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Based on document review and interview the facility failed to provide documented evidence that it developed and maintained an emergency preparedness plan that included a process for cooperation and collaboration with local, regional, State, and Federal emergency preparedness officials, including documentation of the facility's efforts to contact such officials and its participation in collaborative and cooperative planning efforts.

The deficiency had the potential of not having an integrated response to provide assistance during a disaster or emergency situation.

Finding:

During a document review on 11/2/18 at 11:40 a.m., the evaluator noted that there was no documented evidence that the facility will make efforts to contact emergency preparedness officials to engage in collaborative planning for an integrated emergency response.

During an interview at the same time as document review, the Associate Administrator of Hospital Operations stated that a process for cooperation and collaboration with emergency preparedness officials, including the facility's efforts to contact the officials was missing from the Plan.

NFPA 101 Life Safety Code 2012 Edition

Chapter 39 Existing Business Occupancies

39.2.1.1 All means of egress shall be in accordance with Chapter 7 and this chapter.

7.1.6.2 Changes in Elevation. Abrupt changes in elevation of walking surfaces shall not exceed 1.4 in. (6.3 mm). Changes in elevation exceeding 1.4 in. (6.3 mm), but not exceeding 1.2 in. (13 mm), shall be beveled with a slope of 1 in 2. Changes in elevation exceeding 1.2 in. (13 mm) shall be considered a change in level and shall be subject to the requirements of 7.1.7.

7.2.1.5.10.1 The releasing mechanism for any latch shall be located as follows:
(1) Not less than 34 in. (865 mm) above the finished floor for other than existing installations
(2) Not more than 48 in. (1220 mm) above the finished floor

7.2.1.5.10.2 The releasing mechanism shall open the door leaf with not more than one releasing operation, unless otherwise specified in 7.2.1.5.10.3, 7.2.1.5.10.4, or 7.2.1.5.10.6.

The Code was not met as evidenced by:

Based on observation and interview the facility failed to ensure a walking surface was free of a trip hazard and that a door released with a single action with the door latching mechanism was not less than 34 inches and not more than 48 inches above the finished floor.


The deficiencies had a potential to cause a tripping hazard, and to delay or prevent egress.

Signal Hill Partial Hospitalization Program (PHP)

1. On 10/30/18 between 9:20 a.m. and 10:05 a.m., the evaluator observed at the Signal Hill PHP, a 1/2 inch change in elevation of walking surface at a concrete ramp in the path of egress between an exit door and the public way on the Walton Street side of the facility. The change in elevation was where the top landing meets the ramp.

During an interview at the same time as the observation the Vice President of Outpatient Services acknowledged the deficiency and stated that the landlord would be called to repair the ramp.

Alhambra Partial Hospitalization Program (PHP)

2. On 10/30/18 at 2:30 p.m., the evaluator observed an EXIT sign posted next to one of two doors in the Medical Director's office at Alhambra PHP The door had a knob latch and two engaged slide bolts. One slide bolt was 15 inches above the finished floor and the other slide bolt was 70 inches above the finished floor.

During an interview at the same time as the observation the Vice President of Outpatient Services was informed of the deficiency.

NFPA 101 Life Safety Code 2012 Edition

39.2.10 Marking of Means of Egress. Means of egress shall have signs in accordance with Section 7.10.

7.10.1.8* Visibility. Every sign required in Section 7.10 shall be located and of such size, distinctive color, and design that it is readily visible and shall provide contrast with decorations, interior finish, or other signs. No decorations, furnishings, or equipment that impairs visibility of a sign shall be permitted. No brightly illuminated sign (for other than exit purposes), display, or object in or near the line of vision of the required exit sign that could detract attention from the exit sign shall be permitted.

7.10.8.3.1 Any door, passage, or stairway that is neither an exit nor a way of exit access and that is located or arranged so that it is likely to be mistaken for an exit shall be identified by
a sign that reads as follows:

NO
EXIT

The Code was not met as evidenced by:

Based on observation and interview the facility failed to ensure that a NO EXIT sign was readily visible.

The deficiency had the potential to delay or prevent the rapid evacuation of occupants.

Finding:

Signal Hill Partial Hospitalization Program (PHP)

1. On 10/30/18 between 9:20 a.m. and 10:05 a.m., the evaluator observed two doors located below a lighted exit sign at the Signal Hill PHP. The right side door was free of any decorations and exited to the parking lot. The left side door had a decoration on it and opened to an enclosed wood frame smoking patio. Closer observation revealed that the decoration was placed in front of signage that read, NOT AN EXIT.

During an interview at the same time as the observation the Vice President of Outpatient Services and the Program director were informed of the deficiency.

Main Hospital (1 North)

2. On 10/29/18 at 10:30 a.m., the evaluator observed that an exit sign was missing above the cross corridor door across from the 1 North nurses station.

