HospitalInspections.org

*The facility failed to provide complete sprinkler coverage. Findings include:

1 . Light fixtures were observed during the survey untented, not providing a one hour rated ceiling/roof assemblies in the part of the facility without sprinkler coverage. A "UL" design number with a one hour rated assembly for ceiling/roof assemblies is required for Type II (111).

2. Surface mounted light fixtures in the part of the facility without sprinkler coverage were observed during the survey without the ceiling tile installed in the grid system above the light fixture in the corridor.

Buildng Type II (111) requires at least a one hour rated ceiling assembly per NFPA 101, 19.1.6.2. A fire rated ceiling/roof assembly is not required in facilities of Type II construction when the facility is fully sprinklered.

The facility failed to provide smoke barriers that would provide at least a half hour fire resistance rating. Findings include: During the survey, the following was observed:

1. Unsealed penetrations around a group of wiring, in two seperate locations, also at the end of a sleeve, in the Smoke Barrier by the Lab Entrance.

2. Unsealed penetrations around wiring, conduit, in the Smoke Barrier, by Patient Room 117.

NFPA 101, 19.3.7.3 Smoke walls shall have a fire resistance rating of at least half hour and to be continuous from floor-to-deck and from outside-to-outside.

The facility failed to maintain separation of hazardous areas. Findings include: During the survey, the following was observed:

Unsealed penetrations around a sprinkler line, conduit, and a group of wiring in the wall of the Boiler Room.

NFPA 101, 19.3.2.1 and 8.4.1 Hazardous areas to be provided with smoke-resisting partitions and doors when protection consists of an automatic extinguishing system. Doors shall be self-closing with positive latching hardware.

The facility failed to provide a reliable means of egress to the public way. Based upon observation during the survey, the following Exits failed tp provide an all weather surface to the public way:

1. The Exit from PACU.
2. The Exit from Physical Therapy.
3. The Exit from OPC.


NFPA 101, 7.1.10.1 Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.


NFPA 101, A.7.1.10.1 *A proper means of egress allows unobstructed travel at all times. Any type of barrier including, but not limited to, the accumulations of snow and ice in those climates subject to such accumulations is an impediment to free movement in the means of egress.

The facility failed to provide continuous lighting for means of egress. Findings include: During the survey, the Exit Discharge was observed to have single bulbed light fixtures at the following locations:

1. The Exit by X-Ray.
2. The Exit by Education.
3. The Exit by PACU.
4. The Exit by Physical Therapy.
5. The Exit by OPC.
6. The Exit by East Wing.

NFPA 101, 19.2.8 and 7.8.1.2 Illumination of means of egress shall be continuous.

Based on observations and interviews, the facility failed to record the participation of staff in fire drills. Participant signatures were not provided.
NFPA 101, 19.7.1.2: Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms. Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building.

A) Facility failed to maintain the Digital Alarm Communicator Transmitter in the fire alarm system. Findings include:During the survey, the following was observed:

1. When the Auto Dialer was tested for phone line 2, failure after 5 minutes a visible/audible was not indicated at the protected premise, failure must be within four (4) minute time frame.

2. When the Auto Dialer was tested for Communication Failure, failure was not indicated at the protected premise within the allotted fifteen (15) minute time frame (5 minimum to 10 maximum attempts for signal transmission). (Surveyor waited 17 minutes.) Visible/Audible was not inicated for communication failure during this time frame.

1999 NFPA 72, Section 1-5.4.6, 5-5.3.2.1.5, and 5-5.3.2.1.6.2. Phone line and communication failure shall be indicated at the facility.


B) When the surveyors arrived at the facility on 5/5/2010, approximately 8:45am, the Maintenance Director advised the Fire Alarm Panel was indicating trouble, all magnetic hold open devices had released all smoke doors throughout the facility. The Maintenance Director advised he had called service tech to come and determine what the issue was that had caused doors to release. Later during the survey, when we tested the fire alarm visible/audible devices, function properly.

