HospitalInspections.org

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Based on the observation on 7/15/2015, the facility failed to maintain corridor walls that would provide 30 minute fire resistance rating. AS AN EXAMPLE findings include:

1. Unsealed openings in the corridor walls, 2 holes and 2 sleeve's not sealed at the end of each sleeve. These were above the ceiling by the Nurses Station Third Floor.

2. Unsealed penetrations around flex conduit, in the corridor wall, above the ceiling at the West Stairwell Third Floor.


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+ + + Corridor walls throughout the partially sprinklered first floor and the partially sprinklered smoke compartment of the second floor were observed with corridor walls that did not have a fire rating of at least a 30 minute rating and were smoke resistive based on observation on the room side of these corridor walls. Examples:


First Floor
3. Radiology I.T. Room had old pass thru window only has sheetrock on the Waiting Room side.
4. Surgery Waiting Room - unsealed penetrations
5. Women's Bathroom at the Surgery Waiting Room - unsealed penetrations
6. Clean Linen (Laundry) - unsealed penetrations
7. Basement corridor wall on first floor - unsealed penetrations and not sealed at deck
8. Mammogram Room - unsealed penetrations
9. I.T. Room - unsealed penetrations and not sealed at deck
10. Medical Records - unsealed penetrations
11. Lab - unsealed penetrations
12. Lab Break Room - Missing sheetrock this area


Second Floor
13. Mechanical Room (across from the Staff Break Room) - unsealed penetrations
14. Room 217 - unsealed penetrations
15. Room 221 - unsealed penetrations
16. Room 220 - unsealed penetrations and not sealed at deck
17. Corridor side of the Geri-Psych Unit's Nurses' Station (across from the Employees Locker/Bathroom) - unsealed penetrations

This deficiency impacted 4 of 11 smoke compartments.
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Review of 2000 NFPA 101, 19.3.6.2.1 Corridor walls shall be continuous from the floor to the underside of the floor or roof deck above, through any concealed spaces, such as those above suspended ceilings, and through interstitial structural and mechanical spaces, and they shall have a fire resistance rating of not less than 1/2 hour.
Exception No. 1*: In smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.2, a corridor shall be permitted to be separated from all other areas by non-fire-rated partitions and shall be permitted to terminate at the ceiling where the ceiling is constructed to limit the transfer of smoke.
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Based on the observation on 7/14/2015, the facility failed to maintain corridor doors to resist the passage of smoke. Findings include:

The clean Linen Room Door had a dime size hole above the door handle, across the corridor from Patient Room 206 Second Floor East Wing.

The deficiency impacted 1 of 3 smoke compartments.
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NFPA 101, 19.3.6.3.1
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Based on the observation on 7/14/2015, the facility failed to maintain the exit signs. Findings include:

Second Floor West Stairwell exit sign above the stairwell had a directional indicator pointing back down the corridor.

The deficiency impacted 1 of 11 smoke compartments.
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Review of 2000 NFPA 101, 7.10.2* Directional Signs. A sign complying with 7.10.3 with a directional indicator showing the direction of travel shall be placed in every location where the direction of travel to reach the nearest exit is not apparent.
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Based on the observation on 7/14/2015, the facility failed to maintain the smoke barriers with at least a 30 minute fire resistance rating and restrict the movement of smoke. Findings include:

1. Unsealed penetrations around 3 sleeve's, and at the end of 3 sleeve's, in the smoke barrier, by Patient Room 208 Second Floor East Wing.


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The following was observed:
First Floor
2. ER corridor wall is part of the smoke barrier:
a. Two unsealed penetrations above the door
b. Missing sheetrock above the HVAC duct
3. First ER room to the left of the corridor door had unsealed penetrations
4. Radiology Reading Room had unsealed penetrations
Second Floor
5. Smoke Barrier separating the Equipment Storage Room from Physical/Speech Therapy, on the Equipment Storage Room side:
a. One unsealed penetration
b. Unsealed penetration around pipes

The deficiency impacted 4 of 11 smoke compartments.
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Review of 2000 NFPA 101, 8.3.2
Review of 2000 NFPA 101, 8.2.4.4.1
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Based on the observation on 7/14/2015, the facility failed to provide separation of hazardous area. Findings include:

1. Three unsealed penetrations, two were around some wiring, and one was around a section of conduit, in the wall of the boiler room. Location of these are to the left when you enter the room from the outside of the facility.


