HospitalInspections.org

Based on observation and interview, the facility failed to maintain their exit signs. This was evidenced by exit signs with battery-operated emergency illumination that were not equipped with a method to test the battery functionality. This was also evidenced by two exit signs that were dimly illuminated due to worn exit sign covers. This affected two of seven floors of the Tower and the offsite Spine Clinic. This could result in a delay in evacuation, in the event of an emergency.

NFPA 101, Life Safety Code, 2000 Edition.
19.2.10.1 Means of egress shall have signs in accordance with Section 7.10.
Exception: Where the path of egress travel is obvious, signs shall not be required in one-story buildings with an occupant load of fewer than 30 persons.

7.10.1.1 Where Required. Means of egress shall be marked in accordance with Section 7.10 where required in Chapters 11 through 42.

7.10.4 Power Source. Where emergency lighting facilities are required by the applicable provisions of Chapters 11 through 42 for individual occupancies, the signs, other than approved self-luminous signs, shall be illuminated by the emergency lighting facilities. The level of illumination of the signs shall be in accordance with 7.10.6.3 or 7.10.7 for the required emergency lighting duration as specified in 7.9.2.1. However, the level of illumination shall be permitted to decline to 60 percent at the end of the emergency lighting duration.

7.10.5.1 General. Every sign required by 7.10.1.2 or 7.10.1.4, other than where operations or processes require low lighting levels, shall be suitably illuminated by a reliable light source. Externally and internally illuminated signs shall be legible in both the normal and emergency lighting mode.

7.10.5.2 Continuous Illumination. Every sign required to be illuminated by 7.10.6.3 and 7.10.7 shall be continuously illuminated as required under the provisions of Section 7.8.
Exception: Illumination for signs shall be permitted to flash on and off upon activation of the fire alarm system.

7.10.9.1 Inspection. Exit signs shall be visually inspected for operation of the illumination sources at intervals not to exceed 30 days.

7.10.9.2 Testing. Exit signs connected to or provided with a battery-operated emergency illumination source, where required in 7.10.4, shall be tested and maintained in accordance with 7.9.3.

7.9.3 Periodic Testing of Emergency Lighting Equipment. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 11/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and test shall be kept by the owner for inspection by the authority having jurisdiction.
Exception: Self-testing/self-diagnostic, battery-operated emergency lighting equipment that automatically performs a test for not less than 30 seconds and diagnostic routine not less than once every 30 days and indicates failures by a status indicator shall be exempt from the 30 day functional test, provided that a visual inspection is performed at 30-day intervals.

Findings:

During a facility tour with staff from 4/4/16 to 4/8/16, the exit signs were observed.

Spine Clinic:

1. At 9:52 a.m., on 4/7/16, the exit sign in the lobby and the exit sign outside the doctors office were equipped with battery-powered emergency operation. There were no test buttons or indicator lights to verify their battery's operation. The clinic was not equipped with a generator or an uninterruptible emergency power source and relied on battery-powered lights and exit signs, in the event of a power outage.

During an interview at 9:53 a.m., the Vice President of Business Development (VPBD1) stated that the suite underwent a renovation in February. He stated that the exit signs would be modified right away to allow for battery testing.


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Tower Building
Seventh Floor:

2. At 10:13 a.m., on 4/7/16, the exit sign on the exterior wall of the seventh floor courtyard was not illuminated. The exit sign was exposed to outdoor elements, was rusted, and the glass of the "EXIT" lettering was opaque.

During an interview at 10:14 a.m., the Director of Facilities Services (DFS1) confirmed the finding and stated that they needed a new exit sign.

Third Floor:

3. At 10:21 a.m., on 4/7/16, the exit sign of the third floor stairwell was not illuminated. The "EXIT" lettering was foggy and opaque and compromised the illumination from the bulbs.

During an interview at 10:28 a.m., the Director of Facilities Services (DFS1) confirmed the finding and stated that they needed a new exit sign.

Based on record review and interview, the facility failed to ensure that the emergency plans for disruption of essential building systems were readily available to all staff. This was evidenced by fire and disaster manuals that were incomplete. This affected the Van Nuys building and could result in a delay in restoration of essential building systems in the event they were interrupted.

NFPA 99, Standard for Health Care Facilities, 1999 Edition.
Chapter 12 Hospital Requirements
12-1 Scope. This chapter addresses safety requirements of hospitals.
12-3.11 Hospitals shall comply with the provisions of Chapter 11 for disaster planning, as appropriate.

Chapter 11 Health Care Emergency Preparedness
11-5.3.2 Continuity of Essential Building Systems. When designated by the emergency preparedness management plan to provide continuous service in a disaster or emergency, health care facilities shall establish contingency plans for the continuity of essential building systems, as applicable:
(a) Electricity
(b) Water
(c) Ventilation
(d) Fire protection systems
(e) Fuel sources
(f) Medical gas and vacuum systems (if applicable)
(g) Communication systems

Findings:

During a facility tour with staff from 4/4/16 to 4/8/16, the fire/disaster manuals were reviewed.

Van Nuys:

1. At 8:34 a.m., on 4/6/16, the Disruption of Services portion of the fire/disaster manuals at the nurses stations and the administration were incomplete. The water and gas shut off locations and the emergency telephone numbers of the utility companies were not listed on their designated areas in the manuals. The manual from PBX was requested at 8:35 a.m. but not provided until 9:00 a.m. Only the manual from PBX had the Disruption of Services portion filled out completely.

During an interview at 9:01 a.m., the Director of Facilities Services (DFS3) stated that the PBX station did not operate nightly from 11 p.m. to 7 a.m. He stated that the facility would update the rest of the fire/disaster manuals right away.


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Based on record review and interview, the facility failed to ensure that staff members were aware of their duties to protect patients in the event of a fire. This was evidenced by the failure to activate fire alarms during daytime drills, by the failure to hold overnight fire drills independent of other shifts, and by staff that were not aware of their responsibilities in the event of a fire. This affected three of three buildings at the Culver City Campus and the Van Nuys Building. This could result in improper staff response in the event of a fire and an increased risk of injury to patients.

NFPA 101 Life Safety Code, 2000 Edition
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 p.m. (2100 hours) and 6 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to exterior of the building.

19.7.1.3 Employees of health care occupancies shall be instructed in life safety procedures and devices.

19.7.2.3 All health care occupancy personnel shall be instructed in the use of and response to fire alarms. In addition, they shall be instructed in the use of the code phrase to ensure transmission of an alarm under the following condition:
(1) When the individual who discovers a fire must immediately go to the aid of an endangered person
(2)During a malfunction of the building fire alarm system
Personnel hearing the code announced shall first activate the building fire alarm using the nearest manual fire alarm box and then shall execute immediately their duties as outlined in the fire safety plan.

4.7.1 Where Required. Emergency egress and relocation drills conforming to the provisions of this Code shall be conducted as specified by the provisions of Chapters 11 through 42, or by appropriate action of the authority having jurisdiction. Drills shall be designed in cooperation with the local authorities.

4.7.2 Drill Frequency. 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.

Findings:

During a facility tour with staff from 4/4/16 to 4/8/16, the fire drill records were reviewed and staff were interviewed about fire response procedures.

1. At 11:00 a.m., on 4/8/16, fire alarm system monitoring reports for the first three months (first quarter) of 2016 were provided. At that time, all fire alarm signals would have been received by the monitoring company as a fire trouble (See K51). The report showed that no signals, other than the daily scheduled timer test, were received during the 1/28/16 12:30 p.m. AM shift fire drill and none on 2/25/16 5:00 p.m. The facility failed to activate the fire alarm during testing.


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Culver City Campus:

2. At 3:30 p.m., on 4/4/16, the fire drill records provided showed that there were no overnight drills conducted during the first quarter (January through March) of 2016 and that drills were not conducted at varying times. The records also showed that the facility used one fire drill to include two staff shifts.

Records of the fire drill conducted on 2/26/16 at 9 p.m. was marked as including both the evening (swing) shift and the night shift.

Records of the fire drill conducted on 3/7/16 at 8 p.m. was marked as including both the evening shift and the night shift.

Records of the fire drill conducted on 3/12/16 at 8 p.m. was marked as including both the evening shift and the night shift.

At 11:36 a.m., on 4/5/16, documents provide by the Chief Nursing Officer (CNO) showed the overnight shifts of various staff. Overnight security staff worked from 11:00 p.m. to 7:30 a.m., overnight EVS staff worked from 10:00 p.m. to 6:30 a.m., and overnight nursing staff worked from 7:00 p.m. to 7:00 a.m.

These records showed that the facility failed to conduct independent night shift fire drills to include all overnight staff and that all the evening shift drills were conducted between 8 p.m. and 9 p.m.

Pavilion:

The facility's Fire Response Plan, effective 2/2011 and last reviewed on 3/2016, indicated that staff will implement the steps of R.A.C.E. (Rescue any persons in immediate danger, Activate the fire alarm then dial extension 5555 (PBX), Contain the fire by closing doors, and Extinguish only small fires). The plan emphasized that for "Activation" both tasks of activating the fire alarm and dialing 5555 must be performed either individually or by obtaining assistance from another staff.

3. At 10:22 a.m., on 4/5/16, Mental Health Technician (M.H.Tech1) was asked what she would she do upon discovery of a fire. M.H. Tech 1 stated she would bring the patient in the hallway and get ready to evacuate with her team at the nurses station and she would close doors. She failed to mention that she would notify the building by activating a pull station and dialing 5555. She failed to mention the use of a fire extinguisher if possible.

4. At 4:05 p.m., on 4/5/16, Security Officer (SO1) was asked what would he do upon discovery of fire. SO1 stated he would call his dispatcher and the operator, grab a fire extinguisher, keep everyone from the danger and the dispatcher will call the fire department. He failed to mention that he would activate the fire alarm system to notify the rest of the building.

5. At 11:20 a.m., on 4/7/16, Kitchen Supervisor Staff (KSS1), Food Services Staff (FSS1), and Dietary Aide (DA1) were asked what they would do in the event of a fire in the kitchen. They stated they would use the code word R.A.C.E. When asked to explain the R.A.C.E. procedures, they stated that they would get everyone out of the building, check the schedule, and call 5555. KSS1 stated that she would use a K-Class fire extinguisher for a gas fire. The kitchen staff failed to mention activation of the alarm, the containment of a fire, and the proper usage of the extinguishers.

Based on observation, record review, and interview, the facility failed to maintain their fire alarm system. This was evidenced by the repeated failure of fire alarm notification devices, by the failure to transmit the correct type of fire alarm signal to the monitoring station, and by the frequent placement of the fire alarm system in test mode that resulted in the failure to dispatch the fire department during a Code Red event. This was also evidenced by incorrectly addressed smoke detectors that caused personnel to respond to the wrong location during a Code Red event. This affected the entire Culver City Campus and the Van Nuys Building. This could result in a delay in fire department dispatch, a delay in response during a fire, and the increased risk of injury to patients.

NFPA 101, Life Safety Code, 2000 Edition.
19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6.

9.6.1.3 The provisions of Section 9.6 cover the basic functions of a complete fire alarm system, including fire detection, alarm, and communications. These systems are primarily intended to provide the indication and warning of abnormal conditions, the summoning of appropriate aid, and the control of occupancy facilities to enhance protection of life.

9.6.1.4 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.

9.6.1.5 All systems and components shall be approved for the purpose for which they are installed.

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

9.6.3.6 Notification signals for occupants to evacuate shall be by audible and visible signals in accordance with NFPA 72, National Fire Alarm Code, and CABO/ANSI A117.1, American National Standard for Accessible and Usable Buildings and Facilities, or other means of notification acceptable to the authority having jurisdiction shall be provided.
Exception No. 1: Areas not subject to occupancy by persons who are hearing impaired shall not be required to comply with the provisions for visible signals.
Exception No. 2: Visible-only signals shall be provided where specifically permitted in health care occupancies in accordance with the provisions of Chapters 18 and 19.
Exception No. 3: Existing alarm systems shall not be required to comply with the provision for visible signals.
Exception No. 4: Visible signals shall not be required in lodging or rooming houses in accordance with the provisions of Chapter 26.

