HospitalInspections.org

19.3.2.1, NFPA 101, LIFE SAFETY CODE
Hazardous Areas: Any hazardous areas shall be safe-guarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. Hazardous areas shall include, but shall not be restricted to, the following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 ft2 (9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Soiled linen rooms
(6) Trash collection rooms
(7) Rooms or spaces larger than 50 ft2 (4.6 m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction
(8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard.

8.4.1.3, NFPA 101, LIFE SAFETY CODE
Doors in barriers required to have a fire resistance rating shall have a 3/4-hour fire protection rating and shall be self-closing or automatic-closing in accordance with 7.2.1.8.

7.2.1.8.1, NFPA 101, LIFE SAFETY CODE
A door normally required to be kept closed shall not be secured in the open position at any time and shall be self-closing or automatic-closing in accordance with 7.2.1.8.2.

Based on observation and interview the facility failed to ensure that hazardous areas have doors with self closing devices installed and properly maintained.

Findings include:

Observation during tour on 1/5/12 between 1:45 p.m. and 3:00 p.m. with Staff C (Maintenance Manager), Staff D (Plant Operations), Staff E (Maintenance Worker), and Staff F (Director of Compliance) revealed the following:

1. Level 2 Pre-op Soiled Utility Room with an entry door that is equipped with a self-closing device where the door leaf is obstructed from closing by a wheelchair placed in the door opening.

2. Level 2 Storage Room with an entry door that is equipped with a self-closing device where the door leaf is obstructed from closing by a wedge placed at the bottom of the door which prevents the door leaf from swinging to a closed position.

3. Level 3 South Soiled Utility Room with an entry door that is equipped with a self-closing device where the self-closing device has been disconnected rendering the self-closing device inoperable.

Interview during tour on 1/5/12 at the time of discovery with Staff C confirmed the findings.

18.2.1, NFPA 101, LIFE SAFETY CODE
General: Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7.
Exception: As modified by 18.2.2 through 18.2.11.

18.2.2.2.4, NFPA 101, LIFE SAFETY CODE
Doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side.
Exception No. 2: Delayed-egress locks complying with 7.2.1.6.1 shall be permitted, provided that not more than one such device is located in any egress path.

7.2.1.6.1, NFPA 101, LIFE SAFETY CODE
Delayed-Egress Locks: Approved, listed, delayed-egress locks shall be permitted to be installed on doors serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system in accordance with Section 9.6, or an approved, supervised automatic sprinkler system in accordance with Section 9.7, and where permitted in Chapters 12 through 42, provided that the following criteria are met.
(a) The doors shall unlock upon actuation of an approved, supervised automatic sprinkler system in accordance with Section 9.7 or upon the actuation of any heat detector or activation of not more than two smoke detectors of an approved, supervised automatic fire detection system in accordance with Section 9.6.
(b) The doors shall unlock upon loss of power controlling the lock or locking mechanism.
(c) An irreversible process shall release the lock within 15 seconds upon application of a force to the release device required in 7.2.1.5.4 that shall not be required to exceed 15 lbf (67 N) nor be required to be continuously applied for more than 3 seconds. The initiation of the release process shall activate an audible signal in the vicinity of the door. Once the door lock has been released by the application of force to the releasing device, relocking shall be by manual means only.
Exception: Where approved by the authority having jurisdiction, a delay not exceeding 30 seconds shall be permitted.
(d) On the door adjacent to the release device, there shall be a readily visible, durable sign in letters not less than 1 in. (2.5 cm) high and not less than 1/8 in. (0.3 cm) in stroke width on a contrasting background that reads as follows:
PUSH UNTIL ALARM SOUNDS
DOOR CAN BE OPENED IN 15 SECONDS

Based on observation and interview the facility failed to ensure that doors with delayed-egress locks are properly installed and/or maintained.

Findings include:

Observation during tour on 1/5/12 between 11:50 a.m. and 12:00 p.m. with Staff C (Maintenance Manager), Staff D (Plant Operations), Staff E (Maintenance Worker), and Staff F (Director of Compliance) revealed the following in the East Tower, level 1 at Senior Services:

1. The main entrance double door assembly with a delayed-egress door locking device installed that does not have signage.

2. One stairwell door with a delayed-egress door lock installed failed to initiate an audible signal near the door, failed to initiate the irreversible process, and failed to unlock the door within 30 seconds as signage attached to the door indicates it should.

