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Based on observation and interview, the facility failed to ensure 1 of 1 gift shop storage doors and 1 of 1 laundry room doors were held open only by a device which would allow it to close automatically upon activation of the fire alarm system. This deficient practice could affect up to 10 patients in the gift shop and staff in the basement.

Findings include:

Based on observation during a tour of the facility with the Lead Maintenance Technician on 11/09/15 at 11:30 a.m., the following doors were held open with devices that would not release upon activation of the fire alarm:
a. the door leading into the gift shop store room, which was greater than 50 square feet and was filled with boxes of merchandise, was held opened by a wedge door stop.
b. the corridor door leading into the basement laundry room was held opened by a self locking door holder.
Based on interview, these were acknowledged by the Lead Maintenance Technician at the time of observation.

Based on observation and interview, the facility failed to ensure corridor doors to 5 of 35 hazardous areas were provided with self closing devices allowing the doors to automatically close and latch into the door frame. This deficient practice could affect up to all patients in the hospital.

Findings include:

Based on an observation during a tour of the facility with the Lead Maintenance Technician on 11/09/15 Between 10:30 a.m. and 3:30 p.m., and on 11/10/15 between 8:30 a.m. and 9:30 a.m. the following doors to hazardous areas lacked a self closer and/or failed to latch into the frame:
a. both corridor doors leading into the C.T. record storage room, which were greater than 50 square feet and contained 50 plus boxes, was not equipped with a self closing device.
b. the corridor door leading into the third floor Business Office storage room one, which was greater than 50 square feet and contained 50 plus boxes, were not equipped with a self closing device.
c. the corridor door leading into the third floor Business Office storage room two, which was greater than 50 square feet and contained 50 plus boxes, was not equipped with a self closing device.
d. the corridor door leading into the room 303, which was being used for storage, was greater than 50 square feet, and contained 50 plus boxes, was not equipped with a self closing device.
e. the corridor door leading into the basement storage room one, which was greater than 50 square feet and contained 40 plus boxes, was equipped with a self closing device but failed to latch in to the frame.
Based on interview, these were acknowledged by the Lead Maintenance Technician at the times of observation.

Based on record review and interview, the facility failed to conduct fire drills at unexpected times under varying conditions in 12 of 12 fire drills. This deficient practice affects all patients within the facility including staff.

Findings include:

Based on review of monthly fire drill report documentation with the Environmental Services Manager on 11/09/15 at 11:15 a.m., the following was noted:
a) Fire drills were conducted at or near the end of the month on 01/30/15, 02/27/15, 03/30/15, 04/30/15, 05/28/15, 06/30/15, 07/24/15, 08/27/15, 09/29/15, 10/30/14, 11/28/14 and 12/24/14. Based on interview at the time of review, the dates of when fire drills were conducted was acknowledged by the Environmental Services Manager.
b) Fire drills were conducted with a predictable time pattern for both the second and third shifts as follows:
Second Shift: 02/27/15-2:38 p.m.; 05/28/15-2:54 p.m.; 08/27/15-2:46 p.m.; 11/28/15-2:46 p.m.
Third Shift: 03/30/15-6:17 a.m.; 06/30/15-6:12 a.m.; 09/29/15-5:38 p.m.; 12/24/14-6:15 a.m.
Based on interview at the time of review, the time of day the second and third shift fire drills were conducted was acknowledged by the Environmental Services Manager.

Based on observation and interview, the facility failed to ensure a complete automatic sprinkler system was provided for 2 of 2 elevator equipment rooms to provide complete sprinkler coverage for all portions of the building. NFPA 13, 5-13.6.2 states automatic sprinklers in elevator machine rooms shall be ordinary or intermediate temperature rating. ASME/ANSI A17.1 permits sprinklers in elevator machine rooms when there is a means for disconnecting the main line power supply to the affected elevator automatically upon or prior to the application of water from the sprinkler located in the elevator machine room. LSC Section 9.7.3.1 allows alternative automatic extinguishing systems other than an automatic sprinkler system such as a water mist, carbon dioxide, dry chemical foam or a standard extinguishing system of another type in lieu of an automatic sprinkler system. Such systems shall be installed, inspected and maintained in accordance with NFPA standards and shall activate the building fire alarm system. This deficient practice could affect all staff in the basement or any of the 35 patients that would used the elevator to the basement.