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2. Second Floor - Partially sprinklered smoke compartment
The following rooms were being used to store combustibles and were over 50 sq. ft. These rooms were not safeguarded by a fire barrier having a 1-hour fire resistance rating and did not have a 45 minute rated fire door with a self-closing device:
a. Room 220 - six recliners and three beds
b. Room 221 - eleven recliners and one bed
c. Room 214 - eleven recliners, boxes and Janitorial Storage

This deficiency impacted 1 of 11 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.

Review of 2000 NFPA 101, 8.4.1.3 Doors in barriers required to have a fire resistance rating shall have a 3/4-hour fire protection rating and shall be self-closing or automatic-closing in accordance with 7.2.1.8.
Review of 2000 NFPA 101, 7.2.1.8.1 A door normally required to be kept closed shall not be secured in the open position at any time and shall be self-closing or automatic-closing in accordance with 7.2.1.8.2.
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Based on observations on 7/14/2015, the facility failed to maintain the exit enclosures with at least 1 hour fire resistance. Findings include:

1. Unsealed penetrations in the wall of the stairwell, above the ceiling, South Wing Third Floor by ICU.


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2. The stairwell at the G. I. Lab. on the Second Floor was observed not having at least 1 hour fire resistance at the inside corner of the stairwell.
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Review of 2000 NFPA 101, 19.3.1.1 Any vertical opening shall be enclosed or protected in accordance with 8.2.5. Where enclosure is provided, the construction shall have not less than a 1-hour fire resistance rating.
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Based on the observations on 7/14/2015, the facility failed to maintain the exit access. Findings include:

The kitchen walk-in cooler was being locked with a padlock, the releasing handle on the inside the cooler was observed to be 'froze up' (would not turn).

The deficiency impacted 1 of 11 smoke compartments.
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Review of 2000 NFPA 101, 7.2.1.5.1 Doors shall be arranged to be opened readily 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.
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Based on review of documentation on 7/15/2015, the facility failed to provide a complete fire evacuation plan. Findings include:

Per documentation from the facility, the facility's fire evacuation plan did not contain all eight items per code; specifically the evacuation from an affected smoke compartment to an unaffected smoke compartment.

The deficiency impacted 11 of 11 smoke compartments.
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Review of 2000 NFPA 101, 19.7.2.2 A written health care occupancy fire safety plan shall provide for the following: (1) Use of alarms (2) Transmission of alarm to 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
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Based on review of facility documentation and interview on 07/15/2015, the facility failed to conduct fire drills, maintain the documentation for fire drills, and to provide proof of participation of all on duty staff at the time of the drill(s).
First Shift
06/16/2015 - 1:58 pm
02/10/2015 - 1:52 pm
No Drill
No Drill

Second Shift
06/12/2015 - 8:20 pm
03/02/2015 - 9:30 pm
12/11/2014 - 8:15 pm
09/07/2014 - 3:00 pm

Third Shift
06/07/2015 - 6:00 am
03/05/2015 - 3:30 am
12/17/2014 - 5:30 pm
09/10/2014 - 2:07 am

The deficiency impacted 11 of 11 smoke compartments.
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Review of 2000 NFPA 101, 19.7.1.2 Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
Review of 2000 NFPA 101, 4.7.2* Emergency egress and relocation drills, where required by Chapters 11 through 42 or the authority having jurisdiction, shall be held with sufficient frequency to familiarize occupants with the drill procedure and to establish conduct of the drill as a matter of routine. Drills shall include suitable procedures to ensure that all persons subject to the drill participate.
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Based on review of documentation provided by the facility on 7/15/2015, required sensitivity testing of smoke detectors had not been performed. Findings include:

Review of fire alarm documentation indicated that the facility had installed a new fire alarm system. Based on the NFPA 72 completion form, this was completed on 3/6/2014. Sensitivity testing of all smoke detectors should have been conducted one year after installation.

