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

During the survey, the following is an example of what was observed:
The surveyor could not verify the construction type of this two story original building. Based on the information, interviews and observations the construction type appears to be a Type II (111) for the most part with some areas being a Type II (000). This original building is only partially sprinklered.

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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.)
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The facility failed to maintain the construction type per code. Findings include:

During the survey, the following is an example of what was observed:
First Floor
The G.I. Lab. had a penetration in the fire protective membrane above the lay-in ceiling.
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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.)
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The facility failed to provide corridor walls that would provide at least a 30 minute fire resistance rating. Findings include: During the survey, the following are examples of what was observed:

1. Unsealed penetrations around wiring, and at the end of a sleeve, in the corridor wall by Nurses Breakroom Second Floor.

2. Unsealed penetrations in the corridor wall, by 200 Soiled Utility Room.

3. Unsealed penetrations around a group of wiring, in the corridor wall, by Patient room 235.


27382

First Floor
4. The corridor wall for the Laboratory's Storage Room by the Laboratory/Surgery Waiting Rooms was not continuous from above the lay-in ceiling to the ceiling/floor deck above.
5. The Dining Room/Serving Line approximately 672 sq. ft., not sprinklered, no smoke detectors in room, did not have a corridor door. (the corridors do have smoke detectors)

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2000 NFPA 101, 19.3.6.2.1 Corridor walls shall be continuous from the floor to the underside of the floor or roof deck above, through any concealed spaces, such as those above suspended ceilings, and through interstitial structural and mechanical spaces, and they shall have a fire resistance rating of not less than 1/2 hour.
2000 NFPA 101, 19.3.6.1 Corridors shall be separated from all other areas by partitions complying with 19.3.6.2 through 19.3.6.5. (See also 19.2.5.9.) Exception No. 6: Spaces other than patient sleeping rooms, treatment rooms, and hazardous areas shall be permitted to be open to the corridor and unlimited in area, provided that the following criteria are met: (a) The space and the corridors onto which it opens, where located in the same smoke compartment, are protected by an electrically supervised automatic smoke detection system in accordance with 19.3.4. (b) * Each space is protected by automatic sprinklers, or the furnishings and furniture, in combination with all other combustibles within the area, are of such minimum quantity and arrangement that a fully developed fire is unlikely to occur. (c)The space does not obstruct access to required exits.
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The facility failed to provide corridor doors that would close and resist the passage of smoke. Findings include: During the survey, the following are examples of what was observed:

1. Med surg supply room second floor, had large opening around the door handle, door opens into the corridor, this surveyor was able to see into the room from the corridor.

2. Clean Linen Room door failed to positive latch, by Patient Room 226.


27382

First Floor
3. The Breakroom corridor door did not have positive latching hardware.
4. The Gift Shop's corridor door had a wedge holding the door open.
5. The Housekeeping corridor door did not have positive latching hardware.

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2000 NFPA 101, 19.3.6.3.2 Doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door. Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.2.
2007 CMS - 2786R There is no impediment to the closing of the corridor doors.

2000 NFPA 101, 19.3.6.3.3 Hold-open devices that release when the door is pushed or pulled shall be permitted.
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The facility failed to provide corridor doors that would close and resist the passage of smoke. Findings include: During the survey, the following is an example of what was observed:

Large opening around the door handle of Doctors sleep lounge, on the Second Floor, this surveyor was able to see into the room from the corridor.
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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.
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The facility failed to maintain the elevator shaft per code. Findings include:

During the survey, the following is an example of what was observed:
First and Second Floors
Elevator # 1 had two pentrations in the back wall on the First and Second Floors

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2000 NFPA 101, 19.3.1.1 Any vertical opening shall be enclosed or protected in accordance with 8.2.5. Where enclosure is provided, the construction shall have not less than a 1-hour fire resistance rating.
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The facility failed to provide exit signs. Findings include: During the survey, the following is an example of what was observed:

Exit sign was not provided for the Exit at grade level for ICU Stairwell.
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7.10.1.4 Exit access shall be marked by signs.
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The facility failed to maintain separation of hazardous areas. Findings include: During the survey, the following is an example of what was observed:

Unsealed penetrations around water lines in the North Boiler Room wall.
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NFPA 101, 19.3.2.1 or 18.3.2.1 Hazardous areas were observed without the required one-hour fire resistance rating for hazardous rooms which do not have sprinkler coverage.
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The facility failed to maintain stairways with at least 1 hour fire resistance rating. During the survey, the following is an example of what was observed:

Unsealed penetrations around a section of conduit, in the stairwell wall ICU.

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NFPA 101, 19.3.1.1, 8.2.3.2.4, and 7.1.3.2.1 requires a fire resistance rating.
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A) The facility failed to provide a reliable means of egress to the public way. During the survey, the following are examples of what was observed:

1. An all weather surface was not provided to the public way, for the South Stairwell Exit Discharge.

2. The South Stairwell had approximatley a 12" drop at the exit discharge.

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NFPA 101, A.7.1.10.1 *A proper means of egress allows unobstructed travel at all times. Any type of barrier including, but not limited to, the accumulations of snow and ice in those climates subject to such accumulations is an impediment to free movement in the means of egress.

NFPA 101, 7.1.6.2 Abrupt changes in elevation of walking surfaces shall not exceed 1/4 inch.


27382


The facility failed to prohibit locks on doors that can be opened readily from the egress side. Findings include:

B) During the survey, the following are examples of what was observed:
First Floor
The following rooms had bathroom doors that had deadbolt locks on them without the thumb latch on the inside, if locked could not be opened readily from the inside:
a. X-ray Room A
b. X-ray Room B

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2000 NFPA 101, 7.2.1.5.1 Doors shall be arranged to be opened readily from the egress side whenever the building is occupied. Locks, if provided, shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side.
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The facility failed to provide protection of openings in fire barriers to limit the spread of fire and restrict the movement of smoke from one side of the fire barrier to the other. During the survey, the following are examples of what was observed:

1. Unsealed penetrations around a group of wiring, and at the end of a sleeve, in the fire barrier, by Patient Waiting Room for OutPatients, Second Floor.

2. Unsealed penetrations around a group of wiring, in the fire barrier, by 228 Soiled Utility Room.


27382

First Floor
3. The following corridor doors were in a two hour fire barrier and did not have positive latching hardware:
a. Women's Locker Room
b. Men's Locker Room
4. The door to the Laboratory/Surgery Waiting Rooms was in a two hour fire barrier and did not have a self-closing device
5. The four hour fire barrier above the ceiling at the fire doors by Radiology Waiting Area:
a. Unsealed penetration of a green wire
b. Flamable yellow expansion foam used to seal a penetration
6. Four hour fire barrier in Dr. Arcement's Office had an unsealed penetration of approximately 4" x 4" at the back left corner

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2000 NFPA 101, 8.2.3.2.3.2 Where a 20-minute fire protection-rated door is required in existing buildings, an existing 13/4-in. (4.4-cm) solid, bonded wood-core door, or an existing steel-clad (tin-clad) wood door, or an existing solid-core steel door with positive latch and closer shall be permitted.
2000 NFPA 101, 8.2.4.3.5 Doors shall be self-closing or automatic-closing in accordance with 7.2.1.8.
2000 NFPA 101, 8.2.3.2.4.2 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through fire barriers shall be protected as follows: (1) The space between the penetrating item and the fire barrier shall meet one of the following conditions: a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier. b. It shall be protected by an approved device that is designed for the specific purpose. (2) Where the penetrating item uses a sleeve to penetrate the fire barrier, the sleeve shall be solidly set in the fire barrier, and the space between the item and the sleeve shall meet one of the following conditions: a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier. b. It shall be protected by an approved device that is designed for the specific purpose. (3) * Insulation and coverings for pipes and ducts shall not pass through the fire barrier unless one of the following conditions is met: a. The material shall be capable of maintaining the fire resistance of the fire barrier. b. The material shall be protected by an approved device that is designed for the specific purpose. (4) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions: a. It shall be made on either side of the fire barrier. b. It shall be made by an approved device that is designed for the specific purpose.
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The facility failed to provide fire barriers that limit the spread of fire and restrict the movement of smoke from one side of the fire barrier to the other. Findings include: During the survey, the following is an example of what was observed:

This surveyor was unable to verify if the fire barrier located at ICU, was a two hour barrier.
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The facility failed to maintain the fire barriers per code. Findings include:

During the survey, the following are examples of what was observed:
First Floor
1. Unsealed penetration of the fire barrier at the fire doors by the Conference Room
2. Unsealed penetrations of the fire barrier in the Employee Education Room:
a. Right wall - Unsealed penetration of a water pipe
b. Right wall - Unsealed penetration of a red and a grey wires
c. Door wall - Unsealed conduit end
3. Fire barrier in Conference Room had two unsealed penetrations in the back wall, approximately 12" x 12"
4. Fire barrier in the Outpatient Clinic, above Exam Room 2's door had an unsealed penetration approximately 4' x 4'
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2000 NFPA 101, 8.2.3.2.4.2 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through fire barriers shall be protected as follows: (1) The space between the penetrating item and the fire barrier shall meet one of the following conditions: a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier. b. It shall be protected by an approved device that is designed for the specific purpose. (2) Where the penetrating item uses a sleeve to penetrate the fire barrier, the sleeve shall be solidly set in the fire barrier, and the space between the item and the sleeve shall meet one of the following conditions: a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier. b. It shall be protected by an approved device that is designed for the specific purpose. (3) * Insulation and coverings for pipes and ducts shall not pass through the fire barrier unless one of the following conditions is met: a. The material shall be capable of maintaining the fire resistance of the fire barrier. b. The material shall be protected by an approved device that is designed for the specific purpose. (4) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions: a. It shall be made on either side of the fire barrier. b. It shall be made by an approved device that is designed for the specific purpose.

