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Illumination of Means of Egress
Illumination of means of egress, including exit discharge, is arranged in accordance with 7.8 and shall be either continuously in operation or capable of automatic operation without manual intervention.
18.2.8, 19.2.8.

FINDINGS INCLUDE:

On facility tour between 10:00 AM and 3:00 PM on 01/30/2018, observations revealed, three light fixtures not working in the North Doctor Egress Stairway


This deficient practice was verified by the Facility Maintenance Director.

Based on observation and interview, the Facility failed to maintain emergency lighting in accordance with 7.9.

Emergency Lighting Emergency lighting of at least 1-1/2 hour duration is provided automatically in accordance with 7.9. 18.2.9.1, 19.2.9.1

FINDINGS INCLUDE:

On facility tour between 10:00 AM and 3:00 PM on 01/30/2018, it was revealed that there was no record of the emergency lights being tested annually for 90 minutes.


This deficient practice was confirmed by the Facility Maintenance Director at the time of discovery.

Based on documentation review and interview, the Facility failed to test and maintain the Fire Alarm System in accordance with NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code.

Fire Alarm System - Testing and Maintenance
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.7.5, 9.7.7, 9.7.8, and NFPA 25.


FINDINGS INCLUDE:

On facility tour between 10:00 AM and 3:00 PM on 01/30/2018, during documentation review, it was revealed that documentation could not be provided to show that an Annual Fire Alarm inspection had occurred.

This deficient practice was verified by the Facility Maintenance Director.

Based on documentation review and interview, the Facility failed to provide a current and accurate Fire Alarm Out of Service Policy.

Fire Alarm - Out of Service
Where required fire alarm system is out of services for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service.
9.6.1.6

FINDINGS INCLUDE:

On facility tour between 10:00 AM and 3:00 PM on 01/30/2018, documentation review revealed that the Out of Service Policy for the Fire Alarm System does not have current Staff/Fire Marshal contact information.

This deficient practice was verified by the Facility Maintenance Director.

Based on documentation review and interview, the Facility failed to provide a current and accurate Fire Sprinkler Out of Service Policy.

Sprinkler System - Out of Service
Where the sprinkler system is impaired, the extent and duration of the impairment has been determined, areas or buildings involved are inspected and risks are determined, recommendations are submitted to management or designated representative, and the fire department and other authorities having jurisdiction have been notified. Where the sprinkler system is out of service for more than 10 hours in a 24-hour period, the building or portion of the building affected are evacuated or an approved fire watch is provided until the sprinkler system has been returned to service.
18.3.5.1, 19.3.5.1, 9.7.5, 15.5.2 (NFPA 25)

Findings include:

On facility tour between 10:00 AM and 3:00 PM on 01/30/2018, documentation review revealed that the Out of Service Policy for the Fire Sprinkler System does not have current Staff/ Fire Marshal contact information and the 10 hour out of service time needs to be updated.

This deficient practice was verified by the Facility Maintenance Directo

Based on observation and interview, the Facility failed to ensure doors protecting corridor openings were in operable condition.


Corridor - Doors
2012 EXISTING
Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 1-3/4 inch solid-bonded core wood, or capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Doors shall be provided with a means suitable for keeping the door closed.
There is no impediment to the closing of the doors. Clearance between bottom of door and floor covering is not exceeding 1 inch. Roller latches are prohibited by CMS regulations on corridor doors and rooms containing flammable or combustible materials. Powered doors complying with 7.2.1.9 are permissible. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted.
Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies.
19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485
Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc.

FINDINGS INCLUDE:

On facility tour between 10:00 AM and 3:00 PM on 01/30/2018, documentation review revealed that not all the required information is being documented during the Annual Fire and Smoke Door Inspection per NFPA 80.

This deficient practice was verified by the Facility Maintenance Director.

Based on observation and staff interview, the facility failed to maintain smoke barrier walls construction that meet the requirements of NFPA 101 - 2012 edition, Sections 19-3.7.3 and 8.6.7.1.(1).

