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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. Physician Dictation office on the seven floor door failed to positive latch.

2. Equipment Room by Stairwell 4-E-08 door failed to close tight as to resist the passage of smoke.

3. ASD 19 door failed to positive latch fourth floor.

4. Consultation Room "A" by main surgery waiting room, door failed to positive latch.

5. Four holes approximately the size of a dime, around the door handle, of Managed Care Office, this surveyor was able to see into the office from the corridor when door was closed.


27382


Sixth Floor
6. Conference Room corridor door did not have positive latching hardware.
First Floor
7. Radiology Storage Room double doors, both doors had transfer grills in them.

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2000 NFPA 101, 19.3.6.3.1 Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 13/4-in. (4.4-cm) thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke. Compliance with NFPA 80, Standard for Fire Doors and Fire Windows, shall not be required. Clearance between the bottom of the door and the floor covering not exceeding 1 in. (2.5 cm) shall be permitted for corridor doors.
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.
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The facility failed to maintain the corridor openings per code. Findings include:

During the survey, the following is an example of what was observed:
Ground Floor
Emergency Department - Five Treatment Rooms in the Critical Care POD had self-closing devices on the corridor doors, but were being held open by toe sops.
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2000 NFPA 101, 19.3.6.3.3 Hold-open devices that release when the door is pushed or pulled shall be permitted.
2007 CMS - 2786R There is no impediment to the closing of the corridor doors.

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The facility failed to maintain a stairway per code. Findings include:

During the survey, the following is an example of what was observed:
Fourth Floor
Cardiothoracic Surgery Waiting Room, has a stairwell that opens into this room. The fire rated corridor door had a self-closing device, but was being held open by a shred box.

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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.
2000 NFPA 101, 19.2.2.2.6 Any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8.2. The automatic sprinkler system, if provided, and the fire alarm system, and the systems required by 7.2.1.8.2 shall be arranged to initiate the closing action of all such doors throughout the smoke compartment or throughout the entire facility.
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The facility failed to maintain the smoke barriers per code. Findings include:

During the survey, the following are examples of what was observed:
Women's & Children's Center
Second Floor
1. WC2-04 - one unsealed conduit end
Fourth Floor
2. Unsealed penetration in left wall by stair door WC4-08

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2000 NFPA 101, 8.2.4.4.1 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through smoke partitions shall be protected as follows: (1) The space between the penetrating item and the smoke partition shall meet one of the following conditions: a. It shall be filled with a material that is capable of limiting the transfer of smoke. 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 smoke partition, the sleeve shall be solidly set in the smoke partition, 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 limiting the transfer of smoke. b. It shall be protected by an approved device that is designed for the specific purpose. (3) Where designs take transmission of vibrations into consideration, any vibration isolation shall meet one of the following conditions: a. It shall be made on either side of the smoke partitions. b. It shall be made by an approved device that is designed for the specific purpose.
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The facility failed to maintain the smoke barriers per code. Findings include:

During the survey the following are examples of what was observed:
Sixth Floor
1. At 6W-10:
a. Unsealed conduit end with a blue wire
b. Unsealed rockwool at the corrugated roof deck
2. At 6W-05:
a. Unsealed penetration by HVAC duct
b. Unsealed rockwool at the corrugated roof deck
Fifth Floor
3. Unsealed rockwool at the corrugated roof deck at the following locations:
a. 4W-15
b. 4W-14
c. 4W-08
4. 4W-14:
a. Conduit end with blue wires penetrating the smoke barrier not sealed
b. Large group of wires penetrating the smoke barrier not sealed
Third Floor
5. 3W-04 - one unsealed pentration
6. 3E-OL - three unsealed penetrations
Second Floor
7. 2W-31 - unsealed rockwool at the corrugated roof deck

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2000 NFPA 101, 8.2.4.4.1 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through smoke partitions shall be protected as follows:
(1) The space between the penetrating item and the smoke partition shall meet one of the following conditions:
a. It shall be filled with a material that is capable of limiting the transfer of smoke.
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 smoke partition, the sleeve shall be solidly set in the smoke partition, 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 limiting the transfer of smoke.b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibrations into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the smoke partitions.
b. It shall be made by an approved device that is designed for the specific purpose.
2000 NFPA 101, 8.3.2 Smoke barriers required by this Code shall be continuous from an outside wall to an outside wall, from a floor to a floor, or from a smoke barrier to a smoke barrier or a combination thereof. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces.
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The facility failed to maintain the doors in the smoke barriers per code. Findings include:

