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During a tour of the building on January 3, 2012, it was observed that not all self closing corridor doors would close to positive latching.

Findings include:

At 4:05 p.m. on A Wing, the self closing corridor door to the equipment storage room would not close to positive latching when the door was opened and allowed to close by the surveyor.

Based on observations made during a tour of the building on January 4, 2012, the surveyor determined that the facility failed to ensure that all self closing doors serving hazardous areas were adequately maintained.

Findings include:

At approximately 7:30 a.m., the rated door to the room containing the emergency generator was examined. The door when released by the surveyor would not close to positive latching. The latching bolt became stuck once the door knob was turned either to the right or left.

Based on observations made by the surveyor during a tour of the interior of the clinic on 1/04/2012, it was determined not all doors intended to be used for exiting are properly identified for such a purpose.

Findings include:

In accordance with NFPA 101 and Section 39.2.10 Marking of Means of Egress; means of egress shall have signs in accordance with Section 7.10. Within Section 7.10.1.2 Exits; exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign readily visible from any direction of exit access. Further in Annex Section A.7.10.1.2; where a main entrance serves also as an exit, it will usually be sufficiently obvious to occupants so that no exit sign is needed. The character of the occupancy has a practical effect on the need for signs. In any assembly occupancy, hotel, department store, or other building subject to transient occupancy, the need for signs will be greater than in a building subject to permanent or semipermanent occupancy by the same people, such as an apartment house where the residents are presumed to be familiar with exit facilities by reason of regular use thereof. Even in a permanent residence-type building, however, there is need for signs to identify exit facilities such as outside stairs that are not subject to regular use during the normal occupancy of the building.
There are many types of situations where the actual need for signs is debatable. In cases of doubt, however, it is desirable to be on the safe side by providing signs, particularly as posting signs does not ordinarily involve any material expense or inconvenience.

At 10:32 a.m., the surveyor toured the interior of the Clinic and observed there were no exit signs posted in the building.

Based on observations made by the surveyor during a tour of the interior of the clinic on January 4, 2012 at approximately 11:13 a.m., it was determined not all doors intended to be used for exiting are properly identified for such a purpose.

Findings include:

In accordance with NFPA 101 and Section 39.2.10 Marking of Means of Egress; means of egress shall have signs in accordance with Section 7.10. Any door, passage, or stairway that is neither an exit nor a way of exit access and that is located or arranged so that it is likely to be mistaken for an exit shall be identified by a sign that reads NO EXIT or similar language per section 7.10.8.1 of the Life Safety Code .

In addition within Section 7.10.1.2 Exits; exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign readily visible from any direction of exit access. Further in Annex Section A.7.10.1.2; where a main entrance serves also as an exit, it will usually be sufficiently obvious to occupants so that no exit sign is needed. The character of the occupancy has a practical effect on the need for signs. In any assembly occupancy, hotel, department store, or other building subject to transient occupancy, the need for signs will be greater than in a building subject to permanent or semipermanent occupancy by the same people, such as an apartment house where the residents are presumed to be familiar with exit facilities by reason of regular use thereof. Even in a permanent residence-type building, however, there is need for signs to identify exit facilities such as outside stairs that are not subject to regular use during the normal occupancy of the building.
There are many types of situations where the actual need for signs is debatable. In cases of doubt, however, it is desirable to be on the safe side by providing signs, particularly as posting signs does not ordinarily involve any material expense or inconvenience.

1. Off the back exit hallway, there was framed glass door which potentially could be opened into a construction area in the interior of the building. No sign such as NO EXIT or NOT AN EXIT was posted at the glass door to the patio to prevent being mistaken as a means of egress.

2. There is an interior side door that opens into the interior of the front foyer. The use of this door as means of egress should be discouraged due to the restricted width and path of travel to the door from office spaces. This need of this door as a means of exit should be evaluated and if not needed, signage should be installed similar stating NO EXIT.

3. There are no exit signs in the building to aid patients in determine correct exit paths.

Based on observations made by the surveyor during a tour of the interior of the clinic on January 4, 2012, it was determined that the line of exit travel was not obvious and not all doors intended to be used for exiting are properly identified for such a purpose.

Findings include:

In accordance with NFPA 101 and Section 38.2.10 Marking of Means of Egress; means of egress shall have signs in accordance with Section 7.10. Within Section 7.10.1.2 Exits; exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign readily visible from any direction of exit access. Further in Annex Section A.7.10.1.2; where a main entrance serves also as an exit, it will usually be sufficiently obvious to occupants so that no exit sign is needed. The character of the occupancy has a practical effect on the need for signs. In any assembly occupancy, hotel, department store, or other building subject to transient occupancy, the need for signs will be greater than in a building subject to permanent or semipermanent occupancy by the same people, such as an apartment house where the residents are presumed to be familiar with exit facilities by reason of regular use thereof. Even in a permanent residence-type building, however, there is need for signs to identify exit facilities such as outside stairs that are not subject to regular use during the normal occupancy of the building.
There are many types of situations where the actual need for signs is debatable. In cases of doubt, however, it is desirable to be on the safe side by providing signs, particularly as posting signs does not ordinarily involve any material expense or inconvenience.

Between 9:00 a.m. and 9:23 a.m.,the surveyor toured the clinic. Exit signs are located in the perimeter hallways of the clinic. However, there was a lack of exit signs at the ends of one of two interior hallways to indicate path of travel to doors used for exiting from the clinic.

Based on observations of January 4, 2012 in the basement, the surveyor determined the facility failed to maintain a fire separation between the basement and the floor above.