NFPA 72, National Fire Alarm Code, 1999 Edition.
Definitions
1-4 Central Station. A supervising station that is listed for central station service.
Proprietary Supervising Station. A location to which alarm or supervisory signaling devices on proprietary fire alarm systems are connected and where personnel are in attendance at all times to supervise operation and investigate signals.
Proprietary Supervising Station Fire Alarm System. An installation of fire alarm systems that serves contiguous and noncontiguous properties, under one ownership, from a proprietary supervising station located at the protected property, at which trained, competent personnel are in constant attendance. This includes the proprietary supervising station; power supplies; signal-initiating devices; initiating device circuits; signal notification appliances; equipment for the automatic, permanent visual recording of signals; and equipment for initiating the operation of emergency building control services.

1-6.1.1 The authority having jurisdiction shall be notified prior to installation or alteration of equipment or wiring. At its request, complete information regarding the system or system alterations, including specifications, wiring diagrams, battery calculation, and floor plans shall be submitted for approval.

5-2.5.1 The central station shall have sufficient personnel, but not less than two persons, on duty at the central station at all times to ensure disposition of signals in accordance with the requirements of 5-2.6.1.

5-2.5.2 Operation and supervision shall be the primary functions of the operators, and no other interest or activity shall take precedence over the protective service.

5-2.6.1.5.2 Any test signal not received by the central station shall be investigated immediately and action shall be taken to reestablish system integrity.

5-3.2.1 Proprietary supervising stations shall be operated by trained, competent personnel in constant attendance who are responsible to the owner of the protected property. The requirements of 5-3.5.3 shall apply.

5-3.3.1 The proprietary supervising station shall be located in a fire-resistive, detached building or in a cutoff room and shall not be exposed to the hazardous parts of the premises that are protected.

5-3.4.1 Signal-receiving equipment in a proprietary supervising station shall comply with 5-3.4.

5-3.4.2 Provision shall be made to designate the building in which a signal originates. The floor, section, or other subdivision of the building shall be designated at the proprietary supervising station or at the building that is protected.
Exception: Where the area, height, or special conditions of occupancy make detailed designation unessential as approved by the authority having jurisdiction. This detailed designation shall use indicating appliances accepted by the authority having jurisdiction.

5-3.5.1 At least two operators shall be on duty at all times. One of the two operators shall be permitted to be a runner.
Exception: If the means for transmitting alarms to the fire department is automatic, at least one operator shall be on duty at all times.

5-3.5.3 The primary duties of the operator(s) shall be to monitor signals, operate the system, and take such action as shall be required by the authority having jurisdiction. The operator(s) shall not be assigned any additional duties that would take precedence over the primary duties.

5-3.6.6.1 Alarms. Upon receipt of a fire alarm signal, the proprietary supervising station operator shall initiate action to perform the following:
(1) Immediately notify the fire department, the plant fire brigade, and such other parties as the authority having jurisdiction requires.
(2) Promptly dispatch a runner to the alarm location (travel time shall not exceed 1 hour).
(3) Restore the system as soon as possible after disposition of the cause of the alarm signal.

Findings:

During tour of facility with staff from 4/4/16 to 4/8/16, the fire alarm systems were tested and observed. The Pavilion and the Tower building, located across the street from the Pavilion, shared the same fire alarm system.

Van Nuys:

1. From 12:00 p.m., to 12:30 p.m., on 4/6/16, fire alarm testing was conducted and this included initiating devices such as pull stations, smoke detectors, and waterflow switches. At 4:17 p.m., the monitoring report from the testing was provided. The monitoring report showed that the remote monitoring station only received Zone 2 fire trouble signals for all types of initiation devices tested.

During a telephone interview at 4:18 p.m., a representative from the monitoring company stated that they would not dispatch the fire department upon receipt of a Zone 2 trouble signal.

During a telephone interview at 4:47 p.m., another representative from the monitoring company stated that the last Zone 1 fire alarm signal received from the facility was on 12/30/15. He stated that only fire trouble signals were received on 1/23/16. The annual testing of the fire alarm system was conducted on 1/23/16 and documents showed that all initiation devices were tested on that day.

During an interview at 5:00 p.m., the Director of Facilities Services (DFS2) stated that a fire watch would be implemented immediately until the fire alarm panel was fixed.

Records showed that a fire alarm vendor fixed the panel on 4/7/16. The vendor reported that there was a loose wire for Zone 1 in the panel that caused all the signals to be reported as Zone 2.

Pavilion:

2. At 10:28 a.m., on 4/4/16, the fire alarms sounded and a Code Red was paged overhead. PBX paged "Code Red Sixth Floor" three times. At 10:33 a.m., the Head of Security (HS1) reset the fire alarm system at the notification panel in the lobby.

During an interview at 10:33 a.m., HS1 stated that security staff have investigated and saw no signs of fire. He stated that the panel indicated that the smoke detector was activated in the hallway outside the EVS (environmental services) closet on the sixth floor.

At 10:35 a.m., there were two security staff holding fire extinguishers in Wing A of the sixth floor. They stated that the smoke detector inside Room 605, which was adjacent to an EVS closet, was blinking red. They gave an "all clear" after inspecting that room.

At 10:50 a.m., Plant Operations Lead Staff (PO1) removed the detector in Room 605 and an addressable trouble signal on the panel read "Pav 6th Smoke Patient Room 605."

During an interview at 10:51 a.m., PO1 and HS1 were unsure if Room 605 was the origin of the fire alarm activation/Code Red and if security staff responded to the wrong location.

At 2:37 p.m., a print out from the panel indicated that, "Pav 6th Smoke Patient Room 605" caused a "Common Trbl Act" (a local trouble signal) at 10:24 a.m. and that, "Pav 6th Smoke Hall Outside EVS" caused an "Alarm Active" at 10:28 a.m.

During an interview at 2:38 p.m., the Fire Alarm Technician (F.A. Tech2) stated that the source of the fire alarm activation was not Room 605. He said that he and the other technicians were still trying to locate the smoke detector that was addressed incorrectly as "outside EVS."

During an interview at 4:05 p.m., F.A. Tech2 stated that the smoke detector that caused the Code Red was actually in a Wing C linen closet, not in the Wing A corridor outside the EVS closet.

Facility staff responded to the wrong location during the Code Red incident due to a smoke detector that was not addressed correctly on the panel.


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Culver City Campus:

3. Per record review and interviews, it was observed that the fire alarm system was frequently placed on test during the past month. When the system is on test, fire alarm signals received by the remote monitoring station would not result in dispatch of the fire department. During the Code Red on 4/4/16 (Finding 2 above), the fire department was not dispatched.

During an interview at 10:33 a.m., on 4/4/16, HS1 stated that the system was on test and PBX would call the fire department upon investigation by the facility and security staff.

At 4:05 p.m., on 4/6/16, this surveyor was unable to conduct an interview with the PBX operator. There was only one PBX operator at the time and he was busy with phone calls. The fire alarm annunciator in PBX was across the room from the operator. PBX did not meet the NFPA 72 requirements of a listed central station or proprietary supervising station.

During an interview at 1:57 p.m., on 4/5/16, the Los Angeles Fire Prevention Specialist (LAFPS) from Culver City Fire stated that the Fire Department should have been dispatched during the Code Red incident yesterday (Finding 2 above) and the Code Red incident in December (See K48 from the December 2015 Life Safety Code Survey). He stated the last time the fire department was notified of a fire alarm at the facility was on 3/11/16. He stated that the fire department was not notified of the alarms in the building yesterday. He requested to review a month of the monitoring reports from the offsite monitoring stations.

During an interview at 5:01 p.m., on 4/6/16, Plant Operations Lead Staff (PO1) stated that the facility placed the fire alarm system in test mode daily, for both the Tower and Pavilion, although construction was only conducted in the Pavilion Penthouse.

During an interview at 8:49 a.m., on 4/7/16, the LAFPS stated the facility cannot place the fire alarm system on test daily without informing the local AHJ that the system is out of service. He stated he was unaware of any construction work that would require that the entire fire alarm system be put on test daily for both Tower and Pavilion Buildings.

During an interview at 8:50 a.m., on 4/7/16, the Los Angeles Fire Inspector (LAFI) from the local Fire Department stated the facility cannot be on test so often without notifying the local AHJ. He stated that the facility must notify the AHJ when the fire alarm system is on test for construction work.

During an interview at 11:44 a.m., on 4/7/16, the Office of Statewide Health Planning and Development (OSHPD) Fire Life Safety Officer (FLSO) stated the facility should get approval from the FLSO for putting the system on test during any construction.

During an interview at 12:30 p.m., on 4/7/16, the Director of Facilities Services (DFS1) stated that PBX was carrying out instructions from the previous Facilities Director to put the system on test from 5 a.m. to 5 p.m. daily whether the fire alarm system was being worked on or not.

During an interview at 2:48 p.m., on 4/7/16, F.A. Tech1 stated the fire alarm system has the capability to place only certain zones on test, such as specific construction areas or while working on a portion of the fire alarm system.

During an interview at 9:50 a.m., on 4/8/16, F.A. Tech1 stated he was unaware that the facility had placed the fire alarm system on test when he and his staff were not working on the system. F.A. Tech1 provided his staff's work schedule for the month of March 2016. He confirmed that they were not in the building during the Code Red incident on 4/4/16.

At 10 a.m., on 4/13/16, comparison of the facility's fire alarm monitoring reports and the fire alarm vendor's work schedule showed days that the fire system was placed on test while no work was conducted on the system. The monitoring report indicated that the facility placed the entire fire alarm system on test from 5:00 a.m., to 5:00 p.m. for most days, including Saturdays and Sundays, without notifying the local AHJ. The fire alarm system was placed on test late into the evening on other days: on 3/14/16, the system was placed on test from 7:28 p.m., until 11:30 p.m. and on 3/22/16, from 6:16 p.m., until 11:59 p.m.

The monitoring report indicated the system was placed on test on 3/11/16 from 5:00 a.m., to 5:00 p.m., for selective zones only. A fire alarm was activated in an area that was not on test and the fire department was dispatched. Interview with LAFPS above confirmed that this was the last time they received fire alarm signal from the facility.

Per the monitoring report and the fire alarm vendor's schedule for March 2016, the facility had their entire fire alarm system on test from 5:00 a.m., to 5:00 p.m. for 14 days (including Saturdays and Sundays) while there was no fire alarm vendor in the building. The system was on test on 3/9/16 while there was no fire alarm vendor working on the fire alarm panel. The report indicated the panel exhibited a supervisory signal. The signal was not sent to the local fire department.

Tower
First Floor:

4. At 3:53 p.m., on 4/6/16, the pull station on the first floor in the Emergency Department was tested. The fire alarm chimes failed to activate an audible alarm and no fire alarms could be heard throughout the building.

At 3:54 p.m., on 4/6/16, the pull station by the exit door of the Emergency Department was tested. The fire alarm chimes failed to activate an audible alarm and no fire alarms could be heard throughout the building.

During an interview at 3:55 p.m., F.A. Tech1 stated he would go and investigate the problem.

At 5:52 p.m., the notification devices at the Tower were still not repaired.

During an interview at 9:01 a.m., on 4/7/16, F.A. Tech1 stated he finished working on the fire alarm system yesterday at approximately 8:30 p.m., and all the chimes on all the floors of the Tower should be working now.

Tower
Basement:

At 10:29 a.m., a pull station was tested and the fire alarm chime box failed. No alarms could be heard in the basement.

This deficiency was cited during the September 2015 and December 2015 Life Safety Code surveys under K52. During the survey on 9/22/15, the fire alarm chimes on the first floor and fourth floor of the Tower failed during testing of the fire alarm system. During the survey on 12/16/15, the fire alarm chimes failed on the seventh floor of the Tower while fire alarm testing. Documentation from the Inspector of Record (IOR) showed that, during testing on 1/22/16, the audible fire alarms failed on the first floor, third floor, basement, and fifth floor of the Tower. The items were documented as having been corrected on 1/27/16. The recurring failure of the fire alarm chimes had not been corrected.

Based on observation, record review, and interview, the facility failed to ensure that the fire alarm systems are maintained in reliable operating condition. This was evidenced by no records of current smoke detector sensitivity testing for two buildings, by trouble conditions exhibited at fire panels, by the failure to protect an initiation device from mechanical damage, by the failure of one notification device at an offsite clinic, by no records of repairing fire alarm deficiencies, and by fire alarm components that were not readily accessible for inspection. This was also evidenced by the failure to ensure that manual fire alarm pull stations were readily accessible to all staff. This affected two of two offsite outpatient clinics and the Pavilion Building. This could result in delay in notification and response, in the event of a fire, and could result in the increased risk of injury to patients.