During the survey, the following are examples of what was observed:
North Tower
The following automatic doors in the smoke barriers did not loose their power when the fire alarm was teasted:
1. NT7-08
2. NT7-07

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2000 NFPA 101, 7.2.1.8.2 In any building of low or ordinary hazard contents, as defined in 6.2.2.2 and 6.2.2.3, or where approved by the authority having jurisdiction, doors shall be permitted to be automatic-closing, provided that the following criteria are met: (1) Upon release of the hold-open mechanism, the door becomes self-closing. (2) The release device is designed so that the door instantly releases manually and upon release becomes self-closing, or the door can be readily closed. (3) The automatic releasing mechanism or medium is activated by the operation of approved smoke detectors installed in accordance with the requirements for smoke detectors for door release service in NFPA 72, National Fire Alarm Code®. (4) Upon loss of power to the hold-open device, the hold-open mechanism is released and the door becomes self-closing. (5) The release by means of smoke detection of one door in a stair enclosure results in closing all doors serving that stair.
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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:

Mechanical Room 3-W-16 had unsealed penetrations at the end of two sleeve's.
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NFPA 101, 19.3.2.1 and 8.4.1 Hazardous areas to be provided with smoke-resisting partitions and doors when protection consists of an automatic extinguishing system. Doors shall be selfclosing with positive latching hardware.
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The facility failed to provide continuously illuminated exit signs. Findings include: During the survey, the following is an example of what was observed:

Two exits signs in the Chiller Room were not illuminated.
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NFPA 101, 7.10.5 Continuous illumination of exit signs.
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The facility failed to provide a fire evacuation plan per code. Findings include:

During the survey, the following is an example of what was observed:
The fire evacuation plan provided by the facility did not contain the wording "from 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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A) Facility failed to maintain the Digital Alarm Communicator Transmitter in the fire alarm system. Findings include: During the survey, the following are examples of what was observed:

1. When the Auto Dialer was tested for phone line 1, failure was not indicated at the protected premise within the allotted four (5) minute time frame.

2. When the Auto Dialer was tested for phone line 2, failure was not indicated at the protected premise within the allotted four (5) minute time frame.

3. When the Auto Dialer was tested for Communication Failure, failure was not indicated at the protected premise within the allotted fifteen (15) minute time frame (5 minimum to 10 maximum attempts for signal transmission). (Surveyors waited 16 minutes.)

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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.



B) The facility failed to maintain a fire alarm system with approved component devices or equipment installed to provide effective warning of fire in any part of the building. Findings include: During the survey, the following is an example of what was observed:

While testing the fire alarm system the horn/strobes failed to function in Diagnostic.

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NFPA 101, 9.6.1.4 The fire alarm system to be installed, tested, and maintained in accordance with the requirements of NFPA 70 and NFPA 72.

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

1. Starting at W-672 patient room the horn/strobes for this corridor failed to function.


27382

Sixth Floor
2. The audible device was not working by room 615
Fourth Floor
3. The Nurses' Station at West Wing did not have an audible device in that smoke compartment when the smoke doors closed.
Third Floor
4. The Nurses' Station by room 3M-2 did not have an audible device in that smoke compartment when the smoke doors closed.

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2000 NFPA 101, 9.6.1.4 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.
2000 NFPA 101, 9.6.1.9 For the purposes of this Code, a complete fire alarm system shall be used for initiation, notification, and control and shall provide the following.
(a) Initiation. The initiation function provides the input signal to the system.
(b) Notification. The notification function is the means by which the system advises that human action is required in response to a particular condition.
(c) Control. The control function provides outputs to control building equipment to enhance protection of life.
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The facility failed to maintain the fire alarm system per code. Findings include:

During the survey, the following is an example of what was observed:
Third Floor
While testing the fire alarm system, the smoke detector in O.R. 7 read out at the fire alarm panel as "smoke detector in O.R. 1". This same smoke detector although activated failed to activate the fire alarm system or the smoke venting system.