The deficiency impacted 11 of 11 smoke compartments.
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Detector sensitivity shall be checked with one year after installation and every alternate year thereafter per 72, 7-3.2.1. (Up to 5 years permitted under certain circumstances. See 7-3.2.1).

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Based on the observation on 7/14/2015, the facility failed to provide adequate sprinkler coverage. Findings include:

A ceiling tile in the Laundry Room across the corridor from Patient Room 208, observed to have approximately a 2"x 2" hole.

The deficiency impacted 1 of 11 smoke compartments.
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NFPA 13 5-6., Sprinklers shall be arranged to be in compliance.
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Based on the observation on 7/14/2015, the facility failed to maintain the automatic sprinkler system. Findings include:

1. Red wiring attached to the sprinkler branch lines, also blue wiring resting on branch lines, in two different areas above the ceiling, at the fire barrier Administration Offices Third Floor.


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2. Lab - the first automatic sprinkler head on the left was observed with excessive foreign materials.

The deficiency impacted 1 of 11 smoke compartments.

1998 NFPA 25, 2-2.2* Pipe and Fittings. Sprinkler pipe and fittings shall be inspected annually from the floor level. Pipe and fittings shall be in good condition and free of mechanical damage, leakage, corrosion, and misalignment. Sprinkler piping shall not be subjected to external loads by materials either resting on the pipe or hung from the pipe.

Review of 1998 NFPA 25, 2-2.1.1 Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.
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Based on the observation on 7/14-15/2015, the facility failed to provide required maintenance for the fire extinguishers. Findings include:

Two fire extinguishers had May of 2014 indicated on the tag attached to the extinguishers, one located in the Mechanical Room third floor south wing, the other one was located by Patient Room 301.
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1998 NFPA 10, 4-4.1 Fire extinguishers shall be subjected to maintenance intervals of not more than one year.

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Based on the observations on 7/14/2015, the facility failed to prohibit portable space heating devices. Findings include:

The Personnel Office was observed with a portable space heating device plugged into a surge protector. The portable space heating device was not on.

The deficiency impacted 1 of 11 smoke compartments.
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Review of 2000 NFPA 101, 19.7.8 Portable space-heating devices shall be prohibited in all health care occupancies. Exception: Portable space-heating devices shall be permitted to be used in nonsleeping staff and employee areas where the heating elements of such devices do not exceed 212°F (100°C).
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Based on the observations on 7/14/2015, the facility failed to maintain the means of egress. Findings include:

The GI back corridor (by the pharmacy) was observed with three tables, boxes and other equipment narrowing the width to approximately 3'-0".

The deficiency impacted 1 of 11 smoke compartments.
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Review of 2000 NFPA 101, 7.1.10.1 Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.
Review of 2000 NFPA 101, 7.1.10.2.1 No furnishings, decorations, or other objects shall obstruct exits, access thereto, egress therefrom, or visibility thereof.
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1. Based on the observation on 7/14/2015, the facility failed to provide identification for transfer switches. Findings include:

While observing maintenance transfer the generator from normal to emergency power, this surveyor observed that the transfer switches were not identified.
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NFPA 70, 110-22 Identification of Disconnecting Means: Each disconnecting means required by this code for motors and appliances, and each service, feeder, or branch circuit at the point where it originates, shall be legibly marked to indicate its purpose unless located and arranged so the purpose is evident. The marking shall be of sufficient durability to withstand the environment involved.
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2. Based on the observation on 7/14/2015, the facility failed to maintain battery-powered lighting units in the OR. Findings include:

The battery-powered light in OR Two was inoperable.

The deficiency impacted 1 of 11 smoke compartments.
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1999 NFPA 99, 1999 NFPA 99, 3-3.2.1.2 (a) 5. e. Battery-Powered Emergency Lighting Units. One or more battery-powered emergency lighting units shall be provided in accordance with NFPA 70, National Electrical Code, Section 700-12(e).
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3. Based on the review of documentation on 7/15/2015, the facility failed to maintain the piped medical gas. Findings include:

Per documentation from the facility, the facility failed to correct the "comments and recommendations" from the piped medical gas company from the report on 03/02/2015.

