HospitalInspections.org

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Based on the observation on 12/02/2014 of this building's fire barriers, the facility failed to maintain the fire barriers to provide a fire resistance rating of not less than 2 hours. Findings include:

1. The fire barrier above the ceiling at the main elevator on the first floor there was a yellow material in this wall, that the fire rating could not be determined.

This deficiency impacted 2 of 2 smoke compartments on the first floor of this building.


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2. Unsealed penetrations at 5 electrical conduits above the ceiling inside the Coders Office.
3. Unsealed penetrations at (3) ¾" electrical conduits and (1) 3" metal conduit above the ceiling outside in the corridor outside the Chapel.

The deficiency impacted 2 of 2 smoke compartments.

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Review of 2000 NFPA 101, 8.2.3.2.4.2 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through fire barriers shall be protected as follows: (1) The space between the penetrating item and the fire barrier shall meet one of the following conditions: a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier. b. It shall be protected by an approved device that is designed for the specific purpose. (2) Where the penetrating item uses a sleeve to penetrate the fire barrier, the sleeve shall be solidly set in the fire barrier, and the space between the item and the sleeve shall meet one of the following conditions: a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier. b. It shall be protected by an approved device that is designed for the specific purpos(3) * Insulation and coverings for pipes and ducts shall not pass through the fire barrier unless one of the following conditions is mea. The material shall be capable of maintaining the fire resistance of the fire barrier b. The material shall be protected by an approved device that is designed for the specific purpose. (4) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions: a. It shall be made on either side of the fire barrier. b. It shall be made by an approved device that is designed for the specific purpose.
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Based on the observation on 12/02/2014 of this building's fire barriers, the facility failed to maintain the fire barriers to provide a fire resistance rating of not less than 2 hours. Findings include:

Per observation of the fire barriers:
1. First floor above the fire barrier doors on the Outpatient side of the barrier:
a. There were three large approximately a foot wide unsealed penetrations, two at the joist and one under the joist on the left.
b. The rock wool where the wall meets the corrugated roof deck was not sealed.
2. Basement above the fire barrier doors on the hospital side had an unsealed 8" x 8" penetration of a conduit.

This deficiency impacted 2 of 4 smoke compartments on the first floor and in the basement of this building.
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Review of 2000 NFPA 101, 8.2.3.2.4.2 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through fire barriers shall be protected as follows: (1) The space between the penetrating item and the fire barrier shall meet one of the following conditions: a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier. b. It shall be protected by an approved device that is designed for the specific purpose. (2) Where the penetrating item uses a sleeve to penetrate the fire barrier, the sleeve shall be solidly set in the fire barrier, and the space between the item and the sleeve shall meet one of the following conditions: a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier. b. It shall be protected by an approved device that is designed for the specific purpos(3) * Insulation and coverings for pipes and ducts shall not pass through the fire barrier unless one of the following conditions is mea. The material shall be capable of maintaining the fire resistance of the fire barrier b. The material shall be protected by an approved device that is designed for the specific purpose. (4) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions: a. It shall be made on either side of the fire barrier. b. It shall be made by an approved device that is designed for the specific purpose.
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Based on the observation of all fire barrier doors on 12/02/2014, the facility failed to maintain fire barrier doors with a suitable means of closing the doors and resisting the passage of smoke. Findings include:

The left fire barrier door in the corridor near the Wellness Center failed to release from the magnetic hold open device and close upon activation of the fire alarm.

The deficiency impacted 2 of 4 smoke compartments.

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2000 NFPA 101, 19.1.1.4.2 Communicating openings in dividing fire barriers required by 19.1.1.4.1 shall be permitted only in corridors and shall be protected by approved self-closing fire doors. (See also Section 8.2.)
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Based on the observation on 12/02-03/2014 of this building's construction type, the facility failed to maintain a Type I (332) throughout this three story partially sprinklered building. Findings include:

Based on this sampling survey, the following 2 areas did not meet the construction requirements for a three story building:
1. First Floor - Type II (000) construction was observed in the main corridor outside of the Surgery Waiting Room.
2. Basement - Type II (000) construction was observed in the Kitchen.

This deficiency impacted 2 of 4 smoke compartments of the basement and first floor of this building.
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Review of 2000 NFPA 101, 19.1.6.2 Health care occupancies shall be limited to the types of building construction shown in Table 19.1.6.2. (See 8.2.1.)Exception*: Any building of Type I(443), Type I(332), Type II(222), or Type II(111) construction shall be permitted to include roofing systems involving combustible supports, decking, or roofing, provided that the following criteria are met:(a) The roof covering meets Class C requirements in accordance with NFPA 256, Standard Methods of Fire Tests of Roof Coverings.
(b) The roof is separated from all occupied portions of the building by a noncombustible floor assembly that includes not less than 21/2 in. (6.4 cm) of concrete or gypsum fill.
(c) The attic or other space is either unoccupied or protected throughout by an approved automatic sprinkler system.
Table 19.1.6.2 Construction Type Limitations
Construction Stories
Type
1 2 3 4 or
More
I(443) X X X X
I(332) X X X X
II(222) X X X X
II(111) X X* X* NP
II(000) X* X* NP NP
III(211) X* X* NP NP
III(200) X* NP NP NP
IV(2HH) X* X* NP NP
V(111) X* X* NP NP
V(000) X* NP NP NP
X: Permitted type of construction.
NP: Not permitted.
*Building requires automatic sprinkler protection. (See 19.3.5.1.)
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Based on the observation on 12/04/2014 of this building's construction type, the facility failed to provide a building construction type for a one story building of Type II (000) with a complete automatic sprinkler system or a Type II (111) for a building with a partial automatic sprinkler system. Findings include:

The basement ceiling/floor assembly did not have recessed light fixture tenting and ceiling/floor assembly rating could not be verify if this meets a Type II (111) construction type. Based on this sampling survey the following areas did not have automatic sprinkler protection in this building: the main corridor in the basement, from the stairwell in this building to and including the "Existing Autopsy Room".