Findings include:

Based on observations during a tour of the facility with the Lead Maintenance Technician and the Environmental Services Manager on 11/09/15 from 2:28 p.m. to 3:30 p.m., the following was noted:
a. the service elevator equipment room in the basement lacked sprinkler coverage.
b. the passenger elevator equipment room in the basement lacked sprinkler coverage.
Based on an interview at the time of observations, the Environmental Services Manager acknowledged the elevator equipment rooms lacked sprinkler coverage.

Based on record review and interview, the facility failed to ensure 1 of 1 fire pumps was provided with an adequate and reliable water supply for the automatic sprinkler system. The deficient practice would affect all occupants.

Findings include:

Based on review of the "Sprinkler Inspection Certificate" dated 06/08/15 for the hospital on 11/09/15 at 12:15 p.m. with the Environmental Services Manager, the report indicated the pump failed the "Annual Pump Test Under Flow". Based on interview with the Environmental Services Manager after a phone call to the facility's sprinkler contractor, the fire pump failed to reach 100% capacity and recommended contacting the city to verify the city water valves were fully open.

Based on observation and interview, the facility failed to ensure 2 of 30 oxygen cylinders in the oxygen storage room on the surgery hall were properly restrained. NFPA 99, Section 8-3.1.11.2(h) requires cylinder restraint to meet the requirements of Section 4-3.5.2.1(b) 27 which requires freestanding cylinders to be chained or supported in a cylinder stand or cart. This deficient practice could affect up to 10 patients on the first floor surgery hall.

Findings include:

Based on an observation during a tour of the facility with the Lead Maintenance Technician on 11/09/15 at 12:05 p.m., there were two unsupported "E" cylinder of compressed oxygen in the oxygen storage room on the first floor surgery hall. Based on interview, this was acknowledged by the Lead Maintenance Technician at the time of observation.

1. Based on observation and interview, the facility failed to ensure emergency lighting was tested in accordance with LSC 7.9 for 9 of 9 battery operated emergency lights. LSC 4.6.12.2 states life safety features obvious to the public, even if not required, shall be maintained or removed. LSC 101, Section 7.9.3 requires a functional test shall be conducted on every required emergency lighting system at 30 day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery powered emergency lighting system for not less than 1 1/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. This deficient practice could affect all occupants in the Cancer Institute including staff, visitors and patients if the facility were required to evacuate in an emergency during a loss of normal power.

Findings include:

Based on observations with the Environmental Services Manager from 9:00 a.m. to 915 a.m., on 11/10/15, the Cancer Institute had nine battery operated emergency lights. A ceiling mounted battery operated light above the receptionist ' s desk failed to illuminate when tested. Based on interview from 10:30 a.m. to 12:30 p.m. on 11/09/15 with the Environmental Services Manager, there was no written record of 30 second monthly tests or a 90 minute annual test regarding the battery operated emergency lights available for review.

2. Based on observations and interview, the facility failed to ensure exit signs connected to or provided with a battery operated emergency illumination source was tested for 7 of 7 exit signs with battery back-up. LSC 38.2.10 states means of egress shall have signs in accordance with Section 7.10. Section 7.10.9.2 states exit signs connected to or provided with a battery-operated emergency illumination source shall be tested and maintained in accordance with 7.9.3.
Section 7.9.3 Periodic Testing of Emergency Lighting Equipment requires a functional test to be conducted at 30-day intervals and an annual test to be conducted on every required battery-powered emergency lighting system for not less than 1 ½ -hr duration. 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. This deficient practice could affect all occupants in the facility including staff, visitors and patients if the facility were required to evacuate in an emergency during a loss of normal power.

Findings include:

Based on observation with the Environmental Services Manager from 9:00 a.m. to 9:15 a.m., on 11/10/15, the Cancer Institute had seven exit signs with battery-up. Based on interview from 10:30 a.m. to 12:30 p.m. on 11/09/15 with the Environmental Services Manager, there was no written record of 30 second monthly tests or a 90 minute annual test regarding the exit signs with battery back-up available for review.