The deficiency impacted 11 of 11 smoke compartments.
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Review of 1999 NFPA 99, 4-3.5.2.3 Patient Gas Systems - Level 1.
(a) * Piping systems shall not be used for the distribution of flammable anesthetic gases.
(b) Nonflammable medical gas systems used to supply gases for respiratory therapy shall be installed in accordance with 4-3.1 of this chapter.
(c) Maintenance programs in accordance with the manufacturers ' recommendations shall be established for the medical air compressor supply system as connected in each individual installation.
(d) * The responsible authority of the facility shall establish procedures to ensure that all signal warnings are promptly evaluated and that all necessary measures are taken to reestablish the proper functions of the medical gas system.
(e) Piping systems for gases shall not be used as a grounding electrode.
(f) The facility shall have the capability and organization to implement a plan to cope with a complete loss of any medical gas system.
(g) A periodic testing procedure for nonflammable medical gas and related alarm systems shall be implemented.
(h) The test specified in 4-3.4.1.3(i) shall be conducted on the downstream portions of the medical gas piping system whenever a system is breached or whenever modifications are made or maintenance performed.
(i) * 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.
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4. Based on observations on 7/15/2015, the facility failed to maintain the fire doors. Findings include:

The 90 minute left leaf fire door at the ER failed to close and latch under activation of the fire alarm system. this door was tested twice.

The deficiency impacted 2 of 11 smoke compartments.
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Review of 2000 NFPA 101, 7.2.4.3.7 Doors in horizontal exits shall be designed and installed to minimize air leakage.
Review of 2000 NFPA 101, 7.2.4.3.8 All fire doors in horizontal exits shall be self-closing or automatic-closing in accordance with 7.2.1.8. Horizontal exit doors located across a corridor shall be automatic-closing in accordance with 7.2.1.8.
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Based on observations on 7/14/2015, the facility failed to maintain the electrical wiring and equipment. Findings include:

1. One end of blank was broken in half in the electrical panel in the maintenance department.
2. A junction box cover was missing in the ceiling above unit #1 air handler in the boiler room.
3. Three junction box covers were missing on the outside control lighting panels, located in the boiler room.
4. A junction box cover was missing above the ceiling by Patient Room 309.


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5. Pre/Post OP had extension cord that was observed plugged in, per OR nurse it is used at night to charge the computer on wheels.
6. Cashier's Desk had a surge protector (extension cord) plugged into a surge protector (extension cord).
7. Insurance Office had a surge protector (extension cord) plugged into a surge protector (extension cord).
8. Second Floor - Outpatient Services Office:
a. Had a surge protector (extension cord) plugged into a surge protector (extension cord).
b. Had a refrigerator plugged into a surge protector (extension cord).

The deficiency impacted 3 of 11 smoke compartments.
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Review of 1999 NFPA 70, 373-4 Unused opening shall be effectively closed to afford protection substantially equivalent to that of the enclosures.

Review of 1999 NFPA 70, 370-25 and 410-12. Each box in completed installations to have a cover, face plate, or fixture canopy.

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 review of documentation on 7/14/2015, the facility failed to provide a fire watch plan to implement where a required automatic sprinkler system is out of service for more than 4 hours in a 24-hour period. Findings include:


The facility failed to provide a fire watch plan.

The deficiency impacted 11 of 11 smoke compartments.
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Review of 2000 NFPA 101, 9.7.6.1 Where a required automatic sprinkler system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the sprinkler system has been returned to service.
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Based on review of documentation on 7/14/2015, the facility failed to provide a fire watch plan to implement where a required fire alarm system is out of service for more than 4 hours in a 24-hour period. Findings include:

The facility failed to provide a fire watch plan.

The deficiency impacted 11 of 11 smoke compartments.
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Review of 2000 NFPA 101, 9.6.1.8 Where a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service.