Interview during tour on 1/5/12 with Staff C at the time of discovery confirmed the findings.

19.2.10.1, NFPA 101, LIFE SAFETY CODE
Means of egress shall have signs in accordance with Section 7.10.

7.10.1.2, NFPA 101, LIFE SAFETY CODE
Exits: Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign readily visible from any direction of exit access.

7.10.2, NFPA 101, LIFE SAFETY CODE
Directional Signs: A sign complying with 7.10.3 with a directional indicator showing the direction of travel shall be placed in every location where the direction of travel to reach the nearest exit is not apparent.

Based on observation and interview the facility failed to ensure that all exit doors have signage posted.

Findings include:

Observation during tour on 1/5/12 with Staff C (Maintenance Manager), Staff D (Plant Operations), Staff E (Maintenance Worker), Staff F (Director of Compliance), and Staff G (Central Sterile Supply Unit Coordinator) revealed that two of the four exit doors in the O.R. Central Supply do not have exit signs.

Interview during tour on 1/5/12 with Staff C and Staff G confirmed the findings at the time of discovery.

19.3.5.1, NFPA 101, LIFE SAFETY CODE
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.

9.7.1.1, NFPA 101, LIFE SAFETY CODE
Each automatic sprinkler system required by another section of this Code shall be in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.

9.7.5, NFPA 101, LIFE SAFETY CODE
Maintenance and Testing: All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

5-1.1, NFPA 13, INSTALLATION OF SPRINKLER SYSTEMS
The requirements for spacing, location, and position of sprinklers shall be based on the following principles:
(1) Sprinklers installed throughout the premises
(2) Sprinklers located so as not to exceed maximum protection area per sprinkler
(3) Sprinklers positioned and located so as to provide satisfactory performance with respect to activation time and distribution

5-6.5.1.2 Sprinklers shall be arranged to comply with... Table 5-6.5.1.2
Table 5-6.5.1.2 Positioning of Sprinklers to Avoid Obstructions to Discharge (SSU/SSP):

Distance from Sprinklers to Side of Obstruction: Less than 1 ft
Maximum Allowable Distance of Deflector above Bottom of Obstruction (in.): 0

Distance from Sprinklers to Side of Obstruction: 1 ft to less than 1 ft 6 in.
Maximum Allowable Distance of Deflector above Bottom of Obstruction (in.): 2-1/2

Distance from Sprinklers to Side of Obstruction: 1 ft 6 in. to less than 2 ft
Maximum Allowable Distance of Deflector above Bottom of Obstruction (in.): 3-1/2

Distance from Sprinklers to Side of Obstruction: 2 ft to less than 2 ft 6 in.

Maximum Allowable Distance of Deflector above Bottom of Obstruction (in.): 5-1/2

Distance from Sprinklers to Side of Obstruction: 2 ft 6 in. to less than 3 ft
Maximum Allowable Distance of Deflector above Bottom of Obstruction (in.): 7-1/2

Distance from Sprinklers to Side of Obstruction: 3 ft to less than 3 ft 6 in.
Maximum Allowable Distance of Deflector above Bottom of Obstruction (in.): 9-1/2

Distance from Sprinklers to Side of Obstruction: 3 ft 6 in. to less than 4 ft
Maximum Allowable Distance of Deflector above Bottom of Obstruction (in.): 12

Distance from Sprinklers to Side of Obstruction: 4 ft to less than 4 ft 6 in.
Maximum Allowable Distance of Deflector above Bottom of Obstruction (in.): 14

Distance from Sprinklers to Side of Obstruction: 4 ft 6 in. to less than 5 ft
Maximum Allowable Distance of Deflector above Bottom of Obstruction (in.): 16-1/2

Distance from Sprinklers to Side of Obstruction: 5 ft and greater
Maximum Allowable Distance of Deflector above Bottom of Obstruction (in.): 18

5-5.3.4, NFPA 13, INSTALLATION OF SPRINKLER SYSTEMS
Minimum Distance Between Sprinklers: A minimum distance shall be maintained between sprinklers to prevent operating sprinklers from wetting adjacent sprinklers and to prevent skipping of sprinklers. The minimum distance permitted between sprinklers shall comply with the value indicated in the section for each type or style of sprinkler.

5-6.3.4, NFPA 13, INSTALLATION OF SPRINKLER SYSTEMS
Minimum Distance Between Sprinklers: Sprinklers shall be spaced not less than 6 ft (1.8 m) on center.