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The facility failed to provide continuous lighting for means of egress. Findings include: During the survey, the following are examples of what was observed:


1. The Exit Discharge had a single light bulb fixture, for the Southeast Stairwell.

2. The fixture was controlled by a switch located in the corridor.
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NFPA 101, 19.2.8 and 7.8.1.2 Illumination of means of egress shall be continuous.

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The facility failed to provide continuous lighting for means of egress. Findings include: During the survey, the following are examples of what was observed:

1. The Exit Discharge had a single light bulb fixture, for the East Exit.

2. The Exit Discharge had a single light bulb fixture, for the ICU Exit.

3. The Exit Discharge lighting was controlled by a switch, located in the corridor, for the Physical Therapy Exit.
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NFPA 101, 19.2.8 and 7.8.1.2 Illumination of means of egress shall be continuous.
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The facility failed to provide continuous lighting for means of egress. Findings include: During the survey, the following are examples of what was observed:

The Exit Discharge lighting for the Emergency Room Exit, was controlled by a switch located at the Exit.

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NFPA 101, 19.2.8 and 7.8.1.2 Illumination of means of egress shall be continuous.

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The facility failed to provide an emergency lighting system per code. Findings include:

During the survey, the following is an example of what was observed:
First Floor
The corridor emergency lighting system was observed not to be continuously in operation. It could be switched off, then it would require manual intervention.

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2000 NFPA 101, 7.9.2.5 The emergency lighting system shall be either continuously in operation or shall be capable of repeated automatic operation without manual intervention.
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The facility failed to maintain continuously illuminated exit signs. Findings include: During the survey, the following is an example of what was observed:


The exit sign was not illuminated at the Stairwell by Patient room 240.

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NFPA 101, 7.10.5 Continuous illumination of exit signs.

The facility failed to provide a written evacuation plan per code. Findings include:

During the survey, the following is an example of what was observed:
The written evacuation plan provided by the facility did not include "evacuation of an effected smoke compartment to an uneffected smoke compartment".

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2000 NFPA 101, 19.7.2.2 A written health care occupancy fire safety plan shall provide for the following: (1) Use of alarms (2) Transmission of alarm to fire department (3) Response to alarms (4) Isolation of fire (5) Evacuation of immediate area (6) Evacuation of smoke compartment (7) Preparation of floors and building for evacuation (8) Extinguishment of fire
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The facility failed to provide a written evacuation plan per code. Findings include:

During the survey, the following is an example of what was observed:
The written evacuation plan provided by the facility did not include "evacuation of an effected smoke compartment to an uneffected smoke compartment".

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2000 NFPA 101, 19.7.2.2 A written health care occupancy fire safety plan shall provide for the following: (1) Use of alarms (2) Transmission of alarm to fire department (3) Response to alarms (4) Isolation of fire (5) Evacuation of immediate area (6) Evacuation of smoke compartment (7) Preparation of floors and building for evacuation(8) Extinguishment of fire
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The facility failed to provide a written evacuation plan per code. Findings include:

During the survey, the following is an example of what was observed:
The written evacuation plan provided by the facility did not include "evacuation of an effected smoke compartment to an uneffected smoke compartment".

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2000 NFPA 101, 19.7.2.2 A written health care occupancy fire safety plan shall provide for the following: (1) Use of alarms (2) Transmission of alarm to fire department (3) Response to alarms (4) Isolation of fire (5) Evacuation of immediate area (6) Evacuation of smoke compartment (7) Preparation of floors and building for evacuation (8) Extinguishment of fire
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The facility failed to provide a written evacuation plan per code. Findings include:

During the survey, the following is an example of what was observed:
The written evacuation plan provided by the facility did not include "evacuation of an effected smoke compartment to an uneffected smoke compartment".

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2000 NFPA 101, 19.7.2.2 A written health care occupancy fire safety plan shall provide for the following: (1) Use of alarms (2) Transmission of alarm to fire department (3) Response to alarms (4) Isolation of fire (5) Evacuation of immediate area (6) Evacuation of smoke compartment (7) Preparation of floors and building for evacuation (8) Extinguishment of fire
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The facility failed to conduct fire drills per code. Findings include:

During the survey, the following are examples of what was observed:
Per documentation and interview the following was discovered:
1. The Lab and X-ray Departments have Baylor (weekend) shifts and these shifts were not doing fire drills
2. No first shift/first quarter for 2012 fire drill documentation
3. The facility was not getting all staff to sign-in/participate in the fire drills

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2000 NFPA 101, 19.7.1.2 Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
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The facility failed to conduct fire drills per code. Findings include:

During the survey, the following are examples of what was observed:
Per documentation and interview the following was discovered:
1. The Lab. and X-ray Departments have Baylor (weekend) shifts and these shifts were not doing fire drills
2. No first shift/first quarter for 2012 fire drill documentation
3. The facility was not getting all staff to sign-in/participate in the fire drills
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2000 NFPA 101, 19.7.1.2 Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
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The facility failed to maintain a fire alarm system with approved component devices finding include: During the survey, the following is an example of what was observed:

1) While testing the fire alarm system upon activation of alarm, the HVAC failed to shut down, in the Administration corridor.

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NFPA 101, 9.6.1.7 Components of the fire alarm system were not maintained.

NFPA 101, 9.6.5.1 and 1999 NFPA 90a, 4-4.3 The HVAC system in the facility shut down automatically upon activation of alarm.



2) Facility failed to maintain the Digital Alarm Communicator Transmitter in the fire alarm system. Findings include: During the survey, the surveyors were unable to test the phone lines. The phone lines had been installed in a way that the Maintenance Director was not sure how to disconnect the lines.

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1999 NFPA 72, Section 1-5.4.6, 5-5.3.2.1.5, and 5-5.3.2.1.6.2. Phone line and communication failure shall be indicated at the facility.
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Facility failed to maintain the Digital Alarm Communicator Transmitter in the fire alarm system. Findings include: During the survey, the surveyors were unable to test the phone lines. The phone lines had been installed in a way that the Maintenance Director was not sure how to disconnect the lines.

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1999 NFPA 72, Section 1-5.4.6, 5-5.3.2.1.5, and 5-5.3.2.1.6.2. Phone line and communication failure shall be indicated at the facility.
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Facility failed to maintain the Digital Alarm Communicator Transmitter in the fire alarm system. Findings include: During the survey, the surveyors were unable to test the phone lines. The phone lines had been installed in a way that the Maintenance Director was not sure how to disconnect the lines.

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1999 NFPA 72, Section 1-5.4.6, 5-5.3.2.1.5, and 5-5.3.2.1.6.2. Phone line and communication failure shall be indicated at the facility.

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Facility failed to maintain the Digital Alarm Communicator Transmitter in the fire alarm system. Findings include: During the survey, the surveyors were unable to test the phone lines. The phone lines had been installed in a way that the Maintenance Director was not sure how to disconnect the lines.

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1999 NFPA 72, Section 1-5.4.6, 5-5.3.2.1.5, and 5-5.3.2.1.6.2. Phone line and communication failure shall be indicated at the facility.

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A) Sprinkler coverage was observed during the survey not adequately provided. Findings include: During the survey, the following are examples of what was observed:

1. The Exit Discharge for Medical Records has a 50" overhang combustible.
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1999 NFPA 13, 5-13.8 Sprinklers shall be installed under exterior combustible roofs or canopies exceeding four feet in width, or over areas where combustibles are stored.



2. Six ceiling tiles were missing in the Body Cooler Room First Floor.
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NFPA 13 5-6., Sprinklers shall be arranged to be in compliance.



27382


B) The facility failed to maintain the sprinkler head per code. Findings include:

During the survey, the following is an example of what was observed:
First Floor
A sprinkler head in the Laboratory was completely covered in foreign material.
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1998 NFPA 25, 2-2.1.1 Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.
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Sprinkler coverage was observed during the survey not adequately provided. Findings include: During the survey, the following is an example of what was observed:

Sprinkler coverage was not provided for a storage room located in ICU Supply Room.

NFPA 19.3.5.1 Where required by 19.1.6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.
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The facility failed to maintain the fire extinguishers per code. Findings include:

During the survey, the following is an example of what was observed:
First and Second Floors
The facility failed to provide annual inspections of the fire extinguishers by an outside company, the last anual inspection documented was January 2011.

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1998 NFPA 10, 4-4.1 Fire extinguishers shall be subjected to maintenance at intervals of not more than 1 year, at the time of hydrostatic test, or when specifically indicated by an inspection.

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The facility failed to maintain the fire extinguishers per code. Findings include:

During the survey, the following is an example of what was observed:
First and Second Floors
The facility failed to provide annual inspections of the fire extinguishers by an outside company, the last anual inspection documented was January 2011.

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1998 NFPA 10, 4-4.1 Fire extinguishers shall be subjected to maintenance at intervals of not more than 1 year, at the time of hydrostatic test, or when specifically indicated by an inspection.

