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Based on review of facility documents and employee interviews (EMP), it was determined the facility failed to ensure the condition of the physical plant was maintained in such a manner that the safety and well-being of patients are assured (A0701), and subsequently experienced a fire on the penthouse roof top on September 3, 2024. In addition, the facility failed to maintain written evidence of regular inspection and approval by State or local fire control agencies (A0175).


Cross reference:
482.41(a) Physical Environment: Buildings.
482.41(b)(6) Physical Environment: Life Safety From Fire

Based on a review of facility documents, tour, and employee interview (EMP), it was determined the facility failed to comply with policy while welding on the facility's roof top which resulted in a spark causing a fire on September 3, 2024.


Findings include:


On September 4, 2024, a review of facility policy, "Hot Works Permits" (Last Revised: 10/1/2019; Last Approved 1/6/2023) revealed, "Terms and Definitions: A. Hot Works Projects- An activity that may result in sparks, fire, molten slag or hot material that has combustible potential that could cause fires or explosions. 1. Hot Works Project Examples include: welding, soldering, cutting thawing pipes, brazing, grinding, torch applied roofing, etc ... D. OSHA requires fire prevention activities when welding or doing hot works including: 1. If possible and practical, relocate combustibles at least 35 feet from the work site. If relocation of combustibles is not practical, protect/shield combustibles with flame proof covers, metal guards to prevent ignition. 2. Shut down or protect HVAC systems, ducts or other sources that may carry sparks to far away combustibles. 3. Fire resistant shields will be used to prevent ignition when welding or cutting is performed near walls, partitions, ceilings or roof combustible construction materials. 4. To prevent ignition of combustibles on the other side of a metal wall, partition, roof or ceiling, precautions will be taken by placing a fire watch, person who will be posted on the opposite side of the wall to watch for sparks and ignition... ."



A review of facility documents revealed that on September 3, 2024, at 11:19 AM, a spark from welding on the hospital "penthouse roof" contacted roof insulation resulting in fire and smoke and initiation of the facility's fire response plan. Smoke entered the facility through the roof air handler. There was response from multiple fire departments.



On September 4, 2024, between approximately 1:00 PM and 1:20 PM, a tour of the roof and penthouse were conducted. Visual inspection of the affected area on penthouse roof, revealed an area of roofing material measuring approximately ten feet by fifteen feet was removed, exposing the steel roof decking material beneath. The roofing material cut away was approximately ten inches thick, and consisted of a rubberized top layer, with multiple layers of foam insulation boards laying atop a corrugated steel decking surface. EMP3 was present and demonstrated the locations of the welding work and fire that occurred on September 3, 2024. Palpable air flow was noted to be drawn into the penthouse from a gap in the roof decking near where the fire had occurred. EMP3 confirmed that this gap was present on the day of the incident as well as a large opening, approximately two foot by four foot, created for the future air handler.



During an interview on September 4, 2024, at 9:49 AM, EMP3 stated that the roof fire was contained by use of facility fire extinguishers, both ABC and "dry chem." The fire department hosed a smoldering area with water. All fire units were released on September 3, 2024, at approximately 2:00 PM.


During an interview on September 4, 2024, at 11:06 AM, EMP8 stated that the roof project was a part of the bigger project which was the replacement of the rooftop HVAC system. The construction team was working to add additional support to the "penthouse" roof to accept the "weight of the new HVAC system." EMP8 and EMP 9 explained the job was bid to "patch in" the supports for the new HVAC system and that the job needed to be watertight by the end of each work day.



During an interview on September 5, 2024, at 10:01 AM, EMP10 detailed that this project was "novel" and could not be approached in a "conventional process" since there was penetration of the roof assembly and drawing outside air into the work area. EMP10 also stated that it was not "possible or practical" to relocate combustibles (insulation) or to shut down the HVAC system and have "stale air" in patient areas.


During an interview on September 6, 2024, at 9:30 AM, EMP11 explained being responsible for conducting the roof weld for the "duct stand." EMP11 described that the right weld was completed and as EMP11 began the left weld, "My fire watch stated that he saw smoke." EMP11 stated that they were not using fire blankets. EMP11 stated the fire blankets were "below" (in the penthouse) in EMP11's "gang box" (toolbox). EMP11 stated that the work area was approximately 16 inches by 12 inches and had "some concern" with the size of the work area. However, the welding team was "blowing and cleaning the decking before the welding work" to reduce hazards.


During an interview on September 6, 2024, at approximately 9:40 AM, EMP10, further explained that it had been decided to keep the work area "as small as possible" to prevent water infiltration and assure the work area would be "watertight" at the end of each workday. In addition, EMP10 acknowledged that fire blankets are "heavy duty," and in a work area of this size, the fire blanket would eliminate the contractors "room to work" and could not be used.

During an interview on September 6, 2024, at 9:30 AM, EMP11 confirmed that the facility did not use "flame proof covers..." (fire blankets) when completing the welds, on September 3, 2024, for the roof "duct stands.

Based upon a review of facility documents and employee interview (EMP), it was determined that the facility failed to maintain written evidence of regular inspection by local fire control agencies.

Findings include:

On September 4, 2024, at approximately 9:15 AM, a request was made for documentation of fire inspection by the local fire control agency. At approximately 2:15 PM, two letters from the local Fire Chief were provided by EMP3. One undated letter was a commitment of resources by the fire department incase of emergency to evacuate wheelchair bound patients from the dialysis suite on the second floor of the medical office building. The second undated letter was an acknowledgement of a meeting in May, 2024, between EMP3 and the Fire Chief about a kitchen sink being placed near a fire suppression system in the kitchen. The Fire Chief had requested a paper towel dispenser be moved away from the suppression system activation handles. Neither document provided evidence that the facility conducted regular inspections by stat or local fire agencies.

On September 4, 2024, at 2:30pm, EMP3 confirmed there was no documentation or evidence of regular inspections and approval by State and local fire department.