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Based on the observation on 7/15/2015, the facility failed to maintain corridor walls that would provide 30 minute fire resistance rating. AS AN EXAMPLE findings include:

1. Unsealed openings in the corridor walls, 2 holes and 2 sleeve's not sealed at the end of each sleeve. These were above the ceiling by the Nurses Station Third Floor.

2. Unsealed penetrations around flex conduit, in the corridor wall, above the ceiling at the West Stairwell Third Floor.


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+ + + Corridor walls throughout the partially sprinklered first floor and the partially sprinklered smoke compartment of the second floor were observed with corridor walls that did not have a fire rating of at least a 30 minute rating and were smoke resistive based on observation on the room side of these corridor walls. Examples:


First Floor
3. Radiology I.T. Room had old pass thru window only has sheetrock on the Waiting Room side.
4. Surgery Waiting Room - unsealed penetrations
5. Women's Bathroom at the Surgery Waiting Room - unsealed penetrations
6. Clean Linen (Laundry) - unsealed penetrations
7. Basement corridor wall on first floor - unsealed penetrations and not sealed at deck
8. Mammogram Room - unsealed penetrations
9. I.T. Room - unsealed penetrations and not sealed at deck
10. Medical Records - unsealed penetrations
11. Lab - unsealed penetrations
12. Lab Break Room - Missing sheetrock this area


Second Floor
13. Mechanical Room (across from the Staff Break Room) - unsealed penetrations
14. Room 217 - unsealed penetrations
15. Room 221 - unsealed penetrations
16. Room 220 - unsealed penetrations and not sealed at deck
17. Corridor side of the Geri-Psych Unit's Nurses' Station (across from the Employees Locker/Bathroom) - unsealed penetrations

This deficiency impacted 4 of 11 smoke compartments.
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Review of 2000 NFPA 101, 19.3.6.2.1 Corridor walls shall be continuous from the floor to the underside of the floor or roof deck above, through any concealed spaces, such as those above suspended ceilings, and through interstitial structural and mechanical spaces, and they shall have a fire resistance rating of not less than 1/2 hour.
Exception No. 1*: In smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.2, a corridor shall be permitted to be separated from all other areas by non-fire-rated partitions and shall be permitted to terminate at the ceiling where the ceiling is constructed to limit the transfer of smoke.
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Based on the observation on 7/14/2015, the facility failed to maintain corridor doors to resist the passage of smoke. Findings include:

The clean Linen Room Door had a dime size hole above the door handle, across the corridor from Patient Room 206 Second Floor East Wing.

The deficiency impacted 1 of 3 smoke compartments.
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NFPA 101, 19.3.6.3.1
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Based on the observation on 7/14/2015, the facility failed to maintain the exit signs. Findings include:

Second Floor West Stairwell exit sign above the stairwell had a directional indicator pointing back down the corridor.

The deficiency impacted 1 of 11 smoke compartments.
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Review of 2000 NFPA 101, 7.10.2* Directional Signs. A sign complying with 7.10.3 with a directional indicator showing the direction of travel shall be placed in every location where the direction of travel to reach the nearest exit is not apparent.
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Based on the observation on 7/14/2015, the facility failed to maintain the smoke barriers with at least a 30 minute fire resistance rating and restrict the movement of smoke. Findings include:

1. Unsealed penetrations around 3 sleeve's, and at the end of 3 sleeve's, in the smoke barrier, by Patient Room 208 Second Floor East Wing.


27382


The following was observed:
First Floor
2. ER corridor wall is part of the smoke barrier:
a. Two unsealed penetrations above the door
b. Missing sheetrock above the HVAC duct
3. First ER room to the left of the corridor door had unsealed penetrations
4. Radiology Reading Room had unsealed penetrations
Second Floor
5. Smoke Barrier separating the Equipment Storage Room from Physical/Speech Therapy, on the Equipment Storage Room side:
a. One unsealed penetration
b. Unsealed penetration around pipes

The deficiency impacted 4 of 11 smoke compartments.
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Review of 2000 NFPA 101, 8.3.2
Review of 2000 NFPA 101, 8.2.4.4.1
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Based on the observation on 7/14/2015, the facility failed to provide separation of hazardous area. Findings include:

1. Three unsealed penetrations, two were around some wiring, and one was around a section of conduit, in the wall of the boiler room. Location of these are to the left when you enter the room from the outside of the facility.


