as air dryers, final line regulators, etc.), to be isolated from the piping system. The source valve shall be located in the immediate vicinity of the source equipment. It shall be labeled " SOURCE VALVE FOR THE (SOURCE NAME). "

B) There were no records available to document the periodic testing of the medical gas alarm system, as required. The Maintenance Manager confirmed that there were no records documenting the periodic testing of the alarm system.
NFPA 99 Section 4-3.5.2.3(g) requires that a periodic testing procedure for nonflammable medical gas and related alarm systems be implemented. Section 4-3.5.2.3(i) requires that periodic retesting of audible and visual alarm indicators shall be performed to determine that they are functioning properly and records of the test shall be maintained until the next test.

C) Medical gas master alarm panels were not arranged to monitor oxygen or medical air high and low line pressure signals, as required.
NFPA 99 Section 4-3.1.1.2(b)3e requires, in part, that the master alarm panel include visual indicators for each medical gas piping system when the pressure in the main line increases 20 percent or decreases 20 percent from the normal operating pressure.

D) The manifold/supply system room was not ventilated to the outside by a dedicated mechanical ventilation system or provided with natural ventilation, as required. The supply system room was not provided with natural ventilation openings to the outside or mechanical ventilation.
NFPA 99 Section 4-3.1.1.2 (b) 4 requires, in part, that locations for supply systems of more than 3000 cubic feet total capacity (connected and in storage) be vented to the outside by a dedicated mechanical ventilation system or by natural venting. If natural venting is used, the vent opening or openings shall be a minimum of 72 square inches in total free area.

E) There were no records available to document the required periodic tests for detecting leaks in the vacuum system, as required. NFPA 99 Section 4-3.5.6.1 (b) Leakage Tests: " The facility shall perform periodic tests for detecting leaks in the system in accordance with Section 4-3.4.2.2.

F) Records were not available to document vacuum system station inlet performance tests, as required. NFPA 99 Section 4-3.5.6.1(c) requires, in part, that inlet performance be tested on a regular preventive maintenance schedule as determined by the facility maintenance staff. Section 4-3.5.7 requires that a written record of tests be maintained in the permanent records of the facility.

Original Hospital Building (Aspen ID: A-1)
Based on staff interview during the course of the survey, it was determined that the facility failed to protect anesthetizing locations in accordance with National Fire Protection Association Standard 99, Health Care Facilities. This deficient practice could affect patients in the procedure room should a fire or smoke condition occur without proper automatic ventilation to remove the products of combustion. This was evidenced by the following:

Anesthetizing locations (first floor procedure room) were not arranged to automatically vent smoke and products of combustion in accordance with NFPA 99 Section 5-4.1.2, as required. The CEO confirmed that inhalation anesthetics are used in the room and that an automatic system to vent smoke was not installed.
NFPA 99 Section 5-4.1.2: Supply and exhaust systems for windowless anesthetizing locations shall be arranged to automatically vent smoke and products of combustion. Section 5-4.1.3: Ventilating systems for anesthetizing locations shall be provided that automatically (a) prevent recirculation of smoke originating within the surgical suite and (b) prevent the circulation of smoke entering the system intake, without in either case interfering with the exhaust function of the system.

Original Hospital Building (Aspen ID: A-1)
Based on record review and staff interview during the course of the survey, it was determined that the facility failed to establish procedures for laboratory emergencies in accordance with NFPA 99 Health Care Facilities. This deficient practice could affect patients and staff in the laboratory should a laboratory emergency occur without a knowledgeable response by laboratory staff. This was evidenced by the following:

The laboratory did not have established written procedures for laboratory emergencies, as required. The laboratory manager confirmed there were no written procedures for laboratory emergencies.

NFPA 99 Section 10-2.1.2 requires that fire prevention procedures be established in accordance with Section 10-8. Section 10-2.1.3.1 Emergency Procedures:
Procedures for laboratory emergencies shall be developed. Such procedures shall include alarm actuation, evacuation, and equipment shutdown procedures, and provisions for control of emergencies that could occur in the laboratory, including specific detailed plans for control operations by an emergency control group within the organization or a public fire department.
Section 10-2.1.3.3: Emergency procedures shall be established for extinguishing clothing fires.

2005 Emergency Department Building (Aspen ID: A-2)
Based on observation and staff interview during the course of the survey, it was determined that the facility failed to maintain the Type I essential electrical system in accordance with NFPA 99-Health Care Facilities. This deficient practice could affect patients throughout the facility if the critical branch of the essential electrical system were to have a failure due to non-allowed branch circuits on the system. This was evidenced by the following:

The Critical Branch of the essential electrical system was supplying a branch circuit that was not related to patient care in accordance with Section 3-4.2.2.2 (c). Panelboard "CR " circuit breaker #59 was labeled " sump pump " . The Maintenance Manager confirmed that the sump pump was part of the courtyard drainage system.

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

Original Hospital Building (Aspen ID: A-1)
Based on observation and staff interview during the course of the survey, it was determined that the facility failed to maintain the Type I essential electrical system in accordance with NFPA 99-Health Care Facilities. This deficient practice could affect patients throughout the facility if the critical branch of the essential electrical system were to have a failure due to non-allowed branch circuits on the system. This was evidenced by the following:

The Critical Branch of the essential electrical system was supplying a branch circuit that was not related to patient care in accordance with Section 3-4.2.2.2 (c). Panelboard "CR " circuit breaker #59 was labeled " sump pump " . The Maintenance Manager confirmed that the sump pump was part of the courtyard drainage system.

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

Original Hospital Building (Aspen ID: A-1)
Based on observation and staff interview, it was determined that the facility failed to install electrical equipment in accordance with National Fire Protection Association (NFPA) 70, National Electric Code. This deficient practice could affect all residents, staff and visitors in the 500-700 smoke compartment due to the increased potential hazard of electrical a fire ignited by a non-code compliant electrical source. This was evidenced by the following:

A) Flexible electric cords were being used as a substitute for permanent wiring in the basement boiler room. Three extension cords were plugged into a multi-outlet adapter that was supplied by a ceiling incandescent light bulb fixture. The extension cords were supplying power to ceiling mounted fluorescent light fixtures.

B) A flexible cord was routed through the suspended ceiling in room 7.

The Maintenance Manager acknowledged the flexible cords during a tour of the facility.

NFPA 70 National Electric Code Section 400-8. (Uses Not Permitted)
Unless specifically permitted in Section 400-7, flexible cords and cables shall not be used for the following:
1. As a substitute for the fixed wiring of a structure
2. Where run through holes in walls, structural ceilings suspended ceilings, dropped ceilings, or floors
3. Where run through doorways, windows, or similar openings
4. Where attached to building surfaces
Exception: Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of Section 364-8.
5. Where concealed behind building walls, structural ceilings, suspended ceilings, dropped ceilings, or floors