Based on observation and interview the facility failed to ensure that the automatic, supervised sprinkler system(s) are properly maintained.

Findings include:

Observation during tour on 1/5/12 between 10:00 a.m. and 1:45 p.m. with Staff C (Maintenance Manager), Staff D (Plant Operations), Staff E (Maintenance Worker), and Staff F (Director of Compliance) revealed the following:

1. Level 1, West 1: At least one corridor closet has the spray pattern of the sprinkler head partially obstructed due to a soffit, with a width of approximately 6 inches, being located approximately 7 inches away from the sprinkler head which projects from the ceiling approximately 2-1/2 inches.

2. Level 2, West 2: At least one closet has two sprinkler heads within 2 feet of each other.

Interview during tour on 1/5/12 with Staff C, Staff D, Staff E, and Staff F at the time of discovery confirmed the findings.

19.3.7.3, NFPA 101, LIFE SAFETY CODE
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.

8.3.6.1, NFPA 101, LIFE SAFETY CODE
Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Based on observation and interview the facility failed to ensure that all penetrations are properly and adequately sealed.

Findings include:

Interview during tour between 1/4/12 and 1/5/12 with Staff C (Maintenance Manager), Staff D (Plant Operations), Staff E (Maintenance Worker), and Staff F (Director of Compliance) confirmed the locations of smoke barriers.

Observation during tour between 1/4/12 and 1/5/12 with Staff C, Staff D, Staff E, and Staff F revealed that unsealed penetrations are present in the following locations:

1. Level L, penetration at the smoke barrier separation between the office and the Old Coumadin Clinic.
2. Level L west wing, penetration at the smoke barrier separation between the Emergency Room and "Fast Track".
3. North 1, penetration at the smoke barrier separation at the Senior Psychiatric Unit.
4. Level 1, penetration at the smoke barrier separation at the Central Elevator Lobby.

Interview during tour between 1/4/12 and 1/5/12 with Staff C confirmed the findings.

4.6.12.1, NFPA 101, LIFE SAFETY CODE
Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

4.6.12.3, NFPA 101, LIFE SAFETY CODE
Equipment requiring periodic testing or operation to ensure its maintenance shall be tested or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction.

9.7.3.1, NFPA 101, LIFE SAFETY CODE
In any occupancy where the character of the potential fuel for fire is such that extinguishment or control of fire is effectively accomplished by a type of automatic extinguishing system other than an automatic sprinkler system, such as water mist, carbon dioxide, dry chemical, foam, Halon 1301, water spray, or a standard extinguishing system of another type, that system shall be permitted to be installed in lieu of an automatic sprinkler system. Such systems shall be installed, inspected, and maintained in accordance with appropriate NFPA standards.

7.3.2.1, NFPA 2001, CLEAN AGENT FIRE EXTINGUISHING SYSTEMS
All hose shall be tested every 5 years.

Based on observation and interview the facility failed to have the clean agent suppression system maintained properly.

Findings include:

Observation during tour on 1/5/12 at approximately 10:15 a.m. with Staff C (Maintenance Manager), Staff D (Plant Operations), Staff E (Maintenance Worker), and Staff F (Director of Compliance) revealed that the clean agent suppression system located in the computer/IT area has flexible hoses.

Interview during tour on 1/5/12 with Staff C at the time of discovery confirmed that the clean agent suppression system had been installed more than 5 years ago and revealed that there is no documentation present that demonstrates that the hose for the clean agent suppression system has been pressure tested within the last 5 years.

19.5.1, NFPA 101, LIFE SAFETY CODE
Utilities: Utilities shall comply with the provisions of Section 9.1.

9.1.2, NFPA 101, LIFE SAFETY CODE
Electric: Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

