HospitalInspections.org

Based on observations made on June 25, 2012, the facility failed to assure that a fire door in a two-hour barrier wall closed and latched properly.

The findings include:

The ambulance bay is separated from the remainder of the building by a two-hour barrier wall that remained intact after the 2009 remodel and addition. The set of 3 hour rated doors in this wall were exercised at 5:07 p.m. on June 25, 2012. The east door of the set did not close and positively latch when exercised.

Based on observations made on June 25, 2012, the facility failed to maintain the fire and smoke resistance rating of interior walls, ceiling and floor assemblies.

The findings include:

1. The Bio-hazard room adjacent to the medical gas manifold room was examined at 1:35 p.m. on June 25, 2012. A penetration for a sprinkler pipe between this room and the exit corridor on the other side of the wall was not sealed.

2. The janitor's room in the Emergency Room (ER) which includes the access ladder to the roof was examined at 3:26 p.m. on June 25, 2012. There were open penetrations around pipe in the ceiling assembly of this room that were not sealed.

3. The room housing the nurse call and communications equipment was examined at 3:35 p.m. on June 25, 2012. Open faced conduit were being used as a means of running the communication wiring and cables to other portions of the building. These open faced conduit were located in the ceiling assembly and also penetrated the floor level to the crawl space below. The open face conduit were not sealed to prevent the extension of fire or smoke to other parts of the building.

Based on observations made on June 25, 2012, the facility failed to provide for a smoke detection device in a room or area that opens onto the exit corridor system.

The findings include:

The sink room across from the Director of Nurse's office was lacking a corridor door and open to the corridor system as observed at 2:57 p.m. on June 25, 2012. The room was not subject to continuous direct supervision from a 24 hour staffed location necessitating that it have a smoke detection device in this open area to take advantage of the exceptions granted in section 19.6.3.1 of the Life Safety Code. No smoke detector was observed to be in the room.

Based on observations made on June 25, 2012, the facility failed to assure that corridor doors can be opened a full 90? to its required width and failed to prevent a corridor from being held open by means unacceptable to the Life Safety Code.

The findings include:

Any door in a means of egress shall be of the side-hinged or pivoted-swinging type. The door shall be designed and installed so that it is capable of swinging from any position to the full required width of the opening in which it is installed per section 7.2.1.4.1 of the Life Safety Code.

1. The south corridor door to the main level purchasing room/storeroom was exercised at 1:43 p.m. on June 25, 2012. Items stored against the wall in the swing of this door impeded it from opening a full 90? to its required width.

Hold-open devices that release when the door is pushed or pulled shall be permitted (this does not apply to doors in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, fire barrier or hazardous area enclosure) per section 19.3.6.3.3 of the Life Safety Code . Doors cannot be blocked open by furniture, door stops, chocks or devices that necessitate manual releasing action to close the door.

2. The west corridor door to the X-Ray room was observed at 4:30 p.m. on June 25, 2012, to have a weighed bag placed against it to hold it open. This particular means in not acceptable to the Life Safety Code as it requires manual releasing action.

Based on observations made on June 25, 2012, the facility failed to maintain the one-hour fire resistance rating of a vertical opening (elevator shaft) connecting two floors and failed to provide for at least a one hour fire rated door assembly at the top of a vertical opening (stairway).

The findings include:

1. The elevator mechanical room in the basement portion of the building was examined at 2:10 p.m. on June 25, 2012. There were two unsealed penetrations from this room into the elevator shaft. One was around a sprinkler pipe into the pit of the shaft and the other was around the hydraulic pipe to the shaft.

2. The door at the top of the stairway to the mechanical room in the basement area under the Emergency Room (ER) was examined at 3:39 p.m. on June 25, 2012. The door did not have a label or tag attesting to it being at least a one-hour fire door nor did it have a self-closing device as required of any door protecting a vertical opening of less than four floors in height.

Based on observations made on June 26, 2012, the facility failed to maintain at least a one-half hour fire resistance rating for smoke barriers. Furthermore the facility failed to assure that openings in

The findings include:

Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1/2 hour per section 19.3.7.3 of the Life Safety Code (LSC). Smoke barriers required by the LSC 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 per section 8.3.2 of the LSC with the exception that a smoke barrier required for an occupied space below an interstitial space shall not be required to extend through the interstitial space, provided that the construction assembly forming the bottom of the interstitial space provides resistance to the passage of smoke equal to that provided by the smoke barrier.

1. The smoke barrier above the suspended ceiling in the corridor by the time clock was examined at 7:06 a.m. on June 26, 2012. Penetrations around a sprinkler riser and conduit were not sealed.

2. The smoke barrier above the suspended ceiling in the break room was examined at 7:12 a.m. on June 26, 2012. Penetrations around flexible conduit were not sealed nor were holes drilled through the barrier.