NFPA 101, Life Safety Code, 2000 Edition.
19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6.

9.6.1.3 The provisions of Section 9.6 cover the basic functions of a complete fire alarm system, including fire detection, alarm, and communications. These systems are primarily intended to provide the indication and warning of abnormal conditions, the summoning of appropriate aid, and the control of occupancy facilities to enhance protection of life.

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

9.6.3.6 Notification signals for occupants to evacuate shall be by audible and visible signals in accordance with NFPA 72, National Fire Alarm Code, and CABO/ANSI A117.1, American National Standard for Accessible and Usable Buildings and Facilities, or other means of notification acceptable to the authority having jurisdiction shall be provided.
Exception No. 1: Areas not subject to occupancy by persons who are hearing impaired shall not be required to comply with the provisions for visible signals.
Exception No. 2: Visible-only signals shall be provided where specifically permitted in health care occupancies in accordance with the provisions of Chapters 18 and 19.
Exception No. 3: Existing alarm systems shall not be required to comply with the provision for visible signals.
Exception No. 4: Visible signals shall not be required in lodging or rooming houses in accordance with the provisions of Chapter 26.

4.2.3 Systems Effectiveness. Systems utilized to achieve the goals of Section 4.1 shall be effective in mitigating the hazard or condition for which they are being used, shall be reliable, shall be maintained to the level at which they were designed to operate, and shall remain operational.

NFPA 72, National Fire Alarm Code, 1999 Edition.
1-6.3 Records. A complete, unalterable record of the tests and operations of each system shall be kept until the next test and for 1 year thereafter. The record shall be available for examination and, if required, reported to the authority having jurisdiction. Archiving of records by any means shall be permitted if hard copies of the records can be provided promptly when requested.
Exception: If off-premises monitoring is provided, records of all signals, tests, and operations recorded at the supervising station shall be maintained for not less than 1 year.

2-1.3.3 Initiating devices shall be installed in all areas where required by other NFPA codes and standards or the authority having jurisdiction. Each installed initiating device shall be accessible for periodic maintenance and testing.

2-8.2.1 Manual fire alarm boxes shall be located throughout the protected area so that they are unobstructed and accessible.

7-1.1.1 Inspection, testing, and maintenance programs shall satisfy the requirements of this code, shall conform to the equipment manufacturer's recommendations, and shall verify correct operation of the fire alarm system.

7-3.2.1 Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed. To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method
(2) Manufacturer's calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction
Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.
Exception No. 1: Detectors listed as field adjustable shall be permitted
to be either adjusted within the listed and marked sensitivity range and
cleaned and recalibrated, or they shall be replaced.
Exception No. 2: This requirement shall not apply to single station detectors referenced in 7-3.3 and Table 7-2.2.

Findings:

During a facility tour with staff from 4/4/16 to 4/8/16, the fire alarm systems were observed and maintenance records were requested.

Offsite IOP and Spine Clinics:

1. At 3:36 p.m., on 4/4/16, smoke detector sensitivity testing was requested for both offsite clinics. There were no records of smoke detector sensitivity testing provided.

Spine Clinic:

2. At 9:00 a.m., on 4/7/16, fire alarm system maintenance records showed that the system failed the annual inspection on 3/9/16. The deficiencies listed were "no access to first floor pharmacy" and "incorrect identification and location indicated for alarms, supervisory, and trouble signals." There were no records of repairing the system deficiencies.

3. At 9:38 a.m., on 4/7/16, the fire alarm panel at the Culver Medical Plaza was exhibiting a "Power Supply 1 Fault" trouble.

During an interview at 9:39 a.m., the Culver Medical Plaza Maintenance Staff (CMP Maint1) stated he was aware of the trouble signal and the vendor has been scheduled to come out to investigate.

4. At 10:07 a.m., on 4/7/16, one of two pull stations in the west exit corridor behind the spine clinic was tested. The fire alarm strobe directly outside the spine clinic exit door failed. The strobe failed again at 10:09 a.m. when the second pull station in the corridor was tested. This fire alarm notification device was the closest in proximity to the spine clinic.

Pavilion
Penthouse:

5. At 8:34 a.m., on 4/8/16, there was a "ground fault" trouble exhibited on the fire alarm panel.

During an interview at 8:40 a.m., the fire alarm technician (F.A. Tech1) stated that water leaked into a device in the penthouse.

At 8:45 a.m., drops of water were observed leaking into a heat detector close to the new air handler and there was plastic wrapped around one side of the detector.


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Pavilion
Sixth Floor:

6. At 10:22 a.m., on 4/6/16, the manual pull stations in the Locked Unit were key-operated. Mental Health Technician (M.H.Tech1) was not equipped with a key to readily activate the manual pull stations.

During an interview at 10:23 a.m., M.H. Tech1 stated she would have to find the Charge Nurse to activate the manual pull station.

7. At 10:56 a.m., on 4/6/16, there were 5-gallon water bottles and other supplies that obstructed access to the fire alarm component boxes in the supplies room.

Based on observation, record review, and interview, the facility failed to maintain their automatic sprinkler systems and standpipe hose systems. This was evidenced by incomplete maintenance records for weekly, quarterly, annual, and five-year testing of the automatic sprinkler systems and standpipe hose systems. This was also evidenced by no records of repairing deficiencies listed during inspections, by a sprinkler pipe that was subject to an external load, by storage in close proximity to sprinkler heads, and by one leaking test valve. This could result in a delay in extinguishing a fire and could result in the increased risk of injury to patients, staff, and visitors. This affected the entire Culver City Campus, two of two offsite clinics, and one of six floors in the Hollywood Building.

NFPA 101, Life Safety Code, 2000 Edition
19.3.5.1 Where required by 19.1.6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.
Exception: In Type I and Type II construction, where approved by the authority having jurisdiction, alternative protection measures shall be permitted to be substituted for sprinkler protection in specified areas where the authority having jurisdiction has prohibited sprinklers, without causing a building to be classified as nonsprinklered.

9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 Edition.
1-8 Records. Records of inspections, tests, and maintenance of the system and its components shall be made available to the authority having jurisdiction upon request. Typical records include, but are not limited to, valve inspections; flow, drain, and pump tests; and trip tests of dry pipe, deluge, and preaction valves.

1-8.1 Records shall indicate the procedure performed (e.g., inspection, test, or maintenance), the organization that performed the work, the results, and the date.

1-8.2 Records shall be maintained by the owner. Original records shall be retained for the life of the system. Subsequent records shall be retained for a period of one year after the next inspection, test, or maintenance required by the standard.

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.

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.
Exception No. 1:Pipe and fittings installed in concealed spaces such as above suspended ceilings shall not require inspection.
Exception No. 2: Pipe installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown.

2-2.6 Alarm Devices. Alarm devices shall be inspected quarterly to verify that they are free of physical damage.

2-3.3 Alarm Devices. 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.

3-2.1 Components of standpipe and hose systems shall be visually inspected quarterly or as specified in Table 3-1.

3-3.1.1 A flow test shall be conducted at the hydraulically most remote hose connection of each zone of a standpipe system to verify the water supply still adequately provides the design pressure at the required flow. Where a flow test of the hydraulically most remote outlet(s) is not practical, the authority having jurisdiction shall be consulted for the appropriate location for the test. A flow test shall be conducted every 5 years.

Table 3-1 Summary of Standpipe and Hose System Inspection, Testing, and Maintenance
Components Activity Frequency Reference
Control valves Inspection Weekly/monthly Table 9-1
Pressure regulating devices Inspection Quarterly Table 9-1
Piping Inspection Quarterly 3-2.1
Hose connections Inspection Quarterly Table 9-1
Cabinet Inspection Annually NFPA 1962
Hose Inspection Annually NFPA 1962
Hose storage device Inspection Annually NFPA 1962
Alarm device Test Quarterly Table 9-1
Hose nozzle Test Annually NFPA 1962
Hose storage device Test Annually NFPA 1962
Hose Test 5 years/3 years NFPA 1962
Pressure control valve Test 5 years Table 9-1
Pressure reducing valve Test 5 years Table 9-1
Hydrostatic test Test 5 years 3-3.2
Flow test Test 5 years 3-3.1
Main drain test Test Annually Table 9-1
Hose connections Maintenance Annually
Valves (all types) Maintenance Annually/as needed Table 9-1

3-4 Maintenance. Maintenance/repairs shall be in accordance with 3-2.3 and Table 3-2.3.

Table 3-2.3 Standpipe and Hose Systems
If cabinet is break-glass type, is lock functioning properly? Repair or replace

9-2.7 Waterflow Alarm. All waterflow alarms shall be tested quarterly in accordance with the manufacturer's instructions.

9-3.3.1 All valves shall be inspected weekly.
Exception No. 1: Valves secured with locks or supervised in accordance with applicable NFPA standards shall be permitted to be inspected monthly.
Exception No. 2: After any alterations or repairs, an inspection shall be made by the owner to ensure that the system is in service and all valves are in the normal position and properly sealed, locked, or electrically supervised.

9-4.2 Check Valves
9-4.2.1 Inspection. Valves shall be inspected internally every 5 years to verify that all components operate properly, move freely, and are in good condition.

9-5.1.1 All valves shall be inspected quarterly. The inspection shall verify that the valves are in the following condition:
(a) In the open position
(b) Not leaking
(c) Maintaining downstream pressures in accordance with the design criteria
(d) In good condition, with handwheels installed and unbroken

9-7 Fire Department Connections.
9-7.1 Fire department connections shall be inspected quarterly. The inspection shall verify the following:
(a) The fire department connections are visible and accessible.
(b) Couplings or swivels are not damaged and rotate smoothly.
(c) Plugs or caps are in place and undamaged.
(d) Gaskets are in place and in good condition.
(e) Identification signs are in place.
(f) The check valve is not leaking.
(g) The automatic drain valve is in place and operating properly.
3-1 General. This chapter provides the minimum requirements for the routine inspection, testing, and maintenance of standpipe and hose systems. Table 3-1 shall be used to determine the minimum required frequencies for inspection, testing, and maintenance.
Exception: Valves and fire department connections shall be inspected, tested, and maintained in accordance with Chapter 9.

10.2.1 To ensure that piping remains clear of all obstructive foreign matter, an obstruction investigating shall be conducted for system or yard main piping wherever any of the following condition exits:
(a) Defective intake for fire pumps taking suction from open bodies of water.
(b) The discharge of obstructive material during routine water tests.
(c) Foreign materials in fire pumps, in dry pipe valves, or in check valves
(d) Foreign materials in water during drain tests or plugging of inspector's test connection(s)
(e) Plugged sprinklers
(f) Plugged piping in sprinklers system dismantled during building alterations.
(g) Failure to flush yard piping or surrounding public mains following new installations or repairs
(h) A record of broken public mains in the vicinity
(i) Abnormally frequent false tripping of a dry pipe valve (s)
(j) A system that is returned to service after an extended shutdown (greater than 1 year)
(k) There is reason to believe that the sprinkler system contains sodium silicate or highly corrosive fluxes in copper system.
(l) A system has been supplied with raw water via the fire department connection.

NFPA 13, Standard for the Installation of Sprinkler System, 1999 Edition.
5-14.3.2.1 Where corrosive conditions are known to exist due to moisture or fumes from corrosive chemicals or both, special types of fittings, pipes, and hangers that resist corrosion shall be used or a protective coating shall be applied to all un protected exposed surfaces of the sprinkler system. (see 3-2.6.)

Findings:

During a facility tour with staff from 4/4/16 to 4/8/16, the automatic sprinkler systems and standpipe systems were observed.

Offsite Spine Clinic:

1. At 3:30 p.m., on 4/4/16, maintenance records for the standpipe system were requested. At 9:05 a.m., on 4/7/16, records of a 9/21/13 inspection of the Class II wet standpipe system were provided. There were no records of inspecting the system and hoses annually.

At 9:56 a.m., on 4/7/16, the inspection tag on the standpipe system in the west exit corridor behind the Spine Clinic was dated January 2008.