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

Based on observations and interviews performed during the survey, the facility failed to comply with NFPA 72 requirements for testing and maintenance of the fire alarm system. Findings include:
Documentation indicated the fire alarm system had not been inspected and tested since 2005. This was confirmed during an interview with maintenance staff.
NFPA 101, 9.6.1.4: The fire alarm system to be installed, tested, and maintained in accordance with the requirements of NFPA 70 and NFPA 72.
NFPA 72, Table 7-3.1: Visual Inspection Frequencies
NFPA 72, Table 7-3.2: Testing Frequencies
NFPA 72, Section 7-5.2.2: A permanent record of all inspections, testing, and maintenance shall be provided.

The facility failed to provide complete sprinkler coverage to all parts of the facility.
Findings include: During the survey, the following locations were not provided with sprinkler coverage:

1. Biohazard Room.
2. The Riser Room.
3. A 8' x 19' 6' overhang at the East Wing Exit by Patient Room 122, was covered with what appeared to be a vinyl material.
4. A 10' x 8' overhang with wood framing, and a metal deck, which is used to cover an A/C unit, and a Gas Meter, by Dining Room Patio.

1999 NFPA 13, 5-13.8 Sprinklers shall be installed under exterior combustible roofs or canopies exceeding four feet in width, or over areas where combustibles are stored.

Based on observations and interviews, the facility failed to comply with the requirements of NFPA 96 and referenced standards for the maintenance and protection of cooking facilities. Findings include:

A) The dietary kitchen was not observed with a "K" labeled Portable Fire Extinguisher installed. Staff at the facility confirmed this finding.

B) Records were not available for the monthly inspection of fire-extinguishing system serving the cooking equipment. This documentation was not provided on the label at the manual release and was not documented in a separate log. Maintenance staff confirmed these findings during an interview and was not previously aware of this requirement.

NFPA 96, 7-10.1 & NFPA 10, 2-3.2, 3-7: Portable fire extinguishers shall be installed in kitchen cooking areas in accordance with NFPA 10, Standard for Portable Fire Extinguishers. Fire extinguishers provided for the protection of cooking appliances that use combustible cooking media (vegetable or animal oils and fats) shall be listed and labeled for Class K fires. Exception: Extinguishers installed specifically for these hazards prior to June 30, 1998. Maximum travel distance shall not exceed 30 ft (9.15 m) from the hazard to the extinguishers.

NFPA 96, 7-2.2.1; NFPA 17, 9-2.4 & NFPA 17A, 5-2.4; NFPA 17, 9-2.1 & NFPA 17A, 5-2.1: On a monthly basis, inspection shall be conducted in accordance with the manufacturer's listed installation and maintenance manual or owner's manual. At least monthly, the date the inspection is performed and the initials of the person performing the inspection shall be recorded. The records shall be retained for the period between the semiannual maintenance inspections. As a minimum, this "quick chec "or inspection shall include verification of the following:
a) The extinguishing system is in its proper location.
b) The manual actuators are unobstructed.
c) The tamper indicators and seals are intact.
d) The maintenance tag or certificate is in place.
e) The system shows no physical damage or condition that might prevent operation.
f) The pressure gauge(s), if provided, is in operable range.
g) The nozzle blow-off caps, where provided, are intact and undamaged.
h) Neither the protected equipment nor the hazard has been replaced, modified, or relocated.

The facility failed to provide proper storage of oxygen cylinders. Findings include:

During the survey, signage was not provided for full/empty cylinders, and full/empty cylinders were being stored together.

CGA G-4, 4.1.10, and 1999 NFPA 99, 4-3.5.2.2(b)2 and 4-5.5.2.2(b)2 Full and empty cylinders shall be stored separately, with appropriate signage.

Based on observations and interviews, the facility failed to maintain the piped medical gas system. Findings include:

The most recent inspection report was dated 4/25/2005, and contained deficiencies citied during the inspection of the medical gas system to which had not been responded. In addition, the report specifically indicated the system did not meet the code requirements of NFPA 99 (1999 Edition).