3. The smoke barrier above the suspended ceiling by the waiting room/CSR was examined at 7:30 a.m. on June 25, 2012. Insulation type material of a mineral wool design was being used as a barrier sealant at the fluted deck. This type of insulation material is not an acceptable sealant in smoke barriers as it does not meet a fire resistance rating of at least one-half hour.

4. The smoke barrier above the suspended ceiling across from the nurse's station was examined at 7:36 a.m. on June 26, 2012. Penetrations around wiring and pipes were not sealed. Insulation type material of a mineral wool design was being used as a barrier sealant at the fluted deck. This type of insulation material is not an acceptable sealant in smoke barriers as it does not meet a fire resistance rating of at least one-half hour.

5. The smoke barrier above the suspended ceiling by the smoke barrier doors in the corridor by the ICU room 100 was examined at 7:38 a.m. on June 26, 2012. Holes in the smoke barrier were not sealed.

6. The smoke barrier along the corridor by the ICU room 100 was examined at 7:40 a.m. on June 26, 2012. Penetrations around PVC sprinkler pipe and conduit were not sealed.

Doors (openings) in smoke barriers shall comply with 8.3.4 and shall be self-closing or automatic-closing in accordance with 19.2.2.2.6 of the LSC. In any building of low or ordinary hazard contents 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.

7. The Clinic reception office/area is part of a smoke barrier wall. The reception office was observed to have three window opening in the smoke barrier wall as observed at 8:26 a.m. on June 26, 2012. These openings in the smoke barrier were protected by rolling metal doors to prevent the passage of smoke. When the fire alarm system was activated at 8:26 a.m. on June 26, 2012, the three rolling doors did not close upon the alarm to be meet the requirement for automatic closing doors.

Based on observations made on June 25, 2012, the facility failed to maintain the fire and smoke resistance rating of interior walls in hazardous rooms and failed to assure that a doorway in a new wall assembly protecting a hazardous room was a fire rated assembly.

The findings include:

1. The boiler room was examined at 1:52 p.m. on June 25, 2012. Two abandoned open faced pipes in a wall of this room were not sealed nor were the penetrations around the pipes sealed.

2. The door between the medical records room (a hazardous area due to large amounts of combustibles) and the business office was examined at 2:49 p.m. on June 25, 2012. The door did have a self-closure mechanism on it but did not have a label attesting to it being at least a 3/4 hour rated door or greater.

Based on observations made on June 25, 2012, the facility failed to provide for two exits from the basement of the Critical Access Hospital.

The finding include:

The basement portion of the facility that houses storage rooms, a repair shop and the elevator mechanical room was examined at 2:06 p.m. on June 26, 2012. There was only one interior stairway from the basement that served as an exit whereas two means of egress are required.

Based on observations made on June 25, 2012, the facility failed to assure that a fire door protecting an exit stairway was equipped with a self-closing device to maintain the fire resistance rating of the door assembly.

The findings include:

7.1.3.2.1
Where the Life Safety Code (LSC) requires an exit, such as a stairway, to be separated from other parts of the building, the separating construction shall meet the requirements of Section 8.2 and the separation shall have not less than a 1-hour fire resistance rating where the exit connects three stories or less per section 7.1.3.2.1 of the LSC. Openings in the separation shall be protected by fire door assemblies equipped with door closers.

The one and one-half hour fire door at the west basement exit stairway of the Clinic was examined at 5:10 p.m. on June 25, 2012. The fire door did not have a self-closer device on it.

Based on review of the generator and other maintenance logs or reports on June 25, 2012, the facility failed to document the annual 90 minute test of the battery-powered emergency lights in Anesthetizing locations and other locations in the building. Furthermore, based on observations made on June 25, 2012, the facility failed to provide a battery-powered emergency light in a room where Anesthesia was being used.

The findings include:

One or more battery-powered emergency lighting units shall be provided in any Anesthetizing location per section 3-3.2.1.2(a)5e of NFPA 99, 1999 Edition and Article 517-63 of NFPA 70, 1999 Edition) . In addition the Level 1 or Level 2 EPS equipment (generator) location shall be provided with battery-powered emergency lighting per section 3-4.2.2.2(b)5 of NFPA 99 and section 5-3.1 of NFPA 110, 1999 Edition. In accordance with 7.9.3 of the Life Safety Code a functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than one and one-half hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

1. The generator and other maintenance logs and reports were reviewed at the facility on June 25, 2012. The logs were current on the monthly tests for the battery-powered emergency lights in use in the building including those installed in the Anesthetizing locations. No documentation was available that the annual one and one-half hour tests had been performed on these battery-powered emergency lights.

2. The entry door to the Scope room had a sign posted that noted "Anesthesia in Use". Upon examination of this room at 4:11 p.m. on June 25, 2012, it was observed that there was no battery-powered emergency light in this room where Anesthesia was in use.