This deficiency impacted 1 of 1 smoke compartments in the basement of this building.
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Review of 2000 NFPA 101, 19.1.6.2 Health care occupancies shall be limited to the types of building construction shown in Table 19.1.6.2. (See 8.2.1.)Table 19.1.6.2 Construction Type Limitations
Construction Stories
Type
1 2 3 4 or
More
I(443) X X X X
I(332) X X X X
II(222) X X X X
II(111) X X* X* NP
II(000) X* X* NP NP
III(211) X* X* NP NP
III(200) X* NP NP NP
IV(2HH) X* X* NP NP
V(111) X* X* NP NP
V(000) X* NP NP NP
X: Permitted type of construction.
NP: Not permitted.
*Building requires automatic sprinkler protection. (See 19.3.5.1.)
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Based on the observation on 12/04/2014 of this building's corridor walls in smoke compartments without a complete automatic sprinkler protection, the facility failed to maintain the corridor walls to a 1/2 hour fire resistive rating. Findings include:

The corridor wall above the ceiling across from Nuclear Medicine had an unsealed penetration of pipes, conduits and wires.

This deficiency impacted 1 of 2 smoke compartments on the first floor of this building.
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Review of 2000 NFPA 101, 19.3.6.2.1 Corridor walls shall be continuous from the floor to the underside of the floor or roof deck above, through any concealed spaces, such as those above suspended ceilings, and through interstitial structural and mechanical spaces, and they shall have a fire resistance rating of not less than 1/2 hour.
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Based on the observation on 12/02/2014 of this building's smoke barriers, the facility failed to maintain resist the passage of smoke the smoke barriers. Findings include:

The smoke barrier in the first floor Shelled Storage Room was observed with the following:
1. Incomplete at the corridor wall inside the Shelled Storage Room
2. Had an unsealed penetration in the back wall.


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3. The smoke barrier in the corridor above the ceiling outside the Registration Office was observed with an unsealed penetration around a metal conduit.
4. The smoke barrier in the corridor above the ceiling outside the Insurance Office was observed with 2 holes approximately 2" each.

The deficiency impacted 2 of 4 smoke compartments.

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Based on the observation of all smoke barriers on 12/03/2014, the facility failed to maintain smoke barriers that would provide at least a half hour fire resistance rating. Findings include:

The smoke barrier in the corridor outside Room 304 was observed with an unsealed penetration at metal conduit sleeve with a red, yellow, and white wire.

The deficiency impacted 2 of 2 smoke compartments.

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2000 NFPA 101, 8.3.6.1
Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke
barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
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Based on the observation of all smoke barrier doors on 12/03/2014, the facility failed to maintain smoke barrier doors with a suitable means of closing the doors and resisting the passage of smoke. Findings include:

1. The Surgery Waiting Room corridor door located in the smoke barrier was observed with the self-closing device removed.


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2. The magnetic hold open device at the left smoke barrier door in the corridor near Admitting Business Office failed to release and allow the door to close upon activation of the fire alarm.
3. The magnetic hold open device at the left smoke barrier door in the corridor near Stairway "A" failed to release and allow the door to close upon activation of the fire alarm.

The deficiency impacted 4 of 4 smoke compartments.

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Review of 2000 NFPA 101, 19.3.7.6 Doors in smoke barriers shall comply with 8.3.4 and shall be self-closing or automatic-closing in accordance with 19.2.2.2.6.

NFPA 101, 19.3.7.6., 8.3.4 Doors in smoke barriers to be self-closing. Doors in smoke barriers shall close the opening in the wall leaving only a minimum clearance to allow door(s) to function properly.
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Based on the observation of hazardous areas on 12/03/2014, the facility failed to maintain hazardous areas separation from other spaces by smoke-resisting self closing positive latching doors. Findings include:

1. The basement Central Supply Room was over 50 sq. ft. with combustibles, the double doors for this room had self-closing devices but 1 door was being held open by a bungee strap screwed into the wall


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2. The vacant room across from Room 306 was observed being used for combustible storage and the door had no self closing device, the room was over 50 square feet.
3. The Clean Storage Room door failed to self close and latch into the frame.
4. Delivery Room #1 was observed with combustible storage and the existing door been removed from the frame.
5. The Soiled Utility Room door at 200 North Hall was taped up at the door latch not allowing the door to self close and latch into the frame.
6. The MICU Soiled Utility Room door was rubbing against the door frame not allowing the door to self close and latch into the frame.

The deficiency impacted 4 of 4 smoke compartments.

