HospitalInspections.org

NFPA 101 LIFE SAFETY CODE (2012 edition)
7.2.9.4 Emergency generators providing power to emergency lighting systems shall be installed, tested and maintained in accordance with NFPA 110 STANDARD for EMERGENCY and STANDBY POWER SYSTEMS (2010 edition).
7.9.3.1.1 Testing of the emergency lighting systems shall be permitted to be conducted as follows:
(1) Functional testing shall be conducted monthly, with a minimum of 3 weeks and a maximum of 5 weeks between tests, for not less than 30 seconds.
(2) The test interval shall be permitted to be extended beyond 30 days with the approval of the AHJ (Authority Having Jurisdiction).
(3) Functional testing shall be conducted annually for a minimum of 1 1/2 hours if the emergency lighting system is battery powered.
(4) The emergency lighting equipment shall be fully operational for the duration of the tests required by 7.9.3.1.1 (1) and (3).

NFPA 110 STANDARD for EMERGENCY and STANDBY POWER SYSTEMS (2010 edition)
7.3 Lighting
7.3.1 The level 1 or level 2 EPS (Emergency Power Supply) equipment locations shall be provided with battery powered emergency lighting.
This requirement shall not apply to units located outdoors in enclosures that do not include walk in access.



Based on observation and interview the facility failed to ensure that an emergency power ATS (Automatic Transfer Switch) panel was equipped with battery powered emergency lighting.

Findings include:

Observation during tour on 04/18/19 between 12:30 p.m. and 12:45 p.m. with Staff A (Director of Facilities and Safety Officer) and Staff B (Facilities and Emergency Management Coordinator) revealed that the ATS panel, located in the main electrical room, failed to be equipped with a 90 minute battery powered emergency lighting unit.

Interview with Staff A and Staff B confirmed the above finding and location.

NORTHEAST REHAB IN SALEM, NH

Based on observation and interview the facility failed to ensure that 1 storage room (exceeding 50 sq. ft.) failed to be equipped with an automatic door closing device.

Findings include:

Observation during tour on 04/16/19 between 1:30 p.m. and 2:00 p.m. with Staff A (Director of Facilities and Safety Officer) and Staff B (Facilities and Emergency Management Coordinator) revealed that the entrance door to the Clean Utility Storage room in the 200 unit, approximately 64 sq. ft., failed to be equipped with an automatic door closing device.

Interview with Staff A and Staff B confirmed the above finding and location.

NORTHEAST REHAB at PEASE in PORTSMOUTH NH

Based on observation and interview the facility failed to ensure that 1 ABHR (Alcohol Based Hand Rub) dispenser is not installed directly over an electrical outlet.

Findings include:

Observation during tour on 04/17/19 between 11:30 a.m. and 11:40 a.m. with Staff A (Director of Facilities and Safety Officer), Staff B (Facilities and Emergency Management Coordinator) and Staff C (Building Maintenance Supervisor) revealed that 1 ABHR dispenser is mounted directly over an electrical outlet. The dispenser was located in the 2nd floor physical therapy gym, on the south wall between 2 window openings.

Interview with Staff A, Staff B and Staff C confirmed the above findings. The ABHR dispenser was removed during survey.

NFPA 13 Standard for the Installation of Sprinkler Systems (2010 edition)
8.5.5.3 Obstructions that Prevent Sprinkler Discharge from Reaching the Hazard. Continuous or non-continuous obstructions that interrupt the water discharge in a horizontal plane more than 18 inches below the sprinkler deflector in a manner to limit the distribution from reaching the protected hazard shall comply with 8.5.5.3.

8.5.5.3.1 Sprinklers shall be installed under fixed obstructions over 4 feet wide such as ducts, decks, open grate flooring, cutting tables, and overhead doors.

8.5.5.3.2 Sprinklers shall not be required under obstructions that are not fixed in place such as conference tables.

NORTHEAST REHAB IN SALEM, NH

Based on observations and interview the facility failed to ensure that complete sprinkler coverage was available behind the 2 commercial clothes dryers, in the 1st floor laundry department.