3. Based on observation and interview, the facility failed to ensure the fire alarm system was maintained in accordance with the applicable requirements of NFPA 72, National Fire Alarm Code,1999 Edition. LSC 4.6.12.2 states life safety features obvious to the public, even if not required, shall be maintained or removed. NFPA 72, 1-5.4.8 states, a means for turning off activated alarm notification appliances shall be permitted only where it is key-operated, located within a locked cabinet, or arranged to provide equivalent protection against unauthorized use. Such means shall be permitted only if a visible zone alarm indication or the equivalent has been provided as specified in 1-5.7.1, and subsequent actuation of initiating devices on other initiating device circuits or subsequent actuation of addressable initiating devices on signaling line circuits cause the notification appliances to reactivate. A means that is left in the " off " position when there is no alarm shall operate an audible trouble signal until the means is restored to normal. If automatically turning off the alarm notification appliances is permitted by the authority having jurisdiction, the alarm shall not be turned off in less than 5 minutes.
Exception No. 1: If otherwise permitted by the authority having jurisdiction, the 5-minute requirement shall not apply.
Exception No. 2: If permitted by the authority having jurisdiction, subsequent actuation of another addressable initiating device of the same type in the same room or space shall not be required to cause the notification appliance(s) to reactivate. This deficient practice could affect all occupants in the facility.

Findings include:

Based on observation with the Environmental Services Manager at 9:20 a.m., on 11/10/15, the fire alarm control panel (FACP) was located just inside the main public entrance of the Cancer Institute and was unlocked. Based on interview at the time of observation, the aforementioned condition was acknowledged by the Environmental Services Manager.

4. Based on observation and interview, the facility failed to ensure the sprinkler system was maintained in accordance with the applicable requirements of NFPA 25, the Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 Edition.
LSC 4.6.12.2 states life safety features obvious to the public, even if not required, shall be maintained or removed.
NFPA 25, 2-3.3 requires waterflow alarm devices including, but not limited to, mechanical water motor gongs, vane-type waterflow devices, and pressure switches that provide audible or visual signals shall be tested quarterly.
NFPA 25, Section 2-4.1.4 requires supply of at least six spare sprinklers shall be stored in a cabinet on the premises for replacement purposes. The stock of spare sprinklers shall be proportionally representative of the types and temperature ratings of the system sprinklers. A minimum of two sprinklers of each type and temperature rating installed shall be provided.
This deficient practice could affect all occupants in the facility.

Findings include:

Based on observation and review with the Environmental Services Manager, the following was noted:
a) At 9:00 a.m.on 11/10/15, the stock of spare sprinklers in the spare cabinet was not complete. There were only three pendant sprinklers and no upright sprinklers in the box. At least one upright sprinkler was observed in the facility mechanical room. Based on interview at the time of observation, the aforementioned condition was acknowledged by the Environmental Services Manager.
b) At 11:00 a.m. on 11/09/15, the sprinkler system waterflow devices were documented as being tested semiannually instead of quarterly on 06/09/15 and 12/18/14. Based on interview at the time of review and later, the Environmental Services Manager was unable to locate any additional documentation to verify the waterflow devices were tested quarterly.

1. Based on observation and interview, the facility failed to maintain 1 of 1 sprinkler systems in accordance with LCS 9.7.5. LSC 4.6.12.2 states life safety features obvious to the public, even if not required, shall be maintained or removed. LCS 9.7.5 refers to NFPA 25, the Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. NFPA 25, at 2-3.3 requires waterflow alarm devices and pressure switches that provide audible or visual signals to be tested quarterly. This deficient practice affects all occupants in the Berne Outpatient Clinic.

Findings include:

Based on review of the facility's sprinkler inspection documentation with the Director of Maintenance on 11/09/15 at 11:22 a.m., the facility lacked documentation of a sprinkler inspection where the waterflow alarms were tested for the fourth quarter of 2014, first quarter of 2015 and the third quarter of 2015. Based on an interview at the time of record review, Director of Maintenance acknowledged the missing sprinkler inspections.

3.1-19(b)


2. Based on observation and interview, the facility failed to ensure 1 of 3 vertical openings was enclosed with construction having at least a one hour fire resistance. LSC 38.2.2.3.1 requires stairs comply with LSC 7.2.2. LSC 7.2.2 refers to 7.1.3.2.1 for enclosure of exits. LSC 7.1.3.2.1(a) states the separation shall have not less than a 1-hour fire resistance rating where the exit connects three stories or less. This deficient practice could affect all occupants in the Berne Outpatient Clinic if the facility were required to use the north stairs in an emergency.