Based on observations and interviews, the facility failed to inspect the generator in accordance with NFPA 110. Findings include:

Documentation of the weekly inspection of the generator was not available for review for several weeks in March of 2010. Maintenance staff confirmed the weekly inspections did not occurr during this time.

NFPA 110, 6-4.1, 6-3.4: Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly. Exception: If the generator set is used for standby power or for peak load shaving, such use shall be recorded and shall be permitted to be substituted for scheduled operations and testing of the generator set, provided the appropriate data is recorded. A written record of the EPSS inspections, tests, exercising, operation, and repairs shall be maintained on the premises. The written record shall include the following:
a) The date of the maintenance report
b) Identification of the servicing personnel
c) Notation of any unsatisfactory condition and the corrective action taken, including parts replaced
d) Testing of any repair for the appropriate time as recommended by the manufacturer.

The facility failed to provide supervision of the emergency generator. Findings include:

At the time of the survey, it was observed that the remote Generator Alarm Annunciator was not provided in a continuously monitored location in the facility.

1999 NFPA 99, 3-4.1.1.15 + Alarm Annunciator. A remote annunciator, storage battery powered, shall be provided to operate outside of the Generating Room in a location readily observed by operating personnel at a regular work station.

The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows:
(a) Individual visual signals shall indicate the following:
1. When the emergency or auxiliary power source is operating to supply power to load
2. When the battery charger is malfunctioning
(b) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following:
1. Low lubricating oil pressure
2. Low water temperature (below those required in 3-4.1.1.9)
3. Excessive water temperature
4. Low fuel - when the main fuel storage tank contains less than a 3-hour operating supply
5. Overcrank (failed to start)
6. Overspeed

Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions in 3-4.1.1.15(a) and (b) occur, but need not display these conditions individually. [110: 3-5.5.2]

The facility failed to provide approved electrical utilities. Findings include: During the survey, the following was observed:

1. Electrical boxes (2) were missing covers in the Biohazard Room.
2. Electrical boxes (2) were missing covers in the Main Boiler Room.
3. Electrical boxes (3) were missing covers in the HVAC Room.

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

*The facility failed to provide complete sprinkler coverage. Findings include:

1 . Light fixtures were observed during the survey untented, not providing a one hour rated ceiling/roof assemblies in the part of the facility without sprinkler coverage. A "UL" design number with a one hour rated assembly for ceiling/roof assemblies is required for Type II (111).

2. Surface mounted light fixtures in the part of the facility without sprinkler coverage were observed during the survey without the ceiling tile installed in the grid system above the light fixture in the corridor.

Buildng Type II (111) requires at least a one hour rated ceiling assembly per NFPA 101, 19.1.6.2. A fire rated ceiling/roof assembly is not required in facilities of Type II construction when the facility is fully sprinklered.

The facility failed to provide smoke barriers that would provide at least a half hour fire resistance rating. Findings include: During the survey, the following was observed:

1. Unsealed penetrations around a group of wiring, in two seperate locations, also at the end of a sleeve, in the Smoke Barrier by the Lab Entrance.

2. Unsealed penetrations around wiring, conduit, in the Smoke Barrier, by Patient Room 117.

NFPA 101, 19.3.7.3 Smoke walls shall have a fire resistance rating of at least half hour and to be continuous from floor-to-deck and from outside-to-outside.

The facility failed to maintain separation of hazardous areas. Findings include: During the survey, the following was observed:

Unsealed penetrations around a sprinkler line, conduit, and a group of wiring in the wall of the Boiler Room.

NFPA 101, 19.3.2.1 and 8.4.1 Hazardous areas to be provided with smoke-resisting partitions and doors when protection consists of an automatic extinguishing system. Doors shall be self-closing with positive latching hardware.

The facility failed to provide a reliable means of egress to the public way. Based upon observation during the survey, the following Exits failed tp provide an all weather surface to the public way:

1. The Exit from PACU.
2. The Exit from Physical Therapy.
3. The Exit from OPC.


NFPA 101, 7.1.10.1 Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.