Findings include:

Observation during tour on 04/17/19 between 10:30 a.m. and 10:45 a.m. with Staff A (Director of Facilities and Safety Officer), Staff B (Facilities and Emergency Management Coordinator) and Staff C (Building Maintenance Supervisor) revealed that behind the 2 commercial clothes dryers, in the service and exhaust ductwork room,was an approximately 5' x 7' piece of sheet metal ductwork assembly located above the 2 dryer's, which effectively blocked sprinkler coverage in the area. There is 1 sprinkler head located on the side wall, next to the sheet metal ductwork preventing an effective sprinkler discharge pattern.

Interview with Staff A, Staff B and Staff C confirmed the above finding and location.

NFPA 25 Standard for the Inspection, Testing and Maintenance of Water-based Fire Protection Systems. (2011 edition)

13.2.7 Gauges.
13.2.7.1 Gauges shall be inspected monthly to verify that they are in good condition and that normal pressure is being maintained.
13.2.7.1.1 Where other sections of this standard have different frequency requirements for specific gauges, those requirements shall be used.
13.2.7.2 Gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge.
13.2.7.3 Gauges not accurate within 3% of the full scale shall be recalibrated or replaced.

13.2.8 Records shall be maintained.

Based on record review and interview the facility failed to ensure that at least 3 sprinkler system pressure gauges could be verified for recalibration or installation dates.

Findings include:

Record review during tour on 04/18/19 between 11:30 a.m. and 12:30 p.m. with Staff A (Director of Facilities and Safety Officer) and Staff B (Facilities and Emergency Management Coordinator) revealed that the 3 pressure gauges installed on the sprinkler system riser, located in the main boiler room, failed to have a manufacturers date stamp, install date label, or documentation of the original installation date tagged on the sprinkler riser assembly. No documentation of the gauges was able to be located.

Interview with Staff A and Staff B confirmed the above finding and location.

NFPA 10 Standard for Portable Fire Extinguishers (2010 edition)

7.1.2.3 Persons performing 30-day inspections shall not be required to be certified.
7.2.1 Frequency
7.2.1.1 Fire extinguishers shall be manually inspected when initially placed in service.
7.2.1.2 Fire extinguishers shall be inspected either manually or by means of an electronic monitoring device/system at a minimum of 30 day intervals.

Based on observation and interview the facility failed to ensure that 1 fire extinguisher was inspected for the month of February 2019.

Observation during tour on 04/18/19 between 12:00 p.m. and 12:15 p.m. with Staff A (Director of Facilities and Safety Officer) and Staff B (Facilities and Emergency Management Coordinator) revealed that the fire extinguisher located at the Nurse's Station, failed to have the February inspection documented on the tag.

Interview with Staff A and Staff B confirmed the above finding and location.

Based on observation and interview the facility failed to ensure that 2 patient room doors and 1 office door could resist the passage of smoke or effects from fire.

Findings include:

Observations during tour on 04/18/19 between 12:00 p.m. and 12:45 p.m. with Staff A (Director of Facilities and Safety Officer) and Staff B (Facilities and Emergency Management Coordinator) revealed 3 doors, protecting the corridor, have a gap between the door slab and the door frame that exceeds 1/2".
These doors and conditions are as follows:
1. Patient room door # 303 has a gap of at least 3/4" between the door slab and the door frame.
2. Patient room door # 312 has a gap of at least 3/4" between the door slab and the door frame.
3. The Nurse Managers office door has a gap of at least 3/4" between the door slab and the door frame.

The 3 doors, protecting the egress corridor, will not resist the passage of smoke or the effects from fire.

Interview with Staff A and Staff B confirmed the above findings and locations.

NORTHEAST REHAB IN SALEM, NH

Based on observation and interview the facility failed to ensure that the "Bulk Oxygen Storage" enclosure was posted with "No Smoking" signs on the chain link fencing enclosure or on the access gates.

Findings include:

Observation during tour on 04/16/19 between 2:00 p.m. and 2:30 p.m. with Staff A (Director of Facilities and Safety Officer) and Staff B (Facilities and Emergency Management Coordinator) revealed that the "Bulk Oxygen Storage" enclosure, located next to the rear parking lot, failed to have visible "No Smoking" signs posted on the chain link fencing or on the 2 enclosure access gates.

Interview with Staff A and Staff B confirmed the above finding and location. No Smoking signs were installed during the survey.