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2. Second Floor - Partially sprinklered smoke compartment
The following rooms were being used to store combustibles and were over 50 sq. ft. These rooms were not safeguarded by a fire barrier having a 1-hour fire resistance rating and did not have a 45 minute rated fire door with a self-closing device:
a. Room 220 - six recliners and three beds
b. Room 221 - eleven recliners and one bed
c. Room 214 - eleven recliners, boxes and Janitorial Storage

This deficiency impacted 1 of 11 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.

Review of 2000 NFPA 101, 8.4.1.3 Doors in barriers required to have a fire resistance rating shall have a 3/4-hour fire protection rating and shall be self-closing or automatic-closing in accordance with 7.2.1.8.
Review of 2000 NFPA 101, 7.2.1.8.1 A door normally required to be kept closed shall not be secured in the open position at any time and shall be self-closing or automatic-closing in accordance with 7.2.1.8.2.
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Based on observations on 7/14/2015, the facility failed to maintain the exit enclosures with at least 1 hour fire resistance. Findings include:

1. Unsealed penetrations in the wall of the stairwell, above the ceiling, South Wing Third Floor by ICU.


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2. The stairwell at the G. I. Lab. on the Second Floor was observed not having at least 1 hour fire resistance at the inside corner of the stairwell.
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Review of 2000 NFPA 101, 19.3.1.1 Any vertical opening shall be enclosed or protected in accordance with 8.2.5. Where enclosure is provided, the construction shall have not less than a 1-hour fire resistance rating.
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Based on the observations on 7/14/2015, the facility failed to maintain the exit access. Findings include:

The kitchen walk-in cooler was being locked with a padlock, the releasing handle on the inside the cooler was observed to be 'froze up' (would not turn).

The deficiency impacted 1 of 11 smoke compartments.
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Review of 2000 NFPA 101, 7.2.1.5.1 Doors shall be arranged to be opened readily 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.
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Based on review of documentation on 7/15/2015, the facility failed to provide a complete fire evacuation plan. Findings include:

Per documentation from the facility, the facility's fire evacuation plan did not contain all eight items per code; specifically the evacuation from an affected smoke compartment to an unaffected smoke compartment.

The deficiency impacted 11 of 11 smoke compartments.
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Review of 2000 NFPA 101, 19.7.2.2 A written health care occupancy fire safety plan shall provide for the following: (1) Use of alarms (2) Transmission of alarm to 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
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Based on review of facility documentation and interview on 07/15/2015, the facility failed to conduct fire drills, maintain the documentation for fire drills, and to provide proof of participation of all on duty staff at the time of the drill(s).
First Shift
06/16/2015 - 1:58 pm
02/10/2015 - 1:52 pm
No Drill
No Drill

Second Shift
06/12/2015 - 8:20 pm
03/02/2015 - 9:30 pm
12/11/2014 - 8:15 pm
09/07/2014 - 3:00 pm

Third Shift
06/07/2015 - 6:00 am
03/05/2015 - 3:30 am
12/17/2014 - 5:30 pm
09/10/2014 - 2:07 am

The deficiency impacted 11 of 11 smoke compartments.
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Review of 2000 NFPA 101, 19.7.1.2 Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
Review of 2000 NFPA 101, 4.7.2* Emergency egress and relocation drills, where required by Chapters 11 through 42 or the authority having jurisdiction, shall be held with sufficient frequency to familiarize occupants with the drill procedure and to establish conduct of the drill as a matter of routine. Drills shall include suitable procedures to ensure that all persons subject to the drill participate.
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Based on review of documentation provided by the facility on 7/15/2015, required sensitivity testing of smoke detectors had not been performed. Findings include:

Review of fire alarm documentation indicated that the facility had installed a new fire alarm system. Based on the NFPA 72 completion form, this was completed on 3/6/2014. Sensitivity testing of all smoke detectors should have been conducted one year after installation.