Based on review of the fire alarm system inspection and testing reports on June 25, 2012, the facility failed to assure that a sensitivity test was conducted on the smoke detection devices every alternate year following the second year after the installation of a new system.

The findings include:

Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter per section 7-3.2.1 of NFPA 72, 1999 edition. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. It is being required by Centers for Medicare and Medicaid Services, as the authority having jurisdiction, that those systems that automatically monitor sensitivity shall have a paper printout available verifying the calibration of each detector.

The fire alarm system inspection and testing reports were reviewed at the facility on June 25, 2012. A new fire alarm system was installed and certified on February 15, 2006. The last sensitivity test that could be confirmed was in 2008. No documentation was available that any sensitivity testing of the smoke detection devices had been performed in 2010 (two years after the 2008 test), 2011 or thus far in 2012.

Based on observations made on June 25, 2012, the facility failed to provide for complete coverage of the building by an automatic sprinkler system.

The findings include:

Upright or pendent spray sprinklers shall be installed at the top of elevator hoistways per section 5-13.6.3 of NFPA 13, 1999 Edition. Exception: Sprinklers are not required at the tops of noncombustible hoistways of passenger elevators with car enclosure materials that meet the requirements of ASME A17.1, Safety Code for Elevators and Escalators.

1. The service elevator shaft was examined at 2:20 p.m. on June 25, 2012 and it was determined that it lacked a sprinkler at the top of the shaft/hoistway. The shaft is of non-combustible design, however the service elevator has an accordion open faced metal door on it. The openings on both the upper and lower floors are protected by one and one-half hour doors. Since this is a service elevator and not a passenger car elevator there is no exception for the lack of a sprinkler at the top of the shaft.

2. The mechanical room in the basement under a portion of the Emergency Room (ER) was examined at 3:39 p.m. on June 25, 2012. According to the drawings on file with the State Agency, this particular building type in the ER is Type II (000) which requires a complete sprinkler system be installed throughout the building. It was determined through observation that the mechanical room did not have sprinkler protection.

Based on observations made on June 25, 2012, the facility failed to maintain the sprinkler system and/or its components in accordance with the standards of NFPA 13, 1999 Edition or NFPA 25, 1998 Edition.

The findings include:

In accordance with 2-2.1.1 of NFPA 25 (1998 edition) 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).

1. The original orange plastic installation protective cap was in place over the bulb of the sprinkler located in the restroom across from the elevator on the main level of the building as observed at 1:41 p.m. on June 25, 2012.

2. The original orange plastic installation protective cap was in place over the bulb of the sprinkler located in the women's restroom by the business office as observed at 2:31 p.m. on June 25, 2012.

3. One of the sprinklers in the housekeeping storeroom in the basement was exhibiting signs of corrosion as observed at 2:20 p.m. on June 25, 2012.

Continuous or noncontinuous obstructions that interrupt the water discharge in a horizontal plane below the sprinkler deflector or the top of storage shall be maintained with a minimum of 18" clearance per sections 5-5.5.3 and 5-5.6 of NFPA 13.

4. The housekeeping storeroom on the basement level was examined at 2:16 p.m. on June 25, 2012. The room contained storage shelves that were located mid-aisle in the room. Items stored on these shelves were such that the minimum 18 inch clearance from the sprinkler(s) was not being maintained.

5. The medical records storeroom in the Clinic was examined at 5:02 p.m. on June 25, 2012. The room contained storage shelves that were located mid-aisle in the room. Items stored on these shelves were such that the minimum 18 inch clearance from the sprinkler(s) was not being maintained.

6. The laboratory/X-ray storage room in the Clinic was examined at 5:04 p.m. on June 25, 2012. The room contained storage shelves that were located mid-aisle in the room. Items stored on these shelves were such that the minimum 18 inch clearance from the sprinkler(s) was not being maintained.

Based on observations made on June 25 and 26, 2012, the facility failed to maintain the means of egress, including exit corridors, free from obstructions that would interfere with their instant use in case of fire or other emergency and also failed to prevent the means of egress from being used for storage purposes.

The findings include:

In accordance with Centers for Medicare and Medicaid Services Survey and Certification letters S&C-04-41 and S&C-10-18 items not in use in exit corridors (i.e. left unattended for more than 30 minutes), such as linen carts, medication carts, janitorial equipment, chairs, wheelchairs, delivery items and other similar items must be stored properly or removed from the corridor.

1. Delivered items were located in the exit corridor by the purchasing room/elevator as initially observed at 1:57 p.m. on June 25, 2012. These were observed to be in the corridor until the conclusion of the survey for the day on June 25, 2012. Items were observed at 8:20 a.m. on June 26, 2012 to still be in the exit corridor. The items were in the corridor for periods exceeding the 30 minute limit imposed by CMS.