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The facility failed to maintain the fire extinguishers per code. Findings include:

During the survey, the following is an example of what was observed:
First and Second Floors
The facility failed to provide annual inspections of the fire extinguishers by an outside company, the last anual inspection documented was January 2011.

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1998 NFPA 10, 4-4.1 Fire extinguishers shall be subjected to maintenance at intervals of not more than 1 year, at the time of hydrostatic test, or when specifically indicated by an inspection.

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The facility failed to maintain the fire extinguishers per code. Findings include:

During the survey, the following is an example of what was observed:
First and Second Floors
The facility failed to provide annual inspections of the fire extinguishers by an outside company, the last anual inspection documented was January 2011.
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1998 NFPA 10, 4-4.1 Fire extinguishers shall be subjected to maintenance at intervals of not more than 1 year, at the time of hydrostatic test, or when specifically indicated by an inspection.

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The facility failed to maintain the cooking facilities per code. Findings include:

During the survey, the following are examples of what was observed:
First Floor
1. The facility was not inspecting the kitchen hood suppression system on a monthly basis.
2. The K-extinguisher did not have the required signage.
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1998 NFPA 17A, 5-2.1 Inspection shall be conducted on a monthly basis in accordance with the manufacturer ' s listed installation and maintenance manual or the owner ' s manual. As a minimum, this " quick check " or inspection shall include verification of the following: (a) The extinguishing system is in its proper location. (b) The manual actuators are unobstructed. (c) The tamper indicators and seals are intact. (d) The maintenance tag or certificate is in place. (e) No obvious physical damage or condition exists that might prevent operation. (f)The pressure gauge(s), if provided, is in operable range. (g) The nozzle blowoff caps are intact and undamaged. (h) The hood, duct, and protected cooking appliances have not been replaced, modified, or relocated.
1998 NFPA 96, 7-2.1.1 A placard identifying the use of the extinguisher as a secondary backup means to the automatic fire suppression system shall be conspicuously placed near each portable fire extinguisher in the cooking area.
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The facility failed to prohibit portable heating devices per code. Findings include:

During the survey, the following sre examples of what was observed:
First Floor
Portable Heating Devices were observed in the following locations:
1. Gift Shop - was not plugged in
2. X-ray Breakroom - was plugged in

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2000 NFPA 101, 19.7.8 Portable space-heating devices shall be prohibited in all health care occupancies. Exception: Portable space-heating devices shall be permitted to be used in nonsleeping staff and employee areas where the heating elements of such devices do not exceed 212?F (100?C).
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The facility failed to provide a readily accessible means of egress pathway at all times. Findings include: During the survey, the following is an example of what was observed:

The means of egress at the Exit Discharge, for the SouthEast Stairwell, was blocked by a vehicle
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NFPA 101, 7.1.10.1 Means of egress shall be continuously maintained free of all obstructions or impediments for full instant use in case of fire or other emergencies.

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The facility failed to maintain the curtains/draperies per code. Findings include:

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

1. The facility failed to provide flame resistant documentation for the curtains throughout the Second Floor for Patient Rooms.


27382


First Floor
2. The facility failed to provide flame resistant documentation for the sheer curtain in the Dietary Office in the kitchen.

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2000 NFPA 101, 10.3.1 Where required by the applicable provisions of this Code, draperies, curtains, and other similar loosely hanging furnishings and decorations shall be flame resistant as demonstrated by testing in accordance with NFPA 701, Standard Methods of Fire Tests for Flame Propagation of Textiles and Films.
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The facility failed to maintain the anesthetizing locations (O.R.s) per code. Findings include:

During the survey, the following are examples of what was observed:
First Floor
1. The battery back-up light in O.R. "A" did not work when tested and was not plugged in.
2. Per interview and observation O.R. "A" and O.R. "B" did not have smoke venting systems.

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1999 NFPA 99, 3-3.2.1.2 All Patient Care Areas. 5. Wiring in Anesthetizing Locations. e. Battery-Powered Emergency Lighting Units. One or more battery-powered emergency lighting units shall be provided in accordance with NFPA 70, National Electrical Code, Section 700-12(e).
1999 NFPA 70, 700-12. General Requirements (e) Unit Equipment. Individual unit equipment for emergency illumination shall consist of the following: 1. A rechargeable battery 2. A battery charging means 3. Provisions for one or more lamps mounted on the equipment, or shall be permitted to have terminals for remote lamps, or both, and 4. A relaying device arranged to energize the lamps automatically upon failure of the supply to the unit equipment. The batteries shall be of suitable rating and capacity to supply and maintain at not less than 87? percent of the nominal battery voltage for the total lamp load associated with the unit for a period of at least 1? hours, or the unit equipment shall supply and maintain not less than 60 percent of the initial emergency illumination for a period of at least 1? hours. Storage batteries, whether of the acid or alkali type, shall be designed and constructed to meet the requirements of emergency service. Unit equipment shall be permanently fixed in place (i.e., not portable) and shall have all wiring to each unit installed in accordance with the requirements of any of the wiring methods in Chapter 3. Flexible cord and plug connection shall be permitted, provided that the cord does not exceed 3 ft (914 mm) in length. The branch circuit feeding the unit equipment shall be the same branch circuit as that serving the normal lighting in the area and connected ahead of any local switches. The branch circuit that feeds unit equipment shall be clearly identified at the distribution panel. Emergency illumination fixtures that obtain power from a unit equipment and are not part of the unit equipment shall be wired to the unit equipment as required by Section 700-9 and by one of the wiring methods of Chapter 3.
1999 NFPA 99, 5-4.1.2 Supply and exhaust systems for windowless anesthetizing locations shall be arranged to automatically vent smoke and products of combustion.
1999 NFPA 99, 5-4.1.3 Ventilating systems for anesthetizing locations shall be provided that automatically (a) prevent recirculation of smoke originating within the surgical suite and (b) prevent the circulation of smoke entering the system intake, without in either case interfering with the exhaust function of the system.
1999 NFPA 99, 5-4.1.4 The electric supply to the ventilating system shall be served by the equipment system of the essential electrical system specified in Chapter 3, " Electrical Systems. "
.

During the survey, the following are examples of what was observed:

1. Generator/day fuel tank was not protected from damage.

2. Battery-powered light not provided in the generator set control room.

3. Identification was not provided for the transfer swiches.

4. A written emergency power plan was not provided, in case generator failed.
________________________
NFPA 110, 5-2.4* Consideration shall be given to the location of the Level 1 and Level 2 EPSS equipment to minimize the possibility of damage resulting from interruptions of the emergency power source caused by the following:
(a) * Natural conditions such as storms, floods, earthquakes, tornadoes, hurricanes, lightning, ice storms, wind, and fire
(b) Conditions such as vandalism, sabotage, and other similar occurrences
(c) Material and equipment failures.

1999 NFPA 99, 3-6.1.1 and 3-4.1.1.4, and 1999 NFPA 110, 5-3.1 The Level 1 or Level 2 EPS equipment location shall be provided with battery-powered emergency lighting.

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.

NFPA 110 6-1.2 Consideration shall be given to temporarily providing a portable or alternate source whenever the emergency generator is out of service.
.

.
During the survey, the following are examples of what was observed:

1. Generator/day fuel tank was not protected from damage.

2. Battery-powered light not provided in the generator set control room.

3. Identification was not provided for the transfer swiches.

4. A written emergency power plan was not provided, in case generator failed.

_________________
NFPA 110, 5-2.4* Consideration shall be given to the location of the Level 1 and Level 2 EPSS equipment to minimize the possibility of damage resulting from interruptions of the emergency power source caused by the following:
(a) * Natural conditions such as storms, floods, earthquakes, tornadoes, hurricanes, lightning, ice storms, wind, and fire
(b) Conditions such as vandalism, sabotage, and other similar occurrences
(c) Material and equipment failures.

1999 NFPA 99, 3-6.1.1 and 3-4.1.1.4, and 1999 NFPA 110, 5-3.1 The Level 1 or Level 2 EPS equipment location shall be provided with battery-powered emergency lighting.

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.

NFPA 110 6-1.2 Consideration shall be given to temporarily providing a portable or alternate source whenever the emergency generator is out of service.
.

.
During the survey, the following are examples of what was observed:

1. Generator/day fuel tank was not protected from damage.

2. Battery-powered light not provided in the generator set control room.

3. Identification was not provided for the transfer swiches.

4. A written emergency power plan was not provided, in case generator failed.

__________________
NFPA 110, 5-2.4* Consideration shall be given to the location of the Level 1 and Level 2 EPSS equipment to minimize the possibility of damage resulting from interruptions of the emergency power source caused by the following:
(a) * Natural conditions such as storms, floods, earthquakes, tornadoes, hurricanes, lightning, ice storms, wind, and fire
(b) Conditions such as vandalism, sabotage, and other similar occurrences
(c) Material and equipment failures.

1999 NFPA 99, 3-6.1.1 and 3-4.1.1.4, and 1999 NFPA 110, 5-3.1 The Level 1 or Level 2 EPS equipment location shall be provided with battery-powered emergency lighting.

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.

NFPA 110 6-1.2 Consideration shall be given to temporarily providing a portable or alternate source whenever the emergency generator is out of service.
.