At 10:27 a.m., on 4/7/16, the inspection tag on the fire hose in the lobby of the Culver Medical Plaza (CMP) was dated September 2012. The hose cabinet could not be opened but the tag was viewed through its window. The Vice President of Facilities (VPFS1) and Maintenance Staff (CMP Maint1) both confirmed the 2012 date of the tag.

2. At 10:30 a.m., on 4/7/16, CMP Maint1 could not find the keys to unlock the fire hose and fire extinguisher cabinets throughout the building.

Offsite IOP Clinic:

2. At 3:31 p.m., on 4/4/16, maintenance records for the fire pump and sprinkler system were requested. At 8:58 a.m., on 4/7/16, records showed that a five year inspection of the sprinkler system was conducted on 8/19/15 and that Brotman Physician Plaza Maintenance Staff (BBP Maint1) was running the fire pump weekly.

During an interview at 8:59 a.m., BPP Maint1 stated that only a five year inspection was conducted on the sprinkler system and no quarterly or annual inspections were scheduled for the system.

Hollywood
Third Floor:

3. At 3:01 p.m., on 4/6/16, the Inspector's Test Valve (ITV) in Stairwell 1 was tested. The valve was leaking at the stem.

During at 3:02 p.m., the Director of Facilities Services (DFS2) stated that the valve needed new packing.


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Culver City Campus:

4. The Culver City Campus was equipped with more than one automatic sprinkler system risers for the multiple buildings. The vendor reports indicated automatic sprinkler systems were tested and inspected at Watseka Street, Delmas Terrace, and Hughes Street. The facility stated that Delmas Terrace corresponded to both the Pavilion and Tower. The facility indicated that the Watsek Street report was for a warehouse. The facility could not clarify which building corresponded to the Hughes Street report.

At 10:01 a.m., on 4/5/16, the facility's sprinkler system inspection documents, dated 1/26/16 and 3/14/16, were reviewed. The report dated 1/26/16 indicated that sprinkler heads failed inspection due to approximately 18,800 recalled sprinkler heads that needed to be replaced.

During an interview at 4:15 p.m., all the maintenance and repairs records for the automatic fire sprinkler system for the Tower and Pavilion were requested from the Vice President of Facilities (VPFS1). A quote for replacing the sprinkler heads was provided. There was no documentation that confirmed when the recalled sprinkler heads would be replaced.

5. At 9:50 a.m., on 4/8/16, there were no documents of quarterly testing conducted for the Tower sprinkler system during the first quarter (January through March) of 2016. There were no records of fourth quarter (October to December) 2015 testing of the Pavilion and Tower sprinkler systems.

6. At 9:55 a.m., on 4/8/16, the facility failed to provide documents to show quarterly, annual, and 5 years/3 year inspections of the standpipe and hose systems of the Tower.

7. At 11: 20 a.m., on 4/8/16, the vendor report, for the five-year test conducted 9/22/14, indicated that interior inspection of the check valves were and fire department connection back flush were "not applicable." The facility was equipped with check valves and fire department connections. The facility failed to provide documentation of a complete five-year test of the Pavilion's automatic sprinkler system.

8. At 10:08 a.m., on 4/5/16, a maintenance log indicated incomplete weekly inspections of the control valves. The facility's policy was to inspect the control valves weekly. The records indicated weekly inspections were not conducted during one week in January 2016, during two weeks in February 2016, and during two weeks in March 2016.

Pavilion
Sixth Floor:

9. At 10:35 a.m., on 4/6/16, there were several layers of duct tape wrapped around the sprinkler pipe in the environmental services closet. The pipe had a red and silver label that hung from the wrapped pipe. The label indicated that it was an automatic flow control valve.

Basement- Surgery Suite:

10. At 10:53 a.m., on 4/7/16, the water dispersion pattern of the sprinkler head in the anesthesia supplies room was blocked by supplies located on two shelves. The supplies were positioned approximately 10 inches directly below the sprinkler head.

Based on observation, the facility failed to maintain their portable fire extinguishers. This was evidenced by fire extinguishers that were mounted greater than 5 feet from floor level. This affected one of six floors in the Pavilion and the basement of the Tower. This could result in a delay in accessing a fire extinguisher.

NFPA 101, Life Safety Code, 2000 Edition.
19.3.5.6 Portable fire extinguishers shall be provided in all health care occupancies in accordance with 9.7.4.1.

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.

NFPA 10, Standard for Portable Fire Extinguishers, 1998 Edition.
1-6.3 Fire extinguishers shall be conspicuously located where they will be readily accessible and immediately available in the event of fire. Preferably they shall be located along normal paths of travel, including exits from areas.

1-6.10 Fire extinguishers having a gross weight not exceeding 40 lb. (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft. (1.53 m) above the floor. Fire extinguishers having a gross weight greater than 40 lb. (18.14 kg) (except wheeled type) shall be so installed that the top of the fire extinguisher is not more than 3 1/2 ft. (1.07 m) above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 in. (10.2 cm).

Findings:

During a facility tour with staff from 4/4/16 to 4/8/16, the fire extinguishers were observed.

Pavilion
First Floor:

1. At 3:05 p.m., on 4/6/16, the top of the fire extinguisher in the laboratory, by the northeast exit, was mounted approximately 5 feet 7 inches from the floor.

2. At 3:15 p.m., on 4/6/16, the top of the fire extinguisher in the chemistry section of the laboratory was mounted approximately 5 feet 7 inches from the floor.

Tower
Basement:

3. At 10:39 a.m., on 4/7/16, the top of the fire extinguisher, located by the High Voltage Room, was mounted approximately 5 feet 7 inches from the floor.


29665

Based on observation and interview, the facility failed to maintain their heating, ventilating, and air conditioning (HVAC) system. This was evidenced by the use of a portable air conditioners (AC) that were exhausted into the return air inlets and by the failure to repair fire dampers that failed inspection. This was also evidenced by the use of temporary air handler that was unsecured in a public parking lot without approval from the authority having jurisdiction (AHJ). This affected one of seven floors of the Tower, one of six floors of Hollywood Building, and the Van Nuys Building. These deficient practices could result in the faster spread of smoke and fire through the HVAC system, an unapproved change in the air exchange rate, and the increased risk of injury from the unsecured temporary air handler.

NFPA 101, Life Safety Code, 2000 Edition.
19.5.2.1 Heating, ventilating, and air conditioning shall comply with the provisions of Section 9.2 and shall be installed in accordance with the manufacturer ' s specifications.
Exception: As modified in 19.5.2.2.

9.2.1 Air Conditioning, Heating, Ventilating Ductwork, and Related Equipment. Air conditioning, heating, ventilating ductwork, and related equipment shall be in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, or NFPA 90B, Standard for the Installation of Warm Air Heating and Air-Conditioning Systems, as applicable, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

8.2.3.2.4.1 Openings in fire barriers for air-handling duct work or air movement shall be protected in accordance with 9.2.1.

NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, 1999 Edition.
2-1.2 Equipment shall be selected and installed based on its proper application with respect to the manufacturer's installation instructions and listing as applicable.

2-1.3 Equipment shall be guarded for personnel protection and against the intake of foreign matter into the system.

2-2.4.1 Installation. Heating and cooling equipment shall be installed in accordance with the applicable NFPA standards and the manufacturer's instructions. The equipment shall be approved for the specific installation.

2-2.4.3 Mechanical Cooling. Mechanical refrigeration used with air duct systems shall be installed in accordance with recognized safety practices. Installations conforming to ANSI/ASHRAE 15, Safety Code for Mechanical Refrigeration, shall be considered in compliance with these requirements.

2-3.1.2 Air ducts shall be permitted to be rigid or flexible and shall be constructed of materials that are reinforced and sealed to satisfy the requirements for the use of the air duct system, such as the supply air system, the return or exhaust air system, and the variable volume/pressure air system.

2-3.1.3 All air duct materials shall be suitable for continuous exposure to the temperature and humidity conditions of the environmental air in the air duct.

2-3.7 Air Inlets -- Return or Exhaust or Return and Exhaust
2-3.7.1 General. Air shall not be recirculated from any space in which flammable vapors, flyings, or dust is present in quantities and concentrations that would introduce a hazardous condition into the return air system.

3-1.4 Other Spaces Housing Air-Handling Units. Other spaces housing air-handling units shall meet the requirements of the building code the authority having jurisdiction

3-3.1.2 Approved fire dampers shall be provided in all air transfer openings in partitions that are required to have a fire resistance rating and in which other openings are required to be protected.

3-3.3 Floor- or Roof- Ceiling Assemblies having a fire Resistance Rating. Where air ducts and openings for air ducts are used in a floor- or roof-ceiling assembly that is required to have fire resistance rating, all the materials and the construction of the assembly, including the air duct materials and the size and protection of the openings, shall conform with the design of the fire-resistive assembly, as tested in accordance with NFPA 251, Standard Methods of Tests of Fire Endurance of Building Construction and Materials. (Where dampers are required, see 3-4.4.)

Findings:

During a facility tour with staff from 4/4/16 to 4/8/16, the HVAC systems were observed.

Tower
Second Floor:

1. At 12:20 p.m., on 4/4/16, records indicated that fire dampers on the second floor of the tower were tested on 2/26/16. The "Fire Damper Repair" portion of the testing report indicated that Dampers 2-003, 2-004, 2-005, 2-006, 2-008, 2-017, and 2-019 did not pass inspection because the dampers were "missing."

This finding was previously cited during a Life Safety Code Survey conducted in December 2015. During that survey, there were no records of repairing five of these dampers (2-003, 2-004, 2-005, 2-006, and 2-008) after they failed testing on 11/4/10.

Van Nuys:

2. At 10:57 a.m., on 4/6/16, there was a temporary air handler on wheels outside the kitchen in the west parking lot. There was no permit for this air handler and it was not anchored. The Director of Facilities Services (DFS3) slightly pushed the unit and it was unstable. The air handler was close to the cars in the parking lot and was not secured. This portable air handler was cited during the last Life Safety Code survey in December 2015.

During an interview at 10:58 a.m., DFS2 stated that the temporary air handler has not yet been inspected by the Office of Statewide Health Planning and Development (OSHPD) but an application to replace the kitchen HVAC was requested in October 2015. He stated that Project S152795-19-00 has not yet been approved.


Hollywood
First Floor:

3. At 2:34 p.m., on 4/6/16, there was a portable air conditioner (AC) in the clinical laboratory. It was vented into the return vent which was covered with a thin piece of vinyl. This deficiency was previously cited during the Life Safety Code survey in December 2015.

During an interview at 2:35 p.m., the Chief Engineer (CE1) stated that the AC was removed after the last survey and does not know who put it back.
Air exchange reports indicated that the clinical laboratories required a minimum air exchange per hour (ACH) of 4. The portable AC was vented into the only return air vent of the laboratory.


29566

Based on observation, record review, and interview, the facility failed to maintain their commercial cooking equipment. This was evidenced by no records of repairing deficiencies noted during a vendor's hood inspection, by no evidenced of conducting a hydrostatic test on the wet chemical suppression system, and by one K-Class fire extinguisher that required a recharge. This affected one of six floors in the Hollywood Building and one of four smoke compartments in Van Nuys Building. This could result in a delay in extinguishing a grease fire and the increased risk of injury to patients, staff, and visitors.

NFPA 101, Life Safety Code, 2000 Edition.
19.3.2.6 Cooking Facilities. Cooking facilities shall be protected in accordance with 9.2.3.
Exception: Where domestic cooking equipment is used for food-warming or limited cooking, protection or segregation of food preparation facilities shall not be required.

9.2.3 Commercial Cooking Equipment. Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 1998 Edition.
1-3.1 Cooking equipment used in processes producing smoke or grease-laden vapors shall be equipped with an exhaust system that complies with all the equipment and performance requirements of this standard, and all such equipment and performance shall be maintained per this standard during all periods of operation of the cooking equipment. Specifically, the following equipment shall be kept in good working condition:
(a) Cooking equipment
(b) Hoods
(c) Ducts (if applicable)
(d) Fans
(e) Fire suppression system
(f) Special effluent or energy control equipment
All airflows shall be maintained. Maintenance and repairs shall be performed on all components at intervals necessary to maintain these conditions.