2. Three chairs and two tables were located in the exit corridor by the CEO office as initially observed at 2:35 p.m. on June 25, 2012. These were observed to be in the corridor until the conclusion of the survey for the day on June 25, 2012. The chairs and tables were observed at 6:53 a.m. on June 26, 2012 to still be in the exit corridor. These were in the corridor for periods exceeding the 30 minute limit imposed by CMS.

3. Five chairs were located in the exit corridor by the Clinic office reception desk as initially observed at 2:57 p.m. on June 25, 2012. These were observed to be in the corridor until the conclusion of the survey for the day on June 25, 2012. The chairs were observed at 7:56 a.m. on June 26, 2012 to still be in the exit corridor. These were in the corridor for periods exceeding the 30 minute limit imposed by CMS.

Based on observations made on June 25, 2012, the facility failed to provide for acceptable outside storage areas for liquid oxygen containers. Furthermore, electrical switches located within an oxygen storage area shall be at least 5 feet from the floor surface.

The findings include:

Storage locations for oxygen containers or cylinders that are outdoors shall be within an enclosure with doors or gates that can be secured against unauthorized entry per section 8-3.1.11.2(a) of NFPA 99, 1999 Edition. In no case shall the temperature of the cylinders exceed 130?F per section 8-3.1.11.2(e) of NFPA 99 (generally cylinders stored in the open shall be screened against continuous exposure to direct rays of the sun where extreme temperatures may be experienced). Storage facilities that are outside, but adjacent to a building wall, shall be located such that the distance to any window of the adjacent building is greater than 25 feet per section 4-5.1.1.2(10a) of NFPA 99. No smoking signs conforming to section 8-3.1.11.3 of NFPA 99 shall be posted at all locations where oxygen is stored.

1. Liquid oxygen containers were observed to be stored outside of the building by the medical gas manifold room at 1:10 p.m. on June 25, 2012. These containers/cylinders were exposed to direct sunlight and not secured in an enclosure as required and constructed per NFPA 99. Note: The facility at the time of the survey was in the process of constructing an enclosure to house the liquid oxygen containers.

In any storage location housing nonflammable gases (any quantity; in-storage, connected, or both) the electric wall fixtures, switches, and receptacles in that enclosure shall be installed in fixed locations not less than 5 feet above the floor as a precaution against their physical damage per section 4-3.1.1.2(a)4 of NFPA 99.

2. The medical gas manifold room was examined at 1:24 p.m. on June 25, 2012. The light switch in this room, although of an explosive proof type, was located only 4 feet above the floor level of the room instead of the required 5 feet.

Based on review of the generator test records on June 25, 2012, the facility failed to assure that the generator was inspected weekly on a consistent basis.

The findings include:

The generator test records were reviewed at the facility on June 25, 2012. The weekly test logs were current up to April of 2012. No documentation that the weekly tests had been performed during the month of May and thus far in June of 2012 were available.

Based on observations made on June 25, 2012, the facility failed to maintain the electrical system and/or its components in accordance with the standards of the National Electrical Code, NFPA 70, 1999 Edition or interpretations from the Centers for Medicare and Medicaid Services (CMS).

The findings include:

The limited use of circuit breaker protected power strips or multiple adaptors are acceptable by CMS provided that no major appliances such as air conditioners, refrigerators, microwaves, heating units and oxygen concentrators are connected to the power strip or multiple adaptor.

1. A microwave oven was plugged into a power strip as observed in the kitchen room as observed at 1:56 p.m. on June 25, 2012.

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

2. The electrical shut-off control switch located in the soiled linen room of the Emergency Room (ER) area was examined at 3:20 p.m. on June 25, 2012. It could not be determined what this particular shut-off switch controlled as it was not marked as to service.

3. The electrical panel board by room 104 did not have a complete listing for what each breaker services as observed at 3:49 p.m. on June 25, 2012.

Flexible cords and cables shall be connected to devices and to fittings so that tension will not be
transmitted to joints or terminals per Article 400-10 of NFPA 70.

3. A power strip was hanging loosely exerting tension on its flexible cord at the doctor's desk at the nurse's station as observed at 3:47 p.m. on June 25, 2012.

Unused openings in boxes, raceways, auxiliary gutters, cabinets (panel boards), equipment cases or housings shall be effectively closed to afford protection substantially equivalent to the wall of the equipment per Article 110-12(a) of NFPA 70.

5. The electrical panel board by room 111 (denoted as panel board 64) was missing two protective covers to prevent accidental contact with the bus bar as observed at 3:50 p.m. on June 25, 2012.

6. The electrical panel board in the anteroom of the Operating Room suite was missing two large protective covers to prevent accidental contact with the bus bar as observed at 4:15 p.m. on June 25, 2012.