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Review of 2000 NFPA 101, 19.3.2.1 Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing.
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Based on the observation on 12/02-04/2014 of this building's hazardous areas, the facility failed to maintain the hazardous areas per code. Findings include:

Per observation of the hazardous areas:
1. First floor - Gift Shop Storage Room was over 50 sq. ft. with combustibles the door had a self-closing device, was being held open by a wedge all 3 days during the survey.
2. First floor - H.I.M. Coder Office/Storage Room was over 50 sq. ft. with combustibles:
a. No self-closing device on the door
b. Missing several ceiling tiles, was not smoke resistive
3. Basement - Housekeeping Bio Med Storage Room 160 sq. ft. with combustibles, no self-closing device on the door.
4. Basement - Housekeeping Equipment Storage Room was over 50 sq. ft. with combustibles:
a. No self-closing device on the door
b. 7 ceiling tiles missing or not in place, was not smoke resistive
5. Basement - Housekeeping Equipment Storage Room in the basement was observed without positive latching hardware.


This deficiency impacted 3 of 3 smoke compartments on the first floor and in the basement of this building.
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Review of 2000 NFPA 101, 19.3.2.1 Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing.

HCFA Transmittal 40-93 It is the intent of the code that (smoke-resisting) separation be provided even in a sprinklered hazardous area. "Where the sprinkler option is used, the (hazardous) areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be equipped with self- or automatic closers and be positive latching."

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Based on the observation of hazardous areas on 12/03/2014, the facility failed to maintain hazardous areas separation from other spaces by smoke-resisting self closing positive latching doors. Findings include:

The Outpatient Storage Room was observed to be approximately 64 square feet with combustible storage, the door was not equipped with a self- closing device.

The deficiency impacted 1 of 2 smoke compartments.

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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 selfclosing with positive latching hardware.
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Based on the observation on 12/03/2014 of this building's exit access, the facility failed to maintain the exit access readily accessible at all times. Findings include:

Per observation of the building's exit access the following rooms had pad locks on the exterior of the doors:
1. Housekeeping Equipment Storage Room
2. Enviromental Services Storeroom

This deficiency impacted 1 of 1 smoke compartments in the basement of this building.
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Review of 2000 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.
Review of 2000 NFPA 101, 7.2.1.5.1 Doors shall be arranged to be opened readily from the egress side whenever the building is occupied. Locks, if provided, shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side.
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Based on the observation on 12/03/2014 of this building's exit access, the facility failed to maintain the exit access readily accessible at all times. Findings include:

The releasing mechanisms inside this building's Second Cooler and the Freezer (inside this cooler) were not working when tested, possibly allowing entrapment.

This deficiency impacted 1 of 2 smoke compartments in the basement of this building.
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Review of 2000 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.
Review of 2000 NFPA 101, 7.2.1.5.1 Doors shall be arranged to be opened readily from the egress side whenever the building is occupied. Locks, if provided, shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side.
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Based on the observation of all fire barriers on 12/02/2014, the facility failed to maintain fire barriers to limit the spread of fire and restrict the movement of smoke from one side of the fire barrier to the other. Findings include:

1. Unsealed penetration at a missing junction box cover attached to metal conduit sleeve above the ceiling in the corridor outside Trauma.
2. Unsealed penetration at metal conduit above the ceiling in the corridor over the fire doors outside Nuclear Medicine
3. Unsealed penetration at 3 " black pipe above the ceiling in the corridor outside the service elevator.
4. Unsealed penetration at 2 " diameter hole above the ceiling in the corridor over the fire doors outside Post Anesthesia Recovery Room
5. Unsealed penetration around a steam pipe and a small notch at the top of the right wall at the O.R. Mechanical Room.

The deficiency impacted 2 of 2 smoke compartments.
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Based on the observation of all exit signs on 12/03/2014, the facility failed to maintain exit signs per code. Findings include:

The exit sign was not illuminated over the Outpatient Lobby exit door.

The deficiency impacted 1 of 2 smoke compartments.

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2000 NFPA 101, 7.10.5.2 Every sign required to be illuminated by 7.10.6.3 and 7.10.7 shall be continuously illuminated as required under the provisions of Section 7.8.
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Based on the review of documentation on 12/03/2014 of the facility's fire drill reports, the facility failed to conduct fire drills per code. Findings include:

1. No documentation of fire drills for 2014, for first, second or third shifts for first, second or third quarters.
2. No documentation of a fire drill for first shift in the fourth quarter of 2013.

This deficiency impacted 3 of 3 smoke compartments
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Review of 2000 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.

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Based on the review of documentation on 12/03/2014 of the facility's fire drills documentation, the facility failed to conduct fire drills per code. Findings include:

1. No documentation of fire drills for 2014, for first, second or third shifts for first, second or third quarters.
2. No documentation of a fire drill for first shift in the fourth quarter of 2013.

This deficiency impacted 8 of 8 smoke compartments of this building.
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Review of 2000 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.

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Based on the review of documentation on 12/03/2014 of the facility's fire drills, the facility failed to conduct fire drills per code. Findings include:

1. No documentation of fire drills for 2014, for first, second or third shifts for first, second or third quarters.
2. No documentation of a fire drill for first shift in the fourth quarter of 2013.

This deficiency impacted 3 of 3 smoke compartments of this building.
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Review of 2000 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.

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Based on the observation on 12/03/2014 of the facility's fire alarm system, the facility failed to provide a fire alarm system that was audible throughout the facility. Findings include:

First floor - the Administration Area the fire alarm signal could not be heard when the fire alarm system was tested with the doors closed to this area.

