HospitalInspections.org

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Based on the observation during the survey on 04/12/2016, the facility failed to maintain the corridor doors smoke resistive and with a means suitable for keeping the door closed. Findings include:

The following was observed:
1. Two unsealed penetrations of approximately 1/4", approximately 3" from the top of "Alliance Psychotherapy Service's" Office corridor door (by the kitchen).
2. Four unsealed penetrations of approximately 1/8" at the door handle of the Old Surgery Waiting Room corridor door.
3. Old Purchasing Room's single corridor door was observed with the following around the door handle:
a. An approximately 1" in diameter unsealed penetration
b. An approximately 14" in diameter unsealed penetration
4. The corridor door to Old Labor and Delivery was not positive latching

The deficiency impacted 2 of 7 smoke compartments.
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Review of 2000 NFPA 101, 19.3.6.3.1

Review of 2000 NFPA 101, 19.3.6.3.2

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Based on the observation of the smoke/fire barriers on 04/12/2016, the facility failed to maintain the smoke barriers for the purpose of restricting the movement of smoke. Findings include:

The following was observed:
1. The smoke barrier above the smoke doors by room 327 was observed with an unsealed penetration of approximately 1" with blue/black/red wires.
2. The smoke barrier above the smoke doors by room 103 was observed with an 1 1/2" unsealed conduit end with lots of green/orange/black wires.

The deficiency impacted 2 of 7 smoke compartments.
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Review of 2000 NFPA 101, 19.3.7.3

Review of 2000 NFPA 101, 8.3.1 Where required by Chapters 12 through 42, smoke barriers shall be provided to subdivide building spaces for the purpose of restricting the movement of smoke.

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Based on the observation of the hazardous areas on 04/12/2016, the facility failed to maintain the hazardous areas. Findings include:

The following was observed:
1. The Old Recovery Room was being used for combustible (bed mattresses) storage and was over 50 sq. ft. The door to this room was observed without a self-closing device.
2. The "Light Fixture Room" was over 50 sq. ft. and had combustible (cardboard boxes) storage. The door to this room was observed with a self-closing device that had been deactivated.

The deficiency impacted 1 of 7 smoke compartments.
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Review of 2000 NFPA 101, 19.3.2.1 Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing.

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Based on observation on 4/12-13/2016, the facility failed to provide adequate sprinkler coverage. Findings include:

1. Ceiling tile broken in the generator set control room housing the generator transfer switches.

2. Ceiling tiles missing in the telephone room, located in the office, main entrance of the facility.

3. Documentation not provided for the annual inspection of the antifreeze loop, location of loop front canopy.


27382

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4. Room E159 Storage (Woodland's Storage)was observed with a bent deflector in the back right corner.
5. Ceiling tiles were observed missing in the following locations:
a. Old Recovery Room
b. Old Labor and Delivery
c. Old Surgery
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2000 NFPA 101, 19.7.6 Maintenance and Testing. (See 4.6.12.)

2000 NFPA 101, 4.6.12.1

NFPA 25, 1998 2-3.4* Antifreeze Systems. The freezing point of solutions in antifreeze shall be tested annually by measuring the specific pravity with a hydrometer or refractometer and adjusting the solutions if necessary. Solutions shall be in accordance with tables 2-3.4(a) and (b).

1999 NFPA 13, 5-8.4.2 Deflectors of sprinklers shall be aligned parallel to ceilings or roofs.
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Based on observation on 4/12/2016, the facility failed to maintain the fire extinguishers. Findings include:

1. The following fire extinguishers, per tag attached had the annual inspection conducted on 6/2015. But none of these per tag attached had the monthly inspections conducted.

a. Therapy office last date of monthly 12/30/2015.
b. Telephone room last date of monthly 3/24/2015.
c. Room 326 electrical room last date of monthly 6/24/2015.


27382

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2. The fire extinguisher in Old Labor and Delivery Room was blocked by four rows of old PTAC Units.
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2000 NFPA 101, 19.3.5.6 Portable fire extinguishers shall be provided in all health care occupancies in accordance with 9.7.4.1.