1-3.1.3 All interior surfaces of the exhaust system shall be reasonably accessible for cleaning and inspection purposes.

7-2.1 Fire-Extinguishing equipment shall include both automatic fire-extinguishing systems as primary protection and portable fire extinguishers as secondary backup.

8.3.1 Hoods, Grease removal devices, fans, ducts, and other appurtenances shall be cleaned to bare metal at frequent intervals prior to surfaces becoming heavily contaminated with grease or oily sludge. After the exhaust system is cleaned to bare metal, it shall not be coated with power or there substance. The entire exhaust system shall be inspected by a properly trained, qualified, and certified company or person(s) acceptable to the authority having jurisdiction in accordance with Table 8-3.1

Findings:

During a tour of the facility with staff from 4/6/14 to 4/8/16, the commercial cooking equipment was observed.

Hollywood
First Floor:

1. At 11:11 a.m., on 4/5/16, records of the most recent kitchen hood cleaning and inspection was reviewed. The vendor noted, on 3/31/16, that the exhaust fan belt needed to be replaced, there were areas in the hood that were inaccessible for cleaning, and that there was leaking ductwork in the hood. There were no records of repairing the deficiencies.

During an interview at 11:12 a.m., the Director of Facilities (DFS2) stated that the facility was working on getting a quote for the repairs.

2. At 11:15 a.m., on 4/5/16, records of a 10/15/15 kitchen fire suppression system inspection was reviewed. The vendor indicated that the date of the last hydrostatic test was not known.

During an interview at 2:32 p.m., DFS2 stated that the wet chemical cylinder was not marked with the date of its last hydrostatic test and he was unsure if a hydrostatic test was conducted in the last 12 years.

Van Nuys:

3. At 11:19 a.m., on 4/6/16, the gauge on the K-Class fire extinguisher in the kitchen indicated that the extinguisher needed to be recharged.

Based on observation and interview, the facility failed to ensure that means of egress were free from obstructions. This was evidenced by items blocking the egress paths and by walk-in freezers that could not be opened from the inside when locked. This could result in the delay in evacuation and the increased risk of injury to the patients and staff during an emergency. This affected the basement and one of six floors of the Pavilion.

NFPA 101, Life Safety Code, 2000 Edition.
19.2.1 General. Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7.
Exception: As modified by 19.2.2 through 19.2.11.

7.1.6.1 General. Walking surfaces in the means of egress shall comply with 7.1.6.2 through 7.1.6.4.
Exception: Existing walking surfaces shall be permitted where approved by the authority having jurisdiction.
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.
7.1.10.2.1 No furnishings, decorations, or other objects shall obstruct exits, access thereto, egress therefrom, or visibility thereof.

7.1.10.2.1 No furnishings, decorations, or other objects shall obstruct exits, access thereto, egress therefrom, or visibility thereof.

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.
Exception No. 1: This requirement shall not apply where otherwise provided in Chapters 18 through 23.
Exception No. 2: Exterior doors shall be permitted to have key-operated locks from the egress side, provided that the following criteria are met:
(a) Permission to use this exception is provided in Chapters 12 through 42 for the specific occupancy.
(b) On or adjacent to the door, there is a readily visible, durable sign in letters not less than 1 in. (2.5 cm) high on a contrasting background that reads as follows:
THIS DOOR TO REMAIN UNLOCKED WHEN THE BUILDING IS OCCUPIED
(c) The locking device is of a type that is readily distinguishable as locked.
(d) A key is immediately available to any occupant inside the building when it is locked.
Exception No. 2 shall be permitted to be revoked by the authority having jurisdiction for cause.
Exception No. 3: Where permitted in Chapters 12 through 42, key operation shall be permitted, provided that the key cannot be removed when the door is locked from the side from which egress is to be made.

Findings:

During a facility tour with staff from 4/4/16 to 4/8/16, the egress paths were observed.

Pavilion
Basement:

1. At 10:52 a.m., on 4/7/16, there were surgical supply carts and surgical equipment stored in the means of egress of the surgical suite, leaving less than 4 feet clear width for egress.

2. At 10:57 a.m., on 4/7/16, there were urology surgical supplies on carts stored in the means of egress of the surgical suite directly across from the exit door of the suite.

The facility failed to ensure that egress paths were free from obstructions.

First Floor:

3. At 2:40 p.m., on 4/5/16, there were two walk-in freezers in the kitchen that were equipped with exterior padlocks for closure. The padlocks were hanging from the doors. One walk-in freezer had a broken handle that was broken and modified for use with a padlock. If the freezers were closed and locked, kitchen staff would have no mechanism to exit the freezers from the inside.

Based on observation, the facility failed to maintain their medical gas storage areas. This was evidenced by a light switch in an oxygen storage room that was mounted less than 5 feet from floor level. This affected one of six floors in the Pavilion and could result in the increased risk of hazardous conditions.

NFPA 101, Life Safety Code, 2000 Edition
19.3.2.4 Medical Gas.
Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.

NFPA 99, Standard for Health Care Facilities, 1999 Edition
1-2 Application
Chapters 12 through 18 specify the conditions under which the requirements of Chapters 3 through 11 shall apply in Chapters 12 through 18.

Chapter 12 Hospital Requirements
12-1 Scope. This chapter addresses safety requirements of hospitals.
12-3.4.1 If installed, patient gas systems shall conform to Level 1 gas systems of Chapter 4.
12-3.8.1 Patient. Equipment shall conform to the patient equipment requirements in Chapter 8, "Gas Equipment."
12-3.8.2 Nonpatient. Equipment shall conform to the non-patient equipment requirements in Chapter 8, "Gas Equipment."

Chapter 8 Gas Equipment
8-3.1.11.2 Storage for nonflammable gases less than 3000 ft3 (85 m3).
(c) Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or incompatible materials by either:
1. A minimum distance of 20 ft (6.1 m), or
2. A minimum distance of 5 ft (1.5 m) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, or
3. An enclosed cabinet of noncombustible construction having a minimum fire protection rating of one-half hour for cylinder storage. An approved flammable liquid storage cabinet shall be permitted to be used for cylinder storage.
(f) Electrical fixtures in storage locations shall meet 4-3.1.1.2(a)11d.
(h) Cylinder or container restraint shall meet 4-3.5.2.1(b)27.
(i) Smoking, open flames, electric heating elements, and other sources of ignition shall be prohibited within storage locations and within 20 ft (6.1 m) of outside storage locations.

4-3.1.1.2 Storage Requirements (Location, Construction, Arrangement).
(a) Nonflammable Gases (Any Quantity; In-Storage, Connected, or Both)
11. Construction and Arrangement of Supply System Locations.
d. Ordinary electrical wall fixtures in supply rooms shall be installed in fixed locations not less than 5 ft (1.5 m) above the floor to avoid physical damage.

Findings:

During a facility tour with staff from 4/4/16 to 4/8/16, the medical gas cylinders were observed.

Pavilion Building
Third Floor:

1. At 12:01 p.m., on 4/6/16, there were 4 H-sized oxygen cylinders and 7 E-sized oxygen cylinders stored in the oxygen storage room. The light switch was installed approximately 4 feet 6 inches high from the floor.
The above measurement was confirmed by the Director of Facilities Services (DFS1).

Based on record review and interview, the facility failed to maintain their piped-in medical gas systems. This was evidenced by the absence of an emergency oxygen supply connection. This affected the patients in the Pavilion. This could result in the delay in emergency response upon failure of the piped-in system and the increased risk of hazardous conditions.

NFPA 101, Life Safety Code, 2000 Edition
19.3.2.4 Medical Gas.
Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.

NFPA 99, Standard for Health Care Facilities, 1999 Edition
1-2 Application
Chapters 12 through 18 specify the conditions under which the requirements of Chapters 3 through 11 shall apply in Chapters 12 through 18.

Chapter 12 Hospital Requirements
12-1 Scope. This chapter addresses safety requirements of hospitals.
12-3.4.1 If installed, patient gas systems shall conform to Level 1 gas systems of Chapter 4.

12-3.4.3 If installed, patient vacuum systems shall conform to the safe use of electric appliances. to Level 1 vacuum systems of Chapter 4.

4-3.1.1.8 General Requirements for Gas Central Supply Systems. Piped oxygen and medical air shall not be piped to or used for, any purpose except for use in patient care applications.
(h)Emergency Oxygen Supply Connection. Where the cryogenic oxygen supply is located outside of the building served, there shall be incorporated in the piping system an inlet for connecting a temporary auxiliary source of supply for emergency or maintenance situations. The inlet shall be located on the exterior of the building served and shall be physically protected to prevent tampering and unauthorized access. It shall be labeled "EMERGENCY LOW PRESSURE GASEOUS OXYGEN INLET." This connection shall be installed downstream of the shutoff valve on the main supply line (see 4-3.1.2.3(b)) and be suitably controlled with the necessary valves to allow emergency supply of oxygen and isolation of the piping to the normal source of supply. It shall have one check valve in the main line between the main line shutoff valve and the tee'd connection and one check valve between the tee'd connection and the emergency supply shutoff valve.

Findings:

During a facility tour with staff from 4/4/16 to 4/8/16, the piped-in medical gas system was observed.

Pavilion:

1. The facility was previously cited because the cryogenic system was not equipped with an emergency oxygen supply connection (oxygen autofill port) during a Life Safety Code Survey conducted in December 2015.

At 3:52 p.m., on 4/4/16, the Vice President of Facilities (VPFS1) provided an Office of Statewide Health Planning and Development (OSHPD) application for a new project to install the oxygen fill port and generator alarm (See K144). The autofill port was not installed yet.

During an interview at 3:53 p.m., VPFS1 stated that Project S160471-19-00 was still in the review phase and has not yet been approved.

Based on observation, record review, and interview, the facility failed to maintain the relative humidity levels in the anesthetizing locations. This was evidenced by the adoption of policies to lower the humidity in Operating Rooms (ORs) below 35% without providing documentation confirming election to utilize a categorical waiver in accordance with Centers for Medicare & Medicaid Services Survey & Certification Letter S&C: 13-25-LSC. This was also evidenced by a major repair of humidifiers after they were abandoned for more than 20 years without the inspection of the authority having jurisdiction (AHJ). This affected all the ORs in the Pavilion and in the Hollywood Building. This could result in the increased risk of a fire and the increased risk of injury to surgical patients.

NFPA 101, Life Safety Code, 2000 Edition.
19.3.2.3 Anesthetizing locations shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.

4.6.1.1 The authority having jurisdiction shall determine whether the provisions of this Code are met.

4.6.1.2 Any requirements that are essential for the safety of building occupants and that are not specifically provided for by this Code shall be determined by the authority having jurisdiction.

NFPA 99, Standard for Health Care Facilities, 1999 Edition
Chapter 5 Environmental Systems
5-4.1.1 The mechanical ventilation system supplying anesthetizing locations shall have the capability of controlling the relative humidity at a level of 35 percent or greater.

5-6.1 Anesthetizing Locations.
5-6.1.1 Ventilating and humidifying equipment for anesthetizing locations shall be kept in operable condition and be continually operating during surgical procedures.

Findings:

During document review with staff from 4/4/16 to 4/8/16, the humidity logs were reviewed.

Pavilion and Hollywood:

1. At 3:45 p.m., on 4/4/16, there were no categorical waivers provided during, and more than five hours after, the entrance conference. The policy for maintaining humidity in the ORs stated that the facility will follow the Association of periOperative Registered Nurses (AORN) standard recommended humidity range of 30 to 60 percent. This policy stated that it was applicable to the Culver City Campus and Hollywood Campus.

The facility did not provide documentation of their election to utilize the categorical waiver per Centers for Medicare & Medicaid Services Survey & Certification Letter S&C: 13-25-LSC, dated 4/19/13 to lower relative humidity in the anesthetizing locations below 35%. This finding was previously cited during a Life Safety Code Survey conducted in December 2015.

Hollywood
Basement:

2. At 9:12 a.m., on 4/5/16, new humidistats were observed in the three ORs, in Pre-Op, and in the Recovery Room. Above the ceiling, new humidifiers were observed connected to the steam lines.

During an interview at 9:13 a.m., the Director of Facilities Services (DFS2) stated that the new humidifiers were installed in March 2016. He said that the rooms were always equipped with humidity controls but they had been put out of service.