During an interview at the same time as the observation the Engineering Supervisor acknowledged the missing exit sign and stated that a patient had probably knocked off the sign.

NFPA 96 Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations 2011 Edition

12.1.2.4 All deep-fat fryers shall be installed with at least a 406 mm (16 in.) space between the fryer and surface flames from adjacent cooking equipment.

12.1.2.5 Where a steel or tempered glass baffle plate is installed at a minimum 203 mm (8 in.) in height between the fryer and surface flames of the adjacent appliance, the requirement for a 406 mm (16 in.) space shall not apply.

12.1.2.5.1 If the fryer and the surface flames are at different horizontal planes, the minimum height of 203 mm (8 in.) shall be measured from the higher of the two.

These Standards were not met as evidenced by:

Based on observation and interview the facility failed to have a 16-inch space or a steel or tempered glass baffle at a minimum 8 inches in height between a fryer and surface flames from adjacent cooking equipment.

The deficiencies had the potential of igniting a kitchen fire. Oil could splash and come into contact with an open flame from an adjacent piece of cooking equipment.

Finding:

Main Hospital (Kitchen)

On 10/29/18 at 11:48 a.m., the evaluator observed a deep fryer located next to a natural gas fueled soup stove. The deep fryer was next to the stove, and there was no baffle plate at the deep fryer. The deep fryer was at a higher horizontal plane than the soup stove's surface flame.

During an interview at the same time as the observation the Director of Support services personnel was informed of the deficiency.

Based on record review and interview that facility failed to provide documented evidence that if the fire alarm system was out of service for more than ten hours in a 24-hour period, the authority having jurisdiction (AHJ) would be notified.

The deficiency had the potential of not notify the AHJ timely and to provide information on if building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service.

Finding:

Main Hospital

On 11/2/18 at 11 a.m., a review by the evaluator of the facility's procedure for when the fire system is compromised for more than 4 hours in a 23-hour (24 hour) period indicated that fire watch measures are implemented, but the procedure did not indicate that if the fire alarm system was out of service the AHJ would be notified.

During an interview at the same time as the record review the Associate Administrator of Hospital Operations acknowledged that the facility's procedure for when the fire system is compromised did not include notification of the AHJ when the fire alarm system is out of service.

NFPA 13 Standard for the Installation of Sprinkler Systems 2010 Edition

8.5.5.2.1 Continuous or non-continuous obstructions less than or equal to 18 in. (457 mm) below the sprinkler deflector that prevent the pattern from fully developing shall comply with 8.5.5.2.

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 in. (457 mm) below the sprinkler deflector in a manner to limit the distribution from reaching the protected hazard shall comply with 8.5.5.3.

8.5.6.1* Unless the requirements of 8.5.6.2, 8.5.6.3, 8.5.6.4, or 8.5.6.5 are met, the clearance between the deflector and the top of storage shall be 18 in. (457 mm) or greater.

The Standard was not met as evidenced by:

Based on observation and interview the facility failed to ensure an 18 inch clearance between a sprinkler head deflector and storage.

Finding:

Main Hospital (Back Hallway)

On 10/29/18 at 11:48 a.m., the evaluator observed storage with less than an 18 inch clearance in a horizontal plane between the deflector and the top of storage.

During an interview at the same time as the observation the Associate Administrator of Hospital Operations stated that she was told that the 18 inch clearance from the sprinkler deflector was only required directly under the deflector and not in a horizontal plane.

Based on record review and interview that facility failed to provide documented evidence that if the sprinkler system was out of service for more than ten hours in a 24-hour period, the authority having jurisdiction (AHJ) would be notified.

The deficiency had the potential of not notify the AHJ timely and to provide information on if, the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the sprinkler system has been returned to service.
The deficiency had the potential for the AHJ to not be aware if the facility was not protected by the sprinkler system.

Finding:

Main Hospital

On 11/2/18 at 11 a.m., review by the evaluator of the facility's procedure for when the fire system is compromised for more than 4 hours in a 23-hour (24 hour) period indicated that fire watch measures are implemented, but the procedure did not indicate that if the sprinkler system was out of service the AHJ would be notified.

During an interview at the same time as the record review the Associate Administrator of Hospital Operations acknowledged that the facility's procedure for when the fire system is compromised did not include notification of the AHJ when the sprinkler system is out of service.

NFPA 10 Standard for Portable Fire Extinguishers 2010 Edition

6.1.3.1 Fire extinguishers shall be conspicuously located where they are readily accessible and immediately available in the event of fire.

6.1.3.3.1 Fire extinguishers shall not be obstructed or obscured from view.

This Standard was not met as evidenced by:

Based on observation and interview the facility failed to ensure that a fire extinguisher was readily visible and not obstructed from view.

