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Based on observations and confirmed by staff, the facility failed to ensure that all the buildings are of a conforming construction type. Table 19.1.6.2 requires buildings 4-stories in height or greater to be of at least Type I (443), Type I (332) or Type II (222).

FINDINGS INCLUDE:

During the morning hours of 1/18/17, it was observed that the Lamprey Building is classified as 5-story, Type II (222) construction. Hospital Engineering staff stated that the one-story Radiology addition was completed in 1978 adjoining the first floor level of the Lamprey Building. During the construction of this Radiology addition, the exterior wall of the original building was removed to increase the overall size of the floor area.

On 1/18/17, it was observed that the "new" Radiology addition was built utilizing Type II (000) construction classification without constructing a 2-hour separation from the original Lamprey building.

The omission of the 2-hour separation between the original Lamprey Building and the (c. 1978) Radiology downgrades the original 5-story building to a non-conforming Type II (000) classification.

As a result, the facility failed to comply with section 19.1.6.2.

This observation was confirmed with the Hospital Senior Management Staff as well as Facilities Management Staff.

Based on observations and confirmed by staff, the facility failed to ensure that the means of egress routes are kept clear of all obstructions that could hinder the removal of the occupants.

Section 19.2.1 states every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7.

Section 7.1.6.4 states walking surfaces shall be slip resistant under foreseeable conditions. The walking surface of each element in the means of egress shall be uniformly slip resistant along the natural path of travel.

Section 7.1.10.1 states the means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

THE FINDINGS INCLUDE:

During the morning hours of 1/18/17 at approximately 11:45 A.M., the following items were observed regarding exit egress routes:

1) The exterior stair treads leading from the Stevens' Building stairwell were observed to be completely covered in ice. Each of the approximate 35 steps and 2 landings had an approximate 1/4" build up of ice which would severely hinder the removal of occupants in an emergency situation.
(Note: The ice was observed again on 1/19/17 at approximately 9:00 A.M. When the stairs were checked on 1/20/17, the ice was no longer present)

2) The South Stairwell landing of the 4th floor level had 12" x 12" vinyl floor tiles that were observed to be curling/lifting. The tiles could actually be lifted from the concrete as the adhesive had failed all together. Many of these tiles have curled creating a tripping hazard for any person trying to traverse this stairwell. The tiles were observed to be curled/lifted as much as 1/4" above the walking plane.
(Note: The floor tiles were removed prior to the conclusion of the survey.)

As a result, the facility failed to comply with Section 19.2.7 requiring all egress routes to be maintained and kept clear of all obstructions.

This observation was confirmed with the Hospital Senior Management Staff as well as Facilities Management Staff.

Based on observations and confirmed by staff the facility failed to ensure compliance with section 19.2.2.2.7 of the 2012 edition of NFPA 101, "Life Safety Code."

-Section 19.2.2.2.7 states any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8.2. The automatic sprinkler system, if provided, and the fire alarm system, and the systems required by 7.2.1.8.2, shall be arranged to initiate the closing action of all such doors throughout the smoke compartment or throughout the entire facility.

-Section 7.2.1.8.2 (3) requires that 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 leaf release service in NFPA 72 National Fire Alarm and Signaling Code.

-NFPA 72 Section 17.7.5.6.1 states smoke detectors that are part of an open area protection system covering the room, corridor, or enclosed space on each side of the smoke door and that are located and spaced as required by 17.7.3 shall be permitted to accomplish smoke door release service.

-NFPA 72 Section 17.7.3.2.3.1 states in the absence of specific performance-based design criteria, smooth ceiling smoke detector spacing shall be a nominal 30 ft (9.1 m).

-NFPA 72 Section 17.7.5.6.2 states that smoke detectors that are used exclusively for smoke door release service shall be located and spaced as required by 17.7.5.6.

-NFPA 72 Section 17.7.5.6.5 states the number of detectors required shall be determined in accordance with 17.7.5.6.5.1 through 17.7.5.6.5.4.

-NFPA 72 Section 17.7.5.6.5.1 states if doors are to be closed in response to smoke flowing in either direction, the requirements of 17.7.5.6.5.1(A) through 17.7.5.6.5.1(D) shall apply.

-NFPA 72 Section 17.7.5.6.5.1 (A) If the depth of wall section above the door is 24 in. (610 mm) or less, one ceiling-mounted smoke detector shall be required on one side of the doorway only, or two wall-mounted detectors shall be required, one on each side of the doorway.

