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Based on record review, observation and staff interview, the facility failed to maintain a two hour fire barrier as designed. This deficient practice of not maintaining a two hour fire rated barrier as designed affects the ability of the facility to comply with the original design of the building and affects all patients in three of three smoke zones. The facility has a capacity of 12 with a census of 3 patients at the time of the survey.

Findings include:

During the survey on January 24, 2017 it is observed that the two hour fire barrier indicated on the original construction documents and the 2015 code foot print has the following deficiencies:

1. At 3:00 p.m. a ½ inch gap is observed around a conduit in the two hour fire barrier between the maintenance office and physical therapy. This observation is made above ceiling tile in the maintenance office.

2. At 3:05 p.m. a 1 inch hole is observed in the two hour fire barrier in the corridor between the material management area and the maintenance office where 3 black cables pass through the barrier. This observation is made above ceiling tile directly above the 1 ½ hour fire rated doors.

3. At 3:10 p.m. the following deficiencies are observed above the ceiling tile level from the material management area in the two hour fire barrier between the kitchen and material management:

A. 4 by 4 inch hole is observed in the center of this wall.
B. A ½ inch gap is observed where an electrical conduit passes through this barrier.
C. The joints of the dry wall are not sealed in this barrier.

4. At 3:20 p.m. a ¾ inch gap is observed around a conduit in the two hour fire barrier between the material management area and the kitchen. This observation is made above ceiling tile in the kitchen.

5. At 3:20 p.m. the following deficiencies are observed above the ceiling tile level in the kitchen rest room in the two hour fire barrier between the kitchen and material management:

A. A ¾ inch hole is observed in this two hour fire barrier below the center section of duct work.
B. A ½ inch gap is observed in a sleeve passing through this barrier.
C. A 4 inch by 6 inch section of layered dry wall is missing under the north section of duct work.
D. The joints of the dry wall are not sealed in this barrier.

6. At 3:25 p.m. the following deficiencies are observed above the ceiling tile level in the women ' s locker room in the two hour fire barrier between the central sterile area and mechanical area:

A. Two ½ inch gaps are observed where electrical conduit passes through this barrier.
B. A 6 inch by 1 ½ inch gap is observed where an electrical conduit turn downward and passes through this barrier.
C. A ¾ inch hole is observed in the south portion of this barrier.

The Maintenance Supervisor was present at the time of the observation and acknowledged the findings.

Review of the following NFPA Standard revealed: Fire barriers used to provide enclosure, subdivision, or protection under this Code shall be classified in accordance with one of the following fire resistance ratings:

(1) 3-hour fire resistance rating
(2) 2-hour fire resistance rating
(3) I-hour fire resistance rating
(4) ½ -hour fire resistance rating

Fire barriers shall comply with one of the following:

(1) The fire barriers are continuous from outside wall to outside wall or from one fire barrier to another, or a combination thereof, including continuity through all concealed spaces, such as those found above a ceiling, including interstitial spaces.
(2) The fire barriers are continuous from outside wall to outside wall or from one fire barrier to another, and from the floor to the bottom of the interstitial space, provided that the construction assembly forming the bottom of the interstitial space has a fire resistance rating not less than that of the fire barrier.

Walls used as fire barriers shall comply with Chapter 7 of NFPA 221, Standard for High Challenge Fire Walls, Fire Walls, and Fire Barrier Walls. The NFPA 221 limitation on percentage width of openings shall not apply. 2012 NFPA 101, 8.3.1.1, 8.3.1.2 and 8.3.1.3

Based on record review, observation and staff interview the facility failed to provide emergency lighting as required for exit discharge paths. This deficient practice could leave the exit discharge paths without illumination during a disruption of normal power. This deficiency affects all patients in three of three smoke zones. The facility has a capacity of 12 with a census of 3 patients at the time of the survey.

Findings include:

During the survey on January 25, 2017 the exit discharge lighting for all 8 exit discharge paths could not be confirmed to illuminate in the emergency power mode. The maintenance supervisor could not confirm that the fixtures supplied at the exit discharge were provided with an alternate power source. Consultation with the original building electrical plan did not indicate that these fixtures were provided with an emergency power source and these fixtures were not indicated to be on the life safety branch electrical panel.

The Maintenance Supervisor was present at the time of the observation and acknowledged the findings.

Review of the following NFPA Standard revealed: Emergency lighting shall be provided in accordance with Section 7.9. 2012 NFPA 101, 19.2.9.1

Review of the following NFPA Standard revealed: Emergency illumination shall be provided for a minimum of 1 ½ hours in the event of failure of normal lighting. Emergency lighting facilities shall be arranged to provide initial illumination that is not less than an average of 1 ft-candle (l0.8 lux) and, at any point, not less than 0.1 ft-candle (1.1 lux), measured along the path of egress at floor level. Illumination levels shall be permitted to decline to not less than an average of 0.6 ft-candle (6.5 lux) and, at any point, not less than 0.06 ft-candle (0.65 lux) at the end of 1 ½ hours. A maximum-to minimum illumination uniformity ratio of 40 to 1 shall not be exceeded. 2012 NFPA 101, 7.9.2.1

Review of the following NFPA Standard revealed: The emergency lighting system shall be arranged to provide the required illumination automatically in the event of any interruption of normal lighting due to any of the following:

(1) Failure of a public utility or other outside electrical power supply
(2) Opening of a circuit breaker or fuse
(3) Manual act(s), including accidental opening of a switch controlling normal lighting facilities
2012 NFPA 101, 7.9.2.2

Review of the following NFPA Standard revealed: The emergency lighting system shall be either continuously in operation or shall be capable of repeated automatic operation without manual intervention. 2012 NFPA 101, 7.9.2.7

Review of the following NFPA Standard revealed: The life safety and critical branches shall supply power for lighting, receptacles, and equipment as follows:

(1) Illumination of means of egress in accordance with NFPA 101, Life Safety Code
(2) Exit signs and exit directional signs in accordance with NFPA 101, Life Safety Code
(3) Alarm and alerting systems, including the following:
(a) Fire alarms
(b) Alarms required for systems used for the piping of nonflammable medical gases as specified in Chapter 5
(4)Communications systems, where used for issuing instructions during emergency conditions
(5) Sufficient lighting in dining and recreation areas to provide illumination to exit ways of a minimum of 5 ft-candles
(6) Task illumination and select receptacles at the generator set location
(7) Elevator cab lighting, control, communications, and signal systems
No functions, other than those listed in 6.5.2.2.2.1(1) through (7), shall be connected to the life safety.
2012 NFPA 99, 6.5.2.2.2.1 and 6.5.2.2.2.2

Based on observation and staff interview the facility is not ensuring that fire and smoke rated doors and assemblies are inspected and tested annually. This deficient practice of not ensuring fire and smoke rated doors and assemblies are inspected and tested annually, prevents the ability of the facility to properly confine fire and smoke products and to properly defend occupants in place, affecting all patients in all three smoke zones. The facility has a capacity of 12 with a census of 3 patients at the time of the survey.

Findings include:

During the survey on January 25, 2017 at 2:15 p.m. it is revealed that there is no that fire and smoke rated doors and assemblies are inspected and tested annually.

The Maintenance Supervisor was present at the time of the observation and acknowledged the findings.

Review of the following NFPA Standard revealed: Fire-rated door assemblies shall be inspected and tested in accordance with NFPA 8O, Standard for Fire Doors and Other Opening Protectives. Smoke door assemblies shall be inspected and tested in accordance with NFPA 105, Standard for Smoke Door Assemblies and Other Opening Protectives. 2012 NFPA 101, 7.2.1.15.2

Review of the following NFPA Standard revealed: Fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for inspection by the AHJ. 2010 NFPA 80, 5.2.1

Review of the following NFPA Standard revealed: Functional testing of fire door and window assemblies shall be performed by individuals with knowledge and understanding of the operating components of the type of door being subject to testing. Before testing, a visual inspection shall be performed to identify any damaged or missing parts that can create a hazard during testing or affect operation or resetting. 2010 NFPA 80, 5.2.3.1 and 5.2.3.2

Based on record review and staff interview, the facility fails to provide a supervising central station for the fire alarm system installed according to NFPA 101 and NFPA 72. The deficient practice of failing to provide supervising central station, fails to ensure that a fire alarm has been received and transmitted to the local fire department delaying response time, affecting all patients in three of three smoke zones. The facility has a capacity of 12 with a census of 3 patients at the time of the survey.

Findings include:

During record review on January 24, 2017 at 12:50 p.m. it is revealed that the supervising central station does not keep records of fire alarm activation or trouble signals for this facility. The maintenance supervisor requested an activity or receiving log from the monitoring agency and the agency informed the maintenance supervisor that no records were kept or available.

The Maintenance Supervisor was present at the time of the observation and acknowledged the findings.

Review of the following NFPA Standard revealed: Fire department notification shall be accomplished in accordance with 9.6.4. 2012 NFPA 101, 19.3.4.3.2.1

Review of the following NFPA Standard revealed: Where fire department notification is required by another section of this Code, the fire alarm system shall be arranged to transmit the alarm automatically via any of the following means acceptable to the authority having jurisdiction and shall be in accordance with NFPA 72, National Fire Alarm and Signaling Code:

(1) Auxiliary fire alarm system
(2) Central station fire alarm system
(3) Proprietary supervising station fire alarm system
(4) Remote supervising station fire alarm system
2012 NFPA 101, 9.6.4.2

Review of the following NFPA Standard revealed: For supervising station alarm systems, records pertaining to signals received at the supervising station that result from maintenance, inspection, and testing shall be maintained for not less than 12 months. Records shall be permitted to be maintained on either paper or electronic media.
Upon request, a hard copy record shall be provided to the authority having jurisdiction. 2010 NFPA 72, 14.6.3, 14.6.3.1 and 14.6.3.2

Based on record review, observation and interview the facility fails to insure that the automatic sprinkler system is installed in accordance with NFPA 13. The post indicator valve for the fire sprinkler system is not supervised nor in the secured position. This deficient practice would allow the control valve to be shut off without the sending a signal to the fire alarm control panel or the supervisory central station affecting all patients in three of three smoke zones. The facility has a capacity of 12 with a census of 3 patients at the time of the survey.

Findings include:

During the survey on January 25, 2017 at 1:10 p.m. it is observed that the post indicator valve on the east side of the building exterior to the fire sprinkler riser room is not supervised. This post indicator valve indicated the valve was in the open position but the valve is not secured and the valve wrench was freely available to operate the valve. No supervisory device was observed and review of the sprinkler inspection and testing reports did not indicate a supervisory device was tested. The maintenance supervisor demonstrated that closing the valve did not send a signal to the fire alarm control panel nor to the supervising station.

The Maintenance Supervisor was present at the time of the observation and acknowledged the findings. The maintenance supervisor was instructed to remove the wrench on the post indicator valve and secure it away from the control valve so that it could not be readily available to close the valve.