.
During the survey, the following are examples of what was observed:

1. Generator/day fuel tank was not protected from damage.

2. Battery-powered light not provided in the generator set control room.

3. Identification was not provided for the transfer swiches.

4. A written emergency power plan was not provided, in case generator failed.
__________________
NFPA 110, 5-2.4* Consideration shall be given to the location of the Level 1 and Level 2 EPSS equipment to minimize the possibility of damage resulting from interruptions of the emergency power source caused by the following:
(a) * Natural conditions such as storms, floods, earthquakes, tornadoes, hurricanes, lightning, ice storms, wind, and fire
(b) Conditions such as vandalism, sabotage, and other similar occurrences
(c) Material and equipment failures.

1999 NFPA 99, 3-6.1.1 and 3-4.1.1.4, and 1999 NFPA 110, 5-3.1 The Level 1 or Level 2 EPS equipment location shall be provided with battery-powered emergency lighting.

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.

NFPA 110 6-1.2 Consideration shall be given to temporarily providing a portable or alternate source whenever the emergency generator is out of service.
.

.The facility failed to maintain the emergency generator per code. Findings include:

A) During the survey, the generator was observed not to have met the requirements to transfer from normal to emergency power within 10 seconds. The Facility Maintenance Staff was observed to have made one attempt with the following time noted to transfer from normal to emergency power. The time was observed to be 14 seconds.
_________________
NFPA 101, 7.9.2.3, and 1999 NFPA 99, 3-4.1.1.8, 3-5.3.1 and 3-6.3.1.2 Emergency generator shall start/crank and transfer from normal to emergency power within ten seconds.



27382



B) During the survey, the following are examples of what was observed:
Per documentation provided by the facility, and interviews the following was discovered:
1. The facility was not conducting weekly inspections on the emergency generator
2. The facility was not consistently doing thirty minute load test every month, most were only twenty minute load tests.

____________________
1999 NFPA 110, 6-4.1 Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.
1999 NFPA 110, 6-4.2 Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating (b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer The date and time of day for required testing shall be decided by the owner, based on facility operations.
1999 NFPA 110, 6-4.2.1 Equivalent loads used for testing shall be automatically replaced with the emergency loads in case of failure of the primary source.
1999 NFPA 110, 6-4.2.2 Diesel-powered EPS installations that do not meet the requirements of 6-4.2 shall be exercised monthly with the available EPSS load and exercised annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of 2 continuous hours.
.

1. During the survey, the generator was observed not to have met the requirements to transfer from normal to emergency power within 10 seconds. The Facility Maintenance Staff was observed to have made one attempt with the following time noted to transfer from normal to emergency power. The time was observed to be 14 seconds.
____________________
NFPA 101, 7.9.2.3, and 1999 NFPA 99, 3-4.1.1.8, 3-5.3.1 and 3-6.3.1.2 Emergency generator shall start/crank and transfer from normal to emergency power within ten seconds.



27382


The facility failed to maintain the emergency generator per code. Findings include:

During the survey, the following are examples of what was observed:
Per documentation provided by the facility, and interviews the following was discovered:
2. The facility was not conducting weekly inspections on the emergency generator
3. The facility was not consistently doing thirty minute load test every month, most were only twenty minute load tests.

____________________
1999 NFPA 110, 6-4.1 Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.
1999 NFPA 110, 6-4.2 Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
The date and time of day for required testing shall be decided by the owner, based on facility operations.
1999 NFPA 110, 6-4.2.1 Equivalent loads used for testing shall be automatically replaced with the emergency loads in case of failure of the primary source.
1999 NFPA 110, 6-4.2.2 Diesel-powered EPS installations that do not meet the requirements of 6-4.2 shall be exercised monthly with the available EPSS load and exercised annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of 2 continuous hours.
.

.
The facility failed to maintain the emergency generator per code. Findings include:

1. During the survey, the generator was observed not to have met the requirements to transfer from normal to emergency power within 10 seconds. The Facility Maintenance Staff was observed to have made one attempt with the following time noted to transfer from normal to emergency power. The time was observed to be 14 seconds.

_____________________
NFPA 101, 7.9.2.3, and 1999 NFPA 99, 3-4.1.1.8, 3-5.3.1 and 3-6.3.1.2 Emergency generator shall start/crank and transfer from normal to emergency power within ten seconds.


27382


Per documentation provided by the facility, and interviews the following was discovered:
2. The facility was not conducting weekly inspections on the emergency generator
3. The facility was not consistently doing thirty minute load test every month, most were only twenty minute load tests.
____________________
1999 NFPA 110, 6-4.1 Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.
1999 NFPA 110, 6-4.2 Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods: (a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating (b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer. The date and time of day for required testing shall be decided by the owner, based on facility operations.
1999 NFPA 110, 6-4.2.1 Equivalent loads used for testing shall be automatically replaced with the emergency loads in case of failure of the primary source.
1999 NFPA 110, 6-4.2.2 Diesel-powered EPS installations that do not meet the requirements of 6-4.2 shall be exercised monthly with the available EPSS load and exercised annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of 2 continuous hours.
.

.
The facility failed to maintain the emergency generator per code. Findings include:

1. During the survey, the generator was observed not to have met the requirements to transfer from normal to emergency power within 10 seconds. The Facility Maintenance Staff was observed to have made one attempt with the following time noted to transfer from normal to emergency power. The time was observed to be 14 seconds.
_________________
NFPA 101, 7.9.2.3, and 1999 NFPA 99, 3-4.1.1.8, 3-5.3.1 and 3-6.3.1.2 Emergency generator shall start/crank and transfer from normal to emergency power within ten seconds.


27382


During the survey, the following are examples of what was observed:
Per documentation provided by the facility, and interviews the following was discovered:
2. The facility was not conducting weekly inspections on the emergency generator
3. The facility was not consistently doing thirty minute load test every month, most were only twenty minute load tests.

____________________
1999 NFPA 110, 6-4.1 Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.
1999 NFPA 110, 6-4.2 Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating (b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
The date and time of day for required testing shall be decided by the owner, based on facility operations.
1999 NFPA 110, 6-4.2.1 Equivalent loads used for testing shall be automatically replaced with the emergency loads in case of failure of the primary source.
1999 NFPA 110, 6-4.2.2 Diesel-powered EPS installations that do not meet the requirements of 6-4.2 shall be exercised monthly with the available EPSS load and exercised annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of 2 continuous hours.
.

.
The facility failed to maintain the electrical system per code. Findings include:

During the survey, the following are examples of what was observed:
First Floor
1. The Doctors' Sleeping Lounge:
a. Refrigerator and microwve plugged into a surge protector
b. Extension cord plugged into the wall outlet
2. The corridor at E.R.'s Admission Office had an orange extension cord plugged into a wall outlet on one side of the corridor, ran above the layin ceiling, comes down the wall on the other side of the corridor, this has been run in a raceway on the walls (to permenantly cover up the extension cord).
3. The Outpatient Clinic Waiting Room had the T.V. plugged into an extension cord.

___________________
1999 NFPA 70, 400-7 and 400-8, and HCFA Transmittal Notice 22-99 The 1984 edition of the National Electric Code restricts the use of extension cords to temporary short term uses. It is the policy of HCFA to prohibit non-circuit breaker protected extension cords in health care. The limited use of circuit breaker protected power strips is acceptable, provided the current is limited to 15 amps or less, and no major appliances such as air conditioners, refrigerators, or heating units are connected to the power strip.
.

.
The facility failed to maintain the electrical system per code. Findings include;

During the survey, the following are examples of what was observed:
First Floor
1. A refrigerator and a microwave were plugged into a surge protector
2. An extension cord was plugged into a surge protector in the Phone Room (South Computer Room)

_______________
1999 NFPA 70, 400-7 and 400-8, and HCFA Transmittal Notice 22-99 The 1984 edition of the National Electric Code restricts the use of extension cords to temporary short term uses. It is the policy of HCFA to prohibit non-circuit breaker protected extension cords in health care. The limited use of circuit breaker protected power strips is acceptable, provided the current is limited to 15 amps or less, and no major appliances such as air conditioners, refrigerators, or heating units are connected to the power strip.

.

.
The facility failed to provide a fire watch policy per code. Findings include:

During the survey, the following is an example of what was observed:
The facility failed to provide a fire watch policy per code.

___________________
2000 NFPA 101, 9.7.6.1 Where a required automatic sprinkler system is out of service 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 sprinkler system has been returned to service.
.

.
The facility failed to provide a fire watch policy per code. Findings include:

During the survey, the following is an example of what was observed:
The facility failed to provide a fire watch policy per code.
___________________
2000 NFPA 101, 9.7.6.1 Where a required automatic sprinkler system is out of service 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 sprinkler system has been returned to service.
.

The facility failed to provide a fire watch policy per code. Findings include:

During the survey, the following is an example of what was observed:
The facility failed to provide a fire watch policy per code.

___________________
2000 NFPA 101, 9.6.1.8 Where a required fire alarm system is out of service 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.

.
The facility failed to provide a fire watch policy per code. Findings include:

During the survey, the following is an example of what was observed:
The facility failed to provide a fire watch policy per code.
___________________
2000 NFPA 101, 9.6.1.8 Where a required fire alarm system is out of service 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.
.

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

During the survey, the following is an example of what was observed:
The surveyor could not verify the construction type of this two story original building. Based on the information, interviews and observations the construction type appears to be a Type II (111) for the most part with some areas being a Type II (000). This original building is only partially sprinklered.

_____________________

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.)
.

.
The facility failed to maintain the construction type per code. Findings include:

During the survey, the following is an example of what was observed:
First Floor
The G.I. Lab. had a penetration in the fire protective membrane above the lay-in ceiling.
___________________

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.)
.