-NFPA 72 Section 17.7.5.6.5.1 (B) If the depth of wall section above the door is greater than 24 in. (610 mm) on one side only, one ceiling-mounted smoke detector shall be required on the higher side of the doorway only, or one wall-mounted detector shall be required on both sides of the doorway. Figure 17.7.5.6.5.1(A), part D, shall apply.

-NFPA 72 Section 17.7.5.6.6.1 states if ceiling-mounted smoke detectors are to be installed on a smooth ceiling for a single or double doorway, they shall be located as follows:
(1) On the centerline of the doorway
(2) No more than 5 ft (1.5 m), measured along the ceiling and perpendicular to the doorway.

Findings Include:

While conducting the facility tour during the morning and afternoon hours of 1/18/17, 1/19/17 and 1/20/17 the following was observed regarding doors permitted to be held open by automatic releasing mechanisms compliant with Section 19.2.2.2.7 of NFPA 101.

1. The two (2) sets of cross-corridor smoke barrier doors which are located on the fifth floor level of the Russell Building, the set of cross-corridor smoke barrier doors which are located closest to the elevator lobby on the second floor level of the "Russell Building" and the set of cross-corridor doors which are part of a two hour separation between the Russell Building and the Pediatric Unit of the Hamblet Building are all equipped with magnetic hold open devices which are designed to release upon activation of the fire alarm system. However, observations revealed that there are no smoke detectors located within five (5') feet of these doors and there are no corridor smoke detectors comprising an open air protection system as defined in NFPA 72 Section 17.7.5.6.1.

2. The ninety (90) minute fire rated set of doors included in the two (2) hour fire rated barrier separating the non-sprinklered electrical room located in the Hamblet Building basement is equipped with magnetic hold open devices which are designed to release upon activation of the fire alarm system. However, observations revealed that there are no smoke detectors located within five (5') feet of these doors and there are no corridor smoke detectors comprising an open air protection system as defined in NFPA 72, Section 17.7.5.6.1.

In addition the electrical room side of the doors has a wall depth section of seventy-two (72) inches above one side of the door and as such a smoke detector must be installed in compliance with NFPA 72 Section 17.7.5.6.5.1(B).

As a result of the findings the facility is found to be non-compliant with Chapter 19 Section 19.2.2.2.7 of the 2012 edition of NFPA 101 " Life Safety Code "

This observation was confirmed with the Hospital Senior Management Staff as well as Facilities Management Staff.

Based on observations and confirmed by staff, the facility failed to ensure all egress doors are maintained as required.

Section 7.2.1.2.1.1 states swinging door assemblies clear width shall be measured as follows:

(1) The measurement shall be taken at the narrowest point in the door opening.
(2) The measurement shall be taken between the face of the door leaf and the stop of the frame.
(3) For new swinging door assemblies, the measurement shall be taken with the door leaf open 90 degrees.
(4) For any existing door assembly, the measurement shall be taken with the door leaf in the fully open position.
(5) Projections of not more than 4 in. (100 mm) into the door opening width on the hinge side shall not be considered reductions in clear width, provided that such projections
are for purposes of accommodating panic hardware or fire exit hardware and are located not less than 34 in. (865 mm), and not more than 48 in. (1220 mm), above the floor.
(6) Projections exceeding 6 ft 8 in. (2030 mm) above the floor shall not be considered reductions in clear width.

Section 7.2.1.4.3.1 states during its swing, any door in a means of egress shall leave not less than one-half of the required width of an aisle, a corridor, a passageway, or a landing unobstructed and shall project not more than 7 in. (180 mm) into the required width of
an aisle, a corridor, a passageway, or a landing, when fully open, unless both of the following conditions are met:
(1) The door opening provides access to a stair in an existing building.
(2) The door opening meets the requirement that limits projection to not more than 7 in. (180 mm) into the required width of the stair landing when the door leaf is fully open.

THE FINDINGS INCLUDE:

During the morning hours of 1/19/17 while touring the 2nd floor Radiology suite of the Lamprey Building, it was observed that the North stairwell door does not operate as designed. It was noted that the 44" door opens to a maximum of 40", reducing the designed width opening by approximately 4". In addition, it was observed that the stairwell has a small vertical chase directly adjacent to the door opening on the hinge side. It was further observed that the automatic door closing device is capable of hitting this chase if the door was fully opened. As a result, a floor mounted door stop device was installed preventing the door from opening as originally designed. When fully opened, the door currently projects into the stairwell approximately 12", exceeding the 7" maximum projection allowance.