Review of the following NFPA Standard revealed: Where this Code permits exceptions for fully sprinklered buildings or smoke compartments and specifically references this paragraph, the sprinkler system shall meet all of the following criteria:

(1) It shall be installed throughout the building or smoke compartment in accordance with Section 9.7.
(2) It shall be installed in accordance with 9.7.1.1 (1), unless it is an approved existing system.
(3) It shall be electrically connected to the fire alarm system.
(4) It shall be fully supervised.
(5) It shall be equipped with listed quick-response or listed residential sprinklers throughout all smoke compartments containing patient sleeping rooms.
(6) Standard-response sprinklers shall be permitted to be continued to be used in approved existing sprinkler systems where quick-response and residential sprinklers were not listed for use in such locations at the time of installation.
2012 NFPA 101, 19.3.5.8

Review of the following NFPA Standard revealed: Where supervised automatic sprinkler systems are required by another section of this Code, supervisory attachments shall be installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm and Signaling Code, and a distinctive supervisory signal shall be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system. Supervisory signals shall sound and shall be displayed either at a location within the protected building that is constantly attended by qualified personnel or at an approved, remotely located receiving facility. 2012 NFPA 101, 9.7.2.1

Review of the following NFPA Standard revealed: Where supervised automatic sprinkler systems are required by another section of this Code, supervisory attachments shall be installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm and Signaling Code, and a distinctive supervisory signal shall be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system. Supervisory signals shall sound and shall be displayed either at a location within the protected building that is constantly attended by qualified personnel or at an approved, remotely located receiving facility. 2012 NFPA 101, 9.7.2.1

Review of the following NFPA Standard revealed: Sprinkler piping and fire detection devices shall be automatically supervised where more than 20 sprinklers are on the system. 2010 NFPA 13, 7.3.2.4.1

Based on observation and interview the facility fails to insure that the facility ' s automatic sprinkler system is being inspected, tested and maintained in accordance with NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. This deficient practice fails to ensure that the sprinkler system will operate properly in the event of a fire, affecting all patients in three of three smoke zones. The facility has a capacity of 12 with a census of 3 patients at the time of the survey.

Findings include:

Record review conducted on January 24, 2017 at 1:30 p.m., of the facility ' s sprinkler inspection, testing and maintenance records for the last six quarters revealed that the following:

1. There is no documentation of monthly inspection of wet sprinkler system gauges.
2. The records for quarterly inspection of the wet sprinkler system do not indicate that the hydraulic nameplate and fire department connections are not inspected.
3. The records for quarterly testing of the wet sprinkler system do not indicate that the control valves are being tested.
4. The records for the annual inspection and testing of the wet sprinkler system did not indicate that the post indicator valve is included.

5. The top section of the post indicator valve is observed unsecured from the barrel of the valve.

The Maintenance Supervisor was present at the time of the observation and acknowledged the findings.

Review of the following NFPA Standard revealed: 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. 2012 NFPA 101, 9.7.5

Review of the following NFPA Standard revealed: Gauges on wet pipe sprinkler systems shall be inspected monthly to ensure that they are in good condition and that normal water supply pressure is being maintained. 2011 NFPA 25, 5.2.4.1

Review of the following NFPA Standard revealed: Waterflow alarm and supervisory alarm devices shall be inspected quarterly to verify that they are free of physical damage. 2011 NFPA 25, 5.2.5

Review of the following NFPA Standard revealed: The hydraulic design information sign for hydraulically designed systems shall be inspected quarterly to verify that it is attached securely to the sprinkler riser and is legible. 2011 NFPA 25, 5.2.5

Review of the following NFPA Standard revealed: Mechanical waterflow alarm devices including, but not limited to, water motor gongs, shall be tested quarterly. 2011 NFPA 25, 5.3.3.1

Review of the following NFPA Standard revealed: Testing waterflow alarm devices on wet pipe systems shall be accomplished by opening the inspector ' s test connection. 2011 NFPA 25, 5.3.3.3

Review of the following NFPA Standard revealed: Each control valve shall be operated annually through its full range and returned to its normal position. Post indicator valves shall be opened until spring or torsion is felt in the rod, indicating that the rod has not become detached from the valve. Post indicator and outside screw and yoke valves shall be backed a one-quarter turn from the fully open position to prevent jamming. 2011 NFPA 25, 13.3.3.1 through 13.3.3.3

Review of the following NFPA Standard revealed: Record Keeping and maintenance records required by NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based .Fire Protection Systems, shall be maintained at an approved, secured location. 2012 NFPA 101, 9.7.8

Based on observation, record review and interview the facility does not assure a fire watch procedure and policy is written as required for implementation when the fire sprinkler system is out of service for more than 10 hours in a 24 hour period. This deficient practice would prevent proper notification as required, affecting all patients in all three smoke zones. The facility has a capacity of 12 with a census of 3 patients at the time of the survey.

Findings include:

During record review on January 25, 2017 at 3:00 p.m. this surveyor was presented with 2 fire watch implementation policies. Neither of the fire watch policy indicated that a fire watch would commence when the fire sprinkler system is out of service for more than 10 hours in a 24 hour period. These policies have conflicting information and/or lack of full procedures, including notification, phone numbers and procedures.

The Maintenance Supervisor was present at the time of the observation and acknowledged the findings.

Review of the following NFPA Standard revealed: Sprinkler System Impairments. Sprinkler impairment procedures shall comply with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. 2012 NFPA 101, 9.7.6

Review of the following NFPA Standard revealed: All preplanned impairments shall be authorized by the impairment coordinator. 2011 NFPA 25, 15.5.1

Review of the following NFPA Standard revealed: Before authorization is given, the impairment coordinator shall be responsible for verifying that the following procedures have been implemented:
(1) The extent and expected duration of the impairment have been determined.
(2) The areas or buildings involved have been inspected and the increased risks determined.
(3) Recommendations have been submitted to management or the property owner or designated representative.
(4) Where a required fire protection system is out of service for more than 10 hours in a 24-hour period, the impairment coordinator shall arrange for one of the following:
(a) Evacuation of the building or portion of the building affected by the system out of service
(b) An approved fire watch
(c) Establishment of a temporary water supply
(d) Establishment and implementation of an approved program to eliminate potential ignition sources and limit the amount of fuel available to the fire
(5) The fire department has been notified.
(6) The insurance carrier, the alarm company, property owner or designated representative, and other authorities having jurisdiction have been notified.
(7) The supervisors in the areas to be affected have been notified.
(8) A tag impairment system has been implemented. (See Section 15.3.)
(9) All necessary tools and materials have been assembled on the impairment site. 2011 NFPA 25, 15.5.2