Based on observations made on June 25, 2012, the facility failed to assure that a fire door in a two-hour barrier wall closed and latched properly.

The findings include:

The ambulance bay is separated from the remainder of the building by a two-hour barrier wall that remained intact after the 2009 remodel and addition. The set of 3 hour rated doors in this wall were exercised at 5:07 p.m. on June 25, 2012. The east door of the set did not close and positively latch when exercised.

Based on observations made on June 25, 2012, the facility failed to maintain the fire and smoke resistance rating of interior walls, ceiling and floor assemblies.

The findings include:

1. The Bio-hazard room adjacent to the medical gas manifold room was examined at 1:35 p.m. on June 25, 2012. A penetration for a sprinkler pipe between this room and the exit corridor on the other side of the wall was not sealed.

2. The janitor's room in the Emergency Room (ER) which includes the access ladder to the roof was examined at 3:26 p.m. on June 25, 2012. There were open penetrations around pipe in the ceiling assembly of this room that were not sealed.

3. The room housing the nurse call and communications equipment was examined at 3:35 p.m. on June 25, 2012. Open faced conduit were being used as a means of running the communication wiring and cables to other portions of the building. These open faced conduit were located in the ceiling assembly and also penetrated the floor level to the crawl space below. The open face conduit were not sealed to prevent the extension of fire or smoke to other parts of the building.

Based on observations made on June 25, 2012, the facility failed to provide for a smoke detection device in a room or area that opens onto the exit corridor system.

The findings include:

The sink room across from the Director of Nurse's office was lacking a corridor door and open to the corridor system as observed at 2:57 p.m. on June 25, 2012. The room was not subject to continuous direct supervision from a 24 hour staffed location necessitating that it have a smoke detection device in this open area to take advantage of the exceptions granted in section 19.6.3.1 of the Life Safety Code. No smoke detector was observed to be in the room.

Based on observations made on June 25, 2012, the facility failed to assure that corridor doors can be opened a full 90? to its required width and failed to prevent a corridor from being held open by means unacceptable to the Life Safety Code.

The findings include:

Any door in a means of egress shall be of the side-hinged or pivoted-swinging type. The door shall be designed and installed so that it is capable of swinging from any position to the full required width of the opening in which it is installed per section 7.2.1.4.1 of the Life Safety Code.

1. The south corridor door to the main level purchasing room/storeroom was exercised at 1:43 p.m. on June 25, 2012. Items stored against the wall in the swing of this door impeded it from opening a full 90? to its required width.

Hold-open devices that release when the door is pushed or pulled shall be permitted (this does not apply to doors in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, fire barrier or hazardous area enclosure) per section 19.3.6.3.3 of the Life Safety Code . Doors cannot be blocked open by furniture, door stops, chocks or devices that necessitate manual releasing action to close the door.

2. The west corridor door to the X-Ray room was observed at 4:30 p.m. on June 25, 2012, to have a weighed bag placed against it to hold it open. This particular means in not acceptable to the Life Safety Code as it requires manual releasing action.

Based on observations made on June 25, 2012, the facility failed to maintain the one-hour fire resistance rating of a vertical opening (elevator shaft) connecting two floors and failed to provide for at least a one hour fire rated door assembly at the top of a vertical opening (stairway).

The findings include:

1. The elevator mechanical room in the basement portion of the building was examined at 2:10 p.m. on June 25, 2012. There were two unsealed penetrations from this room into the elevator shaft. One was around a sprinkler pipe into the pit of the shaft and the other was around the hydraulic pipe to the shaft.

2. The door at the top of the stairway to the mechanical room in the basement area under the Emergency Room (ER) was examined at 3:39 p.m. on June 25, 2012. The door did not have a label or tag attesting to it being at least a one-hour fire door nor did it have a self-closing device as required of any door protecting a vertical opening of less than four floors in height.

Based on observations made on June 26, 2012, the facility failed to maintain at least a one-half hour fire resistance rating for smoke barriers. Furthermore the facility failed to assure that openings in

The findings include:

Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1/2 hour per section 19.3.7.3 of the Life Safety Code (LSC). Smoke barriers required by the LSC 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 per section 8.3.2 of the LSC with the exception that a smoke barrier required for an occupied space below an interstitial space shall not be required to extend through the interstitial space, provided that the construction assembly forming the bottom of the interstitial space provides resistance to the passage of smoke equal to that provided by the smoke barrier.

1. The smoke barrier above the suspended ceiling in the corridor by the time clock was examined at 7:06 a.m. on June 26, 2012. Penetrations around a sprinkler riser and conduit were not sealed.

2. The smoke barrier above the suspended ceiling in the break room was examined at 7:12 a.m. on June 26, 2012. Penetrations around flexible conduit were not sealed nor were holes drilled through the barrier.