The deficiency impacted 11 of 11 smoke compartments.
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Detector sensitivity shall be checked with one year after installation and every alternate year thereafter per 72, 7-3.2.1. (Up to 5 years permitted under certain circumstances. See 7-3.2.1).

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Based on the observation on 7/14/2015, the facility failed to provide adequate sprinkler coverage. Findings include:

A ceiling tile in the Laundry Room across the corridor from Patient Room 208, observed to have approximately a 2"x 2" hole.

The deficiency impacted 1 of 11 smoke compartments.
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NFPA 13 5-6., Sprinklers shall be arranged to be in compliance.
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Based on the observation on 7/14/2015, the facility failed to maintain the automatic sprinkler system. Findings include:

1. Red wiring attached to the sprinkler branch lines, also blue wiring resting on branch lines, in two different areas above the ceiling, at the fire barrier Administration Offices Third Floor.


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2. Lab - the first automatic sprinkler head on the left was observed with excessive foreign materials.

The deficiency impacted 1 of 11 smoke compartments.

1998 NFPA 25, 2-2.2* Pipe and Fittings. Sprinkler pipe and fittings shall be inspected annually from the floor level. Pipe and fittings shall be in good condition and free of mechanical damage, leakage, corrosion, and misalignment. Sprinkler piping shall not be subjected to external loads by materials either resting on the pipe or hung from the pipe.

Review of 1998 NFPA 25, 2-2.1.1 Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.
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Based on the observation on 7/14-15/2015, the facility failed to provide required maintenance for the fire extinguishers. Findings include:

Two fire extinguishers had May of 2014 indicated on the tag attached to the extinguishers, one located in the Mechanical Room third floor south wing, the other one was located by Patient Room 301.
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1998 NFPA 10, 4-4.1 Fire extinguishers shall be subjected to maintenance intervals of not more than one year.

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Based on the observations on 7/14/2015, the facility failed to prohibit portable space heating devices. Findings include:

The Personnel Office was observed with a portable space heating device plugged into a surge protector. The portable space heating device was not on.

The deficiency impacted 1 of 11 smoke compartments.
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Review of 2000 NFPA 101, 19.7.8 Portable space-heating devices shall be prohibited in all health care occupancies. Exception: Portable space-heating devices shall be permitted to be used in nonsleeping staff and employee areas where the heating elements of such devices do not exceed 212°F (100°C).
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Based on the observations on 7/14/2015, the facility failed to maintain the means of egress. Findings include:

The GI back corridor (by the pharmacy) was observed with three tables, boxes and other equipment narrowing the width to approximately 3'-0".

The deficiency impacted 1 of 11 smoke compartments.
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Review of 2000 NFPA 101, 7.1.10.1 Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.
Review of 2000 NFPA 101, 7.1.10.2.1 No furnishings, decorations, or other objects shall obstruct exits, access thereto, egress therefrom, or visibility thereof.
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1. Based on the observation on 7/14/2015, the facility failed to provide identification for transfer switches. Findings include:

While observing maintenance transfer the generator from normal to emergency power, this surveyor observed that the transfer switches were not identified.
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NFPA 70, 110-22 Identification of Disconnecting Means: Each disconnecting means required by this code for motors and appliances, and each service, feeder, or branch circuit at the point where it originates, shall be legibly marked to indicate its purpose unless located and arranged so the purpose is evident. The marking shall be of sufficient durability to withstand the environment involved.
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2. Based on the observation on 7/14/2015, the facility failed to maintain battery-powered lighting units in the OR. Findings include:

The battery-powered light in OR Two was inoperable.

The deficiency impacted 1 of 11 smoke compartments.
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1999 NFPA 99, 1999 NFPA 99, 3-3.2.1.2 (a) 5. e. Battery-Powered Emergency Lighting Units. One or more battery-powered emergency lighting units shall be provided in accordance with NFPA 70, National Electrical Code, Section 700-12(e).
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3. Based on the review of documentation on 7/15/2015, the facility failed to maintain the piped medical gas. Findings include:

Per documentation from the facility, the facility failed to correct the "comments and recommendations" from the piped medical gas company from the report on 03/02/2015.