As a result, the facility failed to comply with section 7.2.1.2.1.1 and 7.2.1.4.3.1 regarding door openings and stairwell obstructions.

This observation was confirmed with the Hospital Senior Management Staff as well as Facilities Management Staff.







b

Based on observations and acknowledged by staff, the facility failed to ensure that non-sleeping suites do not exceed the allowable size.

Section 19.2.5.7.3.3 "Patient Care Non-Sleeping Suite Maximum Size" states non-sleeping suites shall not exceed 10,000 ft2 (930 m2).

Per the Centers For Medicare and Medicaid Services (CMS) the Survey and Certification letter S&C-11-05-LSC dated 12/17/10 with a revision on 2/18/11 states the following:

Section 3.3.134.7 of the LSC defines a Health Care Occupancy as, " [a]n occupancy used for the purpose of medical or other treatment or care of four or more persons where such occupants are mostly incapable of self-preservation because of age, because of physical or mental disability, or because of security measures not under the occupants ' control. " According to sections 18/19.1.1.1.3, " health care facilities regulated by these chapters provide sleeping accommodations for their occupants. "Further, sections 18/19.1.1.1.7 provide that," facilities that do not provide housing on a 24-hour basis for their occupants shall be classified as other occupancies and shall be covered by other chapters of this Code. " Therefore, hospital or CAH component facilities that provide sleeping accommodations and medical treatment OR services on a 24-hour basis for patients mostly incapable of self-preservation must be classified as a Health Care Occupancy.

Section 1861(e) of the Social Security Act (the Act) defines a "hospital" as being primarily engaged in providing care to inpatients and is not based upon a minimum number patients receiving treatment, care or services. CMS does not consider the number of patients in determining if a provider is a hospital or a CAH; therefore, a CMS-certified hospital or CAH does not need to have four or more inpatients at all times in order to be classified as a Health Care Occupancy. Occupancy classification must be determined regardless of the number of patients served at a hospital ' s or CAH ' s component facility.

THE FINDINGS INCLUDE:

Hospital staff stated during the initial entrance conference that the Emergency Center is classified as an Ambulatory Health Care Occupancy per the Hospital Basic Building Information (BBI) provided to the Joint Commission.

However, it was explained to hospital staff that according to S&C-11-05-LSC as outlined above, the Emergency Center must be classified as a Health Care Occupancy due to the 24-hour care which is provided.

During the morning hours of 1/18/17 while surveying the Emergency Center, it was observed that the unit is set up as one large suite with one smoke barrier wall providing separation for the suite.

After measuring the compartment sizes and confirming with facility staff, it was determined that each compartment exceeds the 10,000 ft2 allowable size. The compartments were observed to be 11,900 ft2 and 13,848 ft2.

As a result of the compartment sizes, the facility failed to comply with section 19.2.5.7.3.3 limiting non-sleeping suites to a maximum of 10,000 ft2.

This observation was confirmed with the Hospital Senior Management Staff as well as Facilities Management Staff.

Based on observations the facility failed to ensure that flammable liquids were stored in compliance with NFPA regulations.

NFPA 101, Section 19.1.5 states the classification of hazards of contents shall be as defined in Section 6.2.

Section 6.2.1.3 states for the purpose of the Code, where different degrees of hazard of contents exist in different parts of a building or structure, the most hazardous shall govern the classification, unless hazardous areas are separated or protected as specified in Section 8.7 and the applicable sections of Chapters 11 through 43.

Section 8.7.3.1 states the storage and handling of flammable liquids or gases shall be in accordance with the following applicable standards.
1. NFPA 30 Flammable and Combustible Liquids Code
2. NFPA 54 National Fuel Gas Code
3. NFPA 58 Liquefied Petroleum Gas Code.

NFPA 30, 2012 edition, Section 9.9 states storage areas shall be constructed to meet the fire resistance ratings specified in Table 9.9.1. Construction assemblies shall comply with the test specifications given in ASTM E 119, Standard Test Methods for Fire Tests of Building Construction and Materials.