This deficiency impacted 1 of 3 smoke compartments on the first floor of this building.
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Review of 2000 NFPA 101, 9.6.3.7 The general evacuation alarm signal shall operate throughout the entire building.
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Based on the observation of the automatic sprinkler system on 12/03/2014, the facility failed to maintain the automatic sprinkler system per code. Findings include:

1. A hole was observed in the ceiling inside Soiled Linen over the cart washing area, the hole was approximately 12" x 18".
2. The Laundry room was observed missing several ceiling tiles above the washing machines.

The deficiency impacted 1 of 2 smoke compartments.

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NFPA 13 5-6., Sprinklers shall be arranged to be in compliance.
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Based on the review of documentaion on 12/03/2014 of the facility's automatic sprinkler system's quarterly inspections reports, the facility failed to maintain the automatic sprinkler system per code. Findings include:

Per review the last documented quarterly inspection was conducted on 06/25/2014, no documentation of a quarterly inspection after that date.

This deficiency impacted 8 of 8 smoke compartments of this building.
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Review of 2000 NFPA 101, 9.7.5 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.

Review of 1998 NFPA 25, 1-8* Records.
Records of inspections, tests, and maintenance of the system and its components shall be made available to the authority having jurisdiction upon request. Typical records include, but are not limited to, valve inspections; flow, drain, and pump tests; and trip tests of dry pipe, deluge, and preaction valves.
Review of 1998 NFPA 25, 1-8.1 Records shall indicate the procedure performed (e.g., inspection, test, or maintenance), the organization that performed the work, the results, and the date.
Review of 1998 NFPA 25, 1-8.2 Records shall be maintained by the owner. Original records shall be retained for the life of the system. Subsequent records shall be retained for a period of one year after the next inspection, test, or maintenance required by the standard.
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Based on the review of documentation on 12/03/2014 of the facility's automatic sprinkler system's quarterly inspections reports, the facility failed to maintain the automatic sprinkler system per code. Findings include:

No documentation of a quarterly inspection after that date.

This deficiency impacted 3 of 3 smoke compartments of this building.
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Review of 2000 NFPA 101, 9.7.5 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.

Review of 1998 NFPA 25, 1-8* Records.
Records of inspections, tests, and maintenance of the system and its components shall be made available to the authority having jurisdiction upon request. Typical records include, but are not limited to, valve inspections; flow, drain, and pump tests; and trip tests of dry pipe, deluge, and preaction valves.

Review of 1998 NFPA 25, 1-8.1 Records shall indicate the procedure performed (e.g., inspection, test, or maintenance), the organization that performed the work, the results, and the date.
Review of 1998 NFPA 25, 1-8.2 Records shall be maintained by the owner. Original records shall be retained for the life of the system. Subsequent records shall be retained for a period of one year after the next inspection, test, or maintenance required by the standard.
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Based on the review of documentation on 12/03/2014 of the facility's automatic sprinkler system's quarterly inspections reports, the facility failed to maintain the automatic sprinkler system per code. Findings include:

Per observation the last documented quarterly inspection was conducted on 06/25/2014, no documentation of a quarterly inspection after that date.

This deficiency impacted 3 of 3 smoke compartments of this building.
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Review of 2000 NFPA 101, 9.7.5 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.

Review of 1998 NFPA 25, 1-8* Records.
Records of inspections, tests, and maintenance of the system and its components shall be made available to the authority having jurisdiction upon request. Typical records include, but are not limited to, valve inspections; flow, drain, and pump tests; and trip tests of dry pipe, deluge, and preaction valves.

Review of 1998 NFPA 25, 1-8.1 Records shall indicate the procedure performed (e.g., inspection, test, or maintenance), the organization that performed the work, the results, and the date.
Review of 1998 NFPA 25, 1-8.2 Records shall be maintained by the owner. Original records shall be retained for the life of the system. Subsequent records shall be retained for a period of one year after the next inspection, test, or maintenance required by the standard.
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Based on the observation on 12/03/2014 of this building's smoke dampers, the facility failed to maintain the smoke dampers . Findings include:

The smoke damper at room 203 did not fully close upon activation of the fire alarm.

This deficiency impacted 2 of 2 smoke compartments on the second floor of this building.
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Review of 1999 NFPA 90A, 3-4.5.4 Dampers shall close against the maximum calculated airflow of that portion of the air duct system in which they are installed. Fire dampers shall be tested in accordance with UL 555, Standard for Safety Fire Dampers. Smoke dampers shall be tested in accordance with UL 555S, Standard for Safety Smoke Dampers.
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Based on the observation on 12/03/2014 of this building's Line Isolation Monitors (L.I.M.), the facility failed to maintain 1 of the 2 L.I.M. per code. Findings include:

The L.I.M. for OR #2, the test switch for the monitor in OR #2 was missing and the test switch for the monitor outside OR #2 was not working, the facility was unable to test this L.I.M.

This deficiency impacted 1 of 2 smoke compartments of the first floor of this building.
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Review of 1999 NFPA 99, 3-3.2.2.3 Line Isolation Monitor.
(f) A reliable test switch shall be mounted on the line isolation monitor to test its capability to operate (i.e., cause the alarms to operate and the meter to indicate in the " alarm on " zone). This switch shall transfer the grounding connection of the line isolation monitor from the reference grounding point to a test impedance arrangement connected across the isolated line; the test impedance(s) shall be of the appropriate magnitude to produce a meter reading corresponding to the rated total hazard current at the nominal line voltage, or to a lesser alarm hazard current if the line isolation monitor is so rated. The operation of this switch shall break the grounding connection of the line isolation monitor to the reference grounding point before transferring this grounding connector to the test impedance(s), so that making this test will not add to the hazard of a system in actual use, nor will the test include the effect of the line to ground stray impedance of the system. The test switch shall be of a self-restoring type.