.
The facility failed to provide corridor walls that would provide at least a 30 minute fire resistance rating. Findings include: During the survey, the following are examples of what was observed:

1. Unsealed penetrations around wiring, and at the end of a sleeve, in the corridor wall by Nurses Breakroom Second Floor.

2. Unsealed penetrations in the corridor wall, by 200 Soiled Utility Room.

3. Unsealed penetrations around a group of wiring, in the corridor wall, by Patient room 235.


27382

First Floor
4. The corridor wall for the Laboratory's Storage Room by the Laboratory/Surgery Waiting Rooms was not continuous from above the lay-in ceiling to the ceiling/floor deck above.
5. The Dining Room/Serving Line approximately 672 sq. ft., not sprinklered, no smoke detectors in room, did not have a corridor door. (the corridors do have smoke detectors)

___________________
2000 NFPA 101, 19.3.6.2.1 Corridor walls shall be continuous from the floor to the underside of the floor or roof deck above, through any concealed spaces, such as those above suspended ceilings, and through interstitial structural and mechanical spaces, and they shall have a fire resistance rating of not less than 1/2 hour.
2000 NFPA 101, 19.3.6.1 Corridors shall be separated from all other areas by partitions complying with 19.3.6.2 through 19.3.6.5. (See also 19.2.5.9.) Exception No. 6: Spaces other than patient sleeping rooms, treatment rooms, and hazardous areas shall be permitted to be open to the corridor and unlimited in area, provided that the following criteria are met: (a) The space and the corridors onto which it opens, where located in the same smoke compartment, are protected by an electrically supervised automatic smoke detection system in accordance with 19.3.4. (b) * Each space is protected by automatic sprinklers, or the furnishings and furniture, in combination with all other combustibles within the area, are of such minimum quantity and arrangement that a fully developed fire is unlikely to occur. (c)The space does not obstruct access to required exits.
.

The facility failed to provide corridor doors that would close and resist the passage of smoke. Findings include: During the survey, the following are examples of what was observed:

1. Med surg supply room second floor, had large opening around the door handle, door opens into the corridor, this surveyor was able to see into the room from the corridor.

2. Clean Linen Room door failed to positive latch, by Patient Room 226.


27382

First Floor
3. The Breakroom corridor door did not have positive latching hardware.
4. The Gift Shop's corridor door had a wedge holding the door open.
5. The Housekeeping corridor door did not have positive latching hardware.

_________________
2000 NFPA 101, 19.3.6.3.2 Doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door. Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.2.
2007 CMS - 2786R There is no impediment to the closing of the corridor doors.

2000 NFPA 101, 19.3.6.3.3 Hold-open devices that release when the door is pushed or pulled shall be permitted.
.

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

Large opening around the door handle of Doctors sleep lounge, on the Second Floor, this surveyor was able to see into the room from the corridor.
_____________________
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.
.

.
The facility failed to maintain the elevator shaft per code. Findings include:

During the survey, the following is an example of what was observed:
First and Second Floors
Elevator # 1 had two pentrations in the back wall on the First and Second Floors

___________________
2000 NFPA 101, 19.3.1.1 Any vertical opening shall be enclosed or protected in accordance with 8.2.5. Where enclosure is provided, the construction shall have not less than a 1-hour fire resistance rating.
.

.
The facility failed to provide exit signs. Findings include: During the survey, the following is an example of what was observed:

Exit sign was not provided for the Exit at grade level for ICU Stairwell.
_____________________
7.10.1.4 Exit access shall be marked by signs.
.

.
The facility failed to maintain separation of hazardous areas. Findings include: During the survey, the following is an example of what was observed:

Unsealed penetrations around water lines in the North Boiler Room wall.
____________________
NFPA 101, 19.3.2.1 or 18.3.2.1 Hazardous areas were observed without the required one-hour fire resistance rating for hazardous rooms which do not have sprinkler coverage.
.

.
The facility failed to maintain stairways with at least 1 hour fire resistance rating. During the survey, the following is an example of what was observed:

Unsealed penetrations around a section of conduit, in the stairwell wall ICU.

____________________
NFPA 101, 19.3.1.1, 8.2.3.2.4, and 7.1.3.2.1 requires a fire resistance rating.
.

.
A) The facility failed to provide a reliable means of egress to the public way. During the survey, the following are examples of what was observed:

1. An all weather surface was not provided to the public way, for the South Stairwell Exit Discharge.

2. The South Stairwell had approximatley a 12" drop at the exit discharge.

________________________
NFPA 101, A.7.1.10.1 *A proper means of egress allows unobstructed travel at all times. Any type of barrier including, but not limited to, the accumulations of snow and ice in those climates subject to such accumulations is an impediment to free movement in the means of egress.

NFPA 101, 7.1.6.2 Abrupt changes in elevation of walking surfaces shall not exceed 1/4 inch.


27382


The facility failed to prohibit locks on doors that can be opened readily from the egress side. Findings include:

B) During the survey, the following are examples of what was observed:
First Floor
The following rooms had bathroom doors that had deadbolt locks on them without the thumb latch on the inside, if locked could not be opened readily from the inside:
a. X-ray Room A
b. X-ray Room B

____________________
2000 NFPA 101, 7.2.1.5.1 Doors shall be arranged to be opened readily from the egress side whenever the building is occupied. Locks, if provided, shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side.
.

The facility failed to provide protection of openings in fire barriers to limit the spread of fire and restrict the movement of smoke from one side of the fire barrier to the other. During the survey, the following are examples of what was observed:

1. Unsealed penetrations around a group of wiring, and at the end of a sleeve, in the fire barrier, by Patient Waiting Room for OutPatients, Second Floor.

2. Unsealed penetrations around a group of wiring, in the fire barrier, by 228 Soiled Utility Room.


27382

First Floor
3. The following corridor doors were in a two hour fire barrier and did not have positive latching hardware:
a. Women's Locker Room
b. Men's Locker Room
4. The door to the Laboratory/Surgery Waiting Rooms was in a two hour fire barrier and did not have a self-closing device
5. The four hour fire barrier above the ceiling at the fire doors by Radiology Waiting Area:
a. Unsealed penetration of a green wire
b. Flamable yellow expansion foam used to seal a penetration
6. Four hour fire barrier in Dr. Arcement's Office had an unsealed penetration of approximately 4" x 4" at the back left corner

____________________

2000 NFPA 101, 8.2.3.2.3.2 Where a 20-minute fire protection-rated door is required in existing buildings, an existing 13/4-in. (4.4-cm) solid, bonded wood-core door, or an existing steel-clad (tin-clad) wood door, or an existing solid-core steel door with positive latch and closer shall be permitted.
2000 NFPA 101, 8.2.4.3.5 Doors shall be self-closing or automatic-closing in accordance with 7.2.1.8.
2000 NFPA 101, 8.2.3.2.4.2 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through fire barriers shall be protected as follows: (1) The space between the penetrating item and the fire barrier shall meet one of the following conditions: a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier. b. It shall be protected by an approved device that is designed for the specific purpose. (2) Where the penetrating item uses a sleeve to penetrate the fire barrier, the sleeve shall be solidly set in the fire barrier, and the space between the item and the sleeve shall meet one of the following conditions: a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier. b. It shall be protected by an approved device that is designed for the specific purpose. (3) * Insulation and coverings for pipes and ducts shall not pass through the fire barrier unless one of the following conditions is met: a. The material shall be capable of maintaining the fire resistance of the fire barrier. b. The material shall be protected by an approved device that is designed for the specific purpose. (4) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions: a. It shall be made on either side of the fire barrier. b. It shall be made by an approved device that is designed for the specific purpose.
.

.
The facility failed to provide fire barriers that limit the spread of fire and restrict the movement of smoke from one side of the fire barrier to the other. Findings include: During the survey, the following is an example of what was observed:

This surveyor was unable to verify if the fire barrier located at ICU, was a two hour barrier.
.

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The facility failed to maintain the fire barriers per code. Findings include:

During the survey, the following are examples of what was observed:
First Floor
1. Unsealed penetration of the fire barrier at the fire doors by the Conference Room
2. Unsealed penetrations of the fire barrier in the Employee Education Room:
a. Right wall - Unsealed penetration of a water pipe
b. Right wall - Unsealed penetration of a red and a grey wires
c. Door wall - Unsealed conduit end
3. Fire barrier in Conference Room had two unsealed penetrations in the back wall, approximately 12" x 12"
4. Fire barrier in the Outpatient Clinic, above Exam Room 2's door had an unsealed penetration approximately 4' x 4'
__________________
2000 NFPA 101, 8.2.3.2.4.2 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through fire barriers shall be protected as follows: (1) The space between the penetrating item and the fire barrier shall meet one of the following conditions: a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier. b. It shall be protected by an approved device that is designed for the specific purpose. (2) Where the penetrating item uses a sleeve to penetrate the fire barrier, the sleeve shall be solidly set in the fire barrier, and the space between the item and the sleeve shall meet one of the following conditions: a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier. b. It shall be protected by an approved device that is designed for the specific purpose. (3) * Insulation and coverings for pipes and ducts shall not pass through the fire barrier unless one of the following conditions is met: a. The material shall be capable of maintaining the fire resistance of the fire barrier. b. The material shall be protected by an approved device that is designed for the specific purpose. (4) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions: a. It shall be made on either side of the fire barrier. b. It shall be made by an approved device that is designed for the specific purpose.