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2000 NFPA 101, 9.6.1.4 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.
2000 NFPA 101, 9.6.2.1 Where required by other sections of this Code, actuation of the complete fire alarm system shall occur by any or all of the following means of initiation, but shall not be limited to such means:
(1) Manual fire alarm initiation
(2) Automatic detection
(3) Extinguishing system operation
2000 NFPA 101, 9.6.1.9 For the purposes of this Code, a complete fire alarm system shall be used for initiation, notification, and control and shall provide the following.
(a) Initiation. The initiation function provides the input signal to the system.
(b) Notification. The notification function is the means by which the system advises that human action is required in response to a particular condition.
(c) Control. The control function provides outputs to control building equipment to enhance protection of life.
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Sprinkler coverage was observed during the survey not adequately provided. Findings include: During the survey, the following are examples of what was observed:

1. Escutcheon plate missing on a sprinkler in the soiled utility room third floor.

2. Sprinkler coverage not provided in the bathroom, located inside of the soiled utility room fourth floor.

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2000 NFPA 13, 3-2.7.2 Escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly.

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

1. Escutcheon plate missing on a sprinkler seventh floor dialysis.

2. A sprinkler had a build up of sheetrock mud on the link/deflector in 4-W-11 mechanical room.

3. Sprinkler coverage was not provided in E-4-W2 electrical room.

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2000 NFPA 13, 3-2.7.2 Escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly.

1999 NFPA 25, 2-2.1.1 and 2-4.1.2 Sprinklers that are painted, corroded or damaged shall be replaced with new listed sprinklers of the same characteristics, including orifice size, thermal response, and water distribution.

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 adequately perform testing and inspection of the dietary hood
extinguishment system. Findings include:

During survey, the provided documentation for the monthly inspection of the hood system was the inspection card attached to the pull station of the hood extinguishing system. This card was observed with space on the reverse side to date and initial each month an inspection was conducted by facility staff. This side of the inspection card was blank.

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NFPA 17, 9-2.1- On a monthly basis, inspection shall be conducted in accordance with the manufacturer 's listed installation and maintenance manual or 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) The system shows no physical damage or condition that might prevent operation. (f) The pressure gauge(s), if provided, is in operable range.
(g) The nozzle blow-off caps, where provided, are intact and undamaged.
(h) Neither the protected equipment nor the hazard has been replaced, modified, or relocated.

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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:

In Medical Records the means of egress was obstructed by file cabinets.
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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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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:

The Exit Discharge was not provided with an all weather surface to the public way for the Exits.
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NFPA 101, 7.1.10.1 Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

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.


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

1. A 10' noncombustible overhang with combustible items stored under the overhang, was observed at the can wash area.

2. Escutcheon plate was missing on a sprinkler in front of the Elevators first floor.
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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.

2000 NFPA 13, 3-2.7.2 Escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly.


C) The facility failed to perform sensitivity testing of the smoke detectors. Findings include: During the survey, documentation was not provided for the sensitivity testing of the smoke detectors.

Detector sensitivity shall be checked with one year after installation and
every alternate year thereafter per 72, 7-3.2.1. (Up to 5 years permitted under certain circumstances. See 7-3.2.1).



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

Documentation was not provided for the annual partial trip test of the dry riser, or the three year full flow trip test.
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NFPA 25,1998 Edition, 9-5.2.3 A partial flow trip test adequate to move the valve from its seat shall be conducted annually.
NFPA 25, 1998 Edition, 9-4.4.2.2.2 Every 3 years and whenever the system is altered, the dry pipe valve shall be trip tested with the control valve fully open and the quick-opening device, if provided, in service.

E) Battery-powered lighting at the generator equipment and controls was not provided as observed during the survey.
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1999 NFPA 99, 3-6.1.1 and 3-4.1.1.4, and 1999 NFPA 110, 5-3.1. Emergency generator equipment locations.