Findings include:

Based on observation during a tour of the Berne Outpatient Clinic with the Lead Maintenance Technician on 11/10/15 at 11:31 a.m., in the North stairwell there was a five inch by ten inch hole in the ceiling. Based on interview, this was verified by the Lead Maintenance Technician at the time of observations.

3.1-19(b)

3. Based on observation and interview, the facility failed to ensure 1 of 3 vertical openings was enclosed with construction having at least a one hour fire resistance. LSC 38.2.2.3.1 requires stairs comply with LSC 7.2.2. LSC 7.2.2 refers to 7.1.3.2.1 for enclosure of exits. LSC 7.1.3.2.1 requires openings in the separation be protected by fire door assemblies equipped with door closers complying with 7.2.1.8. NFPA 80, the Standard for Fire Doors and Fire Windows at 2-1.2 requires fire door assemblies to include latches. NFPA 80, 2-1.4 requires fire doors to be closed and latched at the time of fire. This deficient practice could affect all occupants in the Berne Outpatient Clinic if the facility were required to use the South stairs in an emergency.

Findings include:

Based on observation during a tour of the Berne Outpatient Clinic with the Lead Maintenance Technician on 11/10/15 at 11:43 a.m., the South stairway doors in the basement leading to the first was provided with a self closer but failed to latch into the door frame. Based on interview, this was verified by the Lead Maintenance Technician at the time of observations.

3.1-19(b)

4. Based on observation and interview, the facility failed to ensure 1 of 10 emergency lighting was working in accordance with LSC 7.9. LSC 4.6.12.2 states life safety features obvious to the public, even if not required, shall be maintained or removed. LSC 101, Section 7.9.3 requires a functional test shall be conducted on every required emergency lighting system at 30 day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery powered emergency lighting system for not less than 1 1/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. This deficient practice could affect all occupants in the Berne Outpatient Clinic if the facility were required to use the Northwest stairs in an emergency during a loss of normal power.

Findings include:

Based on observation during a tour of the Berne Outpatient Clinic with the Lead Maintenance Technician on 11/10/15 at 11:58 a.m., the battery operated emergency light in the Northwest stair well did not operate when tested. Based on interview at the time of observation, the Lead Maintenance Technician acknowledged the battery operated emergency light did not operate when tested.

Based on observation and interview, the facility failed to ensure 1 of 1 gift shop storage doors and 1 of 1 laundry room doors were held open only by a device which would allow it to close automatically upon activation of the fire alarm system. This deficient practice could affect up to 10 patients in the gift shop and staff in the basement.

Findings include:

Based on observation during a tour of the facility with the Lead Maintenance Technician on 11/09/15 at 11:30 a.m., the following doors were held open with devices that would not release upon activation of the fire alarm:
a. the door leading into the gift shop store room, which was greater than 50 square feet and was filled with boxes of merchandise, was held opened by a wedge door stop.
b. the corridor door leading into the basement laundry room was held opened by a self locking door holder.
Based on interview, these were acknowledged by the Lead Maintenance Technician at the time of observation.

Based on observation and interview, the facility failed to ensure corridor doors to 5 of 35 hazardous areas were provided with self closing devices allowing the doors to automatically close and latch into the door frame. This deficient practice could affect up to all patients in the hospital.

Findings include:

Based on an observation during a tour of the facility with the Lead Maintenance Technician on 11/09/15 Between 10:30 a.m. and 3:30 p.m., and on 11/10/15 between 8:30 a.m. and 9:30 a.m. the following doors to hazardous areas lacked a self closer and/or failed to latch into the frame:
a. both corridor doors leading into the C.T. record storage room, which were greater than 50 square feet and contained 50 plus boxes, was not equipped with a self closing device.
b. the corridor door leading into the third floor Business Office storage room one, which was greater than 50 square feet and contained 50 plus boxes, were not equipped with a self closing device.
c. the corridor door leading into the third floor Business Office storage room two, which was greater than 50 square feet and contained 50 plus boxes, was not equipped with a self closing device.
d. the corridor door leading into the room 303, which was being used for storage, was greater than 50 square feet, and contained 50 plus boxes, was not equipped with a self closing device.
e. the corridor door leading into the basement storage room one, which was greater than 50 square feet and contained 40 plus boxes, was equipped with a self closing device but failed to latch in to the frame.
Based on interview, these were acknowledged by the Lead Maintenance Technician at the times of observation.

