HospitalInspections.org

Repeat deficiency from the 2007 recertification survey.


The facility failed to provide a permitted construction type required by code. Findings include:

During the survey, the building construction type was observed to be Type II (000) with a partial automatic sprinkler and a corridor smoke detection system. The original plaster ceiling was observed not to be maintained throughout the building.

In 2007, the facility was granted a one year waiver to install the sprinkler system in the unsprinklered areas of the building. The waiver expired in October 2008. The sprinkler installations were not made.

2000 NFPA 101, 19.1.6.2 Health care occupancies shall be limited to the types of building construction shown in Table 19.1.6.2. (See 8.2.1.)



Table 19.1.6.2 Construction Type Limitations
Construction Stories
Type
1 2 3 4 or
More
I(443) X X X X
I(332) X X X X
II(222) X X X X
II(111) X X* X* NP
II(000) X* X* NP NP
III(211) X* X* NP NP
III(200) X* NP NP NP
IV(2HH) X* X* NP NP
V(111) X* X* NP NP
V(000) X* NP NP NP
X: Permitted type of construction.
NP: Not permitted.
*Building requires automatic sprinkler protection. (See 19.3.5.1.)
.

27382



The facility failed to provide corridor doors that would close and resist the passage of smoke. Findings include: During the revisit, the following is an example of what was observed:

The door to the Doctor's Dictation Office was not provided with positive latching hardware.

NFPA 101, 19.3.6.3.1 Exception No.2. In the smoke compartments protected throughout by an approved, supervised automatic sprinkler system, doors in corridor walls shall be constructed to resist the passage of smoke and be provided with suitable means of keeping the doors closed.

.

During the survey, the following is an example of what was observed:

An Exit sign was observed at the door to the Doctor's Dictation Office, thus providing exiting from the facility through this office.

NFPA 101 7.5.1 General

7.5.1.1 Exits shall be located and exit access shall be arranged so that exits are readily accessible at all times.

7.5.1.2* Where exits are not immediately accessible from an open floor area, continuous passageways, aisles, or corridors leading directly to every exit shall be maintained and shall be arranged to provide access for each occupant to not less than two exits by separate ways of travel. Exit access corridors shall provide access to not less than two approved exits without passing through any intervening rooms other than corridors, lobbies, and other spaces permitted to be open to the corridor.

.

The facility failed to maintain the fire alarm system in proper working order. Findings include: During the survey, the following is an example of what was observed:

The audible device in the OR was not operable during the test of the fire alarm system.


2000 NFPA 101, 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.
.

The facility failed to perform the required maintenance of the facility sprinkler system. During the survey, the following are examples of what was observed:

A) The Fire Department Connection was obstructed by the AC Unit, connection is located by the Main Entrance of the facility.

NFPA 101,2000 Edition, 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, Standards for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

NFPA 25, 1998 Edition, 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.

.

The facility failed to perform the required maintenance of the facility sprinkler system. During the survey, the following is an example of what was observed:

The Fire department connection was obstructed by the AC Unit, connection is located by the Main Entrance of the facility.

NFPA 101, 2000 Edition, 9.7.5 All automatic sprinkler and standpipe systems required by this code shall be inspected, tested, and maintained in accordance with NFPA 25, Standards for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

NFPA 25, 1998 Edition, 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.


.

During the revisit, the following is an example of what was observed:

Documentation was provided by the facility for the annual inspection of the medical gas system. Upon review of the report, several items were not in compliance with code and items had not been corrected.


4.2 Maintenance.
4.2.1 Each bulk oxygen system installed on consumer premises shall be inspected annually and maintained by a qualified representative of the equipment owner.

.


27382

During the revisit, the following is an example of what was observed:

Documentation was provided by the facility for the annual inspection of the medical gas system. Upon review of the report, several items were not in compliance with code and items had not been corrected.


4.2 Maintenance.
4.2.1 Each bulk oxygen system installed on consumer premises shall be inspected annually and maintained by a qualified representative of the equipment owner.

.

Facility failed to maintain the Type 1 EES. During the survey, the following are examples of what was observed:

A) During the survey, based upon observation and interview with Maintenance, the two generators were not provided with remote annunciator panels.

1999 NFPA 99, 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 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

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. [110: 3-5.5.2]

B) At the time of the survey, the transfer switches were not identified in the Generator Set Control Room for Generator One or Two.

NFPA 70, 110-22 Identification of Disconnecting Means:

Each disconnecting means required by this code for motors and appliances, and each service, feeder, or branch circuit at the point where it originates, shall be legibly marked to indicate its purpose unless located and arranged so the purpose is evident. The marking shall be of sufficient durability to withstand the environment involved.

Facility failed to maintain the Type 1 EES. During the survey, the following are examples of what was observed:

A) During the survey, based upon observation and interview with Maintenance, the two generators were not provided with remote annunciator panels.

1999 NFPA 99, 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 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
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. [110: 3-5.5.2]

B) At the time of the survey, the transfer switches were not identified in Generator Set Control Room for Generator One or Two.

NFPA 70, 110-22 Identification of Disconnecting Means:
Each disconnecting means required by this code for motors and appliances, and each service, feeder, or branch circuit at the point where it originates, shall be legibly marked to indicate its purpose unless located and arranged so the purpose is evident. The marking shall be of sufficient durability to withstand the environment involved.

During the survey, the following is an example of what was observed:

An Exit sign was observed at the door to the Doctor's Dictation Office, thus providing exiting from the facility through this office.

NFPA 101 7.5.1 General

7.5.1.1 Exits shall be located and exit access shall be arranged so that exits are readily accessible at all times.

7.5.1.2* Where exits are not immediately accessible from an open floor area, continuous passageways, aisles, or corridors leading directly to every exit shall be maintained and shall be arranged to provide access for each occupant to not less than two exits by separate ways of travel. Exit access corridors shall provide access to not less than two approved exits without passing through any intervening rooms other than corridors, lobbies, and other spaces permitted to be open to the corridor.

.

The facility failed to maintain the fire alarm system in proper working order. Findings include: During the survey, the following is an example of what was observed:

The audible device in the OR was not operable during the test of the fire alarm system.


2000 NFPA 101, 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.
.