27382


F) The facility failed to maintain the following systems per code. Findings include:
During the survey, the following are examples of what was observed:
The one hour atrium wall at New Patient Scheduling had the following unsealed penetrations:
a. White and blue wires
b. One flex conduit in two places
1. The automatic sprinkler gauges had not been calibrated or replaced in the last five years
2. The emergency generator remote annunciator did not indicate "generator under load" when the generator was tested

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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.
1998 NFPA 25, 2-3.2 Gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge. Gauges not accurate to within 3 percent of the full scale shall be recalibrated or replaced.
1999 NFPA 99, 3-4.1.1.15 A remote annunciator, storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station (see NFPA 70, National Electrical Code, Section 700-12.)
The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows:
(a) Individual visual signals shall indicate the following:
1. When the emergency or auxiliary power source is operating to supply power to load
2. When the battery charger is malfunctioning
(b) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following:
1. Low lubricating oil pressure
2. Low water temperature (below those required in 3-4.1.1.9)
3. Excessive water temperature
4. Low fuel - when the main fuel storage tank contains less than a 3-hour operating supply
5. Overcrank (failed to start)
6. Overspeed
Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions in 3-4.1.1.15(a) and (b) occur, but need not display these conditions individually. [110: 3-5.5.2]

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The facility failed to provide proper emergency lighting at the generator set and controls. Findings include: During the survey, the following is an example of what was observed:

Emergency battery-powered light was not provided in the generator set and controls room.
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1999 NFPA 99, 3-6.1.1 and 3-4.1.1.4, and 1999 NFPA 110, 5-3.1. Emergency generator equipment locations.
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The facility failed to provide a remote annunciator for the emergency generator per code. Findings include:

During the survey, the following is an example of what was observed:
Per observation and interview the Women's & Children's Center emergency generator did not have a remote annunciator.

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1999 NFPA 99, 3-4.1.1.15 A remote annunciator, storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station (see NFPA 70, National Electrical Code, Section 700-12.)
The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows:
(a) Individual visual signals shall indicate the following:
1. When the emergency or auxiliary power source is operating to supply power to load
2. When the battery charger is malfunctioning
(b) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following:
1. Low lubricating oil pressure
2. Low water temperature (below those required in 3-4.1.1.9)
3. Excessive water temperature
4. Low fuel - when the main fuel storage tank contains less than a 3-hour operating supply
5. Overcrank (failed to start)
6. Overspeed
Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions in 3-4.1.1.15(a) and (b) occur, but need not display these conditions individually. [110: 3-5.5.2]
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The facility failed to maintain the emergency generator per code. Findings include:

During the survey, the following are examples of what was observed:
Per observation and interview the facility was not doing:
1. Weekly inspections
2. Monthly 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.
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The facility failed to provide approved electrical utilities. Findings include: During the survey, the following is an example of what was observed:

The electrical breaker box in room E7M1, observed with open blanks in the interior of the box.

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1999 NFPA 70, 373-4 Unused opening shall be effectively closed to afford protection substantially equivalent to that of the enclosures.
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The facility failed to provide receptacles for appliances. Findings include: During the survey, the following is an example of what was observed:

A junction box was missing the cover in the fire monitoring room.

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1999 NFPA 70, 370-25 and 410-12. Each box in completed installations to have a cover, face plate, or fixture canopy.
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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:
Ground Floor
Security Room:
2. Refrigerator and microwave were plugged into an overcurrent device
3. Two overcurrent devices were plugged, one into the other (piggy back)

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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:
Per observation and interview the facility did not know the following:
1. The person doing the fire watch this is the only thing he/she can do
2. To notify the authority having jurisdiction, ADPH, of the fire watch

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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:
Per observation and interview the facility did not know the following:
1. The person doing the fire watch this is the only thing he/she can do
2. To notify the authority having jurisdiction, ADPH, of the fire watch

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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:
Per observation and interview the facility did not know the following:
1. The person doing the fire watch this is the only thing he/she can do
2. To notify the authority having jurisdiction, ADPH, of the fire watch

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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:
Per observation and interview the facility did not know the following:
1. The person doing the fire watch this is the only thing he/she can do
2. To notify the authority having jurisdiction, ADPH, of the fire watch

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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 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. Physician Dictation office on the seven floor door failed to positive latch.