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The facility failed to provide continuous lighting for means of egress. Findings include: During the survey, the following are examples of what was observed:


1. The Exit Discharge had a single light bulb fixture, for the Southeast Stairwell.

2. The fixture was controlled by a switch located in the corridor.
______________________
NFPA 101, 19.2.8 and 7.8.1.2 Illumination of means of egress shall be continuous.

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The facility failed to provide continuous lighting for means of egress. Findings include: During the survey, the following are examples of what was observed:

1. The Exit Discharge had a single light bulb fixture, for the East Exit.

2. The Exit Discharge had a single light bulb fixture, for the ICU Exit.

3. The Exit Discharge lighting was controlled by a switch, located in the corridor, for the Physical Therapy Exit.
__________________
NFPA 101, 19.2.8 and 7.8.1.2 Illumination of means of egress shall be continuous.
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The facility failed to provide continuous lighting for means of egress. Findings include: During the survey, the following are examples of what was observed:

The Exit Discharge lighting for the Emergency Room Exit, was controlled by a switch located at the Exit.

____________________________
NFPA 101, 19.2.8 and 7.8.1.2 Illumination of means of egress shall be continuous.

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The facility failed to provide an emergency lighting system per code. Findings include:

During the survey, the following is an example of what was observed:
First Floor
The corridor emergency lighting system was observed not to be continuously in operation. It could be switched off, then it would require manual intervention.

________________
2000 NFPA 101, 7.9.2.5 The emergency lighting system shall be either continuously in operation or shall be capable of repeated automatic operation without manual intervention.
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The facility failed to maintain continuously illuminated exit signs. Findings include: During the survey, the following is an example of what was observed:


The exit sign was not illuminated at the Stairwell by Patient room 240.

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NFPA 101, 7.10.5 Continuous illumination of exit signs.

The facility failed to provide a written evacuation plan per code. Findings include:

During the survey, the following is an example of what was observed:
The written evacuation plan provided by the facility did not include "evacuation of an effected smoke compartment to an uneffected smoke compartment".

_______________
2000 NFPA 101, 19.7.2.2 A written health care occupancy fire safety plan shall provide for the following: (1) Use of alarms (2) Transmission of alarm to fire department (3) Response to alarms (4) Isolation of fire (5) Evacuation of immediate area (6) Evacuation of smoke compartment (7) Preparation of floors and building for evacuation (8) Extinguishment of fire
.

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The facility failed to provide a written evacuation plan per code. Findings include:

During the survey, the following is an example of what was observed:
The written evacuation plan provided by the facility did not include "evacuation of an effected smoke compartment to an uneffected smoke compartment".

_______________
2000 NFPA 101, 19.7.2.2 A written health care occupancy fire safety plan shall provide for the following: (1) Use of alarms (2) Transmission of alarm to fire department (3) Response to alarms (4) Isolation of fire (5) Evacuation of immediate area (6) Evacuation of smoke compartment (7) Preparation of floors and building for evacuation(8) Extinguishment of fire
..

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The facility failed to provide a written evacuation plan per code. Findings include:

During the survey, the following is an example of what was observed:
The written evacuation plan provided by the facility did not include "evacuation of an effected smoke compartment to an uneffected smoke compartment".

_______________
2000 NFPA 101, 19.7.2.2 A written health care occupancy fire safety plan shall provide for the following: (1) Use of alarms (2) Transmission of alarm to fire department (3) Response to alarms (4) Isolation of fire (5) Evacuation of immediate area (6) Evacuation of smoke compartment (7) Preparation of floors and building for evacuation (8) Extinguishment of fire
.

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The facility failed to provide a written evacuation plan per code. Findings include:

During the survey, the following is an example of what was observed:
The written evacuation plan provided by the facility did not include "evacuation of an effected smoke compartment to an uneffected smoke compartment".

_______________
2000 NFPA 101, 19.7.2.2 A written health care occupancy fire safety plan shall provide for the following: (1) Use of alarms (2) Transmission of alarm to fire department (3) Response to alarms (4) Isolation of fire (5) Evacuation of immediate area (6) Evacuation of smoke compartment (7) Preparation of floors and building for evacuation (8) Extinguishment of fire
.

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The facility failed to conduct fire drills per code. Findings include:

During the survey, the following are examples of what was observed:
Per documentation and interview the following was discovered:
1. The Lab and X-ray Departments have Baylor (weekend) shifts and these shifts were not doing fire drills
2. No first shift/first quarter for 2012 fire drill documentation
3. The facility was not getting all staff to sign-in/participate in the fire drills

_______________________
2000 NFPA 101, 19.7.1.2 Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
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The facility failed to conduct fire drills per code. Findings include:

During the survey, the following are examples of what was observed:
Per documentation and interview the following was discovered:
1. The Lab. and X-ray Departments have Baylor (weekend) shifts and these shifts were not doing fire drills
2. No first shift/first quarter for 2012 fire drill documentation
3. The facility was not getting all staff to sign-in/participate in the fire drills

_______________________
2000 NFPA 101, 19.7.1.2 Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
.

.
The facility failed to conduct fire drills per code. Findings include:

During the survey, the following are examples of what was observed:
Per documentation and interview the following was discovered:
1. The Lab. and X-ray Departments have Baylor (weekend) shifts and these shifts were not doing fire drills
2. No first shift/first quarter for 2012 fire drill documentation
3. The facility was not getting all staff to sign-in/participate in the fire drills
_______________________
2000 NFPA 101, 19.7.1.2 Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
.

The facility failed to maintain a fire alarm system with approved component devices finding include: During the survey, the following is an example of what was observed:

1) While testing the fire alarm system upon activation of alarm, the HVAC failed to shut down, in the Administration corridor.

_______________________
NFPA 101, 9.6.1.7 Components of the fire alarm system were not maintained.

NFPA 101, 9.6.5.1 and 1999 NFPA 90a, 4-4.3 The HVAC system in the facility shut down automatically upon activation of alarm.



2) Facility failed to maintain the Digital Alarm Communicator Transmitter in the fire alarm system. Findings include: During the survey, the surveyors were unable to test the phone lines. The phone lines had been installed in a way that the Maintenance Director was not sure how to disconnect the lines.

____________________________
1999 NFPA 72, Section 1-5.4.6, 5-5.3.2.1.5, and 5-5.3.2.1.6.2. Phone line and communication failure shall be indicated at the facility.
.

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Facility failed to maintain the Digital Alarm Communicator Transmitter in the fire alarm system. Findings include: During the survey, the surveyors were unable to test the phone lines. The phone lines had been installed in a way that the Maintenance Director was not sure how to disconnect the lines.

___________________
1999 NFPA 72, Section 1-5.4.6, 5-5.3.2.1.5, and 5-5.3.2.1.6.2. Phone line and communication failure shall be indicated at the facility.
.

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Facility failed to maintain the Digital Alarm Communicator Transmitter in the fire alarm system. Findings include: During the survey, the surveyors were unable to test the phone lines. The phone lines had been installed in a way that the Maintenance Director was not sure how to disconnect the lines.

_____________________
1999 NFPA 72, Section 1-5.4.6, 5-5.3.2.1.5, and 5-5.3.2.1.6.2. Phone line and communication failure shall be indicated at the facility.

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Facility failed to maintain the Digital Alarm Communicator Transmitter in the fire alarm system. Findings include: During the survey, the surveyors were unable to test the phone lines. The phone lines had been installed in a way that the Maintenance Director was not sure how to disconnect the lines.

_____________________
1999 NFPA 72, Section 1-5.4.6, 5-5.3.2.1.5, and 5-5.3.2.1.6.2. Phone line and communication failure shall be indicated at the facility.

.

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A) Sprinkler coverage was observed during the survey not adequately provided. Findings include: During the survey, the following are examples of what was observed:

1. The Exit Discharge for Medical Records has a 50" overhang combustible.
____________________
1999 NFPA 13, 5-13.8 Sprinklers shall be installed under exterior combustible roofs or canopies exceeding four feet in width, or over areas where combustibles are stored.



2. Six ceiling tiles were missing in the Body Cooler Room First Floor.
_______________
NFPA 13 5-6., Sprinklers shall be arranged to be in compliance.



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B) The facility failed to maintain the sprinkler head per code. Findings include:

During the survey, the following is an example of what was observed:
First Floor
A sprinkler head in the Laboratory was completely covered in foreign material.
_______________________
1998 NFPA 25, 2-2.1.1 Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.
.

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Sprinkler coverage was observed during the survey not adequately provided. Findings include: During the survey, the following is an example of what was observed:

Sprinkler coverage was not provided for a storage room located in ICU Supply Room.

NFPA 19.3.5.1 Where required by 19.1.6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.
.

The facility failed to maintain the fire extinguishers per code. Findings include:

During the survey, the following is an example of what was observed:
First and Second Floors
The facility failed to provide annual inspections of the fire extinguishers by an outside company, the last anual inspection documented was January 2011.

______________
1998 NFPA 10, 4-4.1 Fire extinguishers shall be subjected to maintenance at intervals of not more than 1 year, at the time of hydrostatic test, or when specifically indicated by an inspection.

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The facility failed to maintain the fire extinguishers per code. Findings include:

During the survey, the following is an example of what was observed:
First and Second Floors
The facility failed to provide annual inspections of the fire extinguishers by an outside company, the last anual inspection documented was January 2011.