370-23, NFPA 70, NATIONAL ELECTRICAL CODE
Supports: Enclosures within the scope of this article shall be supported in accordance with one or more of the provisions in (a) through (h).
(a) Surface Mounting: An enclosure mounted on a building or other surface shall be rigidly and securely fastened in place. If the surface does not provide rigid and secure support, additional support in accordance with other provisions of this section shall be provided.
(b) Structural Mounting: An enclosure supported from a structural member of a building or from grade shall be rigidly supported either directly, or by using a metal, polymeric, or wood brace.
(1) Nails: Nails, where used as a fastening means, shall be attached by using brackets on the outside of the enclosure, or they shall pass through the interior within 1/4 in. (6.35 mm) of the back or ends of the enclosure.
(2) Braces: Metal braces shall be protected against corrosion and formed from metal that is not less than 0.020 in. thick uncoated. Wood braces shall have a cross section not less than nominal 1 in. x 2 in. Wood braces in wet locations shall be treated for the conditions. Polymeric braces shall be identified as being suitable for the use.
(c) Mounting in Finished Surfaces: An enclosure mounted in a finished surface shall be rigidly secured thereto by clamps, anchors, or fittings identified for the application.
(d) Suspended Ceilings: An enclosure mounted to structural or supporting elements of a suspended ceiling shall be not more than 100 in.3 (1640 cm3) in size and shall be securely fastened in place in one of the following ways.
(1) Framing Members: An enclosure shall be fastened to the framing members by mechanical means such as bolts, screws, or rivets, or by the use of clips or other securing means identified for use with the type of ceiling framing member(s) and enclosure(s) employed. The framing members shall be adequately supported and securely fastened to each other and to the building structure.
(2) Support Wires: The installation shall comply with the provisions of Section 300-11(a). The enclosure shall be secured, using methods identified for the purpose, to ceiling support wires, including any additional support wires in stalled for that purpose. Support wires used for enclosure support shall be fastened at each end so as to be taut within the ceiling cavity.

370-28, NFPA 70, NATIONAL ELECTRICAL CODE
Pull and Junction Boxes: Boxes and conduit bodies used as pull or junction boxes shall comply with (a) through (d).
(c) Covers: All pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use.

Based on observation and interview the facility failed to ensure that all electrical wiring is properly installed and/or maintained.

Findings include:

Observation during tour on 1/5/12 between 1:30 p.m. and 4:00 p.m. with Staff C (Maintenance Manager), Staff D (Plant Operations), Staff E (Maintenance Worker), and Staff F (Director of Compliance) revealed that uncovered electrical junction boxes are present above the suspended ceilings in the area of West 2 smoke barrier and North 4 smoke barrier near the mechanical room.

Interview during tour on 1/5/12 with Staff C at the time of discovery confirmed the findings.

19.3.2.1, NFPA 101, LIFE SAFETY CODE
Hazardous Areas: Any hazardous areas shall be safe-guarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. Hazardous areas shall include, but shall not be restricted to, the following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 ft2 (9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Soiled linen rooms
(6) Trash collection rooms
(7) Rooms or spaces larger than 50 ft2 (4.6 m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction
(8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard.

8.4.1.3, NFPA 101, LIFE SAFETY CODE
Doors in barriers required to have a fire resistance rating shall have a 3/4-hour fire protection rating and shall be self-closing or automatic-closing in accordance with 7.2.1.8.

7.2.1.8.1, NFPA 101, LIFE SAFETY CODE
A door normally required to be kept closed shall not be secured in the open position at any time and shall be self-closing or automatic-closing in accordance with 7.2.1.8.2.

Based on observation and interview the facility failed to ensure that hazardous areas have doors with self closing devices installed and properly maintained.

Findings include:

Observation during tour on 1/5/12 between 1:45 p.m. and 3:00 p.m. with Staff C (Maintenance Manager), Staff D (Plant Operations), Staff E (Maintenance Worker), and Staff F (Director of Compliance) revealed the following:

1. Level 2 Pre-op Soiled Utility Room with an entry door that is equipped with a self-closing device where the door leaf is obstructed from closing by a wheelchair placed in the door opening.

2. Level 2 Storage Room with an entry door that is equipped with a self-closing device where the door leaf is obstructed from closing by a wedge placed at the bottom of the door which prevents the door leaf from swinging to a closed position.

3. Level 3 South Soiled Utility Room with an entry door that is equipped with a self-closing device where the self-closing device has been disconnected rendering the self-closing device inoperable.

Interview during tour on 1/5/12 at the time of discovery with Staff C confirmed the findings.

18.2.1, NFPA 101, LIFE SAFETY CODE
General: Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7.
Exception: As modified by 18.2.2 through 18.2.11.

18.2.2.2.4, NFPA 101, LIFE SAFETY CODE
Doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side.
Exception No. 2: Delayed-egress locks complying with 7.2.1.6.1 shall be permitted, provided that not more than one such device is located in any egress path.