Table 9.9.1 Fire Resistance Ratings for Liquid Storage Areas

Fire Resistance Rating (hr) Type of Storage Area

Interior Walls (a), Roofs Exterior Walls
Ceilings,
Intermediate Floors N/A N/A

Liquid storage room
Floor area = 150 ft2 = 1hr FRR

Floor area > 150 ft2,
but = 500 ft2 = 2hr FRR

NFPA 30, 2012 edition, Section 9.9.2 requires that the opening protectives (doors) in one hour fire resistive construction be rated as ¾ hr and in two hour fire resistive construction be rated as 1 ½ hr.

Findings Include:

While conducting the facility tour, during the morning hours of 1/19/17, observations revealed a storage room in the sub-basement of the Russell Building. The entrance door to the room was provided with signage that identifies the room as an accumulation area of highly flammable hazardous waste. Observations further revealed the presence of several fifty-five gallon drums of Class II and Class III flammable liquids being accumulated and stored inside the room. The room is greater than 150 square feet but less than 500 square feet in size, non-rated (according to construction documentation) and not protected by a self-closing fire rated door.

As a result of the finding the facility was found to be non-compliant with Section 8.7.3.1.

This observation was confirmed with the Hospital Senior Management Staff as well as Facilities Management Staff.

Based on documenation, observation and confirmed by staff the facility failed to comply with the following regulations.

NFPA 101, section 19.3.2.5.2 states that where residential cooking equipment is used for food warming or limited cooking, the equipment shall not be required to be protected in accordance with 9.2.3, and the presence of the equipment shall not require the area to be protected as a hazardous area.

Section 9.2.3 states that commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations.

NFPA 96, section 11.4 states that the entire exhaust system shall be inspected for grease buildup by a properly trained, qualified, and certified person(s) acceptable to the authority having jurisdiction and in accordance with Table 11.4.

Table 11.4 states that schedule of Inspection for Grease Buildup for systems serving moderate-volume cooking operations shall be inspected semiannually.

Findings Include:

Observation on 1/20/17 revealed that the hospital failed to maintain the bakery, commercial kitchen exhaust hood semi-annually as required. The last documented inspection the the kitchen hood exhaust system was conducted during 8/2014.

As a result, the facility failed to comply with NFPA 96, section 11.4 (table 11.4).

The finding was confirmed by the Executive Vice President and Senior Director Facility Management, during the exit conference.

Based on observations and confirmed by staff, the facility failed to ensure compliance with Chapter 19, Section 19.3.2.6 of NFPA 101 Life Safety Code.

Findings Include:

On 1/19/17 Alcohol-based hand-rub dispensers (ABHR) were observed installed on the corridor wall of the Hamblet Building second floor level outside rooms #212, #215, #219, and #221. These ABHR(s) were installed separated from each other by horizontal spacing of 26" on center. This does not meet the minimum four foot horizontal spacing requirement.

As a result of the findings the facility is found to be non-compliant with Section 19.3.2.6(4) of NFPA 101.

This observation was confirmed with the Hospital Senior Management Staff as well as Facilities Management Staff.

Based on documenation and confirmed by staff the facility failed to comply with the following regulations.

The NFPA 101, Section 39.3.4.1 states that a fire alarm system in accordance with Section 9.6 shall be provided in all business occupancies where any one of the following conditions exists:
(1) The building is three or more stories in height.
(2) The occupancy is subject to 100 or more occupants above
or below the level of exit discharge.
(3) The occupancy is subject to 1000 or more total occupants.
Chapter 9, section 9.6.1.5 states that to ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code.

Findings Include:

Facility staff was unable to provide any documenation to substantiate that the fire alarm system at the hospital's outpatient building had been inspected, tested and maintained as required.

As a result of the finding, the facility was found to be non-compliant with the NFPA 101, section 39.3.4.1, 9.6.1.5 and NFPA 70 and NFPA 72.

This finding was confirmed with the Hospital Senior Management Staff as well as Facilities Management Staff.

Based on observations the facility failed to ensure compliance with Chapter 8, of the 2010 edition of NFPA 13 " Standard for the Installation of Sprinkler Systems ".

-Section 8.3.3.2 states where quick-response sprinklers are installed, all sprinklers within a compartment shall be quick-response unless otherwise permitted in 8.3.3.3.

-Section 8.3.3.3 states where there are no listed quick-response sprinklers in the temperature range required, standard-response sprinklers shall be permitted to be used.