2000 NFPA 101, 9.7.4.1* Where required by the provisions of another section of this Code, portable fire extinguishers shall be installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.

1998 NFPA 10, 4-3.1 Fire extinguishers shall be inspected when placed in service and thereafter at approximately 30-day intervals.

1998 NFPA 10, 4-3.2 Periodic inspection of fire extinguishers shall include a check of at least the following items:
(a) Location in designated place
(b) No obstruction to access or visibility
(c) Operating instructions on nameplate legible and facing outward
(d) * Safety seals and tamper indicators not broken or missing
(e) Fullness determined by weighing or " hefting "
(f) Examination for obvious physical damage, corrosion, leakage, or clogged nozzle
(g) Pressure gauge reading or indicator in the operable range or position
(h) Condition of tires, wheels, carriage, hose, and nozzle checked (for wheeled units)
(i) HMIS label in place

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Based on observations during the survey on 04/12/2016, the facility failed to maintain the generator remote annunciator. Findings include:

While testing the generator the generator remote annunciator was observed not to indicate "Genset supplying load".

The deficiency impacted 7 of 7 smoke compartments.
___________

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

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Based on observation on 04/12/2016 the facility failed to maintain the electrical wiring in accordance with the National Electrical Code (NFPA 70). Findings include:

The Alliance Psychotherapy Services Room was observed with a microwave plugged into a surge protector (extension cord).

The deficiency impacted 1 of 7 smoke compartments.
___________

Review of the printed statement on the 2567 for K- 147, Electrical wiring and equipment shall be in accordance with National Electrical Code (NFPA 70).

2000 NFPA 101, 9.1.2 Electric. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

Review of 1999 NFPA 70, 400-7 (b) Attachment Plugs. Where used as permitted in subsections (a)(3), (a)(6), and (a)(8), each flexible cord shall be equipped with an attachment plug and shall be energized from a receptacle outlet.

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

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Based on the observation during the survey on 04/12/2016, the facility failed to maintain the corridor doors smoke resistive and with a means suitable for keeping the door closed. Findings include:

The following was observed:
1. Two unsealed penetrations of approximately 1/4", approximately 3" from the top of "Alliance Psychotherapy Service's" Office corridor door (by the kitchen).
2. Four unsealed penetrations of approximately 1/8" at the door handle of the Old Surgery Waiting Room corridor door.
3. Old Purchasing Room's single corridor door was observed with the following around the door handle:
a. An approximately 1" in diameter unsealed penetration
b. An approximately 14" in diameter unsealed penetration
4. The corridor door to Old Labor and Delivery was not positive latching

The deficiency impacted 2 of 7 smoke compartments.
____________

Review of 2000 NFPA 101, 19.3.6.3.1

Review of 2000 NFPA 101, 19.3.6.3.2

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Based on the observation of the smoke/fire barriers on 04/12/2016, the facility failed to maintain the smoke barriers for the purpose of restricting the movement of smoke. Findings include:

The following was observed:
1. The smoke barrier above the smoke doors by room 327 was observed with an unsealed penetration of approximately 1" with blue/black/red wires.
2. The smoke barrier above the smoke doors by room 103 was observed with an 1 1/2" unsealed conduit end with lots of green/orange/black wires.

The deficiency impacted 2 of 7 smoke compartments.
____________

Review of 2000 NFPA 101, 19.3.7.3

Review of 2000 NFPA 101, 8.3.1 Where required by Chapters 12 through 42, smoke barriers shall be provided to subdivide building spaces for the purpose of restricting the movement of smoke.

.

.
Based on the observation of the hazardous areas on 04/12/2016, the facility failed to maintain the hazardous areas. Findings include:

The following was observed:
1. The Old Recovery Room was being used for combustible (bed mattresses) storage and was over 50 sq. ft. The door to this room was observed without a self-closing device.
2. The "Light Fixture Room" was over 50 sq. ft. and had combustible (cardboard boxes) storage. The door to this room was observed with a self-closing device that had been deactivated.