Findings include:

In accordance with Section 39.3.2.1 of NFPA 101, hazardous areas including, but not limited to, areas used for general storage, boiler or furnace rooms, and maintenance shops that include woodworking and painting areas shall be protected in accordance with Section 8.4. Annex A.39.3.2.1 further states that it is not the intent of this provision that rooms inside individual tenant spaces, used to store routine office supplies for that tenant, be required to be separated or sprinklered.

In accordance with Section 8.4.1.1 of NFPA 101, protection from any area having a degree of hazard greater than that normal to the general occupancy of the building or structure shall be provided by one of the following means:
(1) Enclose the area with a fire barrier without windows that has a 1-hour fire resistance rating in accordance with Section 8.2.
(2) Protect the area with automatic extinguishing systems in accordance with Section 9.7.
(3) Apply both 8.4.1.1(1) and (2) where the hazard is severe or where otherwise specified by Chapters 12 through 42.

Between 8:34 a.m. and 8:52 a.m., it was determined that the basement is not separated from the upstairs with fire rated construction. Due to the furnaces in the basement and the the combustible storage in the basement, the basement is considered a hazardous storage area. The clinic is not separated from the basement with at least one hour fire rated construction.

Based on observations of January 4, 2012, the surveyor determined that not all hazardous areas (when required) were separated from other areas by one hour construction and/or walls (includes ceilings) and were being maintained to prevent the passage of smoke from any hazardous area.

Findings include:

The surveyor inspected the kitchen at 1:48 p.m. The space above the lay-in ceiling where the wall separates the kitchen from the former purchasing department was examined. An unsealed two to three inch penetration had been left unsealed where a pipe passed through the wall.

Based on observation on January 4, 2012, the facility failed to maintain surfaces outside exit doors as hard path surfaces.

Findings include:
In accordance with NFPA 101 and Section 38.2.7 Discharge from Exits; exit discharge shall comply with Section 7.7. Section 7.7.1 states that exits shall terminate directly at a public way or at an exterior exit discharge. Yards, courts, open spaces, or other portions of the exit discharge shall be of required width and size to provide all occupants with a safe access to a public way.
Exception No. 1: This requirement shall not apply to interior exit discharge as otherwise provided in 7.7.2.
Exception No. 2: This requirement shall not apply to rooftop exit discharge as otherwise provided in 7.7.6.
Exception No. 3: Means of egress shall be permitted to terminate in an exterior area of refuge as provided in Chapters 22 and 23.

Further guidance can be found in Annex Section A.7.7.1 as follows: An exit from the upper stories, in which the direction of egress travel is generally downward, should not be arranged so that it is necessary to change to travel in an upward direction at any point before discharging to the outside. A similar prohibition of reversal of the vertical component of travel should be applied to exits from stories below the floor of exit discharge. However, an exception is permitted in the case of stairs used in connection with overhead or underfloor exit passageways that serve the street floor only. It is important that ample roadways be available from buildings in which there are large numbers of occupants so that exits will not be blocked by persons already outside. Two or more avenues of departure should be available for all but very small places. Location of a larger theater, for example, on a narrow dead-end street, might be prohibited by the authority having jurisdiction under this rule, unless some alternate way of travel to another street is available.
Exterior walking surfaces within the exit discharge are not required to be paved and often are provided by grass or similar surfaces. Where discharging exits into yards, across lawns, or onto similar surfaces, in addition to providing the required width to allow all occupants safe access to a public way, such access also is required to meet the following:
(1) The provisions of 7.1.7 with respect to changes in elevation
(2) The provisions of 7.2.2 for stairs, as applicable
(3) The provisions of 7.2.5 for ramps, as applicable
(4) The provisions of 7.1.10 with respect to maintaining the means of egress free of obstructions that would prevent its use, such as snow and the need for its removal in some climates

At 9:23 a.m., it was determined that there was not a hardened path of travel outside one of the two identified exit doors.

Based on observations made on January 4, 2012, the facility failed to maintain at all clinics, safe conditions for exiting at doors used as exits from clinic buildings.

Findings include:

At approximately 10:50 a.m.,the vertical step height from doors to used in exiting,excluding the main entrance, were excessive in height

Based on a review of documentation, observation and a discussion with the Director of Engineering on January 3, 2012, the facility failed to ensure that all locations requiring battery powered emergency light fixtures were equipped with such equipment.

The findings include:

Emergency generator locations shall be provided with battery-powered emergency lighting in accordance with Section 3-4.2.2.2(b)5 of NFPA 99, 1999 Edition and 5-3.1 of NFPA 110, 1999 Edition. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch. Additionally in accordance with 7.9.3 of the Life Safety Code, 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 one and one-half hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

During a review of paperwork between 10:00 a.m. and 11:30 a.m., the surveyor was informed that there was no battery backup emergency lighting in the building which included the emergency generator room and the location of transfer switches. Once such equipment is installed, documentation shall be recorded and available to show that the 30-day and annual tests of the battery powered emergency lights in the room housing the generator and the location of transfer switches is being performed.

Based on staff interviews of January 4, 2012, the facility did not ensure that there was a testing and maintenance program for the smoke detectors installed in the facility.

Findings include:

In accordance with NFPA 101 and Section 4.6.12.2, existing life safety features obvious to the public, if not required by the Code, shall be either maintained or removed. Further guidance in the Annex of NFPA 101 in Section A.4.6.12.2
states that examples of such features include automatic sprinklers, fire alarm systems, standpipes, and portable fire extinguishers. The presence of a life safety feature, such as sprinklers or fire alarm devices, creates a reasonable expectation by the public that these safety features are functional. When systems are inoperable or taken out of service but the devices remain, they present a false sense of safety. Also, before taking any life safety features out of service, extreme care needs to be exercised to ensure that the feature is not required, was not originally provided as an alternative or equivalency, or is no longer required due to other new requirements in the current Code. It is not intended that the entire system or protection feature be removed. Instead, components such as sprinklers, initiating devices, notification appliances, standpipe hose, and exit systems should be removed to reduce the likelihood of relying on inoperable systems or features.