The deficiency had the potential to delay or prevent the use of a fire extinguisher in the event of an emergency.

Findings:

Signal Hill Partial Hospitalization Program (PHP)

During the Life Safety Code (LSC) survey on 10/30/18 between 9:20 a.m. and 10:05 a.m., the evaluator observed a fire extinguisher that was mounted on a wall next to an accordion wall in the dining room at the Signal Hill PHP. The fire extinguisher was obstructed from view.

During an interview at the same time as the observation, the Program Director stated that the accordion wall is completely closed when there is a need for another room.

During a second interview at the same time as the observation the Vice President of Outpatient Service stated that another fire extinguisher would be added.

Based on observation and interview the hospital failed to ensure that a corridor doors could resist the passage of smoke and that there were no impediments to the latching of corridor doors.

Doors protecting corridor openings play an integral role in interrupting the spread of smoke. The deficiency had the potential to permit the spread of smoke.

Findings:

Main Hospital (2 North)

1. During the Life Safety Code (LSC) On 10/29/18 at 11 a.m., the evaluator observed that the corridor door of room 227 failed to hold close in the closed potion.

During an interview at the same time as the observation the Director of Support Services/ Engineering acknowledged that the door failed to hold closed.

Main Hospital (4 North)

2. On 10/31/18 at 11:10 a.m., the evaluator observed one of two self closing corridor door of the Day Room at 4 North failed to close and latch within its frame. Closer observation revealed the door was jamming against it's door frame.

During an interview at the same time as the observation the Engineering Supervisor stated he would adjust the door.

NFPA 101 Life Safety Code 2012 Edition

8.5.4.5 Fire window assemblies shall comply with 8.3.3.

8.3.3.1 Openings required to have a fire protection rating by Table 8.3.4.2 shall be protected by approved, listed, labeled fire door assemblies and fire window assemblies and their accompanying hardware, including all frames, closing devices, anchorage, and sills in accordance with the requirements of NFPA 80, Standard for Fire Doors and Other Opening Protectives, except as otherwise specified in this Code.

NFPA 80 Standard for Fire Doors and Other Opening Protectives 2010 Edition

5.1.5.1 Repairs shall be made, and defects that could interfere with operation shall be corrected without delay.

5.2.15.4 When holes are left in a door or frame due to changes or removal of hardware or plant-ons, the holes shall be repaired by the following methods:
(1) Install steel fasteners that completely fill the holes
(2) Fill the screw or bolt holes with the same material as the door or frame

The Code and Standard was not met as evidenced by:

Based on observation and interview the facility failed to maintain a fixed fire window assembly of a cross corridor door.

The deficiency had the potential for the cross corridor door to fail to perform as designed during a fire.

Finding:

Main Hospital (3 South)

During the Life Safety Code (LSC) on 10/31/18 between 10:50 a.m. and 11:10 a.m., at the evaluator observed a vertical crack in the listed fire resistant wired glass of a fixed fire window of a cross corridor door at 3 South.

Closer observation revealed that one of eight screws was missing at the window frame of the cross corridor door leaving a hole in the frame.

During an interview at the same time as the observation the Director of Support Services stated that the damaged glass would be replaced by a listed fire resistant glass.

NFPA 101 Life Safety Code 2012 Edition

Chapter 19 Existing Health Care Occupancies

19.5.1.1 Utilities shall comply with the provisions of Section 9.1.

Chapter 39 Existing Business Occupancies

39.5.1 Utilities. Utilities shall comply with the provisions of Section 9.1.

9.1 9.1.2 Electrical Systems. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless such installations are approved existing installations, which shall be permitted to be continued in service.

NFPA 70 National Electrical Code 2011 Edition

110.12 Mechanical Execution of Work. Electrical equipment shall be installed in a neat and workmanlike manner.

110.13(A) Mounting. Electrical equipment shall be firmly secured to the surface on which it is mounted. Wooden plugs driven into holes in masonry, concrete, plaster, or similar materials shall not be used.

110.26 Spaces About Electrical Equipment. Access and working space shall be provided and maintained about all electrical equipment to permit ready and safe operation and maintenance of such equipment.

(B) Clear Spaces. Working space required by this section shall not be used for storage. When normally enclosed live parts are exposed for inspection or servicing, the working space, if in a passageway or general open space, shall be suitably guarded.

These Codes were not met as evidenced by:

Based on observation and interview the facility failed to ensure that electrical wiring and equipment was in accordance with NFPA 70. There were storage of items in the main electrical panel room with loose electrical boxes and receptacles.

Storage in electrical rooms can delay or prevent access to the electrical panel and can act as a conductor. Loose electrical boxes and receptacles can loosen electrical connections creating a risk of electrical fire.