7.2.1.6.1, NFPA 101, LIFE SAFETY CODE
Delayed-Egress Locks: Approved, listed, delayed-egress locks shall be permitted to be installed on doors serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system in accordance with Section 9.6, or an approved, supervised automatic sprinkler system in accordance with Section 9.7, and where permitted in Chapters 12 through 42, provided that the following criteria are met.
(a) The doors shall unlock upon actuation of an approved, supervised automatic sprinkler system in accordance with Section 9.7 or upon the actuation of any heat detector or activation of not more than two smoke detectors of an approved, supervised automatic fire detection system in accordance with Section 9.6.
(b) The doors shall unlock upon loss of power controlling the lock or locking mechanism.
(c) An irreversible process shall release the lock within 15 seconds upon application of a force to the release device required in 7.2.1.5.4 that shall not be required to exceed 15 lbf (67 N) nor be required to be continuously applied for more than 3 seconds. The initiation of the release process shall activate an audible signal in the vicinity of the door. Once the door lock has been released by the application of force to the releasing device, relocking shall be by manual means only.
Exception: Where approved by the authority having jurisdiction, a delay not exceeding 30 seconds shall be permitted.
(d) On the door adjacent to the release device, there shall be a readily visible, durable sign in letters not less than 1 in. (2.5 cm) high and not less than 1/8 in. (0.3 cm) in stroke width on a contrasting background that reads as follows:
PUSH UNTIL ALARM SOUNDS
DOOR CAN BE OPENED IN 15 SECONDS

Based on observation and interview the facility failed to ensure that doors with delayed-egress locks are properly installed and/or maintained.

Findings include:

Observation during tour on 1/5/12 between 11:50 a.m. and 12:00 p.m. with Staff C (Maintenance Manager), Staff D (Plant Operations), Staff E (Maintenance Worker), and Staff F (Director of Compliance) revealed the following in the East Tower, level 1 at Senior Services:

1. The main entrance double door assembly with a delayed-egress door locking device installed that does not have signage.

2. One stairwell door with a delayed-egress door lock installed failed to initiate an audible signal near the door, failed to initiate the irreversible process, and failed to unlock the door within 30 seconds as signage attached to the door indicates it should.

Interview during tour on 1/5/12 with Staff C at the time of discovery confirmed the findings.

19.2.10.1, NFPA 101, LIFE SAFETY CODE
Means of egress shall have signs in accordance with Section 7.10.

7.10.1.2, NFPA 101, LIFE SAFETY CODE
Exits: Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign readily visible from any direction of exit access.

7.10.2, NFPA 101, LIFE SAFETY CODE
Directional Signs: A sign complying with 7.10.3 with a directional indicator showing the direction of travel shall be placed in every location where the direction of travel to reach the nearest exit is not apparent.

Based on observation and interview the facility failed to ensure that all exit doors have signage posted.

Findings include:

Observation during tour on 1/5/12 with Staff C (Maintenance Manager), Staff D (Plant Operations), Staff E (Maintenance Worker), Staff F (Director of Compliance), and Staff G (Central Sterile Supply Unit Coordinator) revealed that two of the four exit doors in the O.R. Central Supply do not have exit signs.

Interview during tour on 1/5/12 with Staff C and Staff G confirmed the findings at the time of discovery.

19.3.5.1, NFPA 101, LIFE SAFETY CODE
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.

9.7.1.1, NFPA 101, LIFE SAFETY CODE
Each automatic sprinkler system required by another section of this Code shall be in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.

9.7.5, NFPA 101, LIFE SAFETY CODE
Maintenance and Testing: All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

5-1.1, NFPA 13, INSTALLATION OF SPRINKLER SYSTEMS
The requirements for spacing, location, and position of sprinklers shall be based on the following principles:
(1) Sprinklers installed throughout the premises
(2) Sprinklers located so as not to exceed maximum protection area per sprinkler
(3) Sprinklers positioned and located so as to provide satisfactory performance with respect to activation time and distribution

5-6.5.1.2 Sprinklers shall be arranged to comply with... Table 5-6.5.1.2
Table 5-6.5.1.2 Positioning of Sprinklers to Avoid Obstructions to Discharge (SSU/SSP):

Distance from Sprinklers to Side of Obstruction: Less than 1 ft
Maximum Allowable Distance of Deflector above Bottom of Obstruction (in.): 0

Distance from Sprinklers to Side of Obstruction: 1 ft to less than 1 ft 6 in.
Maximum Allowable Distance of Deflector above Bottom of Obstruction (in.): 2-1/2

Distance from Sprinklers to Side of Obstruction: 1 ft 6 in. to less than 2 ft
Maximum Allowable Distance of Deflector above Bottom of Obstruction (in.): 3-1/2

Distance from Sprinklers to Side of Obstruction: 2 ft to less than 2 ft 6 in.