At approximately 10:40 a.m., there was no testing and maintenance schedule made available for the smoke detectors located in the clinic.

Based on observations made at the time of the survey on January 4, 2012 at 9:05 a.m., it was determined that the sprinkler equipment originally installed in "prefab" construction of the clinic is not operational.

Findings include:

In accordance with NFPA 101 and Section 4.6.12.2, existing life safety features obvious to the public, if not required by the Code, shall be either maintained or removed. Further guidance in the Annex of NFPA 101 in Section A.4.6.12.2
states that examples of such features include automatic sprinklers, fire alarm systems, standpipes, and portable fire extinguishers. The presence of a life safety feature, such as sprinklers or fire alarm devices, creates a reasonable expectation by the public that these safety features are functional. When systems are inoperable or taken out of service but the devices remain, they present a false sense of safety. Also, before taking any life safety features out of service, extreme care needs to be exercised to ensure that the feature is not required, was not originally provided as an alternative or equivalency, or is no longer required due to other new requirements in the current Code. It is not intended that the entire system or protection feature be removed. Instead, components such as sprinklers, initiating devices, notification appliances, standpipe hose, and exit systems should be removed to reduce the likelihood of relying on inoperable systems or features.

Although the structure of the clinic is equipped with sprinkler piping and sprinkler heads, the entire extent of the sprinkler equipment is not being maintained to be operational. The Director of Engineering indicated that no water supply is plumbed into the sprinkler riser located in the building. This was verified by the surveyor at the time of survey. This business occupancy is not required to have a sprinkler system.

Based on observation, record review and interview with the Director of Engineering on January 3, 2010, the facility failed to notify the proper authorities when changing the configuration of cooking services in the kitchen.

Findings include:

In accordance with Section 1-3.4 of NFPA 96, if required by the authority having jurisdiction, notification in writing shall be given of any alteration, replacement, or relocation of any exhaust or extinguishing system or part thereof or cooking equipment. Satisfaction shall be provided to the authority having jurisdiction that the complete exhaust system as addressed in this standard is installed and operable in accordance with the approved design and the manufacturer ' s instructions.

At 2:00 p.m., the kitchen hood system was observed for compliance. The heads for the wet chemical system for the kitchen commercial equipment were not directly over the cooking top. They were on either side of the cooking top. When ask, the Director of Engineering indicated that the previous stove had been removed and a new one put into place. The location of the sprinkler head under the hood should be reviewed by a fire sprinkler installer to verify they will properly protect the new stove.

Based on observations made on January 3, 2012, the facility failed to provide documentation that all window curtains or coverings in use were flame resistant in accordance with the standards of NFPA 701 or had been treated with a flame resistant product.

Findings include:

In accordance with 19.7.5.1 and 10.3.1 of NFPA 101; draperies, curtains or other loosely hanging fabrics in health care occupancies shall be flame resistant as demonstrated by testing in accordance with NFPA 701.

1. The curtains in the labor and delivery room of the hospital were reviewed at 3:59 p.m. There was no documentation that the curtains were inherently flame retardant or that they had been treated with an appropriate flame retardant spray.

2. At approximately 4:00 p.m., the B Wing (west patient wing) was inspected by one of the surveyors. In the patient room 139 across from the nursing station, the newly installed vertical blinds were examined. At that time, specifications of the flame spread rating of the blinds were not available to be examined by the surveyor.

Based on observations made by the surveyor on January 3, 2012, the determination was made that not all requirements of NFPA 99, 1999 Edition, were being followed by the facility.

Findings include:

In accordance with 8-3.1.22.2(h) and 4-3.5.2.1(b27) of NFPA 99; freestanding cylinders of nonflammable gases (such as oxygen) shall be properly chained or supported in a cylinder cart or stand or by means of racks or fastenings to protect them from falling over or being knocked down.

At approximately 2:30 p.m., the outside oxygen storage building was inspected by the surveyors. One small argon cylinder was found to be "free standing" and not properly secured as other cylinders were by chains and/or fasteners.

Based on review of medical gas shut off valves, the facility failed to indicate which specific rooms shut off valves controlled.

Findings include:

In accordance with NFPA 99, 1999 Edition, and Section 4-3.1.2.3 (m) & (n) Gas Shutoff Valves; (m) A shutoff valve shall be located immediately outside each vital life-support or critical care area in each medical gas line, and located so as to be readily accessible in an emergency. Valves shall be protected and marked in accordance with 4-3.5.4.2.
All gas-delivery columns, hose reels, ceiling tracks, control panels, pendants, booms, alarm panels, or other special installations shall be located downstream of this valve.
(n) A shutoff valve shall be located outside each anesthetizing location in each medical gas line, so located as to be readily accessible at all times for use in an emergency. These valves shall be so arranged that shutting off the supply of gas to any one operating room or anesthetizing location will not affect the others. Valves shall be of an approved type, mounted on a pedestal or otherwise properly safeguarded against physical damage, and marked in accordance with 4-3.5.4.2.

Further, NFPA 99 Section 4-3.5.4.2 states that the shutoff valves described in 4-3.1.2.3, 4-3.1.2.3(m), and 4-3.1.2.3(n) shall be labeled to reflect the rooms that are controlled by such valves. Labeling shall be kept current from initial construction through acceptance. Valves shall be labeled in substance as follows:
CAUTION:
(NAME OF MEDICAL GAS) VALVE DO NOT CLOSE EXCEPT IN EMERGENCY THIS VALVE CONTROLS SUPPLY TO . . . .

Various locations of gas shut off valves were reviewed during review of the hospital. While the gas shut offs were labeled, some did not mention the specific rooms that they served. Further, some changes room usage no longer required some valves to be used. One example was two shut off valves labeled EEG and EKG that were no longer in use on the main east to west corridor just inside the main entrance.