Based on record review and interview, the facility failed to conduct fire drills at unexpected times under varying conditions in 12 of 12 fire drills. This deficient practice affects all patients within the facility including staff.

Findings include:

Based on review of monthly fire drill report documentation with the Environmental Services Manager on 11/09/15 at 11:15 a.m., the following was noted:
a) Fire drills were conducted at or near the end of the month on 01/30/15, 02/27/15, 03/30/15, 04/30/15, 05/28/15, 06/30/15, 07/24/15, 08/27/15, 09/29/15, 10/30/14, 11/28/14 and 12/24/14. Based on interview at the time of review, the dates of when fire drills were conducted was acknowledged by the Environmental Services Manager.
b) Fire drills were conducted with a predictable time pattern for both the second and third shifts as follows:
Second Shift: 02/27/15-2:38 p.m.; 05/28/15-2:54 p.m.; 08/27/15-2:46 p.m.; 11/28/15-2:46 p.m.
Third Shift: 03/30/15-6:17 a.m.; 06/30/15-6:12 a.m.; 09/29/15-5:38 p.m.; 12/24/14-6:15 a.m.
Based on interview at the time of review, the time of day the second and third shift fire drills were conducted was acknowledged by the Environmental Services Manager.

Based on observation and interview, the facility failed to ensure a complete automatic sprinkler system was provided for 2 of 2 elevator equipment rooms to provide complete sprinkler coverage for all portions of the building. NFPA 13, 5-13.6.2 states automatic sprinklers in elevator machine rooms shall be ordinary or intermediate temperature rating. ASME/ANSI A17.1 permits sprinklers in elevator machine rooms when there is a means for disconnecting the main line power supply to the affected elevator automatically upon or prior to the application of water from the sprinkler located in the elevator machine room. LSC Section 9.7.3.1 allows alternative automatic extinguishing systems other than an automatic sprinkler system such as a water mist, carbon dioxide, dry chemical foam or a standard extinguishing system of another type in lieu of an automatic sprinkler system. Such systems shall be installed, inspected and maintained in accordance with NFPA standards and shall activate the building fire alarm system. This deficient practice could affect all staff in the basement or any of the 35 patients that would used the elevator to the basement.

Findings include:

Based on observations during a tour of the facility with the Lead Maintenance Technician and the Environmental Services Manager on 11/09/15 from 2:28 p.m. to 3:30 p.m., the following was noted:
a. the service elevator equipment room in the basement lacked sprinkler coverage.
b. the passenger elevator equipment room in the basement lacked sprinkler coverage.
Based on an interview at the time of observations, the Environmental Services Manager acknowledged the elevator equipment rooms lacked sprinkler coverage.

Based on record review and interview, the facility failed to ensure 1 of 1 fire pumps was provided with an adequate and reliable water supply for the automatic sprinkler system. The deficient practice would affect all occupants.

Findings include:

Based on review of the "Sprinkler Inspection Certificate" dated 06/08/15 for the hospital on 11/09/15 at 12:15 p.m. with the Environmental Services Manager, the report indicated the pump failed the "Annual Pump Test Under Flow". Based on interview with the Environmental Services Manager after a phone call to the facility's sprinkler contractor, the fire pump failed to reach 100% capacity and recommended contacting the city to verify the city water valves were fully open.

Based on observation and interview, the facility failed to ensure 2 of 30 oxygen cylinders in the oxygen storage room on the surgery hall were properly restrained. NFPA 99, Section 8-3.1.11.2(h) requires cylinder restraint to meet the requirements of Section 4-3.5.2.1(b) 27 which requires freestanding cylinders to be chained or supported in a cylinder stand or cart. This deficient practice could affect up to 10 patients on the first floor surgery hall.

Findings include:

Based on an observation during a tour of the facility with the Lead Maintenance Technician on 11/09/15 at 12:05 p.m., there were two unsupported "E" cylinder of compressed oxygen in the oxygen storage room on the first floor surgery hall. Based on interview, this was acknowledged by the Lead Maintenance Technician at the time of observation.

1. Based on observation and interview, the facility failed to ensure emergency lighting was tested in accordance with LSC 7.9 for 9 of 9 battery operated emergency lights. LSC 4.6.12.2 states life safety features obvious to the public, even if not required, shall be maintained or removed. LSC 101, Section 7.9.3 requires a functional test shall be conducted on every required emergency lighting system at 30 day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery powered emergency lighting system for not less than 1 1/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. This deficient practice could affect all occupants in the Cancer Institute including staff, visitors and patients if the facility were required to evacuate in an emergency during a loss of normal power.