NFPA 101, A.7.1.10.1 *A proper means of egress allows unobstructed travel at all times. Any type of barrier including, but not limited to, the accumulations of snow and ice in those climates subject to such accumulations is an impediment to free movement in the means of egress.

The facility failed to provide continuous lighting for means of egress. Findings include: During the survey, the Exit Discharge was observed to have single bulbed light fixtures at the following locations:

1. The Exit by X-Ray.
2. The Exit by Education.
3. The Exit by PACU.
4. The Exit by Physical Therapy.
5. The Exit by OPC.
6. The Exit by East Wing.

NFPA 101, 19.2.8 and 7.8.1.2 Illumination of means of egress shall be continuous.

Based on observations and interviews, the facility failed to record the participation of staff in fire drills. Participant signatures were not provided.
NFPA 101, 19.7.1.2: Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms. Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building.

A) Facility failed to maintain the Digital Alarm Communicator Transmitter in the fire alarm system. Findings include:During the survey, the following was observed:

1. When the Auto Dialer was tested for phone line 2, failure after 5 minutes a visible/audible was not indicated at the protected premise, failure must be within four (4) minute time frame.

2. When the Auto Dialer was tested for Communication Failure, failure was not indicated at the protected premise within the allotted fifteen (15) minute time frame (5 minimum to 10 maximum attempts for signal transmission). (Surveyor waited 17 minutes.) Visible/Audible was not inicated for communication failure during this time frame.

1999 NFPA 72, Section 1-5.4.6, 5-5.3.2.1.5, and 5-5.3.2.1.6.2. Phone line and communication failure shall be indicated at the facility.


B) When the surveyors arrived at the facility on 5/5/2010, approximately 8:45am, the Maintenance Director advised the Fire Alarm Panel was indicating trouble, all magnetic hold open devices had released all smoke doors throughout the facility. The Maintenance Director advised he had called service tech to come and determine what the issue was that had caused doors to release. Later during the survey, when we tested the fire alarm visible/audible devices, function properly.

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

Based on observations and interviews performed during the survey, the facility failed to comply with NFPA 72 requirements for testing and maintenance of the fire alarm system. Findings include:
Documentation indicated the fire alarm system had not been inspected and tested since 2005. This was confirmed during an interview with maintenance staff.
NFPA 101, 9.6.1.4: The fire alarm system to be installed, tested, and maintained in accordance with the requirements of NFPA 70 and NFPA 72.
NFPA 72, Table 7-3.1: Visual Inspection Frequencies
NFPA 72, Table 7-3.2: Testing Frequencies
NFPA 72, Section 7-5.2.2: A permanent record of all inspections, testing, and maintenance shall be provided.

The facility failed to provide complete sprinkler coverage to all parts of the facility.
Findings include: During the survey, the following locations were not provided with sprinkler coverage:

1. Biohazard Room.
2. The Riser Room.
3. A 8' x 19' 6' overhang at the East Wing Exit by Patient Room 122, was covered with what appeared to be a vinyl material.
4. A 10' x 8' overhang with wood framing, and a metal deck, which is used to cover an A/C unit, and a Gas Meter, by Dining Room Patio.

1999 NFPA 13, 5-13.8 Sprinklers shall be installed under exterior combustible roofs or canopies exceeding four feet in width, or over areas where combustibles are stored.

Based on observations and interviews, the facility failed to comply with the requirements of NFPA 96 and referenced standards for the maintenance and protection of cooking facilities. Findings include:

A) The dietary kitchen was not observed with a "K" labeled Portable Fire Extinguisher installed. Staff at the facility confirmed this finding.

B) Records were not available for the monthly inspection of fire-extinguishing system serving the cooking equipment. This documentation was not provided on the label at the manual release and was not documented in a separate log. Maintenance staff confirmed these findings during an interview and was not previously aware of this requirement.