Based on review of a remodeled area of the facility on January 3, 2011, the facility failed to ensure that some interior walls were completed without combustible materials.

Findings include:

In accordance with NFPA 101 and Section 19.1.6.3; all interior walls and partitions in buildings of Type I or Type II construction shall be of noncombustible or limited-combustible materials.
Exception*: Listed, fire-retardant-treated wood studs shall be permitted within non-load bearing 1-hour fire-rated partitions. Further, Annex A.19.1.6.3 Exception states that there is a finish capacity in a 1-hour fire-rated partition that would be expected to prevent the generation of smoke and gases from fire retardant-treated wood studs for an extended time during fire exposure. This Code does not intend to permit the use of fire-retardant wood studs and partitions of only 20-minute fire resistance.

While in the new electrical room of the remodeled area in the south east corner of the building, un treated two by four construction was used to support some electrical components.

Based on a review of laboratory policies and procedures and discussion with the lab supervisor on January 4, 2012, the facility failed to provide for a chemical spill kit in the laboratory.

Findings include:

During a review of the emergency procedures for chemical spills, it was determined that a chemical spill kit was to be available for use in the event of such an accident. After a discussion with the lab supervisor, it was learned that a replacement kit had been ordered but had not yet arrived at the laboratory. It was determined that the laboratory did not have a chemical spill kit available for immediate use in case such a spill occurred.

Based on review of the generator location on January 4, 2012, the facility failed to supply an emengency stop station for the generator.

Findings include:

In accordance with NFPA 110, 1999 Edition and Section 3-5.5.6: all Level 1 and Level 2 installations shall have a remote manual stop station of a type similar to a break-glass station located outside the room housing the prime mover, where so installed, or located elsewhere on the premises where the prime mover is located outside the building. Annex A-3-5.5.6 states that for Level 1 and Level 2 systems located outdoors, the manual shutdown should be located external to the weatherproof enclosure and should be appropriately identified.

At 10:00 a.m., the generator location was reviewed inside the boiler room. When asked if a remote stop button existed for the generator, the Director of Engineering stated that there was not one for the generator.

Based on observations made on January 4, 2012 and discussions with staff, it was determined that the facility failed to provide for the Type I EES to be divided into identified branches.

Findings include:

In accordance with 3-4.2.2.1 of NFPA 99 (1999 edition) Type I essential electrical systems are comprised of two separate systems being the emergency system and the equipment system. The emergency system shall be limited to circuits essential to life safety and critical patient care. These are designated the life safety branch and the critical branch. The number of transfer switches to be used shall be based upon reliability, design, and load considerations. Each branch of the emergency system and each equipment system shall have one or more transfer switches. One transfer switch shall be permitted to serve one or more branches or systems in a facility with a maximum demand on the essential electrical system of 150 kVA (120 kW).

At 7:20 a.m., the generator transfer switch panels ATS 1, ATS 2, ATS 3, and ATS 4 were consecutively marked as, "Main", "Entire Building", "Battery Charger" and "Surgery Critical Care". When the legends inside the ATS panel doors were examined, no information was recorded to explicitly identify the circuits as described in the requirement cited in the above Section 3-4.2.2.1 of NFPA 99.

Based on observations made on January 4, 2012, the facility failed insure at all clinic locations, that all requirements were being followed for the electrical system and/or its components in accordance with the standards of NFPA 70, 1999 Edition, NFPA 99, 1999 Edition, or interpretations from the Centers for Medicare and Medicaid Services (CMS).

Findings include:

In accordance with NFPA 101 and Section 39.5.1, utilities shall comply with the provisions of Section 9.1. Further, Section 9.1.2 Electric states that 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.

In accordance with Article 370.28(c) of NFPA 70 (1999 Edition) all pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use. Where metal covers are used, they shall comply with the grounding requirements of Article 250-110.

At approximately 11:20 a.m., an electrical junction box was hanging from the ceiling in the foyer of the front entrance to the Pediatric Clinic.

Based on observations on January 3, 2012, the facility failed to maintain electrical wiring and components with the NFPA 70, 1998 Edition.

Findings include:

In accordance with NFPA 101 and Section 19.5.1, utilities shall comply with the provisions of Section 9.1. Further, Section 9.1.2 Electric states that 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.

Each disconnecting means and each service at the point where it originates shall be legibly marked to indicate its purpose unless located and arranged so the purpose is evident per Article 110-22 of NFPA 70.

In accordance with Article 110-26 and table 110-26(a) of NFPA 70 there shall be maintained a clear working space of at least 36" around electrical equipment such as panel boards to permit ready and safe operations of such equipment. This working space can not be used for storage purposes.

1. An electrical panel was reviewed in the radiology area at 2:43 p.m. Two deficiencies were noted:

a.) The electrical panel did not have a circuit schedule for the breakers in the panel, and

b.) Items were stacked in front of the electrical panel.

Based on observations on January 4, 2012, all electrical installations are not installed per NFPA 70 National Electric Code, 1999 Edition.

Findings include:

In accordance with Section 39.5.1 Utilities; utilities shall comply with the provisions of Section 9.1. Further, Section 9.1.2 Electric states that 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.

Each disconnecting means and each service at the point where it originates shall be legibly marked to indicate its purpose unless located and arranged so the purpose is evident per Article 110-22 of NFPA 70.

Electrical panel B was reviewed at 8:45 a.m. Breakers were in the on position and were not correctly labeled on the panel schedule.

On January 3, 2012, the policy and procedures for the facility's fire watch program were reviewed. Based on that review, it was determined that the facility did not ensure that a program was in place for the sprinkler system.