Subdivision of Building Spaces - Smoke Barrier Construction
2012 EXISTING
Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier.
19.3.7.3, 8.6.7.1(1)
Describe any mechanical smoke control system in REMARKS.

Findings include:

On facility tour between 10:00 AM and 3:00 PM on 01/30/2018, penetrations were observed above the ceiling tiles at the smoke barrier near Med Surg West and the West OB Doors.

NOTE; All smoke barriers and 2 hour fire separations need to be checked to ensure compliance.

These deficient practices were verified by the Facility Maintenance Director.

Based on documentation review and interview, the Facility failed to ensure that the HVAC was installed according to 9.2.

HVAC
Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer's specifications.
18.5.2.1, 19.5.2.1, 9.2

FINDINGS INCLUDE:

On facility tour between 10:00 AM and 3:00 PM on 01/30/2018, a smoke and fire damper inspection report could not be located to show that the inspection had occurred within the last 6 years.

This deficient practice was verified by the Facility Maintenance Director.

Based on documentation review and interview, the Facility failed to maintain a Evacuation and Relocation Plan according to the 2012 Life Safety Code.

Evacuation and Relocation Plan
There is a written plan for the protection of all patients and for their evacuation in the event of an emergency.
Employees are periodically instructed and kept informed with their duties under the plan, and a copy of the plan is readily available with telephone operator or with security. The plan addresses the basic response required of staff per 18/19.7.2.1.2 and provides for all of the fire safety plan components per 18/19.2.2.
18.7.1.1 through 18.7.1.3, 18.7.2.1.2, 18.7.2.2, 18.7.2.3, 19.7.1.1 through 19.7.1.3, 19.7.2.1.2, 19.7.2.2, 19.7.2.3

FINDINGS INCLUDE:

On facility tour between 10:00 AM and 3:00 PM on 01/30/2018, during documentation review, it was discovered that the fire emergency plan needs to be updated to include a statement that directs staff to call 911 upon discovery of smoke or fire.

This deficient practice was verified by the Facility Maintenance Director.

Electrical Systems - Maintenance and Testing
Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered, are tested after initial installation, replacement or servicing. Additional testing is performed at intervals defined by documented performance data. Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. Line isolation monitors (LIM), if installed, are tested at intervals of less than or equal to 1 month by actuating the LIM test switch per 6.3.2.6.3.6, which activates both visual and audible alarm. For LIM circuits with automated self-testing, this manual test is performed at intervals less than or equal to 12 months. LIM circuits are tested per 6.3.3.3.2 after any repair or renovation to the electric distribution system. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results.
6.3.4 (NFPA 99)

FINDINGS INCLUDE:

Based on observation and interview, the Facility failed to comply with (NFPA 99). On facility tour between 10:00 AM and 3:00 PM on 01/30/2018, it was revealed that not all of the testing procedures were being conducted during the electric receptacle testing. The electrical receptacles must receive the following inspections:

1.The physical integrity of each receptacle shall be confirmed by visual inspection.
2. The continuity of the grounding circuit in each electrical receptacle shall be verified.
3. Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.
4. The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz).

This deficient practice was verified by the Facility Maintenance Director.

Based on documentation review and interview, the Facility failed to provide complete written records of Generator maintenance and testing are maintained and readily available.

Electrical Systems - Essential Electric System Maintenance and Testing
The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110.
Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked and readily identifiable. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations.
6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)

FINDINGS INCLUDE:

On facility tour between 10:00 AM and 3:00 PM on 01/30/2018, documentation reviewed revealed that there was no documentation available to review to indicate that a weekly generator inspection was occurring.

This deficient practice was verified by the Facility Maintenance Director.

Based on observation and interview, the Facility failed to comply with 10.2.4 10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5.

Electrical Equipment - Power Cords and Extension Cords
Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4.
10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5

FINDINGS INCLUDE:

On facility tour between 10:00 AM and 3:00 PM on 01/30/2018,observation during the inspection revealed a power strip being used as a source of fixed wiring in the Pharmacy. A small refrigerator, microwave and dehumidifier was plugged into a power strip.

This deficient practice was verified by the Facility Maintenance Director.