Review of 1999 NFPA 99, 3-3.3.4.2 Line Isolation Monitor Tests.
The proper functioning of each line isolation monitor (LIM) circuit shall be ensured by the following:
(a) The LIM circuit shall be tested after installation, and prior to being placed in service, by successively grounding each line of the energized distribution system through a resistor of 200 V ohms, where V = measured line voltage. The visual and audible alarms [see 3-3.2.2.3(b)] shall be activated.
(b) The LIM circuit shall be tested at intervals of not more than 1 month by actuating the LIM test switch [see 3-3.2.2.3(f)]. For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months. Actuation of the test switch shall activate both visual and audible alarm indicators.
(c) After any repair or renovation to an electrical distribution system and at intervals of not more than 6 months, the LIM circuit shall be tested in accordance with paragraph (a) above and only when the circuit is not otherwise in use. For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months.
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Based on the observation on 12/03/2014 of this building's electrical wiring and equipment, the facility failed to prohibit the use of extension cords per code. Findings include:

1. The Pharmacy had a surge protector (extension cord) plugged into a homemade extension cord by the Narcotics Room.


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2. Room 300 was observed with a refrigerator plugged into a surge protector.

The deficiency impacted 1 of 2 smoke compartments.

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1999 NFPA 70, 400-7 and 400-8, and HCFA Transmittal Notice 22-99 The 1984 edition of the National Electric Code restricts the use of extension cords to temporary short term uses. It is the policy of HCFA to prohibit non-circuit breaker protected extension cords in health care. The limited use of circuit breaker protected power strips is acceptable, provided the current is limited to 15 amps or less, and no major appliances such as air conditioners, refrigerators, or heating units are connected to the power strip.

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Based on the observation of the electrical system on 12/03/2014, the facility failed to maintain the electrical system in the facility. Findings include:

Inside the Oncology Control Room Office, this surveyor observed a refrigerator plugged into a surge protector.

The deficiency impacted 1 of 2 smoke compartments.

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1999 NFPA 70, 400-7 and 400-8, and HCFA Transmittal Notice 22-99 The 1984 edition of the National Electric Code restricts the use of extension cords to temporary short term uses. It is the policy of HCFA to prohibit non-circuit breaker protected extension cords in health care. The limited use of circuit breaker protected power strips is acceptable, provided the current is limited to 15 amps or less, and no major appliances such as air conditioners, refrigerators, or heating units are connected to the power strip.
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Based on the observation on 12/02/2014 of this building's fire barriers, the facility failed to maintain the fire barriers to provide a fire resistance rating of not less than 2 hours. Findings include:

1. The fire barrier above the ceiling at the main elevator on the first floor there was a yellow material in this wall, that the fire rating could not be determined.

This deficiency impacted 2 of 2 smoke compartments on the first floor of this building.


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2. Unsealed penetrations at 5 electrical conduits above the ceiling inside the Coders Office.
3. Unsealed penetrations at (3) ¾" electrical conduits and (1) 3" metal conduit above the ceiling outside in the corridor outside the Chapel.

The deficiency impacted 2 of 2 smoke compartments.

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Review of 2000 NFPA 101, 8.2.3.2.4.2 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through fire barriers shall be protected as follows: (1) The space between the penetrating item and the fire barrier shall meet one of the following conditions: a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier. b. It shall be protected by an approved device that is designed for the specific purpose. (2) Where the penetrating item uses a sleeve to penetrate the fire barrier, the sleeve shall be solidly set in the fire barrier, and the space between the item and the sleeve shall meet one of the following conditions: a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier. b. It shall be protected by an approved device that is designed for the specific purpos(3) * Insulation and coverings for pipes and ducts shall not pass through the fire barrier unless one of the following conditions is mea. The material shall be capable of maintaining the fire resistance of the fire barrier b. The material shall be protected by an approved device that is designed for the specific purpose. (4) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions: a. It shall be made on either side of the fire barrier. b. It shall be made by an approved device that is designed for the specific purpose.
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Based on the observation on 12/02/2014 of this building's fire barriers, the facility failed to maintain the fire barriers to provide a fire resistance rating of not less than 2 hours. Findings include:

Per observation of the fire barriers:
1. First floor above the fire barrier doors on the Outpatient side of the barrier:
a. There were three large approximately a foot wide unsealed penetrations, two at the joist and one under the joist on the left.
b. The rock wool where the wall meets the corrugated roof deck was not sealed.
2. Basement above the fire barrier doors on the hospital side had an unsealed 8" x 8" penetration of a conduit.