Findings include:

Between 10:00 a.m. to 11:30 a.m., the policy and procedures for the fire watch program were reviewed. It is identified that a fire watch is to be put in place when the fire alarm system is out of service for 4 hours or more in a 24 hour period. However, there is no fire watch policy also in place for the sprinkler system.

During a tour of the building on January 3, 2012, it was observed that not all self closing corridor doors would close to positive latching.

Findings include:

At 4:05 p.m. on A Wing, the self closing corridor door to the equipment storage room would not close to positive latching when the door was opened and allowed to close by the surveyor.

Based on observations made during a tour of the building on January 4, 2012, the surveyor determined that the facility failed to ensure that all self closing doors serving hazardous areas were adequately maintained.

Findings include:

At approximately 7:30 a.m., the rated door to the room containing the emergency generator was examined. The door when released by the surveyor would not close to positive latching. The latching bolt became stuck once the door knob was turned either to the right or left.

Based on observations made by the surveyor during a tour of the interior of the clinic on 1/04/2012, it was determined not all doors intended to be used for exiting are properly identified for such a purpose.

Findings include:

In accordance with NFPA 101 and Section 39.2.10 Marking of Means of Egress; means of egress shall have signs in accordance with Section 7.10. Within Section 7.10.1.2 Exits; exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign readily visible from any direction of exit access. Further in Annex Section A.7.10.1.2; where a main entrance serves also as an exit, it will usually be sufficiently obvious to occupants so that no exit sign is needed. The character of the occupancy has a practical effect on the need for signs. In any assembly occupancy, hotel, department store, or other building subject to transient occupancy, the need for signs will be greater than in a building subject to permanent or semipermanent occupancy by the same people, such as an apartment house where the residents are presumed to be familiar with exit facilities by reason of regular use thereof. Even in a permanent residence-type building, however, there is need for signs to identify exit facilities such as outside stairs that are not subject to regular use during the normal occupancy of the building.
There are many types of situations where the actual need for signs is debatable. In cases of doubt, however, it is desirable to be on the safe side by providing signs, particularly as posting signs does not ordinarily involve any material expense or inconvenience.

At 10:32 a.m., the surveyor toured the interior of the Clinic and observed there were no exit signs posted in the building.

Based on observations made by the surveyor during a tour of the interior of the clinic on January 4, 2012 at approximately 11:13 a.m., it was determined not all doors intended to be used for exiting are properly identified for such a purpose.

Findings include:

In accordance with NFPA 101 and Section 39.2.10 Marking of Means of Egress; means of egress shall have signs in accordance with Section 7.10. Any door, passage, or stairway that is neither an exit nor a way of exit access and that is located or arranged so that it is likely to be mistaken for an exit shall be identified by a sign that reads NO EXIT or similar language per section 7.10.8.1 of the Life Safety Code .

In addition within Section 7.10.1.2 Exits; exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign readily visible from any direction of exit access. Further in Annex Section A.7.10.1.2; where a main entrance serves also as an exit, it will usually be sufficiently obvious to occupants so that no exit sign is needed. The character of the occupancy has a practical effect on the need for signs. In any assembly occupancy, hotel, department store, or other building subject to transient occupancy, the need for signs will be greater than in a building subject to permanent or semipermanent occupancy by the same people, such as an apartment house where the residents are presumed to be familiar with exit facilities by reason of regular use thereof. Even in a permanent residence-type building, however, there is need for signs to identify exit facilities such as outside stairs that are not subject to regular use during the normal occupancy of the building.
There are many types of situations where the actual need for signs is debatable. In cases of doubt, however, it is desirable to be on the safe side by providing signs, particularly as posting signs does not ordinarily involve any material expense or inconvenience.

1. Off the back exit hallway, there was framed glass door which potentially could be opened into a construction area in the interior of the building. No sign such as NO EXIT or NOT AN EXIT was posted at the glass door to the patio to prevent being mistaken as a means of egress.

2. There is an interior side door that opens into the interior of the front foyer. The use of this door as means of egress should be discouraged due to the restricted width and path of travel to the door from office spaces. This need of this door as a means of exit should be evaluated and if not needed, signage should be installed similar stating NO EXIT.

3. There are no exit signs in the building to aid patients in determine correct exit paths.

Based on observations made by the surveyor during a tour of the interior of the clinic on January 4, 2012, it was determined that the line of exit travel was not obvious and not all doors intended to be used for exiting are properly identified for such a purpose.

Findings include:

In accordance with NFPA 101 and Section 38.2.10 Marking of Means of Egress; means of egress shall have signs in accordance with Section 7.10. Within Section 7.10.1.2 Exits; exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign readily visible from any direction of exit access. Further in Annex Section A.7.10.1.2; where a main entrance serves also as an exit, it will usually be sufficiently obvious to occupants so that no exit sign is needed. The character of the occupancy has a practical effect on the need for signs. In any assembly occupancy, hotel, department store, or other building subject to transient occupancy, the need for signs will be greater than in a building subject to permanent or semipermanent occupancy by the same people, such as an apartment house where the residents are presumed to be familiar with exit facilities by reason of regular use thereof. Even in a permanent residence-type building, however, there is need for signs to identify exit facilities such as outside stairs that are not subject to regular use during the normal occupancy of the building.
There are many types of situations where the actual need for signs is debatable. In cases of doubt, however, it is desirable to be on the safe side by providing signs, particularly as posting signs does not ordinarily involve any material expense or inconvenience.

Between 9:00 a.m. and 9:23 a.m.,the surveyor toured the clinic. Exit signs are located in the perimeter hallways of the clinic. However, there was a lack of exit signs at the ends of one of two interior hallways to indicate path of travel to doors used for exiting from the clinic.

Based on observations of January 4, 2012 in the basement, the surveyor determined the facility failed to maintain a fire separation between the basement and the floor above.