Review of the following NFPA Standard revealed: Emergency impairments shall include, but are not limited to, system leakage, interruption of water supply, frozen or ruptured piping, and equipment failure. When emergency impairments occur, emergency action shall be taken to minimize potential injury and damage.
The coordinator shall implement the steps outlined in Section 15.5. 2011 NFPA 25, 15.6.1, 15.6.2 & 15.6.3

Review of the following NFPA Standard revealed: Restoring Systems to Service. When all impaired equipment is restored to normal working order, the impairment coordinator shall verify that the following procedures have been implemented:
(1) Any necessary inspections and tests have been conducted to verify that affected systems are operational. The appropriate chapter of this standard shall be consulted for guidance on the type of inspection and test required.
(2) Supervisors have been advised that protection is restored.
(3) The fire department has been advised that protection is restored.
(4) The property owner or designated representative, insurance carrier, alarm company, and other authorities having jurisdiction have been advised that protection is restored.
(5) The impairment tag has been removed 2011 NFPA 25, 15.7

Based on observation and staff interview the facility is not ensuring that room doors latch properly. This deficient practice of not ensuring that room doors latch properly prevents the ability of the facility to properly confine fire and smoke products and to properly defend occupants in place, affecting all patients in one of three smoke zones. The facility has a capacity of 12 with a census of 3 patients at the time of the survey.

Findings include:

During the survey on January 25, 2017 at 9:50 a.m. patient room 120 to the corridor is not latching.

The Maintenance Supervisor was present at the time of the observation and acknowledged the findings.

Review of the following NFPA Standard revealed: Doors shall be provided with a means for keeping the door closed that is acceptable to the authority having jurisdiction and the following requirements also shall apply:

(1) The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door.
(2) Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.7. 2012 NFPA 101, 19.3.6.3.5

Based on observation and staff interview the facility fails to maintain one of one smoke barrier to at least one half hour fire resistance. This deficient practice would prevent containment of fire and smoke, affecting all patients in two of three smoke zones. The facility has a capacity of 12 with a census of 3 patients at the time of the survey.

Findings include:

During the survey on January 27, 2017 the following is observed:

1. At 8:50 a.m. the north-south smoke barrier near the physical therapy/ CT scanner area has a 6 inch by 4 inch opening where a grouping of data and other cable pass through the barrier. This was viewed above the ceiling tile level from the corridor directly above the smoke barrier doors.

2. At 8:55 a.m. smoke barrier traveling north and south along the CT scanner area has a ½ inch gap around a flexible conduit powering the operational light in the corridor. This smoke barrier wall also has a ¾ inch gap around a 2 inch by 2 inch metal channel passing through the barrier. These were viewed from the corridor south of the smoke barrier doors along the CT scanner area above the ceiling tile level.

3. At 9:05 a.m. the smoke barrier between occupational therapy and the corridor has a 6 inch by 4 inch opening where a grouping of data and other cable pass through that side barrier. This was viewed above the ceiling tile level from the laboratory looking west from this area.

4. At 9:15 a.m. the smoke barrier between the east side men ' s rest room and the director of nursing ' s office has the following issues:

a. There is a ½ inch open data sleeve with a ¼ inch gap around the circumference.
b. There is a 2 inch by 2 inch opening where a conduit passes through the barrier on the lower east corner near the outside wall.
c. The joints of the dry wall are not sealed in this barrier.

The Maintenance Supervisor was present at the time of the observation and acknowledged the findings.

Review of the following NFPA Standard revealed: Any required smoke barrier shall be constructed in accordance with Section 8.5 and shall have a minimum ½ hour fire resistance rating, unless otherwise permitted by one of the following:

(1) This requirement shall not apply where an atrium is used, and both of the following criteria also shall apply:
(a) Smoke barriers shall be permitted to terminate at an atrium wall constructed in accordance with 8.6.7 (1) (c).
(b) Not less than two separate smoke compartments shall be provided on each floor.
(2) Smoke dampers shall not be required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air-conditioning systems where an approved, supervised automatic sprinkler system in accordance with 19.3.5.8 has been provided for smoke compartments adjacent to the smoke barrier. 2012 NFPA 101, 19.3.7.3

Review of the following NFPA Standard revealed: Smoke barriers required by this Code shall be continuous from an outside wall to an outside wall, from a floor to a floor, or from a smoke barrier to a smoke barrier, or by use of a combination thereof. Smoke barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces. 2012 NFPA 101, 8.5.2.1 and 8.5.2.2

Review of the following NFPA Standard revealed: The provisions of 8.5.6 shall govern the materials and methods of construction used to protect through-penetrations and membrane penetrations of smoke barriers. Penetrations for cables, cable trays, conduits, pipes, tubes, vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a smoke barrier, or through the ceiling membrane of the roof/ceiling of a smoke barrier assembly, shall be protected by a system or material capable of restricting the transfer of smoke. Where a smoke barrier is also constructed as a fire barrier, the penetrations shall be protected in accordance with the requirements of 8.3.5 to limit the spread of fire for a time period equal to the fire resistance rating of the assembly and 8.5.6 to restrict the transfer of smoke, unless the requirements of 8.5.6.4 are met. Where sprinklers penetrate a single membrane of a fire resistance-rated assembly in buildings equipped throughout with an approved automatic fire sprinkler system, noncombustible escutcheon plates shall be permitted, provided that the space around each sprinkler penetration does not exceed 112 in. (13 mm), measured between the edge of the membrane and the sprinkler. Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be securely set in the smoke barrier, and the space between the item and the sleeve shall be filled with a material capable of restricting the transfer of smoke. 2012 NFPA 101, 8.5.6.1 through 8.5.6.5

Based on observation and staff interview the facility fails to provide doors that will close properly in a smoke barrier. The deficient practice of not providing properly closing doors in a smoke barrier would prevent the door from closing as required allowing smoke and fire product to spread beyond the smoke barrier more rapidly, affecting all patients in two of three smoke zones. The facility has a capacity of 12 with a census of 3 patients at the time of the survey.