2. Equipment Room by Stairwell 4-E-08 door failed to close tight as to resist the passage of smoke.

3. ASD 19 door failed to positive latch fourth floor.

4. Consultation Room "A" by main surgery waiting room, door failed to positive latch.

5. Four holes approximately the size of a dime, around the door handle, of Managed Care Office, this surveyor was able to see into the office from the corridor when door was closed.


27382


Sixth Floor
6. Conference Room corridor door did not have positive latching hardware.
First Floor
7. Radiology Storage Room double doors, both doors had transfer grills in them.

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2000 NFPA 101, 19.3.6.3.1 Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 13/4-in. (4.4-cm) thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke. Compliance with NFPA 80, Standard for Fire Doors and Fire Windows, shall not be required. Clearance between the bottom of the door and the floor covering not exceeding 1 in. (2.5 cm) shall be permitted for corridor doors.
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.
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The facility failed to maintain the corridor openings per code. Findings include:

During the survey, the following is an example of what was observed:
Ground Floor
Emergency Department - Five Treatment Rooms in the Critical Care POD had self-closing devices on the corridor doors, but were being held open by toe sops.
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2000 NFPA 101, 19.3.6.3.3 Hold-open devices that release when the door is pushed or pulled shall be permitted.
2007 CMS - 2786R There is no impediment to the closing of the corridor doors.

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The facility failed to maintain a stairway per code. Findings include:

During the survey, the following is an example of what was observed:
Fourth Floor
Cardiothoracic Surgery Waiting Room, has a stairwell that opens into this room. The fire rated corridor door had a self-closing device, but was being held open by a shred box.

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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.
2000 NFPA 101, 19.2.2.2.6 Any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8.2. The automatic sprinkler system, if provided, and the fire alarm system, and the systems required by 7.2.1.8.2 shall be arranged to initiate the closing action of all such doors throughout the smoke compartment or throughout the entire facility.
.

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

During the survey, the following are examples of what was observed:
Women's & Children's Center
Second Floor
1. WC2-04 - one unsealed conduit end
Fourth Floor
2. Unsealed penetration in left wall by stair door WC4-08

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2000 NFPA 101, 8.2.4.4.1 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through smoke partitions shall be protected as follows: (1) The space between the penetrating item and the smoke partition shall meet one of the following conditions: a. It shall be filled with a material that is capable of limiting the transfer of smoke. 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 smoke partition, the sleeve shall be solidly set in the smoke partition, 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 limiting the transfer of smoke. b. It shall be protected by an approved device that is designed for the specific purpose. (3) Where designs take transmission of vibrations into consideration, any vibration isolation shall meet one of the following conditions: a. It shall be made on either side of the smoke partitions. b. It shall be made by an approved device that is designed for the specific purpose.
.

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

During the survey the following are examples of what was observed:
Sixth Floor
1. At 6W-10:
a. Unsealed conduit end with a blue wire
b. Unsealed rockwool at the corrugated roof deck
2. At 6W-05:
a. Unsealed penetration by HVAC duct
b. Unsealed rockwool at the corrugated roof deck
Fifth Floor
3. Unsealed rockwool at the corrugated roof deck at the following locations:
a. 4W-15
b. 4W-14
c. 4W-08
4. 4W-14:
a. Conduit end with blue wires penetrating the smoke barrier not sealed
b. Large group of wires penetrating the smoke barrier not sealed
Third Floor
5. 3W-04 - one unsealed pentration
6. 3E-OL - three unsealed penetrations
Second Floor
7. 2W-31 - unsealed rockwool at the corrugated roof deck

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2000 NFPA 101, 8.2.4.4.1 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through smoke partitions shall be protected as follows:
(1) The space between the penetrating item and the smoke partition shall meet one of the following conditions:
a. It shall be filled with a material that is capable of limiting the transfer of smoke.
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 smoke partition, the sleeve shall be solidly set in the smoke partition, 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 limiting the transfer of smoke.b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibrations into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the smoke partitions.
b. It shall be made by an approved device that is designed for the specific purpose.
2000 NFPA 101, 8.3.2 Smoke barriers required by this Code shall be continuous from an outside wall to an outside wall, from a floor to a floor, or from a smoke barrier to a smoke barrier or a combination thereof. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces.
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The facility failed to maintain the doors in the smoke barriers per code. Findings include:

During the survey, the following are examples of what was observed:
North Tower
The following automatic doors in the smoke barriers did not loose their power when the fire alarm was teasted:
1. NT7-08
2. NT7-07

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2000 NFPA 101, 7.2.1.8.2 In any building of low or ordinary hazard contents, as defined in 6.2.2.2 and 6.2.2.3, or where approved by the authority having jurisdiction, doors shall be permitted to be automatic-closing, provided that the following criteria are met: (1) Upon release of the hold-open mechanism, the door becomes self-closing. (2) The release device is designed so that the door instantly releases manually and upon release becomes self-closing, or the door can be readily closed. (3) The automatic releasing mechanism or medium is activated by the operation of approved smoke detectors installed in accordance with the requirements for smoke detectors for door release service in NFPA 72, National Fire Alarm Code®. (4) Upon loss of power to the hold-open device, the hold-open mechanism is released and the door becomes self-closing. (5) The release by means of smoke detection of one door in a stair enclosure results in closing all doors serving that stair.
.

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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:

Mechanical Room 3-W-16 had unsealed penetrations at the end of two sleeve's.
____________________
NFPA 101, 19.3.2.1 and 8.4.1 Hazardous areas to be provided with smoke-resisting partitions and doors when protection consists of an automatic extinguishing system. Doors shall be selfclosing with positive latching hardware.
.

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

Two exits signs in the Chiller Room were not illuminated.
____________________
NFPA 101, 7.10.5 Continuous illumination of exit signs.
.

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

During the survey, the following is an example of what was observed:
The fire evacuation plan provided by the facility did not contain the wording "from 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
.

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

During the survey, the following is an example of what was observed:
The fire evacuation plan provided by the facility did not contain the wording "from 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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A) Facility failed to maintain the Digital Alarm Communicator Transmitter in the fire alarm system. Findings include: During the survey, the following are examples of what was observed:

1. When the Auto Dialer was tested for phone line 1, failure was not indicated at the protected premise within the allotted four (5) minute time frame.

2. When the Auto Dialer was tested for phone line 2, failure was not indicated at the protected premise within the allotted four (5) minute time frame.

3. When the Auto Dialer was tested for Communication Failure, failure was not indicated at the protected premise within the allotted fifteen (15) minute time frame (5 minimum to 10 maximum attempts for signal transmission). (Surveyors waited 16 minutes.)

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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.



B) The facility failed to maintain a fire alarm system with approved component devices or equipment installed to provide effective warning of fire in any part of the building. Findings include: During the survey, the following is an example of what was observed:

While testing the fire alarm system the horn/strobes failed to function in Diagnostic.

_______________________
NFPA 101, 9.6.1.4 The fire alarm system to be installed, tested, and maintained in accordance with the requirements of NFPA 70 and NFPA 72.

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

1. Starting at W-672 patient room the horn/strobes for this corridor failed to function.


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Sixth Floor
2. The audible device was not working by room 615
Fourth Floor
3. The Nurses' Station at West Wing did not have an audible device in that smoke compartment when the smoke doors closed.
Third Floor
4. The Nurses' Station by room 3M-2 did not have an audible device in that smoke compartment when the smoke doors closed.

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2000 NFPA 101, 9.6.1.4 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.
2000 NFPA 101, 9.6.1.9 For the purposes of this Code, a complete fire alarm system shall be used for initiation, notification, and control and shall provide the following.
(a) Initiation. The initiation function provides the input signal to the system.
(b) Notification. The notification function is the means by which the system advises that human action is required in response to a particular condition.
(c) Control. The control function provides outputs to control building equipment to enhance protection of life.
.

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

During the survey, the following is an example of what was observed:
Third Floor
While testing the fire alarm system, the smoke detector in O.R. 7 read out at the fire alarm panel as "smoke detector in O.R. 1". This same smoke detector although activated failed to activate the fire alarm system or the smoke venting system.