Findings include:

Based on observations with the Environmental Services Manager from 9:00 a.m. to 915 a.m., on 11/10/15, the Cancer Institute had nine battery operated emergency lights. A ceiling mounted battery operated light above the receptionist ' s desk failed to illuminate when tested. Based on interview from 10:30 a.m. to 12:30 p.m. on 11/09/15 with the Environmental Services Manager, there was no written record of 30 second monthly tests or a 90 minute annual test regarding the battery operated emergency lights available for review.

2. Based on observations and interview, the facility failed to ensure exit signs connected to or provided with a battery operated emergency illumination source was tested for 7 of 7 exit signs with battery back-up. LSC 38.2.10 states means of egress shall have signs in accordance with Section 7.10. Section 7.10.9.2 states exit signs connected to or provided with a battery-operated emergency illumination source shall be tested and maintained in accordance with 7.9.3.
Section 7.9.3 Periodic Testing of Emergency Lighting Equipment requires a functional test to be conducted at 30-day intervals and an annual test to be conducted on every required battery-powered emergency lighting system for not less than 1 ½ -hr duration. 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. This deficient practice could affect all occupants in the facility including staff, visitors and patients if the facility were required to evacuate in an emergency during a loss of normal power.

Findings include:

Based on observation with the Environmental Services Manager from 9:00 a.m. to 9:15 a.m., on 11/10/15, the Cancer Institute had seven exit signs with battery-up. Based on interview from 10:30 a.m. to 12:30 p.m. on 11/09/15 with the Environmental Services Manager, there was no written record of 30 second monthly tests or a 90 minute annual test regarding the exit signs with battery back-up available for review.


3. Based on observation and interview, the facility failed to ensure the fire alarm system was maintained in accordance with the applicable requirements of NFPA 72, National Fire Alarm Code,1999 Edition. LSC 4.6.12.2 states life safety features obvious to the public, even if not required, shall be maintained or removed. NFPA 72, 1-5.4.8 states, a means for turning off activated alarm notification appliances shall be permitted only where it is key-operated, located within a locked cabinet, or arranged to provide equivalent protection against unauthorized use. Such means shall be permitted only if a visible zone alarm indication or the equivalent has been provided as specified in 1-5.7.1, and subsequent actuation of initiating devices on other initiating device circuits or subsequent actuation of addressable initiating devices on signaling line circuits cause the notification appliances to reactivate. A means that is left in the " off " position when there is no alarm shall operate an audible trouble signal until the means is restored to normal. If automatically turning off the alarm notification appliances is permitted by the authority having jurisdiction, the alarm shall not be turned off in less than 5 minutes.
Exception No. 1: If otherwise permitted by the authority having jurisdiction, the 5-minute requirement shall not apply.
Exception No. 2: If permitted by the authority having jurisdiction, subsequent actuation of another addressable initiating device of the same type in the same room or space shall not be required to cause the notification appliance(s) to reactivate. This deficient practice could affect all occupants in the facility.

Findings include:

Based on observation with the Environmental Services Manager at 9:20 a.m., on 11/10/15, the fire alarm control panel (FACP) was located just inside the main public entrance of the Cancer Institute and was unlocked. Based on interview at the time of observation, the aforementioned condition was acknowledged by the Environmental Services Manager.

4. Based on observation and interview, the facility failed to ensure the sprinkler system was maintained in accordance with the applicable requirements of NFPA 25, the Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 Edition.
LSC 4.6.12.2 states life safety features obvious to the public, even if not required, shall be maintained or removed.
NFPA 25, 2-3.3 requires waterflow alarm devices including, but not limited to, mechanical water motor gongs, vane-type waterflow devices, and pressure switches that provide audible or visual signals shall be tested quarterly.
NFPA 25, Section 2-4.1.4 requires supply of at least six spare sprinklers shall be stored in a cabinet on the premises for replacement purposes. The stock of spare sprinklers shall be proportionally representative of the types and temperature ratings of the system sprinklers. A minimum of two sprinklers of each type and temperature rating installed shall be provided.
This deficient practice could affect all occupants in the facility.