During an interview at 9:14 a.m., the Chief Engineer (CE1) stated that the previous humidifiers were abandoned more than 20 years ago.

At 2:46 p.m., the building's mechanical blue prints from 1960 showed that humidifiers were connected to the steam pipe lines for the ORs and that the rooms were equipped with humidistats and thermostats.

During an interview at 2:47 p.m., DFS2 stated that humidifier replacement parts were ordered from an HVAC vendor but the installation was conducted by facility engineers and a general contractor. He stated that the Office of Statewide Health Planning and Development was not notified of the repair.


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Based on observation, record review, and interview, the facility failed to ensure that equipment was installed in accordance with manufacturer's specifications and was approved by the authority having jurisdiction (AHJ). This was evidenced by medication dispensers that were not seismically anchored and by a commercial washer and dryer that were installed without field review and approval. This affected the basement of the Hollywood Building and one of six floors of the Pavilion. This could result in the increased risk of injury and could result in the increased risk of a lint fire.

NFPA 101, Life Safety Code, 2000 Edition.
4.5.7 Maintenance. Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be maintained unless the Code exempts such maintenance.

4.6.1.1 The authority having jurisdiction shall determine whether the provisions of this Code are met.

4.6.1.2 Any requirements that are essential for the safety of building occupants and that are not specifically provided for by this Code shall be determined by the authority having jurisdiction.

NFPA 99, Standard for Health Care Facilities, 1999 Edition.
Chapter 9 Manufacturer Requirements
9-1 Scope. This chapter covers the performance, maintenance, and testing, with regard to safety, required of manufacturers of equipment used within health care facilities.

9-2.1.1.2 Mechanical Stability. The appliance shall be mechanically stable in the position of normal use. If the appliance is intended for use in an anesthetizing location, 12-4.1 applies.

9-2.1.6.3 Chemical Agents. Electric appliances containing hazardous chemicals shall be designed to facilitate the replenishment of these chemicals without spillage to protect the patient, the operating personnel, and the safety features of the appliance from such chemicals.

Findings:

During a facility tour with staff from 4/4/16 to 4/8/16, the medication dispensers and laundry equipment were observed.

Hollywood
Basement:

1. At 9:35 a.m., on 4/5/16, there was an approximately 6 foot 5 inch tall medication cabinet directly across from the bed in the recovery room. The medication cabinet was not anchored and this was confirmed by the Director of Facilities Services (DFS2).

During an interview at 3:40 p.m., on 4/6/16, Pharmacy Staff 1 stated that the medication cabinet in the recovery room was installed two weeks ago.

The manufacturer's specifications for the cabinet contained Seismic Specifications in Appendix B. The instructions contained pre-approved plans for anchoring from the Office of Statewide Health Planning and Development (OSHPD) and that were in accordance with the 2013 California Building Code.


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Pavilion
Sixth Floor:

2. At 11:05 a.m., on 4/5/16, there was an approximately 6 foot high medication cabinet in the medication room that was not anchored. The facility failed to provide documents to show that installation of the cabinet was approved and seismically anchored. The cabinet could fall over, block means of egress, and cause injury during a disaster.

3. At 10:59 a.m., on 4/6/16, the facility installed a commercial washer and dryer in the soiled linen/laundry without approval from the authority having jurisdiction (AHJ). The AHJ would ensure all applicable local, State and Federal safety codes are implemented. The drain pipe was made of a flexible material coming from the back of the washer went up and then down into a pipe behind the commercial dryer. The dryer exhaust was vented into a container on the floor.

During an interview at 11:00 a.m., the Vice President of Facilities (VPFS1) stated the flexible pipe was the drain for the washer and could not provide documents to show that the commercial washer and dryer were installed with approval from the AHJ.

The facility installed the commercial washer and dryer without field review and approval from the AHJ to ensure the electrical, plumbing, and exhaust systems met the fire and safety codes for healthcare facilities.

Based on observation, record review, and interview, the facility failed to maintain their emergency generators. This was evidenced by generators that were not monitored by remote alarm annunciators, by the use of a portable generator without approval, by the failure to correct a deficiency noted during generator service inspection, and by one generator with a battery charger that required a load study. This affected the Pavilion, the Tower, the Hollywood Building, and the Van Nuys Building. This could result in the increased risk of generator failure, in the event of a power outage, and the increased risk of injury to the patients.

NFPA 101, Life Safety Code, 2000 Edition.
7.9.2.3 Emergency generators providing power to emergency lighting systems shall be installed, tested, and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. Stored electrical energy systems, where required in this Code, shall be installed and tested in accordance with NFPA 111, Standard on Stored Electrical Energy Emergency and Standby Power Systems.

9.1.3 Emergency Generators. Emergency generators, where required for compliance with this Code, shall be tested and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power System.

NFPA 99, Standard for Health Care Facilities, 1999 Edition.
3-4.1.1.4 General. Generator sets installed as an alternate source of power for essential electrical systems shall be designed to meet the requirements of such service.
(a) Type I and Type II essential electrical system power (107C) or the engine water-jacket temperature at not less than sources shall be classified as Type 10, Class X, Level 1 generator sets per NFPA 110, Standard for Emergency and Standby Power Systems.

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:
1. When the emergency 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. Over crank (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.

NFPA 70 , National Electrical Code, 1999 Edition
700-12 The annunciator shall indicate alarm condition 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

3-5.5.2 (d) Battery powered individual alarm indication to annunciate visually at the control panel the occurrence of any of the conditions in Table 3-5.5.2 (d); additional contacts or circuits for a common audible alarm that signals locally and remotely when any of the itemized conditions occurs. A lamp test switch(es) shall be provided to test the operation of all alarm lamps listed in Table 3-5.5.2(d).

3-5.6.1 A remote,, common audible alarm powered by the storage battery shall be provided as specified in 3-5.5.2(d). This remote alarm shall be located outside of the EPS service room at a work site readily observable by personnel.

NFPA 110, Standard for Emergency and Standby Power Systems, 1999 edition.
1-1.3 This standard covers installation, maintenance, operation, and testing requirements as they pertain to the performance of the emergency power supply system (EPSS).

1-3 Application. This document applies to new installations of EPSSs. Existing systems shall not be required to be modified to conform, except where the authority having jurisdiction determines that nonconformity presents a distinct hazard to life.

1-4 Discretionary Powers of the Authority Having Jurisdiction. Nothing in this document is intended to prevent the use of systems, methods, or devices of equivalent or superior quality, strength, fire resistance, effectiveness, durability, and safety to those prescribed by this document, provided the following:
(a) Technical Justification is submitted to the authority having jurisdiction to demonstrate equivalency.
(b) The system, method, or device is approved for intended use.

2-2.4 Level. It is recognized that EPSSs are utilized in many different locations and for many different purposes. The requirement for one application might not be appropriate for other applications. Therefore, this standard recognizes two levels of equipment installation, performance, maintenance, and testing.

2-2.4.1 Level 1 defines the most stringent equipment performance requirements for applications where failure of the equipment to perform could result in loss of human life or serious injuries. All Level 1 equipment shall be permanently installed.

2-2.4.2 Level 2 defines equipment performance requirements for applications where failure of the EPSS to perform is less critical to human life and safety and where it is expected that the authority having jurisdiction will exercise its option to allow a higher degree of flexibility than provided by Level 1. All Level 2 equipment shall be permanently installed.

3-5.5.2 An automatic control and safety panel shall be a part of the EPS and shall contain the following equipment or possess the following characteristics, or both:
(a) Cranking control equipment to provide the complete cranking cycle described in 3-5.4.2 and Table 3-5.4.2.
(b) A panel-mounted control switch(es) marked " run-off-automatic " to perform the following functions:
1. Run: Manually initiate, start, and run prime mover
2. Off: Stop prime mover or reset safeties, or both
3. Automatic: Allow prime mover to start by closing a remote contact and stop by opening the remote contact
(c) Controls to shut down and lock out the prime mover under the following conditions: failing to start after specified cranking time, overspeed, low lubricating-oil pressure, high engine temperature, or operation of remote manual stop station. An automatic engine shutdown device for high lubricating-oil temperature shall not be required. (See 3-5.5.6.)
(d) Battery-powered individual alarm indication to annunciate visually at the control panel the occurrence of any of the conditions in Table 3-5.5.2(d); additional contacts or circuits for a common audible alarm that signals locally and remotely when any of the itemized conditions occurs. A lamp test switch(es) shall be provided to test the operation of all alarm lamps listed in Table 3-5.5.2(d).
(e) Controls to shut down the prime mover upon removal of the initiating signal or manual emergency shutdown.
(f) The ac instruments listed in 3-5.9.7. Where the control panel is mounted on the energy converter, it shall be mounted by means of antivibration shock mounts, if required, to maximize reliability.

3-5.6 Remote Controls and Alarms
3-5.6.1 A remote, common audible alarm powered by the storage battery shall be provided as specified in 3-5.5.2 (d). This remote alarm shall be located outside of the EPS service room at a work site readily observable by personnel.

3-5.6.2 An alarm-silencing means shall be provided, and the panel shall include repetitive alarm circuitry so that, after the audible alarm is silenced, it is reactivated after clearing the fault condition and must be restored to its normal position to be silenced.
Exception: In lieu of the requirement of 3-5.6.2, a manual alarm-silencing means shall be permitted that silences the audible alarm after the occurrence of the alarm condition, provided such means do not inhibit any subsequent alarms from sounding the audible alarm again without further manual action.

3-5.10 Miscellaneous Considerations.
3-5.10.1 Where applicable, the prime mover and generator shall be factory mounted on a common base of sufficient rigidity in order to maintain satisfactory dynamic alignment of the rotating element of the system prior to shipment to the installation site.

3-5.10.2 A certification shall be supplied with the unit that verifies the torsional vibration compatibility of the rotating element of the prime mover and generator for the intended use of the energy converter.

3-5.10.3 Vibration isolators, as necessary, shall be furnished to minimize vibration transmission to the permanent structure. Where unusual vibration conditions are anticipated, adequate isolation treatment shall be supplied.

5-13 Installation acceptance
5-13.1 Upon completion of the installation of the EPSS, the EPS shall be tested to ensure conformity to the requirements of the standard with respect to both power output and function. The authority having jurisdiction shall be given advance notification of the time at which the final test is to be performed so that the authority can witness the test.

Findings:

During a facility tour with staff on 4/4/16 to 4/8/16, the facility generators were observed.

Culver City Campus:

1. The facility was previously cited during a Life Safety Code Survey conducted in December 2015 because there were no remote alarm annunciators monitoring the status of three of three generators.

At 3:52 p.m., on 4/4/16, the Vice President of Facilities (VPFS1) provided an Office of Statewide Health Planning and Development (OSHPD) application for a new project to install the oxygen fill port (See K77) and the "generator alarm." The remote annunciators were not installed yet.
During an interview at 3:53 p.m., VPFS1 stated that Project S160471-19-00 was still in the review phase and has not yet been approved.

2. At 3:56 p.m., on 4/4/16, a report showed that a vendor was called to the facility on 2/19/16 because the portable generator for the Emergency Department (ED) Decontamination (Decontam) trailer would not start. The vendor indicated on the report that it was due to a bad battery that had been overcharged. He reported that the generator was equipped with a manual plug-in type battery charger but it needed to be replaced by an automatic battery charger to avoid overcharging.

During an interview at 4:14 p.m., on 4/7/16, the Plant Operations Lead Staff (PO1) stated that the facility has not changed the battery charger yet because they were waiting for a quote.

Van Nuys:

3. The facility was previously cited during a Life Safety Code Survey conducted in December 2015 because there was no remote alarm annunciators monitoring the status of the generator.

At 8:31 a.m., on 4/6/16, the Director of Facilities Services (DFS2) provided a copy of a March 2016 application to OSHPD to install an annunciation panel at the nurses station.

At 11:35 a.m., there was a low fuel sensor alarm for the generator's main diesel tank at the Unit 2 nurses station but no remote alarm annunciator. There was a new derangement signal connected to the low fuel sensor alarm.

During an interview at 11:36 a.m., DFS2 stated that the derangement signal has been installed temporarily until the annunciator project was approved.