3. The smoke barrier above the suspended ceiling by the waiting room/CSR was examined at 7:30 a.m. on June 25, 2012. Insulation type material of a mineral wool design was being used as a barrier sealant at the fluted deck. This type of insulation material is not an acceptable sealant in smoke barriers as it does not meet a fire resistance rating of at least one-half hour.

4. The smoke barrier above the suspended ceiling across from the nurse's station was examined at 7:36 a.m. on June 26, 2012. Penetrations around wiring and pipes were not sealed. Insulation type material of a mineral wool design was being used as a barrier sealant at the fluted deck. This type of insulation material is not an acceptable sealant in smoke barriers as it does not meet a fire resistance rating of at least one-half hour.

5. The smoke barrier above the suspended ceiling by the smoke barrier doors in the corridor by the ICU room 100 was examined at 7:38 a.m. on June 26, 2012. Holes in the smoke barrier were not sealed.

6. The smoke barrier along the corridor by the ICU room 100 was examined at 7:40 a.m. on June 26, 2012. Penetrations around PVC sprinkler pipe and conduit were not sealed.

Doors (openings) in smoke barriers shall comply with 8.3.4 and shall be self-closing or automatic-closing in accordance with 19.2.2.2.6 of the LSC. In any building of low or ordinary hazard contents 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.

7. The Clinic reception office/area is part of a smoke barrier wall. The reception office was observed to have three window opening in the smoke barrier wall as observed at 8:26 a.m. on June 26, 2012. These openings in the smoke barrier were protected by rolling metal doors to prevent the passage of smoke. When the fire alarm system was activated at 8:26 a.m. on June 26, 2012, the three rolling doors did not close upon the alarm to be meet the requirement for automatic closing doors.

Based on observations made on June 25, 2012, the facility failed to maintain the fire and smoke resistance rating of interior walls in hazardous rooms and failed to assure that a doorway in a new wall assembly protecting a hazardous room was a fire rated assembly.

The findings include:

1. The boiler room was examined at 1:52 p.m. on June 25, 2012. Two abandoned open faced pipes in a wall of this room were not sealed nor were the penetrations around the pipes sealed.

2. The door between the medical records room (a hazardous area due to large amounts of combustibles) and the business office was examined at 2:49 p.m. on June 25, 2012. The door did have a self-closure mechanism on it but did not have a label attesting to it being at least a 3/4 hour rated door or greater.

Based on observations made on June 25, 2012, the facility failed to provide for two exits from the basement of the Critical Access Hospital.

The finding include:

The basement portion of the facility that houses storage rooms, a repair shop and the elevator mechanical room was examined at 2:06 p.m. on June 26, 2012. There was only one interior stairway from the basement that served as an exit whereas two means of egress are required.

Based on observations made on June 25, 2012, the facility failed to assure that a fire door protecting an exit stairway was equipped with a self-closing device to maintain the fire resistance rating of the door assembly.

The findings include:

7.1.3.2.1
Where the Life Safety Code (LSC) requires an exit, such as a stairway, to be separated from other parts of the building, the separating construction shall meet the requirements of Section 8.2 and the separation shall have not less than a 1-hour fire resistance rating where the exit connects three stories or less per section 7.1.3.2.1 of the LSC. Openings in the separation shall be protected by fire door assemblies equipped with door closers.

The one and one-half hour fire door at the west basement exit stairway of the Clinic was examined at 5:10 p.m. on June 25, 2012. The fire door did not have a self-closer device on it.

Based on review of the generator and other maintenance logs or reports on June 25, 2012, the facility failed to document the annual 90 minute test of the battery-powered emergency lights in Anesthetizing locations and other locations in the building. Furthermore, based on observations made on June 25, 2012, the facility failed to provide a battery-powered emergency light in a room where Anesthesia was being used.

The findings include:

One or more battery-powered emergency lighting units shall be provided in any Anesthetizing location per section 3-3.2.1.2(a)5e of NFPA 99, 1999 Edition and Article 517-63 of NFPA 70, 1999 Edition) . In addition the Level 1 or Level 2 EPS equipment (generator) location shall be provided with battery-powered emergency lighting per section 3-4.2.2.2(b)5 of NFPA 99 and section 5-3.1 of NFPA 110, 1999 Edition. In accordance with 7.9.3 of the Life Safety Code a functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than one and one-half hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

1. The generator and other maintenance logs and reports were reviewed at the facility on June 25, 2012. The logs were current on the monthly tests for the battery-powered emergency lights in use in the building including those installed in the Anesthetizing locations. No documentation was available that the annual one and one-half hour tests had been performed on these battery-powered emergency lights.

2. The entry door to the Scope room had a sign posted that noted "Anesthesia in Use". Upon examination of this room at 4:11 p.m. on June 25, 2012, it was observed that there was no battery-powered emergency light in this room where Anesthesia was in use.