Findings include:

In accordance with Section 39.3.2.1 of NFPA 101, hazardous areas including, but not limited to, areas used for general storage, boiler or furnace rooms, and maintenance shops that include woodworking and painting areas shall be protected in accordance with Section 8.4. Annex A.39.3.2.1 further states that it is not the intent of this provision that rooms inside individual tenant spaces, used to store routine office supplies for that tenant, be required to be separated or sprinklered.

In accordance with Section 8.4.1.1 of NFPA 101, protection from any area having a degree of hazard greater than that normal to the general occupancy of the building or structure shall be provided by one of the following means:
(1) Enclose the area with a fire barrier without windows that has a 1-hour fire resistance rating in accordance with Section 8.2.
(2) Protect the area with automatic extinguishing systems in accordance with Section 9.7.
(3) Apply both 8.4.1.1(1) and (2) where the hazard is severe or where otherwise specified by Chapters 12 through 42.

Between 8:34 a.m. and 8:52 a.m., it was determined that the basement is not separated from the upstairs with fire rated construction. Due to the furnaces in the basement and the the combustible storage in the basement, the basement is considered a hazardous storage area. The clinic is not separated from the basement with at least one hour fire rated construction.

Based on observations of January 4, 2012, the surveyor determined that not all hazardous areas (when required) were separated from other areas by one hour construction and/or walls (includes ceilings) and were being maintained to prevent the passage of smoke from any hazardous area.

Findings include:

The surveyor inspected the kitchen at 1:48 p.m. The space above the lay-in ceiling where the wall separates the kitchen from the former purchasing department was examined. An unsealed two to three inch penetration had been left unsealed where a pipe passed through the wall.

Based on observation on January 4, 2012, the facility failed to maintain surfaces outside exit doors as hard path surfaces.

Findings include:
In accordance with NFPA 101 and Section 38.2.7 Discharge from Exits; exit discharge shall comply with Section 7.7. Section 7.7.1 states that exits shall terminate directly at a public way or at an exterior exit discharge. Yards, courts, open spaces, or other portions of the exit discharge shall be of required width and size to provide all occupants with a safe access to a public way.
Exception No. 1: This requirement shall not apply to interior exit discharge as otherwise provided in 7.7.2.
Exception No. 2: This requirement shall not apply to rooftop exit discharge as otherwise provided in 7.7.6.
Exception No. 3: Means of egress shall be permitted to terminate in an exterior area of refuge as provided in Chapters 22 and 23.

Further guidance can be found in Annex Section A.7.7.1 as follows: An exit from the upper stories, in which the direction of egress travel is generally downward, should not be arranged so that it is necessary to change to travel in an upward direction at any point before discharging to the outside. A similar prohibition of reversal of the vertical component of travel should be applied to exits from stories below the floor of exit discharge. However, an exception is permitted in the case of stairs used in connection with overhead or underfloor exit passageways that serve the street floor only. It is important that ample roadways be available from buildings in which there are large numbers of occupants so that exits will not be blocked by persons already outside. Two or more avenues of departure should be available for all but very small places. Location of a larger theater, for example, on a narrow dead-end street, might be prohibited by the authority having jurisdiction under this rule, unless some alternate way of travel to another street is available.
Exterior walking surfaces within the exit discharge are not required to be paved and often are provided by grass or similar surfaces. Where discharging exits into yards, across lawns, or onto similar surfaces, in addition to providing the required width to allow all occupants safe access to a public way, such access also is required to meet the following:
(1) The provisions of 7.1.7 with respect to changes in elevation
(2) The provisions of 7.2.2 for stairs, as applicable
(3) The provisions of 7.2.5 for ramps, as applicable
(4) The provisions of 7.1.10 with respect to maintaining the means of egress free of obstructions that would prevent its use, such as snow and the need for its removal in some climates

At 9:23 a.m., it was determined that there was not a hardened path of travel outside one of the two identified exit doors.

Based on observations made on January 4, 2012, the facility failed to maintain at all clinics, safe conditions for exiting at doors used as exits from clinic buildings.

Findings include:

At approximately 10:50 a.m.,the vertical step height from doors to used in exiting,excluding the main entrance, were excessive in height

Based on a review of documentation, observation and a discussion with the Director of Engineering on January 3, 2012, the facility failed to ensure that all locations requiring battery powered emergency light fixtures were equipped with such equipment.

The findings include:

Emergency generator locations shall be provided with battery-powered emergency lighting in accordance with Section 3-4.2.2.2(b)5 of NFPA 99, 1999 Edition and 5-3.1 of NFPA 110, 1999 Edition. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch. Additionally in accordance with 7.9.3 of the Life Safety Code, 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 one and one-half hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

During a review of paperwork between 10:00 a.m. and 11:30 a.m., the surveyor was informed that there was no battery backup emergency lighting in the building which included the emergency generator room and the location of transfer switches. Once such equipment is installed, documentation shall be recorded and available to show that the 30-day and annual tests of the battery powered emergency lights in the room housing the generator and the location of transfer switches is being performed.

Based on staff interviews of January 4, 2012, the facility did not ensure that there was a testing and maintenance program for the smoke detectors installed in the facility.

Findings include:

In accordance with NFPA 101 and Section 4.6.12.2, existing life safety features obvious to the public, if not required by the Code, shall be either maintained or removed. Further guidance in the Annex of NFPA 101 in Section A.4.6.12.2
states that examples of such features include automatic sprinklers, fire alarm systems, standpipes, and portable fire extinguishers. The presence of a life safety feature, such as sprinklers or fire alarm devices, creates a reasonable expectation by the public that these safety features are functional. When systems are inoperable or taken out of service but the devices remain, they present a false sense of safety. Also, before taking any life safety features out of service, extreme care needs to be exercised to ensure that the feature is not required, was not originally provided as an alternative or equivalency, or is no longer required due to other new requirements in the current Code. It is not intended that the entire system or protection feature be removed. Instead, components such as sprinklers, initiating devices, notification appliances, standpipe hose, and exit systems should be removed to reduce the likelihood of relying on inoperable systems or features.