Finding:

Main Hospital (1 North)

1. During the Life Safety Code (LSC) on 10/29/18 at 10:15 a.m., the evaluator observed a loose electrical junction box at the wall in the telephone room 1 North.

During an interview at the same time as the observation the Director of Support Services/ Engineering acknowledged the loose electrical junction box.

Main Hospital (1 South)

2. During the Life Safety Code (LSC)On 10/29/18 at 10:55 a.m., the evaluator observed a loose electrical receptacle at the back wall in the nurses station of 1 South.

During an interview at the same time as the observation the Director of Support Services/ Engineering acknowledged the loose electrical receptacle.

Cerritos Outpatient Partial Hospitalization Program (PHP)

3. During the Life Safety Code (LSC) on 10/29/18 at 11 a.m., the evaluator observed the electrical panel room at Cerritos PHP. The evaluator also noted that there were two stored mop buckets, one ladder, one large cork and wood bulletin board, four cardboard boxes, and one wood shelf. The bulletin board was observed leaning against the front of the electrical panel and the boxes and shelf were on top of the electrical panel.

During an interview at the same time as the observation the Senior Vice President of Hospital Division stated that the items should not been stored in the electrical panel room.

Main Hospital (Kitchen)

4. During the Life Safety Code (LSC) on 10/31/18 at 10:05 a.m., the evaluator observed a loose electrical box at the wall between an entrance and a reach in cooler unit in the kitchen.

During an interview at the same time as the observation the Engineering Supervisor acknowledged the loose electrical box.

Main Hospital (3 South)

5. During the Life Safety Code (LSC) on 10/31/18 at 10:50 a.m., the evaluator observed a loose electrical receptacle at the corridor next to room 310 of 3 South.

During an interview at the same time as the observation the Engineering Supervisor acknowledged the loose electrical receptacle.

Santa Ana Outpatient Partial Hospitalization Program (PHP)

6. During the Life Safety Code (LSC) on 11/1/18 at 11 a.m., the evaluator observed the electrical panel room at Santa Ana PHP. The evaluator also noted that the area was used to store a student desk and four portable air conditioning (A/C) units. The student desk and A/C units were in front of the electrical panels.

During an interview at the same time as the observation the Vice President of Outpatient Services acknowledged the storage in front of the electrical panels.

NFPA 70 National Electrical Code 2011 Edition

400.8 Uses Not Permitted. Unless specifically permitted in 400.7, flexible cords and cables shall not be used for the following:

(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
Exception to (4): Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of 368.56(B)
(5) Where concealed by walls, floors, or ceilings or located above suspended or dropped ceilings
(6) Where installed in raceways, except as otherwise permitted in this Code
(7) Where subject to physical damage

400.9 Splices. Flexible cord shall be used only in continuous lengths without splice or tap where initially installed in applications permitted by 400.7(A). The repair of hard-service cord and junior hard-service cord (see Trade Name column in Table 400.4) 14 AWG and larger shall be permitted if conductors are spliced in accordance with 110.14(B) and the completed splice retains the insulation, outer sheath properties, and usage characteristics of the cord being spliced.

This Code was not met as evidenced by:

Based on observation and interview the facility failed to ensure that electrical wiring and equipment was in accordance with NFPA 70. The facility was using extension cords as permanent wiring.

To meet power supply needs in buildings with an inadequate supply of readily available electrical receptacles, extension cords and/or power strips are often interconnected ("daisy chained") to provide more receptacles and/or reach greater distances. Interconnecting these devices can cause them to become overloaded, leading to their failure and a possible fire. Because electrical resistance increases with increased power cord length, interconnecting cords increases the total resistance and resultant heat generation. This creates an additional risk of equipment failure and fire.

Findings:

Signal Hill Outpatient Partial Hospitalization Program (PHP)

During the Life Safety Code (LSC) on 10/30/18 at 9:20 a.m., the evaluator observed a daisy chaining of extension cords connected to a second power strip that was connected to a wall electrical receptacle in the nurses station of the Signal Hill PHP

During an interview at the same time as the observation, the Vice President of Outpatient Services acknowledged the daisy chaining of the power strips.

Santa Ana Outpatient Partial Hospitalization Program (PHP)

During the Life Safety Code (LSC) on 10/30/18 at 9:20 a.m., the evaluator observed that there was an extension cord in a wall mounted conduit located next to an electrical receptacle in the clerical room of the Santa Ana PHP. Closer observation revealed the conduit went through the drop down ceiling into a mechanical suite on the roof that was being used as make-shift storage area. At the mechanical suite the extension cord was no longer in a conduit, but ran over a make-shift partial wall into a make-shift room.

During an interview at the same time as the observation, the Transportation Coordinator stated that he built the makeshift room in the suite and uses the extension cord to cut wood in the makeshift room.