HospitalInspections.org

Based on observations and confirmed by staff, the facility failed to ensure that smoke barrier doors are maintained as required.

THE FINDINGS INCLUDE:

During the afternoon hours of 2/11/15 at approximately 3:00 P.M. it was observed that not all smoke barrier doors are maintained as required. The door to Occupational Therapy Room is not equipped with a self closing device. This door is part of the smoke barrier assembly and a self closing device is required on the door.

This was acknowledged by the Administrative staff during the exit interview process.

Based on observations and confirmed by staff, the facility failed to ensure that hazardous areas are separated as required.

THE FINDINGS INCLUDE:

The following items were observed during the course of the survey regarding hazardous areas:

1) The door to the Soiled Linen Room on the North Unit is not equipped with a self closing device.

2) The door to the Environmental Service's Office is not equipped with a self closing device. This room is used for the storage of paper goods and cleaning supplies.

3) There is an approximate 1" unsealed hole in the elevator machine room wall where it is penetrated by an electrical conduit.

These were acknowledged by the Administrative staff during the exit interview process.

Based on observations and confirmed by staff, the facility failed to ensure that the building is fully sprinklered as required. Section 19.1.6.2 requires buildings 1-story in height to be of at least Type I (443), Type I (332), Type II (222) or Type II (111). If the building is fully sprinklered it may be of Type II (000), Type III (211), Type III (200), Type IV (2HH), Type V (111) or Type V (000) construction.

NFPA 13 section 5-13.11 states that sprinkler protection shall be required in electrical equipment rooms. Hoods or shields installed to protect important electrical equipment from sprinkler discharge shall be noncombustible.
The exception states sprinklers shall not be required where all of the following conditions are met:
(a) The room is dedicated to electrical equipment only.
(b) Only dry-type electrical equipment is used.
(c) Equipment is installed in a 2-hour fire-rated enclosure including protection for penetrations.
(d) No combustible storage is permitted to be stored in the room.

THE FINDINGS INCLUDE:

The building was observed as being classified as 1-story Type III (200) construction requiring complete sprinkler protection. Although the building has two levels, more than 50% of the 1st floor level is below grade level and not considered a story per section 19.1.6.1.

During the course of the survey day on 2/11/15, the following areas but not limited too were observed as not being equipped with sprinkler protection:

1) The small closet adjacent to the exit door of the 1st floor large meeting room.

2) The stairwell which use to connect the kitchen to the 1st floor level has been removed and the floor opening has been sealed. As a result, the area below this enclosed opening is now used as a storage area. This area and the connecting corridor are lacking sprinkler protection.

3) The 1st floor level computer server room.
Note: This room requires sprinkler protection as it does not meet the 2-hour separation requirement in lieu of sprinklers.

4) The closet within the medical records room.

5) The closet within the Out-patient Clinical Coordinator's Office.

6) The closets within the basement level electrical shop.

7) The small corridor in the basement by the old pharmacy.

8) The Emergency Electrical Room identified on the building plan as #141 is not sprinklered. The door to the room is not equipped with a self closing device nor an identifying fire rating label. As a result, the room is not properly separated with the 2-hour fire rating to meet the sprinkler exception.

These were acknowledged by the Administrative staff during the exit interview process.

Based on observations and records provided, the facility failed to properly maintain the sprinkler system. NFPA #25 section 1-4.2 states the responsibility for properly maintaining a water-based fire protection system shall be that of the owner(s) of the property. By means of periodic inspections, tests, and maintenance, the equipment shall be shown to be in good operating condition, or any defects or impairments shall be revealed.
Inspection, testing, and maintenance shall be implemented in accordance with procedures meeting or exceeding those established in this document and in accordance with the manufacturer ' s instructions. These tasks shall be performed by personnel who have developed competence through training and experience.