At approximately 10:40 a.m., there was no testing and maintenance schedule made available for the smoke detectors located in the clinic.

Based on observations made at the time of the survey on January 4, 2012 at 9:05 a.m., it was determined that the sprinkler equipment originally installed in "prefab" construction of the clinic is not operational.

Findings include:

In accordance with NFPA 101 and Section 4.6.12.2, existing life safety features obvious to the public, if not required by the Code, shall be either maintained or removed. Further guidance in the Annex of NFPA 101 in Section A.4.6.12.2
states that examples of such features include automatic sprinklers, fire alarm systems, standpipes, and portable fire extinguishers. The presence of a life safety feature, such as sprinklers or fire alarm devices, creates a reasonable expectation by the public that these safety features are functional. When systems are inoperable or taken out of service but the devices remain, they present a false sense of safety. Also, before taking any life safety features out of service, extreme care needs to be exercised to ensure that the feature is not required, was not originally provided as an alternative or equivalency, or is no longer required due to other new requirements in the current Code. It is not intended that the entire system or protection feature be removed. Instead, components such as sprinklers, initiating devices, notification appliances, standpipe hose, and exit systems should be removed to reduce the likelihood of relying on inoperable systems or features.

Although the structure of the clinic is equipped with sprinkler piping and sprinkler heads, the entire extent of the sprinkler equipment is not being maintained to be operational. The Director of Engineering indicated that no water supply is plumbed into the sprinkler riser located in the building. This was verified by the surveyor at the time of survey. This business occupancy is not required to have a sprinkler system.

Based on observation, record review and interview with the Director of Engineering on January 3, 2010, the facility failed to notify the proper authorities when changing the configuration of cooking services in the kitchen.

Findings include:

In accordance with Section 1-3.4 of NFPA 96, if required by the authority having jurisdiction, notification in writing shall be given of any alteration, replacement, or relocation of any exhaust or extinguishing system or part thereof or cooking equipment. Satisfaction shall be provided to the authority having jurisdiction that the complete exhaust system as addressed in this standard is installed and operable in accordance with the approved design and the manufacturer ' s instructions.

At 2:00 p.m., the kitchen hood system was observed for compliance. The heads for the wet chemical system for the kitchen commercial equipment were not directly over the cooking top. They were on either side of the cooking top. When ask, the Director of Engineering indicated that the previous stove had been removed and a new one put into place. The location of the sprinkler head under the hood should be reviewed by a fire sprinkler installer to verify they will properly protect the new stove.

Based on observations made on January 3, 2012, the facility failed to provide documentation that all window curtains or coverings in use were flame resistant in accordance with the standards of NFPA 701 or had been treated with a flame resistant product.

Findings include:

In accordance with 19.7.5.1 and 10.3.1 of NFPA 101; draperies, curtains or other loosely hanging fabrics in health care occupancies shall be flame resistant as demonstrated by testing in accordance with NFPA 701.

1. The curtains in the labor and delivery room of the hospital were reviewed at 3:59 p.m. There was no documentation that the curtains were inherently flame retardant or that they had been treated with an appropriate flame retardant spray.

2. At approximately 4:00 p.m., the B Wing (west patient wing) was inspected by one of the surveyors. In the patient room 139 across from the nursing station, the newly installed vertical blinds were examined. At that time, specifications of the flame spread rating of the blinds were not available to be examined by the surveyor.

Based on observations made by the surveyor on January 3, 2012, the determination was made that not all requirements of NFPA 99, 1999 Edition, were being followed by the facility.

Findings include:

In accordance with 8-3.1.22.2(h) and 4-3.5.2.1(b27) of NFPA 99; freestanding cylinders of nonflammable gases (such as oxygen) shall be properly chained or supported in a cylinder cart or stand or by means of racks or fastenings to protect them from falling over or being knocked down.

At approximately 2:30 p.m., the outside oxygen storage building was inspected by the surveyors. One small argon cylinder was found to be "free standing" and not properly secured as other cylinders were by chains and/or fasteners.

Based on review of medical gas shut off valves, the facility failed to indicate which specific rooms shut off valves controlled.

Findings include:

In accordance with NFPA 99, 1999 Edition, and Section 4-3.1.2.3 (m) & (n) Gas Shutoff Valves; (m) A shutoff valve shall be located immediately outside each vital life-support or critical care area in each medical gas line, and located so as to be readily accessible in an emergency. Valves shall be protected and marked in accordance with 4-3.5.4.2.
All gas-delivery columns, hose reels, ceiling tracks, control panels, pendants, booms, alarm panels, or other special installations shall be located downstream of this valve.
(n) A shutoff valve shall be located outside each anesthetizing location in each medical gas line, so located as to be readily accessible at all times for use in an emergency. These valves shall be so arranged that shutting off the supply of gas to any one operating room or anesthetizing location will not affect the others. Valves shall be of an approved type, mounted on a pedestal or otherwise properly safeguarded against physical damage, and marked in accordance with 4-3.5.4.2.

Further, NFPA 99 Section 4-3.5.4.2 states that the shutoff valves described in 4-3.1.2.3, 4-3.1.2.3(m), and 4-3.1.2.3(n) shall be labeled to reflect the rooms that are controlled by such valves. Labeling shall be kept current from initial construction through acceptance. Valves shall be labeled in substance as follows:
CAUTION:
(NAME OF MEDICAL GAS) VALVE DO NOT CLOSE EXCEPT IN EMERGENCY THIS VALVE CONTROLS SUPPLY TO . . . .