The deficiency impacted 11 of 11 smoke compartments.
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Review of 1999 NFPA 99, 4-3.5.2.3 Patient Gas Systems - Level 1.
(a) * Piping systems shall not be used for the distribution of flammable anesthetic gases.
(b) Nonflammable medical gas systems used to supply gases for respiratory therapy shall be installed in accordance with 4-3.1 of this chapter.
(c) Maintenance programs in accordance with the manufacturers ' recommendations shall be established for the medical air compressor supply system as connected in each individual installation.
(d) * The responsible authority of the facility shall establish procedures to ensure that all signal warnings are promptly evaluated and that all necessary measures are taken to reestablish the proper functions of the medical gas system.
(e) Piping systems for gases shall not be used as a grounding electrode.
(f) The facility shall have the capability and organization to implement a plan to cope with a complete loss of any medical gas system.
(g) A periodic testing procedure for nonflammable medical gas and related alarm systems shall be implemented.
(h) The test specified in 4-3.4.1.3(i) shall be conducted on the downstream portions of the medical gas piping system whenever a system is breached or whenever modifications are made or maintenance performed.
(i) * 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.
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4. Based on observations on 7/15/2015, the facility failed to maintain the fire doors. Findings include:

The 90 minute left leaf fire door at the ER failed to close and latch under activation of the fire alarm system. this door was tested twice.

The deficiency impacted 2 of 11 smoke compartments.
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Review of 2000 NFPA 101, 7.2.4.3.7 Doors in horizontal exits shall be designed and installed to minimize air leakage.
Review of 2000 NFPA 101, 7.2.4.3.8 All fire doors in horizontal exits shall be self-closing or automatic-closing in accordance with 7.2.1.8. Horizontal exit doors located across a corridor shall be automatic-closing in accordance with 7.2.1.8.
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Based on observations on 7/14/2015, the facility failed to maintain the electrical wiring and equipment. Findings include:

1. One end of blank was broken in half in the electrical panel in the maintenance department.
2. A junction box cover was missing in the ceiling above unit #1 air handler in the boiler room.
3. Three junction box covers were missing on the outside control lighting panels, located in the boiler room.
4. A junction box cover was missing above the ceiling by Patient Room 309.


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5. Pre/Post OP had extension cord that was observed plugged in, per OR nurse it is used at night to charge the computer on wheels.
6. Cashier's Desk had a surge protector (extension cord) plugged into a surge protector (extension cord).
7. Insurance Office had a surge protector (extension cord) plugged into a surge protector (extension cord).
8. Second Floor - Outpatient Services Office:
a. Had a surge protector (extension cord) plugged into a surge protector (extension cord).
b. Had a refrigerator plugged into a surge protector (extension cord).

The deficiency impacted 3 of 11 smoke compartments.
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Review of 1999 NFPA 70, 373-4 Unused opening shall be effectively closed to afford protection substantially equivalent to that of the enclosures.

Review of 1999 NFPA 70, 370-25 and 410-12. Each box in completed installations to have a cover, face plate, or fixture canopy.

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 review of documentation on 7/14/2015, the facility failed to provide a fire watch plan to implement where a required automatic sprinkler system is out of service for more than 4 hours in a 24-hour period. Findings include:


The facility failed to provide a fire watch plan.

The deficiency impacted 11 of 11 smoke compartments.
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Review of 2000 NFPA 101, 9.7.6.1 Where a required automatic sprinkler system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the sprinkler system has been returned to service.
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Based on review of documentation on 7/14/2015, the facility failed to provide a fire watch plan to implement where a required fire alarm system is out of service for more than 4 hours in a 24-hour period. Findings include:

The facility failed to provide a fire watch plan.

The deficiency impacted 11 of 11 smoke compartments.
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Review of 2000 NFPA 101, 9.6.1.8 Where a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service.