_____________
1998 NFPA 10, 4-4.1 Fire extinguishers shall be subjected to maintenance at intervals of not more than 1 year, at the time of hydrostatic test, or when specifically indicated by an inspection.

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The facility failed to maintain the fire extinguishers per code. Findings include:

During the survey, the following is an example of what was observed:
First and Second Floors
The facility failed to provide annual inspections of the fire extinguishers by an outside company, the last anual inspection documented was January 2011.

______________
1998 NFPA 10, 4-4.1 Fire extinguishers shall be subjected to maintenance at intervals of not more than 1 year, at the time of hydrostatic test, or when specifically indicated by an inspection.

.

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The facility failed to maintain the fire extinguishers per code. Findings include:

During the survey, the following is an example of what was observed:
First and Second Floors
The facility failed to provide annual inspections of the fire extinguishers by an outside company, the last anual inspection documented was January 2011.
______________
1998 NFPA 10, 4-4.1 Fire extinguishers shall be subjected to maintenance at intervals of not more than 1 year, at the time of hydrostatic test, or when specifically indicated by an inspection.

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The facility failed to maintain the cooking facilities per code. Findings include:

During the survey, the following are examples of what was observed:
First Floor
1. The facility was not inspecting the kitchen hood suppression system on a monthly basis.
2. The K-extinguisher did not have the required signage.
_____________
1998 NFPA 17A, 5-2.1 Inspection shall be conducted on a monthly basis in accordance with the manufacturer ' s listed installation and maintenance manual or the owner ' s manual. As a minimum, this " quick check " or inspection shall include verification of the following: (a) The extinguishing system is in its proper location. (b) The manual actuators are unobstructed. (c) The tamper indicators and seals are intact. (d) The maintenance tag or certificate is in place. (e) No obvious physical damage or condition exists that might prevent operation. (f)The pressure gauge(s), if provided, is in operable range. (g) The nozzle blowoff caps are intact and undamaged. (h) The hood, duct, and protected cooking appliances have not been replaced, modified, or relocated.
1998 NFPA 96, 7-2.1.1 A placard identifying the use of the extinguisher as a secondary backup means to the automatic fire suppression system shall be conspicuously placed near each portable fire extinguisher in the cooking area.
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The facility failed to prohibit portable heating devices per code. Findings include:

During the survey, the following sre examples of what was observed:
First Floor
Portable Heating Devices were observed in the following locations:
1. Gift Shop - was not plugged in
2. X-ray Breakroom - was plugged in

_______________
2000 NFPA 101, 19.7.8 Portable space-heating devices shall be prohibited in all health care occupancies. Exception: Portable space-heating devices shall be permitted to be used in nonsleeping staff and employee areas where the heating elements of such devices do not exceed 212?F (100?C).
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The facility failed to provide a readily accessible means of egress pathway at all times. Findings include: During the survey, the following is an example of what was observed:

The means of egress at the Exit Discharge, for the SouthEast Stairwell, was blocked by a vehicle
____________________
NFPA 101, 7.1.10.1 Means of egress shall be continuously maintained free of all obstructions or impediments for full instant use in case of fire or other emergencies.

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The facility failed to maintain the curtains/draperies per code. Findings include:

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

1. The facility failed to provide flame resistant documentation for the curtains throughout the Second Floor for Patient Rooms.


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First Floor
2. The facility failed to provide flame resistant documentation for the sheer curtain in the Dietary Office in the kitchen.

____________________
2000 NFPA 101, 10.3.1 Where required by the applicable provisions of this Code, draperies, curtains, and other similar loosely hanging furnishings and decorations shall be flame resistant as demonstrated by testing in accordance with NFPA 701, Standard Methods of Fire Tests for Flame Propagation of Textiles and Films.
.

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The facility failed to maintain the anesthetizing locations (O.R.s) per code. Findings include:

During the survey, the following are examples of what was observed:
First Floor
1. The battery back-up light in O.R. "A" did not work when tested and was not plugged in.
2. Per interview and observation O.R. "A" and O.R. "B" did not have smoke venting systems.

__________________
1999 NFPA 99, 3-3.2.1.2 All Patient Care Areas. 5. Wiring in Anesthetizing Locations. e. Battery-Powered Emergency Lighting Units. One or more battery-powered emergency lighting units shall be provided in accordance with NFPA 70, National Electrical Code, Section 700-12(e).
1999 NFPA 70, 700-12. General Requirements (e) Unit Equipment. Individual unit equipment for emergency illumination shall consist of the following: 1. A rechargeable battery 2. A battery charging means 3. Provisions for one or more lamps mounted on the equipment, or shall be permitted to have terminals for remote lamps, or both, and 4. A relaying device arranged to energize the lamps automatically upon failure of the supply to the unit equipment. The batteries shall be of suitable rating and capacity to supply and maintain at not less than 87? percent of the nominal battery voltage for the total lamp load associated with the unit for a period of at least 1? hours, or the unit equipment shall supply and maintain not less than 60 percent of the initial emergency illumination for a period of at least 1? hours. Storage batteries, whether of the acid or alkali type, shall be designed and constructed to meet the requirements of emergency service. Unit equipment shall be permanently fixed in place (i.e., not portable) and shall have all wiring to each unit installed in accordance with the requirements of any of the wiring methods in Chapter 3. Flexible cord and plug connection shall be permitted, provided that the cord does not exceed 3 ft (914 mm) in length. The branch circuit feeding the unit equipment shall be the same branch circuit as that serving the normal lighting in the area and connected ahead of any local switches. The branch circuit that feeds unit equipment shall be clearly identified at the distribution panel. Emergency illumination fixtures that obtain power from a unit equipment and are not part of the unit equipment shall be wired to the unit equipment as required by Section 700-9 and by one of the wiring methods of Chapter 3.
1999 NFPA 99, 5-4.1.2 Supply and exhaust systems for windowless anesthetizing locations shall be arranged to automatically vent smoke and products of combustion.
1999 NFPA 99, 5-4.1.3 Ventilating systems for anesthetizing locations shall be provided that automatically (a) prevent recirculation of smoke originating within the surgical suite and (b) prevent the circulation of smoke entering the system intake, without in either case interfering with the exhaust function of the system.
1999 NFPA 99, 5-4.1.4 The electric supply to the ventilating system shall be served by the equipment system of the essential electrical system specified in Chapter 3, " Electrical Systems. "
.

During the survey, the following are examples of what was observed:

1. Generator/day fuel tank was not protected from damage.

2. Battery-powered light not provided in the generator set control room.

3. Identification was not provided for the transfer swiches.

4. A written emergency power plan was not provided, in case generator failed.
________________________
NFPA 110, 5-2.4* Consideration shall be given to the location of the Level 1 and Level 2 EPSS equipment to minimize the possibility of damage resulting from interruptions of the emergency power source caused by the following:
(a) * Natural conditions such as storms, floods, earthquakes, tornadoes, hurricanes, lightning, ice storms, wind, and fire
(b) Conditions such as vandalism, sabotage, and other similar occurrences
(c) Material and equipment failures.

1999 NFPA 99, 3-6.1.1 and 3-4.1.1.4, and 1999 NFPA 110, 5-3.1 The Level 1 or Level 2 EPS equipment location shall be provided with battery-powered emergency lighting.

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.

NFPA 110 6-1.2 Consideration shall be given to temporarily providing a portable or alternate source whenever the emergency generator is out of service.
.

.
During the survey, the following are examples of what was observed:

1. Generator/day fuel tank was not protected from damage.

2. Battery-powered light not provided in the generator set control room.

3. Identification was not provided for the transfer swiches.

4. A written emergency power plan was not provided, in case generator failed.

_________________
NFPA 110, 5-2.4* Consideration shall be given to the location of the Level 1 and Level 2 EPSS equipment to minimize the possibility of damage resulting from interruptions of the emergency power source caused by the following:
(a) * Natural conditions such as storms, floods, earthquakes, tornadoes, hurricanes, lightning, ice storms, wind, and fire
(b) Conditions such as vandalism, sabotage, and other similar occurrences
(c) Material and equipment failures.

1999 NFPA 99, 3-6.1.1 and 3-4.1.1.4, and 1999 NFPA 110, 5-3.1 The Level 1 or Level 2 EPS equipment location shall be provided with battery-powered emergency lighting.

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.

NFPA 110 6-1.2 Consideration shall be given to temporarily providing a portable or alternate source whenever the emergency generator is out of service.
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.
During the survey, the following are examples of what was observed:

1. Generator/day fuel tank was not protected from damage.

2. Battery-powered light not provided in the generator set control room.

3. Identification was not provided for the transfer swiches.

4. A written emergency power plan was not provided, in case generator failed.

__________________
NFPA 110, 5-2.4* Consideration shall be given to the location of the Level 1 and Level 2 EPSS equipment to minimize the possibility of damage resulting from interruptions of the emergency power source caused by the following:
(a) * Natural conditions such as storms, floods, earthquakes, tornadoes, hurricanes, lightning, ice storms, wind, and fire
(b) Conditions such as vandalism, sabotage, and other similar occurrences
(c) Material and equipment failures.

1999 NFPA 99, 3-6.1.1 and 3-4.1.1.4, and 1999 NFPA 110, 5-3.1 The Level 1 or Level 2 EPS equipment location shall be provided with battery-powered emergency lighting.

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.

NFPA 110 6-1.2 Consideration shall be given to temporarily providing a portable or alternate source whenever the emergency generator is out of service.
.