Various locations of gas shut off valves were reviewed during review of the hospital. While the gas shut offs were labeled, some did not mention the specific rooms that they served. Further, some changes room usage no longer required some valves to be used. One example was two shut off valves labeled EEG and EKG that were no longer in use on the main east to west corridor just inside the main entrance.

Based on review of a remodeled area of the facility on January 3, 2011, the facility failed to ensure that some interior walls were completed without combustible materials.

Findings include:

In accordance with NFPA 101 and Section 19.1.6.3; all interior walls and partitions in buildings of Type I or Type II construction shall be of noncombustible or limited-combustible materials.
Exception*: Listed, fire-retardant-treated wood studs shall be permitted within non-load bearing 1-hour fire-rated partitions. Further, Annex A.19.1.6.3 Exception states that there is a finish capacity in a 1-hour fire-rated partition that would be expected to prevent the generation of smoke and gases from fire retardant-treated wood studs for an extended time during fire exposure. This Code does not intend to permit the use of fire-retardant wood studs and partitions of only 20-minute fire resistance.

While in the new electrical room of the remodeled area in the south east corner of the building, un treated two by four construction was used to support some electrical components.

Based on review of the generator location on January 4, 2012, the facility failed to supply an emengency stop station for the generator.

Findings include:

In accordance with NFPA 110, 1999 Edition and Section 3-5.5.6: all Level 1 and Level 2 installations shall have a remote manual stop station of a type similar to a break-glass station located outside the room housing the prime mover, where so installed, or located elsewhere on the premises where the prime mover is located outside the building. Annex A-3-5.5.6 states that for Level 1 and Level 2 systems located outdoors, the manual shutdown should be located external to the weatherproof enclosure and should be appropriately identified.

At 10:00 a.m., the generator location was reviewed inside the boiler room. When asked if a remote stop button existed for the generator, the Director of Engineering stated that there was not one for the generator.

Based on observations made on January 4, 2012 and discussions with staff, it was determined that the facility failed to provide for the Type I EES to be divided into identified branches.

Findings include:

In accordance with 3-4.2.2.1 of NFPA 99 (1999 edition) Type I essential electrical systems are comprised of two separate systems being the emergency system and the equipment system. The emergency system shall be limited to circuits essential to life safety and critical patient care. These are designated the life safety branch and the critical branch. The number of transfer switches to be used shall be based upon reliability, design, and load considerations. Each branch of the emergency system and each equipment system shall have one or more transfer switches. One transfer switch shall be permitted to serve one or more branches or systems in a facility with a maximum demand on the essential electrical system of 150 kVA (120 kW).

At 7:20 a.m., the generator transfer switch panels ATS 1, ATS 2, ATS 3, and ATS 4 were consecutively marked as, "Main", "Entire Building", "Battery Charger" and "Surgery Critical Care". When the legends inside the ATS panel doors were examined, no information was recorded to explicitly identify the circuits as described in the requirement cited in the above Section 3-4.2.2.1 of NFPA 99.

Based on observations made on January 4, 2012, the facility failed insure at all clinic locations, that all requirements were being followed for the electrical system and/or its components in accordance with the standards of NFPA 70, 1999 Edition, NFPA 99, 1999 Edition, or interpretations from the Centers for Medicare and Medicaid Services (CMS).

Findings include:

In accordance with NFPA 101 and Section 39.5.1, utilities shall comply with the provisions of Section 9.1. Further, Section 9.1.2 Electric states that 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.

In accordance with Article 370.28(c) of NFPA 70 (1999 Edition) all pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use. Where metal covers are used, they shall comply with the grounding requirements of Article 250-110.

At approximately 11:20 a.m., an electrical junction box was hanging from the ceiling in the foyer of the front entrance to the Pediatric Clinic.

Based on observations on January 3, 2012, the facility failed to maintain electrical wiring and components with the NFPA 70, 1998 Edition.

Findings include:

In accordance with NFPA 101 and Section 19.5.1, utilities shall comply with the provisions of Section 9.1. Further, Section 9.1.2 Electric states that 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.

Each disconnecting means and each service at the point where it originates shall be legibly marked to indicate its purpose unless located and arranged so the purpose is evident per Article 110-22 of NFPA 70.

In accordance with Article 110-26 and table 110-26(a) of NFPA 70 there shall be maintained a clear working space of at least 36" around electrical equipment such as panel boards to permit ready and safe operations of such equipment. This working space can not be used for storage purposes.

1. An electrical panel was reviewed in the radiology area at 2:43 p.m. Two deficiencies were noted:

a.) The electrical panel did not have a circuit schedule for the breakers in the panel, and

b.) Items were stacked in front of the electrical panel.

Based on observations on January 4, 2012, all electrical installations are not installed per NFPA 70 National Electric Code, 1999 Edition.

Findings include:

In accordance with Section 39.5.1 Utilities; utilities shall comply with the provisions of Section 9.1. Further, Section 9.1.2 Electric states that 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.

Each disconnecting means and each service at the point where it originates shall be legibly marked to indicate its purpose unless located and arranged so the purpose is evident per Article 110-22 of NFPA 70.

Electrical panel B was reviewed at 8:45 a.m. Breakers were in the on position and were not correctly labeled on the panel schedule.

On January 3, 2012, the policy and procedures for the facility's fire watch program were reviewed. Based on that review, it was determined that the facility did not ensure that a program was in place for the sprinkler system.

Findings include:

Between 10:00 a.m. to 11:30 a.m., the policy and procedures for the fire watch program were reviewed. It is identified that a fire watch is to be put in place when the fire alarm system is out of service for 4 hours or more in a 24 hour period. However, there is no fire watch policy also in place for the sprinkler system.