The deficiency impacted 1 of 7 smoke compartments.
____________

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

.

.
Based on observation on 4/12-13/2016, the facility failed to provide adequate sprinkler coverage. Findings include:

1. Ceiling tile broken in the generator set control room housing the generator transfer switches.

2. Ceiling tiles missing in the telephone room, located in the office, main entrance of the facility.

3. Documentation not provided for the annual inspection of the antifreeze loop, location of loop front canopy.


27382

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4. Room E159 Storage (Woodland's Storage)was observed with a bent deflector in the back right corner.
5. Ceiling tiles were observed missing in the following locations:
a. Old Recovery Room
b. Old Labor and Delivery
c. Old Surgery
_____________
2000 NFPA 101, 19.7.6 Maintenance and Testing. (See 4.6.12.)

2000 NFPA 101, 4.6.12.1

NFPA 25, 1998 2-3.4* Antifreeze Systems. The freezing point of solutions in antifreeze shall be tested annually by measuring the specific pravity with a hydrometer or refractometer and adjusting the solutions if necessary. Solutions shall be in accordance with tables 2-3.4(a) and (b).

1999 NFPA 13, 5-8.4.2 Deflectors of sprinklers shall be aligned parallel to ceilings or roofs.
.

.
Based on observation on 4/12/2016, the facility failed to maintain the fire extinguishers. Findings include:

1. The following fire extinguishers, per tag attached had the annual inspection conducted on 6/2015. But none of these per tag attached had the monthly inspections conducted.

a. Therapy office last date of monthly 12/30/2015.
b. Telephone room last date of monthly 3/24/2015.
c. Room 326 electrical room last date of monthly 6/24/2015.


27382

.
2. The fire extinguisher in Old Labor and Delivery Room was blocked by four rows of old PTAC Units.
____________
2000 NFPA 101, 19.3.5.6 Portable fire extinguishers shall be provided in all health care occupancies in accordance with 9.7.4.1.

2000 NFPA 101, 9.7.4.1* Where required by the provisions of another section of this Code, portable fire extinguishers shall be installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.

1998 NFPA 10, 4-3.1 Fire extinguishers shall be inspected when placed in service and thereafter at approximately 30-day intervals.

1998 NFPA 10, 4-3.2 Periodic inspection of fire extinguishers shall include a check of at least the following items:
(a) Location in designated place
(b) No obstruction to access or visibility
(c) Operating instructions on nameplate legible and facing outward
(d) * Safety seals and tamper indicators not broken or missing
(e) Fullness determined by weighing or " hefting "
(f) Examination for obvious physical damage, corrosion, leakage, or clogged nozzle
(g) Pressure gauge reading or indicator in the operable range or position
(h) Condition of tires, wheels, carriage, hose, and nozzle checked (for wheeled units)
(i) HMIS label in place

.

.
Based on observations during the survey on 04/12/2016, the facility failed to maintain the generator remote annunciator. Findings include:

While testing the generator the generator remote annunciator was observed not to indicate "Genset supplying load".

The deficiency impacted 7 of 7 smoke compartments.
___________

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

.

.
Based on observation on 04/12/2016 the facility failed to maintain the electrical wiring in accordance with the National Electrical Code (NFPA 70). Findings include:

The Alliance Psychotherapy Services Room was observed with a microwave plugged into a surge protector (extension cord).

The deficiency impacted 1 of 7 smoke compartments.
___________

Review of the printed statement on the 2567 for K- 147, Electrical wiring and equipment shall be in accordance with National Electrical Code (NFPA 70).

2000 NFPA 101, 9.1.2 Electric. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

Review of 1999 NFPA 70, 400-7 (b) Attachment Plugs. Where used as permitted in subsections (a)(3), (a)(6), and (a)(8), each flexible cord shall be equipped with an attachment plug and shall be energized from a receptacle outlet.

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