Based on review of the fire alarm system inspection and testing reports on June 25, 2012, the facility failed to assure that a sensitivity test was conducted on the smoke detection devices every alternate year following the second year after the installation of a new system.

The findings include:

Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter per section 7-3.2.1 of NFPA 72, 1999 edition. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. It is being required by Centers for Medicare and Medicaid Services, as the authority having jurisdiction, that those systems that automatically monitor sensitivity shall have a paper printout available verifying the calibration of each detector.

The fire alarm system inspection and testing reports were reviewed at the facility on June 25, 2012. A new fire alarm system was installed and certified on February 15, 2006. The last sensitivity test that could be confirmed was in 2008. No documentation was available that any sensitivity testing of the smoke detection devices had been performed in 2010 (two years after the 2008 test), 2011 or thus far in 2012.

Based on observations made on June 25, 2012, the facility failed to provide for complete coverage of the building by an automatic sprinkler system.

The findings include:

Upright or pendent spray sprinklers shall be installed at the top of elevator hoistways per section 5-13.6.3 of NFPA 13, 1999 Edition. Exception: Sprinklers are not required at the tops of noncombustible hoistways of passenger elevators with car enclosure materials that meet the requirements of ASME A17.1, Safety Code for Elevators and Escalators.

1. The service elevator shaft was examined at 2:20 p.m. on June 25, 2012 and it was determined that it lacked a sprinkler at the top of the shaft/hoistway. The shaft is of non-combustible design, however the service elevator has an accordion open faced metal door on it. The openings on both the upper and lower floors are protected by one and one-half hour doors. Since this is a service elevator and not a passenger car elevator there is no exception for the lack of a sprinkler at the top of the shaft.

2. The mechanical room in the basement under a portion of the Emergency Room (ER) was examined at 3:39 p.m. on June 25, 2012. According to the drawings on file with the State Agency, this particular building type in the ER is Type II (000) which requires a complete sprinkler system be installed throughout the building. It was determined through observation that the mechanical room did not have sprinkler protection.

Based on observations made on June 25, 2012, the facility failed to maintain the sprinkler system and/or its components in accordance with the standards of NFPA 13, 1999 Edition or NFPA 25, 1998 Edition.

The findings include:

In accordance with 2-2.1.1 of NFPA 25 (1998 edition) 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).

1. The original orange plastic installation protective cap was in place over the bulb of the sprinkler located in the restroom across from the elevator on the main level of the building as observed at 1:41 p.m. on June 25, 2012.

2. The original orange plastic installation protective cap was in place over the bulb of the sprinkler located in the women's restroom by the business office as observed at 2:31 p.m. on June 25, 2012.

3. One of the sprinklers in the housekeeping storeroom in the basement was exhibiting signs of corrosion as observed at 2:20 p.m. on June 25, 2012.

Continuous or noncontinuous obstructions that interrupt the water discharge in a horizontal plane below the sprinkler deflector or the top of storage shall be maintained with a minimum of 18" clearance per sections 5-5.5.3 and 5-5.6 of NFPA 13.

4. The housekeeping storeroom on the basement level was examined at 2:16 p.m. on June 25, 2012. The room contained storage shelves that were located mid-aisle in the room. Items stored on these shelves were such that the minimum 18 inch clearance from the sprinkler(s) was not being maintained.

5. The medical records storeroom in the Clinic was examined at 5:02 p.m. on June 25, 2012. The room contained storage shelves that were located mid-aisle in the room. Items stored on these shelves were such that the minimum 18 inch clearance from the sprinkler(s) was not being maintained.

6. The laboratory/X-ray storage room in the Clinic was examined at 5:04 p.m. on June 25, 2012. The room contained storage shelves that were located mid-aisle in the room. Items stored on these shelves were such that the minimum 18 inch clearance from the sprinkler(s) was not being maintained.

Based on observations made on June 25 and 26, 2012, the facility failed to maintain the means of egress, including exit corridors, free from obstructions that would interfere with their instant use in case of fire or other emergency and also failed to prevent the means of egress from being used for storage purposes.

The findings include:

In accordance with Centers for Medicare and Medicaid Services Survey and Certification letters S&C-04-41 and S&C-10-18 items not in use in exit corridors (i.e. left unattended for more than 30 minutes), such as linen carts, medication carts, janitorial equipment, chairs, wheelchairs, delivery items and other similar items must be stored properly or removed from the corridor.

1. Delivered items were located in the exit corridor by the purchasing room/elevator as initially observed at 1:57 p.m. on June 25, 2012. These were observed to be in the corridor until the conclusion of the survey for the day on June 25, 2012. Items were observed at 8:20 a.m. on June 26, 2012 to still be in the exit corridor. The items were in the corridor for periods exceeding the 30 minute limit imposed by CMS.