___________________

2000 NFPA 101, 9.6.1.4 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.
2000 NFPA 101, 9.6.2.1 Where required by other sections of this Code, actuation of the complete fire alarm system shall occur by any or all of the following means of initiation, but shall not be limited to such means:
(1) Manual fire alarm initiation
(2) Automatic detection
(3) Extinguishing system operation
2000 NFPA 101, 9.6.1.9 For the purposes of this Code, a complete fire alarm system shall be used for initiation, notification, and control and shall provide the following.
(a) Initiation. The initiation function provides the input signal to the system.
(b) Notification. The notification function is the means by which the system advises that human action is required in response to a particular condition.
(c) Control. The control function provides outputs to control building equipment to enhance protection of life.
.

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

1. Escutcheon plate missing on a sprinkler in the soiled utility room third floor.

2. Sprinkler coverage not provided in the bathroom, located inside of the soiled utility room fourth floor.

_____________________
2000 NFPA 13, 3-2.7.2 Escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly.

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

1. Escutcheon plate missing on a sprinkler seventh floor dialysis.

2. A sprinkler had a build up of sheetrock mud on the link/deflector in 4-W-11 mechanical room.

3. Sprinkler coverage was not provided in E-4-W2 electrical room.

___________________
2000 NFPA 13, 3-2.7.2 Escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly.

1999 NFPA 25, 2-2.1.1 and 2-4.1.2 Sprinklers that are painted, corroded or damaged shall be replaced with new listed sprinklers of the same characteristics, including orifice size, thermal response, and water distribution.

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 adequately perform testing and inspection of the dietary hood
extinguishment system. Findings include:

During survey, the provided documentation for the monthly inspection of the hood system was the inspection card attached to the pull station of the hood extinguishing system. This card was observed with space on the reverse side to date and initial each month an inspection was conducted by facility staff. This side of the inspection card was blank.

_____________________
NFPA 17, 9-2.1- On a monthly basis, inspection shall be conducted in accordance with the manufacturer 's listed installation and maintenance manual or 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) The system shows no physical damage or condition that might prevent operation. (f) The pressure gauge(s), if provided, is in operable range.
(g) The nozzle blow-off caps, where provided, are intact and undamaged.
(h) Neither the protected equipment nor the hazard has been replaced, modified, or relocated.

.
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:

In Medical Records the means of egress was obstructed by file cabinets.
__________________
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.
.

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:

The Exit Discharge was not provided with an all weather surface to the public way for the Exits.
____________________
NFPA 101, 7.1.10.1 Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

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.


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

1. A 10' noncombustible overhang with combustible items stored under the overhang, was observed at the can wash area.

2. Escutcheon plate was missing on a sprinkler in front of the Elevators first floor.
_____________________
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.

2000 NFPA 13, 3-2.7.2 Escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly.


C) The facility failed to perform sensitivity testing of the smoke detectors. Findings include: During the survey, documentation was not provided for the sensitivity testing of the smoke detectors.

Detector sensitivity shall be checked with one year after installation and
every alternate year thereafter per 72, 7-3.2.1. (Up to 5 years permitted under certain circumstances. See 7-3.2.1).



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

Documentation was not provided for the annual partial trip test of the dry riser, or the three year full flow trip test.
_______________________
NFPA 25,1998 Edition, 9-5.2.3 A partial flow trip test adequate to move the valve from its seat shall be conducted annually.
NFPA 25, 1998 Edition, 9-4.4.2.2.2 Every 3 years and whenever the system is altered, the dry pipe valve shall be trip tested with the control valve fully open and the quick-opening device, if provided, in service.

E) Battery-powered lighting at the generator equipment and controls was not provided as observed during the survey.
_____________________
1999 NFPA 99, 3-6.1.1 and 3-4.1.1.4, and 1999 NFPA 110, 5-3.1. Emergency generator equipment locations.