-Section 8.3.3.4 states when existing light hazard systems are converted to use quick-response or residential sprinklers, all sprinklers in a compartmented space shall be changed.

Note: NFPA 13, Section 3.3.6 defines compartment as a space completely enclosed by walls and a ceiling. Each wall in the compartment is permitted to have openings to an adjoining space if the openings have a minimum lintel depth of 8 in. (200 mm) from the ceiling and the total width of the openings in each wall does not exceed 8 ft (2.4 m). A single opening of 36 in. (900 mm) or less in width without a lintel is permitted when there are no other openings to adjoining spaces.

Findings Include:

While conducting the facility tour during the morning hours of 1/19/17 observations revealed the existence of two (2) standard response sprinkler heads in the ceiling of the two car elevator lobby located in the Hamblet Building sub-basement. The elevator lobby is open to the corridor which leads to the Emergency Center. The corridor is protected throughout by quick response type sprinkler heads. There is a lintel which separates the elevator lobby from the corridor however it is only four (4) inches in depth.
In order to meet compliance with NFPA 13 the separating lintel must be a minimum of eight (8) inches in depth or the two standard response sprinkler heads must be replaced with quick response type heads.

This observation was confirmed with the Hospital Senior Management Staff as well as Facilities Management Staff.

Based on documenation, observation and confirmed by staff the facility failed to comply with the following regulations.

NFPA 101, Section 9.7.5 states that 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.

NFPA 25, Section 5.2.4.1 Gages on wet pipe sprinkler systems shall be inspected monthly to ensure that they are in good condition and that normal water supply pressure is being maintained.

NFPA 25, Section 5.2.4.2 Gages on dry, preaction, and deluge systems shall be inspected weekly to ensure that normal air and water pressures are being maintained.

Findings Include:

1. Facility documentation for inspection, testing and maintenance of the automatic sprinkler system was reviewed during the morning hours of 01/18/17. Record review substantiates that the hospital staff does not record the pressure for the hospital automatic wet and dry type sprinkler systems. Therefore there were no records to indicate that the sprinkler systems are operating under normal conditions.

2. Observation made on 1/20/17 to the wet automatic sprinkler system service supply line, located in the Hamblet Building, that supplies the Hamblet, Stevens, Lamprey, and Russell Buildings, is not equipped with a water sprinkler gage on the supply (city) side of the backflow preventer. This gage is required to ensure that the automatic sprinkler system is operating under normal conditions.

As a result of the finding, the facility is found to be non-compliant with the NFPA 101, section 9.7.5, and NFPA 25 sections 5.2.4.1 and 5.2.4.2

The finding was confirmed by the Executive Vice President and Senior Director Facility Management, during the exit conference.

Based on documenation, observation and confirmed by staff the facility failed to comply with the following regulations.

NFPA 101, Section 9.7.5 states that 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.

NFPA 25, section 5.2.4.1 states that pressure gages on wet pipe sprinkler systems shall be inspected monthly to ensure that they are in good condition and that normal water supply pressure is being maintained.

Findings Include:

1. Building records for sprinkler system maintenance were reviewed during the morning hours of 01/19/17. Hospital staff was unable to provide and stated that no records for monthly sprinkler pressures on the wet type system were maintained.

2. Observations made on 1/20/17 to the wet type automatic sprinkler system revealed it was not equipped with a water pressure gage on the supply (city) side of the backflow preventer.

As a result of the finding, the facility is found to be non-compliant with the NFPA 101, section 9.7.5, and NFPA 25 section 5.2.4.1.

This observation was confirmed with the Hospital Senior Management Staff as well as Facilities Management Staff.

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Based on observations and confirmed by staff, the facility failed to ensure that corridor separation was provided as required.

Section 19.3.6.1 subsection (8) states waiting areas shall be permitted to be open to the corridor, provided that all of the following criteria are met:

(a) Each area does not exceed 600 ft2 (55.7 m2).
(b) The area is equipped with an electrically supervised automatic smoke detection system in accordance with 19.3.4.
(c) The area does not obstruct any access to required exits.

THE FINDINGS INCLUDE:

While conducting the facility tour during the morning and afternoon hours of 1/18/17 and 1/19/17, numerous rooms were observed open to the corridor. These areas include but not limited to the following locations:

1) The 4th floor level reception area of the Lamprey Building has an approximate 4' x 5' sliding glass window. This office area was not equipped with an electrically supervised automatic smoke detector.