This deficiency impacted 2 of 4 smoke compartments on the first floor and in the basement of this building.
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Review of 2000 NFPA 101, 8.2.3.2.4.2 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through fire barriers shall be protected as follows: (1) The space between the penetrating item and the fire barrier shall meet one of the following conditions: a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier. b. It shall be protected by an approved device that is designed for the specific purpose. (2) Where the penetrating item uses a sleeve to penetrate the fire barrier, the sleeve shall be solidly set in the fire barrier, and the space between the item and the sleeve shall meet one of the following conditions: a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier. b. It shall be protected by an approved device that is designed for the specific purpos(3) * Insulation and coverings for pipes and ducts shall not pass through the fire barrier unless one of the following conditions is mea. The material shall be capable of maintaining the fire resistance of the fire barrier b. The material shall be protected by an approved device that is designed for the specific purpose. (4) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions: a. It shall be made on either side of the fire barrier. b. It shall be made by an approved device that is designed for the specific purpose.
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Based on the observation of all fire barrier doors on 12/02/2014, the facility failed to maintain fire barrier doors with a suitable means of closing the doors and resisting the passage of smoke. Findings include:

The left fire barrier door in the corridor near the Wellness Center failed to release from the magnetic hold open device and close upon activation of the fire alarm.

The deficiency impacted 2 of 4 smoke compartments.

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2000 NFPA 101, 19.1.1.4.2 Communicating openings in dividing fire barriers required by 19.1.1.4.1 shall be permitted only in corridors and shall be protected by approved self-closing fire doors. (See also Section 8.2.)
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Based on the observation on 12/02-03/2014 of this building's construction type, the facility failed to maintain a Type I (332) throughout this three story partially sprinklered building. Findings include:

Based on this sampling survey, the following 2 areas did not meet the construction requirements for a three story building:
1. First Floor - Type II (000) construction was observed in the main corridor outside of the Surgery Waiting Room.
2. Basement - Type II (000) construction was observed in the Kitchen.

This deficiency impacted 2 of 4 smoke compartments of the basement and first floor of this building.
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Review of 2000 NFPA 101, 19.1.6.2 Health care occupancies shall be limited to the types of building construction shown in Table 19.1.6.2. (See 8.2.1.)Exception*: Any building of Type I(443), Type I(332), Type II(222), or Type II(111) construction shall be permitted to include roofing systems involving combustible supports, decking, or roofing, provided that the following criteria are met:(a) The roof covering meets Class C requirements in accordance with NFPA 256, Standard Methods of Fire Tests of Roof Coverings.
(b) The roof is separated from all occupied portions of the building by a noncombustible floor assembly that includes not less than 21/2 in. (6.4 cm) of concrete or gypsum fill.
(c) The attic or other space is either unoccupied or protected throughout by an approved automatic sprinkler system.
Table 19.1.6.2 Construction Type Limitations
Construction Stories
Type
1 2 3 4 or
More
I(443) X X X X
I(332) X X X X
II(222) X X X X
II(111) X X* X* NP
II(000) X* X* NP NP
III(211) X* X* NP NP
III(200) X* NP NP NP
IV(2HH) X* X* NP NP
V(111) X* X* NP NP
V(000) X* NP NP NP
X: Permitted type of construction.
NP: Not permitted.
*Building requires automatic sprinkler protection. (See 19.3.5.1.)
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Based on the observation on 12/04/2014 of this building's construction type, the facility failed to provide a building construction type for a one story building of Type II (000) with a complete automatic sprinkler system or a Type II (111) for a building with a partial automatic sprinkler system. Findings include:

The basement ceiling/floor assembly did not have recessed light fixture tenting and ceiling/floor assembly rating could not be verify if this meets a Type II (111) construction type. Based on this sampling survey the following areas did not have automatic sprinkler protection in this building: the main corridor in the basement, from the stairwell in this building to and including the "Existing Autopsy Room".

This deficiency impacted 1 of 1 smoke compartments in the basement of this building.
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Review of 2000 NFPA 101, 19.1.6.2 Health care occupancies shall be limited to the types of building construction shown in Table 19.1.6.2. (See 8.2.1.)Table 19.1.6.2 Construction Type Limitations
Construction Stories
Type
1 2 3 4 or
More
I(443) X X X X
I(332) X X X X
II(222) X X X X
II(111) X X* X* NP
II(000) X* X* NP NP
III(211) X* X* NP NP
III(200) X* NP NP NP
IV(2HH) X* X* NP NP
V(111) X* X* NP NP
V(000) X* NP NP NP
X: Permitted type of construction.
NP: Not permitted.
*Building requires automatic sprinkler protection. (See 19.3.5.1.)
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Based on the observation on 12/04/2014 of this building's corridor walls in smoke compartments without a complete automatic sprinkler protection, the facility failed to maintain the corridor walls to a 1/2 hour fire resistive rating. Findings include:

The corridor wall above the ceiling across from Nuclear Medicine had an unsealed penetration of pipes, conduits and wires.

This deficiency impacted 1 of 2 smoke compartments on the first floor of this building.
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Review of 2000 NFPA 101, 19.3.6.2.1 Corridor walls shall be continuous from the floor to the underside of the floor or roof deck above, through any concealed spaces, such as those above suspended ceilings, and through interstitial structural and mechanical spaces, and they shall have a fire resistance rating of not less than 1/2 hour.
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Based on the observation on 12/02/2014 of this building's smoke barriers, the facility failed to maintain resist the passage of smoke the smoke barriers. Findings include:

The smoke barrier in the first floor Shelled Storage Room was observed with the following:
1. Incomplete at the corridor wall inside the Shelled Storage Room
2. Had an unsealed penetration in the back wall.


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3. The smoke barrier in the corridor above the ceiling outside the Registration Office was observed with an unsealed penetration around a metal conduit.
4. The smoke barrier in the corridor above the ceiling outside the Insurance Office was observed with 2 holes approximately 2" each.