Section 2.3.1.1 states where sprinklers have been in-service for 50 years, they shall be replaced or representative samples from one or more sample areas shall be submitted to a recognized testing laboratory acceptable to the authority having jurisdiction for field service testing. Test procedures shall be repeated at 10-year intervals.
Section 2-3.1.2 states a representative sample of sprinklers shall consist of a minimum of not less than 4 sprinklers or 1 percent of the number of sprinklers per individual sprinkler sample, whichever is greater.
Section 2-3.1.3 states where one sprinkler within a representative sample fails to meet the test requirement, all sprinklers represented by that sample shall be replaced. (See 2-4.1.1.)

NFPA 13 section 4-1.1 states pressure Gauges conforming to 5-15.3.2 shall be installed in each system riser. Pressure gauges shall be installed above and below each alarm check valve where such devices are present.

NFPA 25 section 2-3.2 states gauges on sprinkler systems 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.

NFPA 101 section 9.7.2.1 states where supervised automatic sprinkler systems are required by another section of this Code, supervisory attachments shall be installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm Code, and a distinctive supervisory signal shall be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system. Monitoring shall include, but shall not be limited to, monitoring of control valves, fire pump power supplies and running conditions, water tank levels and temperatures, tank pressure, and air pressure on dry-pipe valves. Supervisory signals shall sound and shall be displayed either at a location within the protected building that is constantly attended by qualified personnel or at an approved, remotely located receiving facility.

NFPA 25 section 2-3.4 states the freezing point of solutions in antifreeze shall be tested annually by measuring the specific gravity with a hydrometer or refractometer and adjusting the solutions if necessary. Solutions shall be in accordance with Tables 2-3.4(a) and (b).
The use of antifreeze solutions shall be in accordance with any state or local health regulations. Table 2-3.4(a) states the glycol system should be protected to a minimum of minus thirteen (-13) degrees Farenheit.

THE FINDINGS INCLUDE:

During the morning hours of 2/11/15 while reviewing the sprinkler system test/inspection reports, the following items were observed regarding the maintenance of the sprinkler system:

1) The first floor level of the facility was observed to be equipped with numerous sprinkler heads with a manufacture date of 1963. These heads were mainly observed in the storage/maintenance areas of this floor level where renovations have not been performed. The heads have been in use for 50+ years and are required to be tested or replaced.

2) The sprinkler system is not equipped with a water pressure gauge before the backflow preventer as required.

3) The water pressure gauges which are provided are dated 3/24/08. There is no documentation to substantiate that the gauges have been calibrated and/or replaced.

4) The control valve on the anti-freeze system is not equipped with a supervision attachment as required.

5) There is no documentation to substantiate that the anti-freeze loop has been tested as required. According to the last 5 sprinkler reports provided, the system is not listed as existing in the facility. The reports have no line items pertaining to the system and the testing of such. In addition, no inspection/test tag was observed attached to the valve of the system indicating the system was properly tested.

These were acknowledged by the Administrative staff during the exit interview process.

Based on observations and confirmed by staff, the facility failed to ensure compliance with NFPA #70 "National Electric Code".
Section 300-15 states where the wiring method is conduit, electrical metallic tubing, Type AC cable, Type MC cable, Type MI cable, nonmetallic-sheathed cable, or other cables, a box or conduit body complying with Article 370 shall be installed at each conductor splice point, outlet, switch point, junction point, or pull point, unless otherwise permitted in (b) through (n).

THE FINDINGS INCLUDE:

During the building tour of the South Unit at approximately 2:30 P.M., numerous romex wires were observed above the ceiling tiles. Some of the wires which were observed do not terminate in junction boxes as required, the wires were observed as having wire nut caps with electrical tape.
Note: This unit had renovations recently performed with construction, electrical, and plumbing work being performed. The new ceiling tiles are fastened to the track system so as they can't be removed. As a result, it could not be determined if there are additional wires throughout the unit/facility which are not installed as required.

This was acknowledged by the Administrative staff during the exit interview process.