Findings include:

Based on observation and review with the Environmental Services Manager, the following was noted:
a) At 9:00 a.m.on 11/10/15, the stock of spare sprinklers in the spare cabinet was not complete. There were only three pendant sprinklers and no upright sprinklers in the box. At least one upright sprinkler was observed in the facility mechanical room. Based on interview at the time of observation, the aforementioned condition was acknowledged by the Environmental Services Manager.
b) At 11:00 a.m. on 11/09/15, the sprinkler system waterflow devices were documented as being tested semiannually instead of quarterly on 06/09/15 and 12/18/14. Based on interview at the time of review and later, the Environmental Services Manager was unable to locate any additional documentation to verify the waterflow devices were tested quarterly.

1. Based on observation and interview, the facility failed to maintain 1 of 1 sprinkler systems in accordance with LCS 9.7.5. LSC 4.6.12.2 states life safety features obvious to the public, even if not required, shall be maintained or removed. LCS 9.7.5 refers to NFPA 25, the Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. NFPA 25, at 2-3.3 requires waterflow alarm devices and pressure switches that provide audible or visual signals to be tested quarterly. This deficient practice affects all occupants in the Berne Outpatient Clinic.

Findings include:

Based on review of the facility's sprinkler inspection documentation with the Director of Maintenance on 11/09/15 at 11:22 a.m., the facility lacked documentation of a sprinkler inspection where the waterflow alarms were tested for the fourth quarter of 2014, first quarter of 2015 and the third quarter of 2015. Based on an interview at the time of record review, Director of Maintenance acknowledged the missing sprinkler inspections.

3.1-19(b)


2. Based on observation and interview, the facility failed to ensure 1 of 3 vertical openings was enclosed with construction having at least a one hour fire resistance. LSC 38.2.2.3.1 requires stairs comply with LSC 7.2.2. LSC 7.2.2 refers to 7.1.3.2.1 for enclosure of exits. LSC 7.1.3.2.1(a) states the separation shall have not less than a 1-hour fire resistance rating where the exit connects three stories or less. This deficient practice could affect all occupants in the Berne Outpatient Clinic if the facility were required to use the north stairs in an emergency.

Findings include:

Based on observation during a tour of the Berne Outpatient Clinic with the Lead Maintenance Technician on 11/10/15 at 11:31 a.m., in the North stairwell there was a five inch by ten inch hole in the ceiling. Based on interview, this was verified by the Lead Maintenance Technician at the time of observations.

3.1-19(b)

3. Based on observation and interview, the facility failed to ensure 1 of 3 vertical openings was enclosed with construction having at least a one hour fire resistance. LSC 38.2.2.3.1 requires stairs comply with LSC 7.2.2. LSC 7.2.2 refers to 7.1.3.2.1 for enclosure of exits. LSC 7.1.3.2.1 requires openings in the separation be protected by fire door assemblies equipped with door closers complying with 7.2.1.8. NFPA 80, the Standard for Fire Doors and Fire Windows at 2-1.2 requires fire door assemblies to include latches. NFPA 80, 2-1.4 requires fire doors to be closed and latched at the time of fire. This deficient practice could affect all occupants in the Berne Outpatient Clinic if the facility were required to use the South stairs in an emergency.

Findings include:

Based on observation during a tour of the Berne Outpatient Clinic with the Lead Maintenance Technician on 11/10/15 at 11:43 a.m., the South stairway doors in the basement leading to the first was provided with a self closer but failed to latch into the door frame. Based on interview, this was verified by the Lead Maintenance Technician at the time of observations.

3.1-19(b)

4. Based on observation and interview, the facility failed to ensure 1 of 10 emergency lighting was working in accordance with LSC 7.9. LSC 4.6.12.2 states life safety features obvious to the public, even if not required, shall be maintained or removed. LSC 101, Section 7.9.3 requires a functional test shall be conducted on every required emergency lighting system at 30 day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery powered emergency lighting system for not less than 1 1/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. This deficient practice could affect all occupants in the Berne Outpatient Clinic if the facility were required to use the Northwest stairs in an emergency during a loss of normal power.

Findings include:

Based on observation during a tour of the Berne Outpatient Clinic with the Lead Maintenance Technician on 11/10/15 at 11:58 a.m., the battery operated emergency light in the Northwest stair well did not operate when tested. Based on interview at the time of observation, the Lead Maintenance Technician acknowledged the battery operated emergency light did not operate when tested.