The deficiency impacted 2 of 4 smoke compartments.

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Based on the observation of all smoke barriers on 12/03/2014, the facility failed to maintain smoke barriers that would provide at least a half hour fire resistance rating. Findings include:

The smoke barrier in the corridor outside Room 304 was observed with an unsealed penetration at metal conduit sleeve with a red, yellow, and white wire.

The deficiency impacted 2 of 2 smoke compartments.

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2000 NFPA 101, 8.3.6.1
Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke
barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
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Based on the observation of all smoke barrier doors on 12/03/2014, the facility failed to maintain smoke barrier doors with a suitable means of closing the doors and resisting the passage of smoke. Findings include:

1. The Surgery Waiting Room corridor door located in the smoke barrier was observed with the self-closing device removed.


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2. The magnetic hold open device at the left smoke barrier door in the corridor near Admitting Business Office failed to release and allow the door to close upon activation of the fire alarm.
3. The magnetic hold open device at the left smoke barrier door in the corridor near Stairway "A" failed to release and allow the door to close upon activation of the fire alarm.

The deficiency impacted 4 of 4 smoke compartments.

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Review of 2000 NFPA 101, 19.3.7.6 Doors in smoke barriers shall comply with 8.3.4 and shall be self-closing or automatic-closing in accordance with 19.2.2.2.6.

NFPA 101, 19.3.7.6., 8.3.4 Doors in smoke barriers to be self-closing. Doors in smoke barriers shall close the opening in the wall leaving only a minimum clearance to allow door(s) to function properly.
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Based on the observation of hazardous areas on 12/03/2014, the facility failed to maintain hazardous areas separation from other spaces by smoke-resisting self closing positive latching doors. Findings include:

1. The basement Central Supply Room was over 50 sq. ft. with combustibles, the double doors for this room had self-closing devices but 1 door was being held open by a bungee strap screwed into the wall


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2. The vacant room across from Room 306 was observed being used for combustible storage and the door had no self closing device, the room was over 50 square feet.
3. The Clean Storage Room door failed to self close and latch into the frame.
4. Delivery Room #1 was observed with combustible storage and the existing door been removed from the frame.
5. The Soiled Utility Room door at 200 North Hall was taped up at the door latch not allowing the door to self close and latch into the frame.
6. The MICU Soiled Utility Room door was rubbing against the door frame not allowing the door to self close and latch into the frame.

The deficiency impacted 4 of 4 smoke compartments.

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Review of 2000 NFPA 101, 19.3.2.1 Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing.
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Based on the observation on 12/02-04/2014 of this building's hazardous areas, the facility failed to maintain the hazardous areas per code. Findings include:

Per observation of the hazardous areas:
1. First floor - Gift Shop Storage Room was over 50 sq. ft. with combustibles the door had a self-closing device, was being held open by a wedge all 3 days during the survey.
2. First floor - H.I.M. Coder Office/Storage Room was over 50 sq. ft. with combustibles:
a. No self-closing device on the door
b. Missing several ceiling tiles, was not smoke resistive
3. Basement - Housekeeping Bio Med Storage Room 160 sq. ft. with combustibles, no self-closing device on the door.
4. Basement - Housekeeping Equipment Storage Room was over 50 sq. ft. with combustibles:
a. No self-closing device on the door
b. 7 ceiling tiles missing or not in place, was not smoke resistive
5. Basement - Housekeeping Equipment Storage Room in the basement was observed without positive latching hardware.


This deficiency impacted 3 of 3 smoke compartments on the first floor and in the basement of this building.
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Review of 2000 NFPA 101, 19.3.2.1 Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing.

HCFA Transmittal 40-93 It is the intent of the code that (smoke-resisting) separation be provided even in a sprinklered hazardous area. "Where the sprinkler option is used, the (hazardous) areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be equipped with self- or automatic closers and be positive latching."

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Based on the observation of hazardous areas on 12/03/2014, the facility failed to maintain hazardous areas separation from other spaces by smoke-resisting self closing positive latching doors. Findings include:

The Outpatient Storage Room was observed to be approximately 64 square feet with combustible storage, the door was not equipped with a self- closing device.

The deficiency impacted 1 of 2 smoke compartments.

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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 selfclosing with positive latching hardware.
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Based on the observation on 12/03/2014 of this building's exit access, the facility failed to maintain the exit access readily accessible at all times. Findings include:

Per observation of the building's exit access the following rooms had pad locks on the exterior of the doors:
1. Housekeeping Equipment Storage Room
2. Enviromental Services Storeroom

This deficiency impacted 1 of 1 smoke compartments in the basement of this building.
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Review of 2000 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.
Review of 2000 NFPA 101, 7.2.1.5.1 Doors shall be arranged to be opened readily from the egress side whenever the building is occupied. Locks, if provided, shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side.
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Based on the observation on 12/03/2014 of this building's exit access, the facility failed to maintain the exit access readily accessible at all times. Findings include:

The releasing mechanisms inside this building's Second Cooler and the Freezer (inside this cooler) were not working when tested, possibly allowing entrapment.