Maximum Allowable Distance of Deflector above Bottom of Obstruction (in.): 5-1/2

Distance from Sprinklers to Side of Obstruction: 2 ft 6 in. to less than 3 ft
Maximum Allowable Distance of Deflector above Bottom of Obstruction (in.): 7-1/2

Distance from Sprinklers to Side of Obstruction: 3 ft to less than 3 ft 6 in.
Maximum Allowable Distance of Deflector above Bottom of Obstruction (in.): 9-1/2

Distance from Sprinklers to Side of Obstruction: 3 ft 6 in. to less than 4 ft
Maximum Allowable Distance of Deflector above Bottom of Obstruction (in.): 12

Distance from Sprinklers to Side of Obstruction: 4 ft to less than 4 ft 6 in.
Maximum Allowable Distance of Deflector above Bottom of Obstruction (in.): 14

Distance from Sprinklers to Side of Obstruction: 4 ft 6 in. to less than 5 ft
Maximum Allowable Distance of Deflector above Bottom of Obstruction (in.): 16-1/2

Distance from Sprinklers to Side of Obstruction: 5 ft and greater
Maximum Allowable Distance of Deflector above Bottom of Obstruction (in.): 18

5-5.3.4, NFPA 13, INSTALLATION OF SPRINKLER SYSTEMS
Minimum Distance Between Sprinklers: A minimum distance shall be maintained between sprinklers to prevent operating sprinklers from wetting adjacent sprinklers and to prevent skipping of sprinklers. The minimum distance permitted between sprinklers shall comply with the value indicated in the section for each type or style of sprinkler.

5-6.3.4, NFPA 13, INSTALLATION OF SPRINKLER SYSTEMS
Minimum Distance Between Sprinklers: Sprinklers shall be spaced not less than 6 ft (1.8 m) on center.

Based on observation and interview the facility failed to ensure that the automatic, supervised sprinkler system(s) are properly maintained.

Findings include:

Observation during tour on 1/5/12 between 10:00 a.m. and 1:45 p.m. with Staff C (Maintenance Manager), Staff D (Plant Operations), Staff E (Maintenance Worker), and Staff F (Director of Compliance) revealed the following:

1. Level 1, West 1: At least one corridor closet has the spray pattern of the sprinkler head partially obstructed due to a soffit, with a width of approximately 6 inches, being located approximately 7 inches away from the sprinkler head which projects from the ceiling approximately 2-1/2 inches.

2. Level 2, West 2: At least one closet has two sprinkler heads within 2 feet of each other.

Interview during tour on 1/5/12 with Staff C, Staff D, Staff E, and Staff F at the time of discovery confirmed the findings.

19.3.7.3, NFPA 101, LIFE SAFETY CODE
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.

8.3.6.1, NFPA 101, LIFE SAFETY CODE
Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Based on observation and interview the facility failed to ensure that all penetrations are properly and adequately sealed.

Findings include:

Interview during tour between 1/4/12 and 1/5/12 with Staff C (Maintenance Manager), Staff D (Plant Operations), Staff E (Maintenance Worker), and Staff F (Director of Compliance) confirmed the locations of smoke barriers.

Observation during tour between 1/4/12 and 1/5/12 with Staff C, Staff D, Staff E, and Staff F revealed that unsealed penetrations are present in the following locations:

1. Level L, penetration at the smoke barrier separation between the office and the Old Coumadin Clinic.
2. Level L west wing, penetration at the smoke barrier separation between the Emergency Room and "Fast Track".
3. North 1, penetration at the smoke barrier separation at the Senior Psychiatric Unit.
4. Level 1, penetration at the smoke barrier separation at the Central Elevator Lobby.

Interview during tour between 1/4/12 and 1/5/12 with Staff C confirmed the findings.

4.6.12.1, NFPA 101, LIFE SAFETY CODE
Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

4.6.12.3, NFPA 101, LIFE SAFETY CODE
Equipment requiring periodic testing or operation to ensure its maintenance shall be tested or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction.