2. Three chairs and two tables were located in the exit corridor by the CEO office as initially observed at 2:35 p.m. on June 25, 2012. These were observed to be in the corridor until the conclusion of the survey for the day on June 25, 2012. The chairs and tables were observed at 6:53 a.m. on June 26, 2012 to still be in the exit corridor. These were in the corridor for periods exceeding the 30 minute limit imposed by CMS.

3. Five chairs were located in the exit corridor by the Clinic office reception desk as initially observed at 2:57 p.m. on June 25, 2012. These were observed to be in the corridor until the conclusion of the survey for the day on June 25, 2012. The chairs were observed at 7:56 a.m. on June 26, 2012 to still be in the exit corridor. These were in the corridor for periods exceeding the 30 minute limit imposed by CMS.

Based on observations made on June 25, 2012, the facility failed to provide for acceptable outside storage areas for liquid oxygen containers. Furthermore, electrical switches located within an oxygen storage area shall be at least 5 feet from the floor surface.

The findings include:

Storage locations for oxygen containers or cylinders that are outdoors shall be within an enclosure with doors or gates that can be secured against unauthorized entry per section 8-3.1.11.2(a) of NFPA 99, 1999 Edition. In no case shall the temperature of the cylinders exceed 130?F per section 8-3.1.11.2(e) of NFPA 99 (generally cylinders stored in the open shall be screened against continuous exposure to direct rays of the sun where extreme temperatures may be experienced). Storage facilities that are outside, but adjacent to a building wall, shall be located such that the distance to any window of the adjacent building is greater than 25 feet per section 4-5.1.1.2(10a) of NFPA 99. No smoking signs conforming to section 8-3.1.11.3 of NFPA 99 shall be posted at all locations where oxygen is stored.

1. Liquid oxygen containers were observed to be stored outside of the building by the medical gas manifold room at 1:10 p.m. on June 25, 2012. These containers/cylinders were exposed to direct sunlight and not secured in an enclosure as required and constructed per NFPA 99. Note: The facility at the time of the survey was in the process of constructing an enclosure to house the liquid oxygen containers.

In any storage location housing nonflammable gases (any quantity; in-storage, connected, or both) the electric wall fixtures, switches, and receptacles in that enclosure shall be installed in fixed locations not less than 5 feet above the floor as a precaution against their physical damage per section 4-3.1.1.2(a)4 of NFPA 99.

2. The medical gas manifold room was examined at 1:24 p.m. on June 25, 2012. The light switch in this room, although of an explosive proof type, was located only 4 feet above the floor level of the room instead of the required 5 feet.

Based on review of the generator test records on June 25, 2012, the facility failed to assure that the generator was inspected weekly on a consistent basis.

The findings include:

The generator test records were reviewed at the facility on June 25, 2012. The weekly test logs were current up to April of 2012. No documentation that the weekly tests had been performed during the month of May and thus far in June of 2012 were available.

Based on observations made on June 25, 2012, the facility failed to maintain the electrical system and/or its components in accordance with the standards of the National Electrical Code, NFPA 70, 1999 Edition or interpretations from the Centers for Medicare and Medicaid Services (CMS).

The findings include:

The limited use of circuit breaker protected power strips or multiple adaptors are acceptable by CMS provided that no major appliances such as air conditioners, refrigerators, microwaves, heating units and oxygen concentrators are connected to the power strip or multiple adaptor.

1. A microwave oven was plugged into a power strip as observed in the kitchen room as observed at 1:56 p.m. on June 25, 2012.

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

2. The electrical shut-off control switch located in the soiled linen room of the Emergency Room (ER) area was examined at 3:20 p.m. on June 25, 2012. It could not be determined what this particular shut-off switch controlled as it was not marked as to service.

3. The electrical panel board by room 104 did not have a complete listing for what each breaker services as observed at 3:49 p.m. on June 25, 2012.

Flexible cords and cables shall be connected to devices and to fittings so that tension will not be
transmitted to joints or terminals per Article 400-10 of NFPA 70.

3. A power strip was hanging loosely exerting tension on its flexible cord at the doctor's desk at the nurse's station as observed at 3:47 p.m. on June 25, 2012.

Unused openings in boxes, raceways, auxiliary gutters, cabinets (panel boards), equipment cases or housings shall be effectively closed to afford protection substantially equivalent to the wall of the equipment per Article 110-12(a) of NFPA 70.

5. The electrical panel board by room 111 (denoted as panel board 64) was missing two protective covers to prevent accidental contact with the bus bar as observed at 3:50 p.m. on June 25, 2012.

6. The electrical panel board in the anteroom of the Operating Room suite was missing two large protective covers to prevent accidental contact with the bus bar as observed at 4:15 p.m. on June 25, 2012.