2) The 4th floor reception area and waiting area of the Greater Lawrence Family Healthcare Center are considered open to the corridor. This office area was open to the waiting room, and the waiting room was not equipped with a door to the corridor. Neither area was equipped with an electrically supervised automatic smoke detector.

3) The 4th floor Cardiac reception area of the Steven's Building has an approximate 2' x 3' sliding glass window. This office area was not equipped with an electrically supervised automatic smoke detector.

4) The 1st floor level waiting room area of the Lamprey Building in the Infusion area was open to the corridor. This waiting area was not equipped with an electrically supervised automatic smoke detector.

As a result, the facility failed to comply with section 19.3.6.1(8).

This observation was confirmed with the Hospital Senior Management Staff as well as Facilities Management Staff.

Based on observations and confirmed by staff, the facility failed to ensure compliance with Chapter 19 of NFPA 101, "Life Safety Code."

-Section 19.3.7.6 states openings in smoke barriers shall be protected using one of the following methods:
(1) Fire-rated glazing
(2) Wired glass panels in steel frames
(3) Doors, such as 13/4 in. (44 mm) thick, solid-bonded wood core doors
(4) Construction that resists fire for a minimum of 20 minutes.

-Section 19.3.7.6.2 states doors shall be permitted to have fixed fire window assemblies in accordance with Section 8.5.

Findings Include:

While conducting the facility tour during the morning hours of 1/20/17 observations revealed that the corridor door to the "Doctor's Room" located within the Russell Building's Fifth floor level Intensive Care Unit is a component of the units designated smoke barrier. Observations further revealed that the door is equipped with a non-fire rated three (3) inch by twenty-three (23) inch vision panel.
As a result of the finding the facility is found to be non-compliant with Section 19.3.7.6.

The finding was confirmed by facility maintenance personnel at time of observation and during the exit conference.

A) Based on observations and confirmed by staff, the facility failed to ensure that the heating, ventilating, and air conditioning systems (HVAC) are maintained in accordance with NFPA 90A.

NFPA 90A, Section 4.3.11.2 states that the space between the top of the finished ceiling and the underside of the floor or roof above shall be permitted to be used to supply air to the occupied area or to return or exhaust air from the occupied area, provided that the conditions in 4.3.11.2.1 through 4.3.11.2.7 are met.

Section 4.3.11.2.4 states that materials used in the construction of a ceiling plenum shall be noncombustible or shall be limited combustible having a maximum smoke developed index of 50, except as permitted in 4.3.11.2.4.1 through 4.3.11.2.4.3, and shall be suitable for continuous exposure to the temperature and humidity conditions of the environmental air in the plenum.

Section 4.3.11.2.6 states that materials within a ceiling cavity plenum exposed to the airflow shall be noncombustible or comply with 4.3.11.2.6.1 through 4.3.11.2.6.10, as applicable.

Section 4.3.11.2.6.1 states that electrical wires and cables and optical fiber cables shall be listed as having a maximum peak optical density of 0.50 or less, an average optical density of 0.15 or less, and a maximum flame spread distance of 1.5 m (5 ft) or less when tested in accordance with NFPA 262, Standard Method of Test for Flame Travel and Smoke of Wires and Cables for Use in Air-Handling Spaces, or shall be installed in metal raceways without an overall nonmetallic covering, metal sheathed cable without an overall nonmetallic covering, or totally enclosed nonventilated metallic busway without an overall nonmetallic covering.

FINDINGS INCLUDE:

During survey from 1/18/17 through 1/23/17 the following was noted:

The facility was utilizing the area between the ceiling tiles and the floor above as a plenum. The areas utilizing the area above the ceiling were noted at the following:
- Women's Locker Room (Hamblet Building- sub-basement),
- Admissions office (Russell Building basement),
- Dialysis Room (Russell Building fourth floor level),
- Greater Lawrence Healthcare Center (Lamprey Building fourth floor level)
- Echo Lab Office (Lamprey second floor level)
- IT Closet (Lamprey second floor level)

In each area noted, an approximate 4" diameter duct from a freestanding portable, air conditioner unit was not continuously tied to the ceiling mounted exhaust duct system. As a result, the exposed data wires, cables, and electrical wiring above the ceiling tiles were exposed to the airflow. There was no documentation provided to substantiate that the exposed wires and cables are permitted in the ceiling cavity plenum.