9.7.3.1, NFPA 101, LIFE SAFETY CODE
In any occupancy where the character of the potential fuel for fire is such that extinguishment or control of fire is effectively accomplished by a type of automatic extinguishing system other than an automatic sprinkler system, such as water mist, carbon dioxide, dry chemical, foam, Halon 1301, water spray, or a standard extinguishing system of another type, that system shall be permitted to be installed in lieu of an automatic sprinkler system. Such systems shall be installed, inspected, and maintained in accordance with appropriate NFPA standards.

7.3.2.1, NFPA 2001, CLEAN AGENT FIRE EXTINGUISHING SYSTEMS
All hose shall be tested every 5 years.

Based on observation and interview the facility failed to have the clean agent suppression system maintained properly.

Findings include:

Observation during tour on 1/5/12 at approximately 10:15 a.m. with Staff C (Maintenance Manager), Staff D (Plant Operations), Staff E (Maintenance Worker), and Staff F (Director of Compliance) revealed that the clean agent suppression system located in the computer/IT area has flexible hoses.

Interview during tour on 1/5/12 with Staff C at the time of discovery confirmed that the clean agent suppression system had been installed more than 5 years ago and revealed that there is no documentation present that demonstrates that the hose for the clean agent suppression system has been pressure tested within the last 5 years.

19.5.1, NFPA 101, LIFE SAFETY CODE
Utilities: Utilities shall comply with the provisions of Section 9.1.

9.1.2, NFPA 101, LIFE SAFETY CODE
Electric: Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

370-23, NFPA 70, NATIONAL ELECTRICAL CODE
Supports: Enclosures within the scope of this article shall be supported in accordance with one or more of the provisions in (a) through (h).
(a) Surface Mounting: An enclosure mounted on a building or other surface shall be rigidly and securely fastened in place. If the surface does not provide rigid and secure support, additional support in accordance with other provisions of this section shall be provided.
(b) Structural Mounting: An enclosure supported from a structural member of a building or from grade shall be rigidly supported either directly, or by using a metal, polymeric, or wood brace.
(1) Nails: Nails, where used as a fastening means, shall be attached by using brackets on the outside of the enclosure, or they shall pass through the interior within 1/4 in. (6.35 mm) of the back or ends of the enclosure.
(2) Braces: Metal braces shall be protected against corrosion and formed from metal that is not less than 0.020 in. thick uncoated. Wood braces shall have a cross section not less than nominal 1 in. x 2 in. Wood braces in wet locations shall be treated for the conditions. Polymeric braces shall be identified as being suitable for the use.
(c) Mounting in Finished Surfaces: An enclosure mounted in a finished surface shall be rigidly secured thereto by clamps, anchors, or fittings identified for the application.
(d) Suspended Ceilings: An enclosure mounted to structural or supporting elements of a suspended ceiling shall be not more than 100 in.3 (1640 cm3) in size and shall be securely fastened in place in one of the following ways.
(1) Framing Members: An enclosure shall be fastened to the framing members by mechanical means such as bolts, screws, or rivets, or by the use of clips or other securing means identified for use with the type of ceiling framing member(s) and enclosure(s) employed. The framing members shall be adequately supported and securely fastened to each other and to the building structure.
(2) Support Wires: The installation shall comply with the provisions of Section 300-11(a). The enclosure shall be secured, using methods identified for the purpose, to ceiling support wires, including any additional support wires in stalled for that purpose. Support wires used for enclosure support shall be fastened at each end so as to be taut within the ceiling cavity.

370-28, NFPA 70, NATIONAL ELECTRICAL CODE
Pull and Junction Boxes: Boxes and conduit bodies used as pull or junction boxes shall comply with (a) through (d).
(c) Covers: All pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use.

Based on observation and interview the facility failed to ensure that all electrical wiring is properly installed and/or maintained.

Findings include:

Observation during tour on 1/5/12 between 1:30 p.m. and 4:00 p.m. with Staff C (Maintenance Manager), Staff D (Plant Operations), Staff E (Maintenance Worker), and Staff F (Director of Compliance) revealed that uncovered electrical junction boxes are present above the suspended ceilings in the area of West 2 smoke barrier and North 4 smoke barrier near the mechanical room.

Interview during tour on 1/5/12 with Staff C at the time of discovery confirmed the findings.