Findings include:

During the survey on January 27, 2017 at 9:00 a.m. it is observed that the CT Scanner area door indicated on the code foot print in the smoke barrier traveling south from the between physical therapy and the CT Scanner area is not equipped with a self-closing device and there is a ¼ inch hole in this door where hardware has been removed leaving this door without smoke resistance.

The Maintenance Supervisor was present at the time of the observation and acknowledged the findings.

Review of the following NFPA Standard revealed: Doors in smoke barriers shall comply with 8.5.4 and all of the following:

(1) The doors shall be self-closing or automatic-closing in accordance with 19.2.2.2.7.
(2) Latching hardware shall not be required
(3) The doors shall not be required to swing in the direction of egress travel. 2012 NFPA 101, 19.3.7.8

Review of the following NFPA Standard revealed: Doors in smoke barriers shall close the opening, leaving only the minimum clearance necessary for proper operation, and shall be 'without louvers or grilles. The clearance under the bottom of a new door shall be a maximum of % in. (19 mm). 2012 NFPA 101, 8.5.4.1

Based on observation and record review, the facility fails to maintain fire dampers in heating, ventilation and air conditioning assemblies as required. This deficient practice of not identifying, testing and maintaining fire dampers as required, increases the risk fire affecting all patients in all three smoke zones. The facility has a capacity of 12 with a census of 3 patients at the time of the survey.

Findings include:

During the record review on January 24, 2017 at 2:45 p.m. the vendor report for the January 2016 fire damper inspection and test does not identify that all fire dampers in the HVAC system have been tested. This documentation indicates that all fire dampers have been visually inspected but does not list the dampers by location and type and that an operational test was performed. This surveyor and the maintenance supervisor consulted the original mechanical plan for the hospital and these plans indicated numerous fusible link type fire dampers throughout the facility.

The Maintenance Supervisor was present at the time of the observation and acknowledged the findings.

Review of the following NFPA Standard revealed: 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 such installations are approved existing installations, which shall be permitted to be continued in service. 2012 NFPA 101, 9.2.1

Review of the following NFPA Standard revealed: Fire dampers and ceiling dampers shall be maintained in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. 2012 NFPA 90A, 5.4.8.1
19.4.8

Review of the following NFPA Standard revealed: The test and inspection frequency shall then be every 4 years, except in hospitals, where the frequency shall be every 6 years.2010 NFPA 80, 19.4.1.1

Review of the following NFPA Standard revealed: If the damper is equipped with a fusible link, the link shall be removed for testing to ensure full closure and lock-in place if so equipped. The operational test of the damper shall verify that there is no damper interference due to rusted, bent, misaligned, or damaged frame or blades, or defective hinges or other moving parts. The damper frame shall not be penetrated by any foreign objects that would affect fire damper operations. The damper shall not be blocked from closure in any way. The fusible link shall be reinstalled after testing is complete. If the link is damaged or painted, it shall be replaced with a link of the same size, temperature, and load rating. 2010 NFPA 80, 19.4.4 through 19.4.8

Review of the following NFPA Standard revealed: All inspections and testing shall be documented, indicating the location of the fire damper or combination fire/ smoke damper, date of inspection, name of inspector, and deficiencies discovered. The documentation shall have a space to indicate when and how the deficiencies were corrected. All documentation shall be maintained and made available for review by the AHJ. 2010 NFPA 80, 19.4.9 and 19.4.10

Based on record review and staff interview the facility failed to provide a properly written plan for the protection of all patients and for their evacuation in the event of an emergency and carry out the provisions of the written fire safety plan during drill activities. The deficient practice may prevent the staff from identifying the proper procedures to take during an actual emergency, affecting all patients in all three smoke zones. The facility has a capacity of 12 with a census of 3 patients at the time of the survey.

Findings include:

During the record review on January 25, 2017 at 3:10 p.m. the following is revealed:

1. The written plan for the protection of all patients and for their evacuation in the event of an emergency indicates that employees detecting a fire should make an announcement using the paging system prior to sound the fire alarm and initiating rescue of those in immediate danger. This plan did not address rescue of patients in immediate danger anywhere in the policy.

2. The written plan did not indicate a telephone call to the fire department would be made.

3. The written plan did not provide detail on how to evacuating a smoke compartment. The triangle of rooms is not listed.

4. The written plan did not provide for the extinguishment of fire.

5. The written plan for the protection of all patients does not indicate that the usage of the kitchen hood suppression systems located in either kitchen and for the usage of the Class K type fire extinguishers.

The Maintenance Supervisor was present at the time of the observation and acknowledged the findings.