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B) Based on observations, record review and confirmed by staff, the facility failed to ensure compliance with section 9.2 requiring the maintenance of Heating Ventilation and Air Conditioning (HVAC) Systems.

Section 9.2.1 states air-conditioning, heating, ventilating ductwork, and related equipment shall be in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, or NFPA 90B, Standard for the Installation of Warm Air Heating and Air-Conditioning Systems, as applicable, unless such installations are approved existing installations, which shall be permitted to be continued in service.

NFPA 90A section 5.4.8.1 states fire dampers and ceiling dampers shall be maintained in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives.

NFPA 80 section 19.4.1 states each damper shall be tested and inspected 1 year after installation.

Section 19.4.1.1 states the test and inspection frequency shall then be every 4 years, except in hospitals, where the frequency shall be every 6 years.

Section 19.4.2 states all tests shall be completed in a safe manner by personnel wearing personal protective equipment.

Section 19.4.3 states full unobstructed access to the fire or combination fire/ smoke damper shall be verified and corrected as required.

Section 19.4.4 states if the damper is equipped with a fusible link, the link shall be removed for testing to ensure full closure and lock-inplace if so equipped.

Section 19.4.5 states the operational test of the damper shall verify that there is no damper interference due to rusted, bent, misaligned, or damaged frame or blades, or defective hinges or other moving parts.

NFPA 90A section 6.4.2.1 states smoke detectors listed for use in air distribution systems
shall be located as follows:
(1) Downstream of the air filters and ahead of any branch connections in air supply systems having a capacity greater than 944 L/sec (2000 ft3/min)
(2) At each story prior to the connection to a common return and prior to any recirculation or fresh air inlet connection in air return systems having a capacity greater than 7080 L/sec
(15,000 ft3/min) and serving more than one story

Section 6.4.3.1 states smoke detectors provided as required by 6.4.2 shall automatically stop their respective fan(s) on detecting the presence of smoke.

THE FINDINGS INCLUDE:

During the morning and afternoon hours of 1/18/17 and 1/19/17 while touring the Lamprey Building, the following items were observed regarding the installation of fire dampers and HVAC systems:

1) The waiting room opposite the South Stairwell door on the 5th floor level (of the Lamprey Building) has an obstructed damper access panel. The room has millwork (2' base cabinetry) along one of the walls perpendicular to the wall with the access panel. As a result of the cabinetry configuration, the cabinet extends approximately 10" over the access panel door preventing it from opening. As configured, required fire damper preventive maintenance can't be performed.

2) The second floor level 2-hour fire barrier wall between the Lamprey and Hamblet buildings has a 6" duct penetrating wall. This duct which is located above the ceiling in the Janitorial closet was not equipped with an access panel. As a result, it could not be substantiated that a fire damper was installed as required.

3) The two air conditioning units located in the Lamprey Mechanical Room identified as AC77-2 and AC77-3 each have a capacity greater than 2000 cubic feet/minute (cfm). After observation, it was determined that these units were not equipped with smoke detection for automatic shutdown.

As a result, the facility failed to comply with section 9.2 requiring the maintenance of Heating Ventilation and Air Conditioning (HVAC) Systems.

This observation was confirmed with the Hospital Senior Management Staff as well as Facilities Management Staff.

Based on observations and confirmed by staff the facility failed to ensure that portable space heaters are used in accordance with Section 19.7.8.

Section 19.7.8 states portable space heating-devices shall be prohibited in all health care occupancies, unless both of the following criteria are met:

(1) Such devices are used only in non-sleeping staff and employee areas.
(2) The heating elements of such devices do not exceed 212 degrees F(100 degrees C).

THE FINDINGS INCLUDE:

While conducting the facility tour during the morning hours of 1/18/17, a portable electric space heater with a heating element capable of exceeding 212 degrees F (100 degrees C) was observed in the Supplies Tech Coordinator's Office.

This observation was confirmed with the Hospital Senior Management Staff as well as Facilities Management Staff.

Based on observations and confirmed by staff the facility failed to ensure compliance with Section 19.7.8 of NFPA 101.

Section 19.7.8, states the portable space heating-devices shall be prohibited in all health care occupancies, unless both of the following criteria are met:
(1) Such devices are used only in non-sleeping staff and employee areas.
(2) The heating elements of such devices do not exceed 212 degrees F (100 degrees C).