Hollywood:

4. At 4:26 p.m., on 4/6/16, the latest field visit report from the OSHPD Compliance Officer (CO) indicated that Project S151968-19-00 for installation of a new generator battery charger was at 95% complete. The report, dated 1/20/16, stated that a load study was needed to complete the project.

During a telephone interview at 4:27 p.m., the Project Manager (PM1) stated that he was unsure who was in charge of this project and the load study was not yet completed.


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Tower:

5. At 3:40 p.m., on 4/5/16, facility installed temporary Biohazard Decontamination trailer (see Finding 2) with a portable generator in the parking lot next to the Emergency Department without the approval from authority having jurisdiction (AHJ). The portable generator was hooked up to the permanent essential electrical system without approval.

During an interview at 3:41 p.m., on 4/5/16, the Plant Operations Lead Staff (PO1) stated the trailer was connected to the facility's generator, electrical power, and water systems.

During an interview at 9:12 a.m., on 4/6/16, the OSHPD Fire Life Safety Officer (FLSO) stated that the facility needed permission from state AHJ to ensure the safety of the trailer and ensure that utility connections to the hospital utilities met all local, state, and federal safety codes.

During an interview at 2:43 p.m., on 4/6/16, the Manager of Environmental Health and Safety (MEHS1) stated the temporary decontamination trailer was installed approximately 8 years ago (2008).

During an interview at 4:35 p.m., on 4/6/16, PM1 stated he was unaware of the temporary biohazard decontamination trailer unit.

Based on observation, record review, and interview, the facility failed to maintain their electrical wiring. This was evidenced by the use of power strips and extension cords in lieu of permanent wiring and by electrical boxes with no covers. This was also evidenced by no records of inspecting a power strip mounted on medical equipment. This affected two of six floors and the basement of the Hollywood Building, the basement of the Van Nuys Building, one of six floors of the Pavilion, and one of seven floors of the Tower. These deficient practices could result in the increased risk of an electrical fire and the increased risk of harm to patients, staff, and visitors.

NFPA 101, Life Safety Code, 2000 Edition.
19.5.1 Utilities. Utilities shall comply with the provisions of Section 9.1.
Exception: Existing installations shall be permitted to be continued in service, provided that the systems do not present a serious hazard to life.

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.

NFPA 70, National Electrical Code, 1999 Edition.
110-3. Examination, Identification, Installation, and Use of Equipment.
(a) Examination. In judging equipment, considerations such as the following shall be evaluated:
(1) Suitability for installation and use in conformity with the provisions of this Code
FPN: Suitability of equipment use may be identified by a description marked on or provided with a product to identify the suitability of the product for a specific purpose, environment, or application. Suitability of equipment may be evidenced by listing or labeling.
(2) Mechanical strength and durability, including, for parts designed to enclose and protect other equipment, the adequacy of the protection thus provided
(3) Wire-bending and connection space
(4) Electrical insulation
(5) Heating effects under normal conditions of use and also under abnormal conditions likely to arise in service
(6) Arcing effects
(7) Classification by type, size, voltage, current capacity, and specific use
(8) Other factors that contribute to the practical safeguarding of persons using or likely to come in contact with the equipment
(b) Installation and Use. Listed or labeled equipment shall be installed and used in accordance with any instructions included in the listing or labeling.

240-4 Flexible cord, including tinsel cord and extension cords, and fixture wires shall be protected against overcurrent by either (a) or (b).
(a) Ampacities. Flexible cord shall be protected by an overcurrent device in accordance with its ampacity as specified in Tables 400-5(A) and (B). Fixture wire shall be protected against overcurrent in accordance with its ampacity as specified in Table 402-5. Supplementary overcurrent protection, as in Section 240-10, shall be permitted to be an acceptable means for providing this protection.

370-25 In completed installations, each box shall have a cover, faceplate, or fixture canopy.

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

Findings:

During a facility tour with staff from 4/4/16 to 4/8/16, the electrical wiring was observed.

Hollywood
Basement:

1. At 9:48 a.m., on 4/5/16, there was a Bovie Cautery plugged into a four-plug power strip in Operating Room (OR) 3.

First Floor:

2. At 2:36 p.m., on 4/6/16, the blood bank freezer in the clinical laboratory was plugged into an extension cord.

Third Floor:

3. At 3:08 p.m., on 4/6/16, there was a duplex outlet with no cover in the nurses lounge.

4. At 3:18 p.m., on 4/6/16, there was a duplex outlet with no cover in the alcove of Room 308.

Fourth Floor:

5. At 3:30 p.m., on 4/6/16, the refrigerator in the utility room was plugged into a yellow extension cord.

Van Nuys
Basement:

6. At 10:37 a.m., on 4/6/16, there were water stains in the ceiling tiles around the light ballast in the closet of the Human Resources Office.

During an interview at 10:38 a.m., the Directors of Facilities Services (DFS2 2 and 3) stated that the shower in Room 104 was leaking directly above this closet. They stated that it has not been fixed.

7. At 10:47 a.m., on 4/6/16, the junction box near the fan coil in the linen closet was missing a cover.


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Pavilion
Fourth Floor:

8. At 11:55 a.m., on 4/6/16, there was a refrigerator plugged into a multi-plug power strip in the Acute Rehab Office.

Tower
Third Floor:

9. At 9:31 a.m., on 4/7/16, facility failed to provide documents to show inspection and testing of the power strip attached to the patient Pal I.V. stand located in the equipment room by the nurses station on the 3rd floor. The patient Pal I.V. stand did not have the facility's biomedical engineer sticker of inspection.

Based on record review, the facility failed to ensure that fire watch rounds were conducted in accordance with the instructions from the authority having jurisdiction (AHJ). This affected the penthouse of the Pavilion and could result in a delay in extinguishing a fire in the mechanical room.

Findings:

During record review with staff from 4/4/16 to 4/8/16, the fire watch logs were provided.

Pavilion
Penthouse:

1. At 11:02 a.m., on 4/4/16, there was scaffolding blocking the spray pattern of the sprinkler heads in the mechanical room. The scaffolding was erected as part of an HVAC (heating, ventilating, and air-conditioning) restoration project after a fire in the penthouse destroyed an air handler on 1/29/15. The facility was instructed by the local fire marshal to conduct fire watch rounds in the mechanical room due to the obstructed sprinkler heads.

At 11:21 a.m., the fire watch instructions on the Fire Watch Log Sheet read in bold and capital letters that "A PATROL IS TO BE CONDUCTED EVERY 30 MINUTES."

The logs from March and April 2016 showed that fire watch patrols were missed during the following dates and times:

a. There was one patrol missing between 2:30 p.m. to 3:30 p.m. on 4/3/16.
b. There was one patrol missing at 11:30 p.m. on 4/2/16.
c. There were two patrols missing between 10:00 p.m. and 11:30 p.m. on 3/31/16.
d. There was one patrol missing between 9:30 a.m. and 10:30 a.m. on 3/30/16.
e. There was one patrol missing at 11:00 p.m. on 3/25/16.
f. There was one patrol missing at 4:00 p.m. on 3/24/16.
g. There was one patrol missing at 1:00 p.m. on 3/23/16.
h. There was one patrol missing at 3:00 p.m. on 3/22/16.
i. There were three patrols missing between 1:30 p.m. and 3:30 p.m. on 3/21/16.

Based on document review and interview, the facility failed to maintain their elevators. This was evidenced by the failure to conduct testing for the Phase I and Phase II Firefighter services on a monthly basis. This affected one of two elevators in the Hollywood Building and the elevator at the Van Nuys Building. This could result in the increased risk of malfunction of the elevators, in the event of a fire.

NFPA 101 Life Safety Code, 2000 Edition
19.5.3 Elevators, Escalators, and Conveyors. Elevators, escalators, and conveyors shall comply with the provisions of Section 9.4.
9.4.6 Elevator Testing. Elevators shall be subject to routine and periodic inspections and test as specified in ASME/ANSI A17.1, Safety Code for Elevators and Escalators. All elevators equipped with fire fighter service in accordance with 9.4.4 and 9.4.5 shall be subject to a monthly operation with a written record of the findings made and kept on the premises as required by ASME/ANSI A17.1, Safety Code for Elevators and Escalators

Findings:

During record review with staff from 4/4/16 to 4/8/16, the elevator inspection records were reviewed.

Hollywood:

1. At 11:33 a.m., on 4/5/16, the elevators' Fire Service Test Logs were provided. The logs indicated that ASME A17.1 requires that all elevators provided with firefighters' emergency operation be tested monthly for the following: Phase 1 recall by use of the key switch and minimum one-floor operation on Phase II. The test logs showed that Phase II was not tested from January 2015 to February 2016 for Conveyance 37307.

Van Nuys:

2. At 9:26 a.m., on 4/6/16, the elevator's Fire Service Test log indicated that there were no monthly inspections conducted in January, February, March, April, and August 2015.

During an interview at 9:27 a.m., the Director of Facilities Services (DFS3) stated that the elevator service company emails him every time they conduct a service.

At 9:41 a.m., the email records matched the test log and there were five missing inspections in 2015.






29665

Based on observation, record review, and interview, the facility failed to maintain their fire alarm system. This was evidenced by the repeated failure of fire alarm notification devices, by the failure to transmit the correct type of fire alarm signal to the monitoring station, and by the frequent placement of the fire alarm system in test mode that resulted in the failure to dispatch the fire department during a Code Red event. This was also evidenced by incorrectly addressed smoke detectors that caused personnel to respond to the wrong location during a Code Red event. This affected the entire Culver City Campus and the Van Nuys Building. This could result in a delay in fire department dispatch, a delay in response during a fire, and the increased risk of injury to patients.

NFPA 101, Life Safety Code, 2000 Edition.
19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6.

9.6.1.3 The provisions of Section 9.6 cover the basic functions of a complete fire alarm system, including fire detection, alarm, and communications. These systems are primarily intended to provide the indication and warning of abnormal conditions, the summoning of appropriate aid, and the control of occupancy facilities to enhance protection of life.

9.6.1.4 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.

9.6.1.5 All systems and components shall be approved for the purpose for which they are installed.

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

9.6.3.6 Notification signals for occupants to evacuate shall be by audible and visible signals in accordance with NFPA 72, National Fire Alarm Code, and CABO/ANSI A117.1, American National Standard for Accessible and Usable Buildings and Facilities, or other means of notification acceptable to the authority having jurisdiction shall be provided.
Exception No. 1: Areas not subject to occupancy by persons who are hearing impaired shall not be required to comply with the provisions for visible signals.
Exception No. 2: Visible-only signals shall be provided where specifically permitted in health care occupancies in accordance with the provisions of Chapters 18 and 19.
Exception No. 3: Existing alarm systems shall not be required to comply with the provision for visible signals.
Exception No. 4: Visible signals shall not be required in lodging or rooming houses in accordance with the provisions of Chapter 26.

NFPA 72, National Fire Alarm Code, 1999 Edition.
Definitions
1-4 Central Station. A supervising station that is listed for central station service.
Proprietary Supervising Station. A location to which alarm or supervisory signaling devices on proprietary fire alarm systems are connected and where personnel are in attendance at all times to supervise operation and investigate signals.
Proprietary Supervising Station Fire Alarm System. An installation of fire alarm systems that serves contiguous and noncontiguous properties, under one ownership, from a proprietary supervising station located at the protected property, at which trained, competent personnel are in constant attendance. This includes the proprietary supervising station; power supplies; signal-initiating devices; initiating device circuits; signal notification appliances; equipment for the automatic, permanent visual recording of signals; and equipment for initiating the operation of emergency building control services.

1-6.1.1 The authority having jurisdiction shall be notified prior to installation or alteration of equipment or wiring. At its request, complete information regarding the system or system alterations, including specifications, wiring diagrams, battery calculation, and floor plans shall be submitted for approval.

5-2.5.1 The central station shall have sufficient personnel, but not less than two persons, on duty at the central station at all times to ensure disposition of signals in accordance with the requirements of 5-2.6.1.

5-2.5.2 Operation and supervision shall be the primary functions of the operators, and no other interest or activity shall take precedence over the protective service.

5-2.6.1.5.2 Any test signal not received by the central station shall be investigated immediately and action shall be taken to reestablish system integrity.

5-3.2.1 Proprietary supervising stations shall be operated by trained, competent personnel in constant attendance who are responsible to the owner of the protected property. The requirements of 5-3.5.3 shall apply.