Review of the following NFPA Standard revealed: Because the safety of health care occupants cannot be ensured adequately by dependence on evacuation of the building, their protection from fire shall be provided by appropriate arrangement of facilities; adequate, trained staff; and development of operating and maintenance procedures composed of the following:

(1) Design, construction, and compartmentation
(2) Provision for detection, alarm, and extinguishment
(3) Fire prevention procedures and planning, training, and drilling programs for the isolation of fire, transfer of occupants to areas of refuge, or evacuation of the building 2012 NFPA 101, 19.1.1.3.2

Review of the following NFPA Standard revealed: The administration of every health care occupancy shall have, in effect and available to all supervisory personnel, written copies of a plan for the protection of all persons in the event of fire, for their evacuation to areas of refuge, and for their evacuation from the building when necessary. All employees shall be periodically instructed and kept informed with respect to their duties under the plan required by 19.7.1.1. A copy of the plan required by 19.7.1.1 shall be readily available at all times in the telephone operator's location or at the security center. 2012 NFPA 101, 19.7.1.1, 19.7.1.2, 19.7.1.3

Review of the following NFPA Standard revealed: For health care occupancies, the proper protection of patients shall require the prompt and effective response of health care personnel. 2012 NFPA 101, 19.7.2.1.1

Review of the following NFPA Standard revealed: The basic response required of staff shall include the following:(1) Removal of all occupants directly involved with the fire emergency (2) Transmission of an appropriate fire alarm signal to warn other building occupants and summon staff (3) Confinement of the effects of the fire by closing doors to isolate the fire area (4) Relocation of patients as detailed in the health care occupancy ' s fire safety plan. 2012 NFPA 101, 19.7.2.1.2

Review of the following NFPA Standard revealed: Fire Safety Plan. A written health care occupancy fire safety plan shall provide for all of the following:

(1) Use of alarms
(2) Transmission of alarms to fire department
(3) Emergency phone call to fire department
(4) Response to alarms
(5) Isolation of fire
(6) Evacuation of immediate area
(7) Evacuation of smoke compartment
(8) Preparation of floors and building for evacuation
(9) Extinguishment of fire
2012 NFPA 101, 19.7.2.2

Based on record review and staff interview, the facility is not conducting fire drills as required and properly recording the results and facts relating to the fire drills. This deficient practice affects the ability of the staff to properly respond in the event of an actual emergency, affecting all patients in all three smoke zones. The facility has a capacity of 12 with a census of 3 patients at the time of the survey.

Findings include:

During record review on January 24, 2017 at 2:15 p.m. the following is observed:

1. Review of fire drill records for the last 6 quarters revealed that the drills conducted on the day shift on December 21, 2015, August 16, 2016, October 18, 2016 and December 21, 2016 all occurred in the 10:00 a.m. hour.

2. Review of fire drill records for the last 6 quarters revealed that the drill conducted on the night shift on May 20, 2016, July 19, 2016, September 20, 2016 and November 21, 2016 all occurred in the 5:00 a.m. hour.

2. Review of fire drill records for the last 6 quarters revealed that there is no record that the drills transmitted an alarm to the monitoring company due to the monitoring company is unable to product a receiving log.

The Maintenance Supervisor was present at the time of the observation and acknowledged the findings.

Review of the following NFPA Standard revealed: Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. 2012 NFPA 101, 19.7.1.4

Review of the following NFPA Standard revealed: 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. 2012 NFPA 101, 19.7.1.6

Based on record review and staff interview the facility fails to provide a documented risk assessment procedure to ensure building systems are designed to meet Categories 1 through 4. This deficient practice prevents the facility from assessing and identifying the risks of buildings systems and could adversely affect all patients in all three smoke zones The facility has a capacity of 12 with a census of 3 patients at the time of the survey.

Findings include:

During the on January 24, 2017 at 3:00 p.m. it is noted that no formal and documented risk assessment procedure has been performed to ensure building systems are designed to meet Categories 1 through 4.

The Maintenance Supervisor was present at the time of the observation and acknowledged the findings.
Review of the following NFPA Standard revealed: Building systems in health care facilities shall be designed to meet system Category 1 through Category 4 requirements as detailed in this code.

Category 1. Facility systems in which failure of such equipment or system is likely to cause major injury or death of patients or caregivers shall be designed to meet system Category 1 requirements as defined in this code.

Category 2. Facility systems in which failure of such equipment is likely to cause minor injury to patients or caregivers shall be designed to meet system Category 2 requirements as defined in this code.

Category 3. Facility systems in which failure of such equipment is not likely to cause injury to patients or caregivers, but can cause patient discomfort, shall be designed to meet system Category 3 requirements as defined in this code.

Category 4. Facility systems in which failure of such equipment would have no impact on patient care shall be designed to meet system Category 4 requirements as defined in this code.

Risk Assessment. Categories shall be determined by following and documenting a defined risk assessment procedure.

Application. The Category definitions in Chapter 4 shall apply to Chapters 5 through 11. 2012 NFPA 99, 4.2 through 4.3

Based on record review and staff interview the facility fails to provide a documented maintenance program for medical gas and vacuum piped systems. This deficient practice prevents the facility from ensuring that medical gas and vacuum piped systems are maintained as required by NFPA 99 Health Care Facilities and could adversely affect all patients in all three smoke zones The facility has a capacity of 12 with a census of 3 patients at the time of the survey.

Findings include:

During the on January 24, 2017 at 3:00 p.m. it is noted that no documented maintenance program is available for the medical gas and vacuum piped systems.

The Maintenance Supervisor was present at the time of the observation and acknowledged the findings.

Review of the following NFPA Standard revealed: Medical Gas. Medical gas storage and administration
areas shall be in accordance with Section 8.7 and the provisions of NFPA 99, Health Care Facilities Code, applicable to administration, maintenance, and testing. 2012 NFPA 101, 19.3.2.4

Review of the following NFPA Standard revealed: Paragraph 5.1.14.4.3 through 5.1.14.4.9 and 5.1.13
through 5.1.15 shall apply to existing health care facilities. 2012 NFPA 99, 5.1.1.6

Review of the following NFPA Standard revealed: An annual review of bulk system capacity shall be conducted to ensure the source system has sufficient capacity. Central supply systems for nonflammable medical
gases shall conform to the following:

(1) They shall be inspected annually.
(2) They shall be maintained by a qualified representative of the equipment owner.
(3) A record of the annual inspection shall be available for review by the authority having jurisdiction.