27382


F) The facility failed to maintain the following systems per code. Findings include:
During the survey, the following are examples of what was observed:
The one hour atrium wall at New Patient Scheduling had the following unsealed penetrations:
a. White and blue wires
b. One flex conduit in two places
1. The automatic sprinkler gauges had not been calibrated or replaced in the last five years
2. The emergency generator remote annunciator did not indicate "generator under load" when the generator was tested

__________________
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.
1998 NFPA 25, 2-3.2 Gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge. Gauges not accurate to within 3 percent of the full scale shall be recalibrated or replaced.
1999 NFPA 99, 3-4.1.1.15 A remote annunciator, storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station (see NFPA 70, National Electrical Code, Section 700-12.)
The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows:
(a) Individual visual signals shall indicate the following:
1. When the emergency or auxiliary power source is operating to supply power to load
2. When the battery charger is malfunctioning
(b) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following:
1. Low lubricating oil pressure
2. Low water temperature (below those required in 3-4.1.1.9)
3. Excessive water temperature
4. Low fuel - when the main fuel storage tank contains less than a 3-hour operating supply
5. Overcrank (failed to start)
6. Overspeed
Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions in 3-4.1.1.15(a) and (b) occur, but need not display these conditions individually. [110: 3-5.5.2]

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The facility failed to provide proper emergency lighting at the generator set and controls. Findings include: During the survey, the following is an example of what was observed:

Emergency battery-powered light was not provided in the generator set and controls room.
______________________
1999 NFPA 99, 3-6.1.1 and 3-4.1.1.4, and 1999 NFPA 110, 5-3.1. Emergency generator equipment locations.
.

The facility failed to provide a remote annunciator for the emergency generator per code. Findings include:

During the survey, the following is an example of what was observed:
Per observation and interview the Women's & Children's Center emergency generator did not have a remote annunciator.

__________________
1999 NFPA 99, 3-4.1.1.15 A remote annunciator, storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station (see NFPA 70, National Electrical Code, Section 700-12.)
The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows:
(a) Individual visual signals shall indicate the following:
1. When the emergency or auxiliary power source is operating to supply power to load
2. When the battery charger is malfunctioning
(b) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following:
1. Low lubricating oil pressure
2. Low water temperature (below those required in 3-4.1.1.9)
3. Excessive water temperature
4. Low fuel - when the main fuel storage tank contains less than a 3-hour operating supply
5. Overcrank (failed to start)
6. Overspeed
Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions in 3-4.1.1.15(a) and (b) occur, but need not display these conditions individually. [110: 3-5.5.2]
.

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

During the survey, the following are examples of what was observed:
Per observation and interview the facility was not doing:
1. Weekly inspections
2. Monthly 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.
.

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

The electrical breaker box in room E7M1, observed with open blanks in the interior of the box.

_____________________
1999 NFPA 70, 373-4 Unused opening shall be effectively closed to afford protection substantially equivalent to that of the enclosures.
.

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

A junction box was missing the cover in the fire monitoring room.

______________________
1999 NFPA 70, 370-25 and 410-12. Each box in completed installations to have a cover, face plate, or fixture canopy.
.

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

During the survey, the following are examples of what was observed:
Ground Floor
Security Room:
2. Refrigerator and microwave were plugged into an overcurrent device
3. Two overcurrent devices were plugged, one into the other (piggy back)

_________________
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:
Per observation and interview the facility did not know the following:
1. The person doing the fire watch this is the only thing he/she can do
2. To notify the authority having jurisdiction, ADPH, of the fire watch

_________________

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:
Per observation and interview the facility did not know the following:
1. The person doing the fire watch this is the only thing he/she can do
2. To notify the authority having jurisdiction, ADPH, of the fire watch

_________________

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:
Per observation and interview the facility did not know the following:
1. The person doing the fire watch this is the only thing he/she can do
2. To notify the authority having jurisdiction, ADPH, of the fire watch

_________________
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:
Per observation and interview the facility did not know the following:
1. The person doing the fire watch this is the only thing he/she can do
2. To notify the authority having jurisdiction, ADPH, of the fire watch

_________________

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:
Per observation and interview the facility did not know the following:
1. The person doing the fire watch this is the only thing he/she can do
2. To notify the authority having jurisdiction, ADPH, of the fire watch

_________________

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:
Per observation and interview the facility did not know the following:
1. The person doing the fire watch this is the only thing he/she can do
2. To notify the authority having jurisdiction, ADPH, of the fire watch

_________________
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.
.