5-3.3.1 The proprietary supervising station shall be located in a fire-resistive, detached building or in a cutoff room and shall not be exposed to the hazardous parts of the premises that are protected.

5-3.4.1 Signal-receiving equipment in a proprietary supervising station shall comply with 5-3.4.

5-3.4.2 Provision shall be made to designate the building in which a signal originates. The floor, section, or other subdivision of the building shall be designated at the proprietary supervising station or at the building that is protected.
Exception: Where the area, height, or special conditions of occupancy make detailed designation unessential as approved by the authority having jurisdiction. This detailed designation shall use indicating appliances accepted by the authority having jurisdiction.

5-3.5.1 At least two operators shall be on duty at all times. One of the two operators shall be permitted to be a runner.
Exception: If the means for transmitting alarms to the fire department is automatic, at least one operator shall be on duty at all times.

5-3.5.3 The primary duties of the operator(s) shall be to monitor signals, operate the system, and take such action as shall be required by the authority having jurisdiction. The operator(s) shall not be assigned any additional duties that would take precedence over the primary duties.

5-3.6.6.1 Alarms. Upon receipt of a fire alarm signal, the proprietary supervising station operator shall initiate action to perform the following:
(1) Immediately notify the fire department, the plant fire brigade, and such other parties as the authority having jurisdiction requires.
(2) Promptly dispatch a runner to the alarm location (travel time shall not exceed 1 hour).
(3) Restore the system as soon as possible after disposition of the cause of the alarm signal.

Findings:

During tour of facility with staff from 4/4/16 to 4/8/16, the fire alarm systems were tested and observed. The Pavilion and the Tower building, located across the street from the Pavilion, shared the same fire alarm system.

Van Nuys:

1. From 12:00 p.m., to 12:30 p.m., on 4/6/16, fire alarm testing was conducted and this included initiating devices such as pull stations, smoke detectors, and waterflow switches. At 4:17 p.m., the monitoring report from the testing was provided. The monitoring report showed that the remote monitoring station only received Zone 2 fire trouble signals for all types of initiation devices tested.

During a telephone interview at 4:18 p.m., a representative from the monitoring company stated that they would not dispatch the fire department upon receipt of a Zone 2 trouble signal.

During a telephone interview at 4:47 p.m., another representative from the monitoring company stated that the last Zone 1 fire alarm signal received from the facility was on 12/30/15. He stated that only fire trouble signals were received on 1/23/16. The annual testing of the fire alarm system was conducted on 1/23/16 and documents showed that all initiation devices were tested on that day.

During an interview at 5:00 p.m., the Director of Facilities Services (DFS2) stated that a fire watch would be implemented immediately until the fire alarm panel was fixed.

Records showed that a fire alarm vendor fixed the panel on 4/7/16. The vendor reported that there was a loose wire for Zone 1 in the panel that caused all the signals to be reported as Zone 2.

Pavilion:

2. At 10:28 a.m., on 4/4/16, the fire alarms sounded and a Code Red was paged overhead. PBX paged "Code Red Sixth Floor" three times. At 10:33 a.m., the Head of Security (HS1) reset the fire alarm system at the notification panel in the lobby.

During an interview at 10:33 a.m., HS1 stated that security staff have investigated and saw no signs of fire. He stated that the panel indicated that the smoke detector was activated in the hallway outside the EVS (environmental services) closet on the sixth floor.

At 10:35 a.m., there were two security staff holding fire extinguishers in Wing A of the sixth floor. They stated that the smoke detector inside Room 605, which was adjacent to an EVS closet, was blinking red. They gave an "all clear" after inspecting that room.

At 10:50 a.m., Plant Operations Lead Staff (PO1) removed the detector in Room 605 and an addressable trouble signal on the panel read "Pav 6th Smoke Patient Room 605."

During an interview at 10:51 a.m., PO1 and HS1 were unsure if Room 605 was the origin of the fire alarm activation/Code Red and if security staff responded to the wrong location.

At 2:37 p.m., a print out from the panel indicated that, "Pav 6th Smoke Patient Room 605" caused a "Common Trbl Act" (a local trouble signal) at 10:24 a.m. and that, "Pav 6th Smoke Hall Outside EVS" caused an "Alarm Active" at 10:28 a.m.

During an interview at 2:38 p.m., the Fire Alarm Technician (F.A. Tech2) stated that the source of the fire alarm activation was not Room 605. He said that he and the other technicians were still trying to locate the smoke detector that was addressed incorrectly as "outside EVS."

During an interview at 4:05 p.m., F.A. Tech2 stated that the smoke detector that caused the Code Red was actually in a Wing C linen closet, not in the Wing A corridor outside the EVS closet.

Facility staff responded to the wrong location during the Code Red incident due to a smoke detector that was not addressed correctly on the panel.


29566

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Culver City Campus:

3. Per record review and interviews, it was observed that the fire alarm system was frequently placed on test during the past month. When the system is on test, fire alarm signals received by the remote monitoring station would not result in dispatch of the fire department. During the Code Red on 4/4/16 (Finding 2 above), the fire department was not dispatched.

During an interview at 10:33 a.m., on 4/4/16, HS1 stated that the system was on test and PBX would call the fire department upon investigation by the facility and security staff.

At 4:05 p.m., on 4/6/16, this surveyor was unable to conduct an interview with the PBX operator. There was only one PBX operator at the time and he was busy with phone calls. The fire alarm annunciator in PBX was across the room from the operator. PBX did not meet the NFPA 72 requirements of a listed central station or proprietary supervising station.

During an interview at 1:57 p.m., on 4/5/16, the Los Angeles Fire Prevention Specialist (LAFPS) from Culver City Fire stated that the Fire Department should have been dispatched during the Code Red incident yesterday (Finding 2 above) and the Code Red incident in December (See K48 from the December 2015 Life Safety Code Survey). He stated the last time the fire department was notified of a fire alarm at the facility was on 3/11/16. He stated that the fire department was not notified of the alarms in the building yesterday. He requested to review a month of the monitoring reports from the offsite monitoring stations.

During an interview at 5:01 p.m., on 4/6/16, Plant Operations Lead Staff (PO1) stated that the facility placed the fire alarm system in test mode daily, for both the Tower and Pavilion, although construction was only conducted in the Pavilion Penthouse.

During an interview at 8:49 a.m., on 4/7/16, the LAFPS stated the facility cannot place the fire alarm system on test daily without informing the local AHJ that the system is out of service. He stated he was unaware of any construction work that would require that the entire fire alarm system be put on test daily for both Tower and Pavilion Buildings.

During an interview at 8:50 a.m., on 4/7/16, the Los Angeles Fire Inspector (LAFI) from the local Fire Department stated the facility cannot be on test so often without notifying the local AHJ. He stated that the facility must notify the AHJ when the fire alarm system is on test for construction work.

During an interview at 11:44 a.m., on 4/7/16, the Office of Statewide Health Planning and Development (OSHPD) Fire Life Safety Officer (FLSO) stated the facility should get approval from the FLSO for putting the system on test during any construction.

During an interview at 12:30 p.m., on 4/7/16, the Director of Facilities Services (DFS1) stated that PBX was carrying out instructions from the previous Facilities Director to put the system on test from 5 a.m. to 5 p.m. daily whether the fire alarm system was being worked on or not.

During an interview at 2:48 p.m., on 4/7/16, F.A. Tech1 stated the fire alarm system has the capability to place only certain zones on test, such as specific construction areas or while working on a portion of the fire alarm system.

During an interview at 9:50 a.m., on 4/8/16, F.A. Tech1 stated he was unaware that the facility had placed the fire alarm system on test when he and his staff were not working on the system. F.A. Tech1 provided his staff's work schedule for the month of March 2016. He confirmed that they were not in the building during the Code Red incident on 4/4/16.

At 10 a.m., on 4/13/16, comparison of the facility's fire alarm monitoring reports and the fire alarm vendor's work schedule showed days that the fire system was placed on test while no work was conducted on the system. The monitoring report indicated that the facility placed the entire fire alarm system on test from 5:00 a.m., to 5:00 p.m. for most days, including Saturdays and Sundays, without notifying the local AHJ. The fire alarm system was placed on test late into the evening on other days: on 3/14/16, the system was placed on test from 7:28 p.m., until 11:30 p.m. and on 3/22/16, from 6:16 p.m., until 11:59 p.m.

The monitoring report indicated the system was placed on test on 3/11/16 from 5:00 a.m., to 5:00 p.m., for selective zones only. A fire alarm was activated in an area that was not on test and the fire department was dispatched. Interview with LAFPS above confirmed that this was the last time they received fire alarm signal from the facility.

Per the monitoring report and the fire alarm vendor's schedule for March 2016, the facility had their entire fire alarm system on test from 5:00 a.m., to 5:00 p.m. for 14 days (including Saturdays and Sundays) while there was no fire alarm vendor in the building. The system was on test on 3/9/16 while there was no fire alarm vendor working on the fire alarm panel. The report indicated the panel exhibited a supervisory signal. The signal was not sent to the local fire department.

Tower
First Floor:

4. At 3:53 p.m., on 4/6/16, the pull station on the first floor in the Emergency Department was tested. The fire alarm chimes failed to activate an audible alarm and no fire alarms could be heard throughout the building.

At 3:54 p.m., on 4/6/16, the pull station by the exit door of the Emergency Department was tested. The fire alarm chimes failed to activate an audible alarm and no fire alarms could be heard throughout the building.

During an interview at 3:55 p.m., F.A. Tech1 stated he would go and investigate the problem.

At 5:52 p.m., the notification devices at the Tower were still not repaired.

During an interview at 9:01 a.m., on 4/7/16, F.A. Tech1 stated he finished working on the fire alarm system yesterday at approximately 8:30 p.m., and all the chimes on all the floors of the Tower should be working now.

Tower
Basement:

At 10:29 a.m., a pull station was tested and the fire alarm chime box failed. No alarms could be heard in the basement.

This deficiency was cited during the September 2015 and December 2015 Life Safety Code surveys under K52. During the survey on 9/22/15, the fire alarm chimes on the first floor and fourth floor of the Tower failed during testing of the fire alarm system. During the survey on 12/16/15, the fire alarm chimes failed on the seventh floor of the Tower while fire alarm testing. Documentation from the Inspector of Record (IOR) showed that, during testing on 1/22/16, the audible fire alarms failed on the first floor, third floor, basement, and fifth floor of the Tower. The items were documented as having been corrected on 1/27/16. The recurring failure of the fire alarm chimes had not been corrected.

Based on record review, the facility failed to ensure that fire watch rounds were conducted in accordance with the instructions from the authority having jurisdiction (AHJ). This affected the penthouse of the Pavilion and could result in a delay in extinguishing a fire in the mechanical room.

Findings:

During record review with staff from 4/4/16 to 4/8/16, the fire watch logs were provided.

Pavilion
Penthouse:

1. At 11:02 a.m., on 4/4/16, there was scaffolding blocking the spray pattern of the sprinkler heads in the mechanical room. The scaffolding was erected as part of an HVAC (heating, ventilating, and air-conditioning) restoration project after a fire in the penthouse destroyed an air handler on 1/29/15. The facility was instructed by the local fire marshal to conduct fire watch rounds in the mechanical room due to the obstructed sprinkler heads.

At 11:21 a.m., the fire watch instructions on the Fire Watch Log Sheet read in bold and capital letters that "A PATROL IS TO BE CONDUCTED EVERY 30 MINUTES."

The logs from March and April 2016 showed that fire watch patrols were missed during the following dates and times:

a. There was one patrol missing between 2:30 p.m. to 3:30 p.m. on 4/3/16.
b. There was one patrol missing at 11:30 p.m. on 4/2/16.
c. There were two patrols missing between 10:00 p.m. and 11:30 p.m. on 3/31/16.
d. There was one patrol missing between 9:30 a.m. and 10:30 a.m. on 3/30/16.
e. There was one patrol missing at 11:00 p.m. on 3/25/16.
f. There was one patrol missing at 4:00 p.m. on 3/24/16.
g. There was one patrol missing at 1:00 p.m. on 3/23/16.
h. There was one patrol missing at 3:00 p.m. on 3/22/16.
i. There were three patrols missing between 1:30 p.m. and 3:30 p.m. on 3/21/16.