A periodic testing procedure for nonflammable medical gas and vacuum and related alarm systems shall be
implemented. 5.1.14.4.7 Procedures, as specified, shall be established for the following:

(1) Maintenance program for the medical air compressor supply system in accordance with the manufacturer ' s recommendations
(2) Facility testing and calibration procedure that ensures carbon monoxide monitors are calibrated at least annually
or more often if recommended by the manufacturer
(3) Maintenance program for both the medical-surgical vacuum piping system and the secondary equipment attached to medical-surgical vacuum station inlets to ensure the continued good performance of the entire
medical-surgical vacuum system
(4) Maintenance program for the WAGD system to ensure performance

Audible and visual alarm indicators shall meet the following requirements:

(1) They shall be periodically tested to determine that they are functioning properly.
(2) Records of the test shall be maintained until the next test is performed.

Medical-surgical vacuum station inlet terminal performance, as required in 5.1.12.3.10.4, shall be tested as follows:

(1) On a regular preventive maintenance schedule as determined by the facility maintenance staff
(2) Based on flow of free air (Nl/min or SCFM) into a station inlet while simultaneously checking the vacuum level
2012 NFPA 99, 5.1.14.4.3 through 5.1.14.4.9

Based on record review and staff interview the facility fails to provide a documented inspection and testing program for medical gas and vacuum piped systems. This deficient practice prevents the facility from ensuring that medical gas and vacuum piped systems are inspected and testing as required by NFPA 99 Health Care Facilities and could adversely affect all patients in all three smoke zones The facility has a capacity of 12 with a census of 3 patients at the time of the survey.

Findings include:

During the on January 24, 2017 at 3:00 p.m. it is noted that no documented inspection and testing program is available for the medical gas and vacuum piped systems.

The Maintenance Supervisor was present at the time of the observation and acknowledged the findings.

Review of the following NFPA Standard revealed: Medical Gas. Medical gas storage and administration
areas shall be in accordance with Section 8.7 and the provisions of NFPA 99, Health Care Facilities Code, applicable to administration, maintenance, and testing. 2012 NFPA 101, 19.3.2.4

Review of the following NFPA Standard revealed: The elements in 5.1.14.2.2.2 through 5.1.15 shall be inspected or tested as part of the maintenance program as follows:

(1)Medical air source, as follows:
(a) Room temperature
(b) Shaft seal condition
(c) Filter condition
(d) Presence of hydrocarbons
(e) Room ventilation
(f) Water quality, if so equipped
(g) Intake location
(h) Carbon monoxide monitor calibration
(i) Air purity
(j) Dew point

(2) Medical vacuum source - exhaust location
(3) WAGD source - exhaust location
(4) Instrument air source - filter condition
(5) Manifold sources (including systems complying with 5.1.3.5.10, 5.1.3.5.11, 5.1.3.5.12, and 5.1.3.5.13), as follows:
(a) Ventilation
(b) Enclosure labeling
(6) Bulk cryogenic liquid source inspected in accordance with NFPA 55, Compressed Gases and Cryogenic Fluids Code
(7) Final line regulation for all positive pressure systems - delivery pressure
(8) Valves - labeling
(9) Alarms and warning systems-lamp and audio operation
(10) Alarms and warning systems, as follows:
(a) Master alarm signal operation
(b) Area alarm signal operation
(c) Local alarm signal operation
(11) Station outlets/inlets, as follows:
(a) Flow
(b) Labeling
(c) Latching/delatching
(d) Leaks

2012 NFPA 99, 5.1.14.2.3.1

Review of the following NFPA Standard revealed: An annual review of bulk system capacity shall be conducted to ensure the source system has sufficient capacity. Central supply systems for nonflammable medical
gases shall conform to the following:

(1) They shall be inspected annually.
(2) They shall be maintained by a qualified representative of the equipment owner.
(3) A record of the annual inspection shall be available for review by the authority having jurisdiction.

A periodic testing procedure for nonflammable medical gas and vacuum and related alarm systems shall be
implemented. 5.1.14.4.7 Procedures, as specified, shall be established for the following:

(1) Maintenance program for the medical air compressor supply system in accordance with the manufacturer ' s recommendations
(2) Facility testing and calibration procedure that ensures carbon monoxide monitors are calibrated at least annually
or more often if recommended by the manufacturer
(3) Maintenance program for both the medical-surgical vacuum piping system and the secondary equipment attached to medical-surgical vacuum station inlets to ensure the continued good performance of the entire
medical-surgical vacuum system
(4) Maintenance program for the WAGD system to ensure performance

Audible and visual alarm indicators shall meet the following requirements:

(1) They shall be periodically tested to determine that they are functioning properly.
(2) Records of the test shall be maintained until the next test is performed.

Medical-surgical vacuum station inlet terminal performance, as required in 5.1.12.3.10.4, shall be tested as follows:

(1) On a regular preventive maintenance schedule as determined by the facility maintenance staff
(2) Based on flow of free air (Nl/min or SCFM) into a station inlet while simultaneously checking the vacuum level
2012 NFPA 99, 5.1.14.4.3 through 5.1.14.4.9

Based on record review and staff interview the facility fails to provide a documented maintenance and testing program for electrical systems. This deficient practice prevents the facility from ensuring that electrical systems are maintained and testing as required by NFPA 99 Health Care Facilities and could adversely affect all patients in all three smoke zones The facility has a capacity of 12 with a census of 3 patients at the time of the survey.

Findings include:

During the on January 24, 2017 at 3:00 p.m. it is noted that no documented maintenance and testing program is available for hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered. No records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results.

The Maintenance Supervisor was present at the time of the observation and acknowledged the findings.

Review of the following NFPA Standard revealed: A record shall be maintained of the tests required by this chapter and associated repairs or modification. At a minimum, the record shall contain the date, the rooms or areas tested, and an indication of which items have met, or have failed to meet, the performance requirements of this chapter.
2012 NFPA 99, 6.3.4.2.1.1 and 6.3.4.2.1.2

Based on record review and staff interview the facility fails to provide markings or distinctive colors for electrical receptacles and cover plates supplied from the life safety and critical. This deficient practice prevents the facility from identifying electrical receptacles or cover plates supplied from the life safety and critical branches as required by NFPA 99 Health Care Facilities and could adversely affect all patients in all three smoke zones The facility has a capacity of 12 with a census of 3 patients at the time of the survey.