Findings Include:

While conducting the facility tour during the morning and afternoon hours of 1/18/17, 1/19/17 and 1/20/17 observations revealed the presence of portable electric space heaters with heating elements capable of exceeding 212 degrees F (100 degrees C) located in the following areas:

1. The Housekeeping offices located in the basement of the Hamblet Building.
2. The Hospitality Suite located in the basement of the Russell Building.
3. The Laboratory Office located on the first floor of the Russell Building.
4. The Admissions Office located in the basement of the Russell Building.
5. The Pharmacy Office located in the basement of the Russell Building.
6. The Ambulatory Procedure Office located on the fourth floor of the Steven's Building.

As a result, the facility failed to comply with section 19.7.8.

This observation was confirmed with the Hospital Senior Management Staff as well as Facilities Management Staff.

Based on observations and confirmed by staff, the facility failed to ensure medical air supply systems are install as required.

NFPA 99 section 5.1.3.6.3.12 states compressor intake air for medical compressors shall meet the following:

(A) The medical air compressors shall draw their air from a source of clean air.
(B) The medical air intake shall be located a minimum of 7.6 m (25 ft) from ventilating system exhausts, fuel storage vents, combustion vents, plumbing vents, vacuum and WAGD discharges, or areas that can collect vehicular exhausts or other noxious fumes.
(C) The medical air intake shall be located a minimum of 6m (20 ft) above ground level.
(D) The medical air intake shall be located a minimum of 3.0m (10 ft) from any door, window, or other opening in the building.
(E) If an air source equal to or better than outside air (e.g., air already filtered for use in operating room ventilating systems) is available, it shall be permitted to be used for the medical air compressors with the following provisions:
(1) This alternate source of supply air shall be available on a continuous 24-hour-per-day, 7-day-per-week basis.
(2) Ventilating systems having fans with motors or drive belts located in the airstream shall not be used as a source of medical air intake.
(F) Compressor intake piping shall be permitted to be made of materials and use a jointing technique as permitted under 5.1.10.2.
(G) Air intakes for separate compressors shall be permitted to be joined together to one common intake where the following conditions are met:
(1) The common intake is sized to minimize back pressure in accordance with the manufacturer's recommendations.
(2) Each compressor can be isolated by manual or check valve, blind flange, or tube cap to prevent open inlet piping when the compressor(s) is removed for service from the consequent
backflow of room air into the other compressor(s).
(H) The end of the intake shall be turned down and screened or otherwise be protected against the entry of vermin, debris, or precipitation by screening fabricated or composed of a
non-corroding material.

THE FINDINGS INCLUDE:

During the afternoon hours of 1/23/17, the medical air intake for the Lamprey Building was viewed for compliance. The following items were observed regarding the installation of this intake piping:

1) The air intake point is located approximately twelve feet (12') directly above the Mechanical Room exhaust from Lamprey Building. In addition, the Radiology Room exhaust is located approximately ten feet (10') horizontally from the intake point.

2) The air intake point is located approximately two feet (2') from a double hung window unit.

3) The air intake point was not observed to have any screening protecting it from vermin and/or debris.

As a result, the facility failed to comply with NFPA 99 section 5.1.3.6.3.12 requiring medical air piping to be installed as required.

This observation was confirmed with the Hospital Senior Management Staff as well as Facilities Management Staff.

Based on observations and confirmed by staff the facility failed to ensure compliance with Section 19.3.2.4 of the 2012 edition of NFPA 101.

-Section 19.3.2.4 "Medical Gas" states medical gas storage and administration areas shall be in accordance with section 8.7 and the provisions of NFPA 99, "Health Care Facilities Code" applicable to administration, maintenance and testing.

-Section 11.6.2.3 (11) of the 2012 edition of NFPA 99 states that freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.

Findings Include:

During the morning hours of 1/18/17, while conducting a tour of the Intensive Care Unit located on the Russell Building's fifth floor level, observations revealed the presence of two (2) freestanding, unsupported "E" sized oxygen cylinders in a small office located adjacent to the "Multi-Purpose Room."

As a result of the finding the facility is found to be non-compliant with NFPA 99 Section 11.6.2.3 (11).

This observation was confirmed with the Hospital Senior Management Staff as well as Facilities Management Staff.