NFPA 96, 7-10.1 & NFPA 10, 2-3.2, 3-7: Portable fire extinguishers shall be installed in kitchen cooking areas in accordance with NFPA 10, Standard for Portable Fire Extinguishers. Fire extinguishers provided for the protection of cooking appliances that use combustible cooking media (vegetable or animal oils and fats) shall be listed and labeled for Class K fires. Exception: Extinguishers installed specifically for these hazards prior to June 30, 1998. Maximum travel distance shall not exceed 30 ft (9.15 m) from the hazard to the extinguishers.

NFPA 96, 7-2.2.1; NFPA 17, 9-2.4 & NFPA 17A, 5-2.4; NFPA 17, 9-2.1 & NFPA 17A, 5-2.1: On a monthly basis, inspection shall be conducted in accordance with the manufacturer's listed installation and maintenance manual or owner's manual. At least monthly, the date the inspection is performed and the initials of the person performing the inspection shall be recorded. The records shall be retained for the period between the semiannual maintenance inspections. As a minimum, this "quick chec "or inspection shall include verification of the following:
a) The extinguishing system is in its proper location.
b) The manual actuators are unobstructed.
c) The tamper indicators and seals are intact.
d) The maintenance tag or certificate is in place.
e) The system shows no physical damage or condition that might prevent operation.
f) The pressure gauge(s), if provided, is in operable range.
g) The nozzle blow-off caps, where provided, are intact and undamaged.
h) Neither the protected equipment nor the hazard has been replaced, modified, or relocated.

The facility failed to provide proper storage of oxygen cylinders. Findings include:

During the survey, signage was not provided for full/empty cylinders, and full/empty cylinders were being stored together.

CGA G-4, 4.1.10, and 1999 NFPA 99, 4-3.5.2.2(b)2 and 4-5.5.2.2(b)2 Full and empty cylinders shall be stored separately, with appropriate signage.

Based on observations and interviews, the facility failed to maintain the piped medical gas system. Findings include:

The most recent inspection report was dated 4/25/2005, and contained deficiencies citied during the inspection of the medical gas system to which had not been responded. In addition, the report specifically indicated the system did not meet the code requirements of NFPA 99 (1999 Edition).

Based on observations and interviews, the facility failed to inspect the generator in accordance with NFPA 110. Findings include:

Documentation of the weekly inspection of the generator was not available for review for several weeks in March of 2010. Maintenance staff confirmed the weekly inspections did not occurr during this time.

NFPA 110, 6-4.1, 6-3.4: Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly. Exception: If the generator set is used for standby power or for peak load shaving, such use shall be recorded and shall be permitted to be substituted for scheduled operations and testing of the generator set, provided the appropriate data is recorded. A written record of the EPSS inspections, tests, exercising, operation, and repairs shall be maintained on the premises. The written record shall include the following:
a) The date of the maintenance report
b) Identification of the servicing personnel
c) Notation of any unsatisfactory condition and the corrective action taken, including parts replaced
d) Testing of any repair for the appropriate time as recommended by the manufacturer.

The facility failed to provide supervision of the emergency generator. Findings include:

At the time of the survey, it was observed that the remote Generator Alarm Annunciator was not provided in a continuously monitored location in the facility.

1999 NFPA 99, 3-4.1.1.15 + Alarm Annunciator. A remote annunciator, storage battery powered, shall be provided to operate outside of the Generating Room in a location readily observed by operating personnel at a regular work station.

The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows:
(a) Individual visual signals shall indicate the following:
1. When the emergency or auxiliary power source is operating to supply power to load
2. When the battery charger is malfunctioning
(b) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following:
1. Low lubricating oil pressure
2. Low water temperature (below those required in 3-4.1.1.9)
3. Excessive water temperature
4. Low fuel - when the main fuel storage tank contains less than a 3-hour operating supply
5. Overcrank (failed to start)
6. Overspeed

Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions in 3-4.1.1.15(a) and (b) occur, but need not display these conditions individually. [110: 3-5.5.2]

The facility failed to provide approved electrical utilities. Findings include: During the survey, the following was observed:

1. Electrical boxes (2) were missing covers in the Biohazard Room.
2. Electrical boxes (2) were missing covers in the Main Boiler Room.
3. Electrical boxes (3) were missing covers in the HVAC Room.

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