Findings include:

During the on January 24, 2017 at 3:00 p.m. it is observed that electrical receptacles or cover plates supplied from the life safety and critical branches do not have a distinctive color or marking.

The Maintenance Supervisor was present at the time of the observation and acknowledged the findings.

Review of the following NFPA Standard revealed: The life safety branch and critical branch shall be kept independent of all other wiring and equipment. 2012 NFPA 99, 6.4.2.2.6.1

Review of the following NFPA Standard revealed: The electrical receptacles or the cover plates for the electrical receptacles supplied from the life safety and equipment branches shall have a distinctive color or marking so as to be readily identifiable. 2012 NFPA 99, 6.5.2.2.4.2

Based on record review and staff interview the facility failed to assure the generator is inspected and tested in accordance with NFPA 110. This deficient practice fails to ensure that the generator will not fail when needed in the event of an emergency, affecting all patients in all three smoke zones. The facility has a capacity of 12 with a census of 3 patients at the time of the survey.

Findings include:

Record review for the last 6 quarters conducted on January 24, 2017 at 1:50 p.m., of the facility ' s generator inspection, testing and maintenance records revealed the documentation for the generator does not indicate the following:

1. The weekly inspection record does not indicate the items requiring weekly inspections have been performed.

2. The generator has tested monthly less than 30% of the nameplate rating for at least 30 minutes. The facility provided a copy of a load bank test in lieu of the 30% monthly test. A load bank test was conducted on January 4, 2017 by running the generator at 99% of capacity for the full duration of the four hour test. The load was not incremental as required.

The Maintenance Supervisor was present at the time of the observation and acknowledged the findings.

Review of the following NFPA Standard revealed: EPSSs, including all appurtenant components, shall be inspected weekly and exercised under load at least monthly. 2010 NFPA 110, 8.4.1

Review of the following NFPA Standard revealed: A permanent record of the EPSS inspections, tests, exercising, operation, and repairs shall be maintained and readily available.

The permanent record shall include the following:
(1) The date of the maintenance report
(2) Identification of the servicing personnel
(3) Notation of any unsatisfactory condition and the corrective action taken, including parts replaced
(4) Testing of any repair for the time as recommended by the manufacturer. 2010 NFPA 110, 8.3.4, 8.3.4.1

Review of the following NFPA Standard revealed: Diesel generator sets in service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(1) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
(2) Under operating temperature conditions and at not less than 30 percent of the EPS nameplate kW rating. 2010 NFPA 110, 8.4.2

Review of the following NFPA Standard revealed: Diesel-powered EPS installations that do not meet the requirements of 8.4.2 shall be exercised monthly with the available EPSS load and shall be exercised annually with supplemental loads at not less than 50 percent of the EPS nameplate kW rating for 30 continuous minutes and at not less than 75 percent of the EPS nameplate kW rating for 1 continuous hour for a total test duration of not less than 1.5 continuous hours.. 2010 NFPA 110, 8.4.2.3

Review of the following NFPA Standard revealed: For a diesel-powered EPS, loading shall be not less than 30 percent of the nameplate kW rating of the EPS. A supplemental load bank shall be permitted to be used to meet or exceed the 30 percent requirement. 8.4.9.5.2 For a diesel-powered EPS, loading shall be that which maintains the minimum exhaust gas temperatures as recommended by the manufacturer. 2010 NFPA 110, 8.4.9.5.1

Based on record review and staff interview the facility fails to provide testing and maintenance policies and procedures for fixed and portable patient-care related electrical equipment. This deficient practice prevents the establishing testing intervals as required by NFPA 99 Health Care Facilities and could adversely affect all patients in all three smoke zones The facility has a capacity of 12 with a census of 3 patients at the time of the survey.

Findings include:

During the on January 24, 2017 at 3:00 p.m. it is observed that there is no documentation of for fixed and portable patient-care related electrical equipment.

The Maintenance Supervisor was present at the time of the observation and acknowledged the findings.

Review of the following NFPA Standard revealed: The facility shall establish policies and protocols for the type of test and intervals of testing for patient care-related electrical equipment.
All patient care-related electrical equipment used in patient care rooms shall be tested in accordance with 10.3.5.4 or 10.3.6 before being put into service for the first time and after any repair or modification that might have compromised electrical safety. 2012 NFPA 99, 10.5.2.1.1 and 10.5.2.1.2

Review of the following NFPA Standard revealed: A record shall be maintained of the tests required by this chapter and associated repairs or modifications.
At a minimum, the record shall contain all of the following:
(1) Date
(2) Unique identification of the equipment tested
(3) Indication of which items have met or have failed to meet
the performance requirements of 10.5.6.2

2012 NFPA 99, 10.5.6.2.1 and 10.5.6.2.2

Review of the following NFPA Standard revealed: A log of test results and repairs shall be maintained and kept for a period of time in accordance with a health care facility ' s record retention policy. 2012 NFPA 99, 10.5.6.3

Review of the following NFPA Standard revealed: Personnel concerned for the application or maintenance of electric appliances shall be trained on the risks associated with their use. The health care facilities shall provide programs of continuing education for its personnel. Continuing education programs shall include periodic review of manufacturers ' safety guidelines and usage requirements for electrosurgical units and similar appliances. Personnel involved in the use of energy-delivering devices including, but not limited to, electrosurgical, surgical laser, and fiber optic devices shall receive periodic training in fire suppression. Equipment shall be serviced by qualified personnel only. 2012 NFPA 99, 10.5.8.1 and 10.5.8.3