.
During the survey, the following are examples of what was observed:

1. Generator/day fuel tank was not protected from damage.

2. Battery-powered light not provided in the generator set control room.

3. Identification was not provided for the transfer swiches.

4. A written emergency power plan was not provided, in case generator failed.
__________________
NFPA 110, 5-2.4* Consideration shall be given to the location of the Level 1 and Level 2 EPSS equipment to minimize the possibility of damage resulting from interruptions of the emergency power source caused by the following:
(a) * Natural conditions such as storms, floods, earthquakes, tornadoes, hurricanes, lightning, ice storms, wind, and fire
(b) Conditions such as vandalism, sabotage, and other similar occurrences
(c) Material and equipment failures.

1999 NFPA 99, 3-6.1.1 and 3-4.1.1.4, and 1999 NFPA 110, 5-3.1 The Level 1 or Level 2 EPS equipment location shall be provided with battery-powered emergency lighting.

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.

NFPA 110 6-1.2 Consideration shall be given to temporarily providing a portable or alternate source whenever the emergency generator is out of service.
.

.The facility failed to maintain the emergency generator per code. Findings include:

A) During the survey, the generator was observed not to have met the requirements to transfer from normal to emergency power within 10 seconds. The Facility Maintenance Staff was observed to have made one attempt with the following time noted to transfer from normal to emergency power. The time was observed to be 14 seconds.
_________________
NFPA 101, 7.9.2.3, and 1999 NFPA 99, 3-4.1.1.8, 3-5.3.1 and 3-6.3.1.2 Emergency generator shall start/crank and transfer from normal to emergency power within ten seconds.



27382



B) During the survey, the following are examples of what was observed:
Per documentation provided by the facility, and interviews the following was discovered:
1. The facility was not conducting weekly inspections on the emergency generator
2. The facility was not consistently doing thirty minute load test every month, most were only twenty minute load tests.

____________________
1999 NFPA 110, 6-4.1 Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.
1999 NFPA 110, 6-4.2 Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating (b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer The date and time of day for required testing shall be decided by the owner, based on facility operations.
1999 NFPA 110, 6-4.2.1 Equivalent loads used for testing shall be automatically replaced with the emergency loads in case of failure of the primary source.
1999 NFPA 110, 6-4.2.2 Diesel-powered EPS installations that do not meet the requirements of 6-4.2 shall be exercised monthly with the available EPSS load and exercised annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of 2 continuous hours.
.

1. During the survey, the generator was observed not to have met the requirements to transfer from normal to emergency power within 10 seconds. The Facility Maintenance Staff was observed to have made one attempt with the following time noted to transfer from normal to emergency power. The time was observed to be 14 seconds.
____________________
NFPA 101, 7.9.2.3, and 1999 NFPA 99, 3-4.1.1.8, 3-5.3.1 and 3-6.3.1.2 Emergency generator shall start/crank and transfer from normal to emergency power within ten seconds.



27382


The facility failed to maintain the emergency generator per code. Findings include:

During the survey, the following are examples of what was observed:
Per documentation provided by the facility, and interviews the following was discovered:
2. The facility was not conducting weekly inspections on the emergency generator
3. The facility was not consistently doing thirty minute load test every month, most were only twenty minute load tests.

____________________
1999 NFPA 110, 6-4.1 Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.
1999 NFPA 110, 6-4.2 Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
The date and time of day for required testing shall be decided by the owner, based on facility operations.
1999 NFPA 110, 6-4.2.1 Equivalent loads used for testing shall be automatically replaced with the emergency loads in case of failure of the primary source.
1999 NFPA 110, 6-4.2.2 Diesel-powered EPS installations that do not meet the requirements of 6-4.2 shall be exercised monthly with the available EPSS load and exercised annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of 2 continuous hours.
.

.
The facility failed to maintain the emergency generator per code. Findings include:

1. During the survey, the generator was observed not to have met the requirements to transfer from normal to emergency power within 10 seconds. The Facility Maintenance Staff was observed to have made one attempt with the following time noted to transfer from normal to emergency power. The time was observed to be 14 seconds.

_____________________
NFPA 101, 7.9.2.3, and 1999 NFPA 99, 3-4.1.1.8, 3-5.3.1 and 3-6.3.1.2 Emergency generator shall start/crank and transfer from normal to emergency power within ten seconds.


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Per documentation provided by the facility, and interviews the following was discovered:
2. The facility was not conducting weekly inspections on the emergency generator
3. The facility was not consistently doing thirty minute load test every month, most were only twenty minute load tests.
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1999 NFPA 110, 6-4.1 Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.
1999 NFPA 110, 6-4.2 Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods: (a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating (b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer. The date and time of day for required testing shall be decided by the owner, based on facility operations.
1999 NFPA 110, 6-4.2.1 Equivalent loads used for testing shall be automatically replaced with the emergency loads in case of failure of the primary source.
1999 NFPA 110, 6-4.2.2 Diesel-powered EPS installations that do not meet the requirements of 6-4.2 shall be exercised monthly with the available EPSS load and exercised annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of 2 continuous hours.
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The facility failed to maintain the emergency generator per code. Findings include:

1. During the survey, the generator was observed not to have met the requirements to transfer from normal to emergency power within 10 seconds. The Facility Maintenance Staff was observed to have made one attempt with the following time noted to transfer from normal to emergency power. The time was observed to be 14 seconds.
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NFPA 101, 7.9.2.3, and 1999 NFPA 99, 3-4.1.1.8, 3-5.3.1 and 3-6.3.1.2 Emergency generator shall start/crank and transfer from normal to emergency power within ten seconds.


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During the survey, the following are examples of what was observed:
Per documentation provided by the facility, and interviews the following was discovered:
2. The facility was not conducting weekly inspections on the emergency generator
3. The facility was not consistently doing thirty minute load test every month, most were only twenty minute load tests.

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1999 NFPA 110, 6-4.1 Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.
1999 NFPA 110, 6-4.2 Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating (b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
The date and time of day for required testing shall be decided by the owner, based on facility operations.
1999 NFPA 110, 6-4.2.1 Equivalent loads used for testing shall be automatically replaced with the emergency loads in case of failure of the primary source.
1999 NFPA 110, 6-4.2.2 Diesel-powered EPS installations that do not meet the requirements of 6-4.2 shall be exercised monthly with the available EPSS load and exercised annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of 2 continuous hours.
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The facility failed to maintain the electrical system per code. Findings include:

During the survey, the following are examples of what was observed:
First Floor
1. The Doctors' Sleeping Lounge:
a. Refrigerator and microwve plugged into a surge protector
b. Extension cord plugged into the wall outlet
2. The corridor at E.R.'s Admission Office had an orange extension cord plugged into a wall outlet on one side of the corridor, ran above the layin ceiling, comes down the wall on the other side of the corridor, this has been run in a raceway on the walls (to permenantly cover up the extension cord).
3. The Outpatient Clinic Waiting Room had the T.V. plugged into an extension cord.

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1999 NFPA 70, 400-7 and 400-8, and HCFA Transmittal Notice 22-99 The 1984 edition of the National Electric Code restricts the use of extension cords to temporary short term uses. It is the policy of HCFA to prohibit non-circuit breaker protected extension cords in health care. The limited use of circuit breaker protected power strips is acceptable, provided the current is limited to 15 amps or less, and no major appliances such as air conditioners, refrigerators, or heating units are connected to the power strip.
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The facility failed to maintain the electrical system per code. Findings include;

During the survey, the following are examples of what was observed:
First Floor
1. A refrigerator and a microwave were plugged into a surge protector
2. An extension cord was plugged into a surge protector in the Phone Room (South Computer Room)

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1999 NFPA 70, 400-7 and 400-8, and HCFA Transmittal Notice 22-99 The 1984 edition of the National Electric Code restricts the use of extension cords to temporary short term uses. It is the policy of HCFA to prohibit non-circuit breaker protected extension cords in health care. The limited use of circuit breaker protected power strips is acceptable, provided the current is limited to 15 amps or less, and no major appliances such as air conditioners, refrigerators, or heating units are connected to the power strip.

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The facility failed to provide a fire watch policy per code. Findings include:

During the survey, the following is an example of what was observed:
The facility failed to provide a fire watch policy per code.

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2000 NFPA 101, 9.7.6.1 Where a required automatic sprinkler system is out of service 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 sprinkler system has been returned to service.
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The facility failed to provide a fire watch policy per code. Findings include:

During the survey, the following is an example of what was observed:
The facility failed to provide a fire watch policy per code.
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2000 NFPA 101, 9.7.6.1 Where a required automatic sprinkler system is out of service 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 sprinkler system has been returned to service.
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The facility failed to provide a fire watch policy per code. Findings include:

During the survey, the following is an example of what was observed:
The facility failed to provide a fire watch policy per code.

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2000 NFPA 101, 9.6.1.8 Where a required fire alarm system is out of service 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.

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The facility failed to provide a fire watch policy per code. Findings include:

During the survey, the following is an example of what was observed:
The facility failed to provide a fire watch policy per code.

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2000 NFPA 101, 9.6.1.8 Where a required fire alarm system is out of service 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.
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The facility failed to provide a fire watch policy per code. Findings include:

During the survey, the following is an example of what was observed:
The facility failed to provide a fire watch policy per code.
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2000 NFPA 101, 9.6.1.8 Where a required fire alarm system is out of service 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.
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