This deficiency impacted 1 of 2 smoke compartments in the basement of this building.
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Review of 2000 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.
Review of 2000 NFPA 101, 7.2.1.5.1 Doors shall be arranged to be opened readily from the egress side whenever the building is occupied. Locks, if provided, shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side.
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Based on the observation of all fire barriers on 12/02/2014, the facility failed to maintain fire barriers to limit the spread of fire and restrict the movement of smoke from one side of the fire barrier to the other. Findings include:

1. Unsealed penetration at a missing junction box cover attached to metal conduit sleeve above the ceiling in the corridor outside Trauma.
2. Unsealed penetration at metal conduit above the ceiling in the corridor over the fire doors outside Nuclear Medicine
3. Unsealed penetration at 3 " black pipe above the ceiling in the corridor outside the service elevator.
4. Unsealed penetration at 2 " diameter hole above the ceiling in the corridor over the fire doors outside Post Anesthesia Recovery Room
5. Unsealed penetration around a steam pipe and a small notch at the top of the right wall at the O.R. Mechanical Room.

The deficiency impacted 2 of 2 smoke compartments.
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Based on the observation of all exit signs on 12/03/2014, the facility failed to maintain exit signs per code. Findings include:

The exit sign was not illuminated over the Outpatient Lobby exit door.

The deficiency impacted 1 of 2 smoke compartments.

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2000 NFPA 101, 7.10.5.2 Every sign required to be illuminated by 7.10.6.3 and 7.10.7 shall be continuously illuminated as required under the provisions of Section 7.8.
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Based on the review of documentation on 12/03/2014 of the facility's fire drill reports, the facility failed to conduct fire drills per code. Findings include:

1. No documentation of fire drills for 2014, for first, second or third shifts for first, second or third quarters.
2. No documentation of a fire drill for first shift in the fourth quarter of 2013.

This deficiency impacted 3 of 3 smoke compartments
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Review of 2000 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.

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Based on the review of documentation on 12/03/2014 of the facility's fire drills documentation, the facility failed to conduct fire drills per code. Findings include:

1. No documentation of fire drills for 2014, for first, second or third shifts for first, second or third quarters.
2. No documentation of a fire drill for first shift in the fourth quarter of 2013.

This deficiency impacted 8 of 8 smoke compartments of this building.
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Review of 2000 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.

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Based on the review of documentation on 12/03/2014 of the facility's fire drills, the facility failed to conduct fire drills per code. Findings include:

1. No documentation of fire drills for 2014, for first, second or third shifts for first, second or third quarters.
2. No documentation of a fire drill for first shift in the fourth quarter of 2013.

This deficiency impacted 3 of 3 smoke compartments of this building.
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Review of 2000 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.

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Based on the observation on 12/03/2014 of the facility's fire alarm system, the facility failed to provide a fire alarm system that was audible throughout the facility. Findings include:

First floor - the Administration Area the fire alarm signal could not be heard when the fire alarm system was tested with the doors closed to this area.

This deficiency impacted 1 of 3 smoke compartments on the first floor of this building.
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Review of 2000 NFPA 101, 9.6.3.7 The general evacuation alarm signal shall operate throughout the entire building.
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Based on the observation of the automatic sprinkler system on 12/03/2014, the facility failed to maintain the automatic sprinkler system per code. Findings include:

1. A hole was observed in the ceiling inside Soiled Linen over the cart washing area, the hole was approximately 12" x 18".
2. The Laundry room was observed missing several ceiling tiles above the washing machines.

The deficiency impacted 1 of 2 smoke compartments.

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NFPA 13 5-6., Sprinklers shall be arranged to be in compliance.
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Based on the review of documentaion on 12/03/2014 of the facility's automatic sprinkler system's quarterly inspections reports, the facility failed to maintain the automatic sprinkler system per code. Findings include:

Per review the last documented quarterly inspection was conducted on 06/25/2014, no documentation of a quarterly inspection after that date.

This deficiency impacted 8 of 8 smoke compartments of this building.
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Review of 2000 NFPA 101, 9.7.5 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.

Review of 1998 NFPA 25, 1-8* Records.
Records of inspections, tests, and maintenance of the system and its components shall be made available to the authority having jurisdiction upon request. Typical records include, but are not limited to, valve inspections; flow, drain, and pump tests; and trip tests of dry pipe, deluge, and preaction valves.
Review of 1998 NFPA 25, 1-8.1 Records shall indicate the procedure performed (e.g., inspection, test, or maintenance), the organization that performed the work, the results, and the date.
Review of 1998 NFPA 25, 1-8.2 Records shall be maintained by the owner. Original records shall be retained for the life of the system. Subsequent records shall be retained for a period of one year after the next inspection, test, or maintenance required by the standard.
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Based on the review of documentation on 12/03/2014 of the facility's automatic sprinkler system's quarterly inspections reports, the facility failed to maintain the automatic sprinkler system per code. Findings include:

No documentation of a quarterly inspection after that date.

This deficiency impacted 3 of 3 smoke compartments of this building.
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Review of 2000 NFPA 101, 9.7.5 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.

Review of 1998 NFPA 25, 1-8* Records.
Records of inspections, tests, and maintenance of the system and its components shall be made available to the authority having jurisdiction upon request. Typical records include, but are not limited to, valve inspections; flow, drain, and pump tests; and trip tests of dry pipe, deluge, and preaction valves.

Review of 1998 NFPA 25, 1-8.1 Records shall indicate the procedure performed (e.g., inspection, test, or maintenance), the organization that performed the work, the results, and the date.
Review of 1998 NFPA 25, 1-8.2 Records shall be maintained by the owner. Original records shall be retained for the life of the system. Subsequent records shall be retained for a period of one year after the next inspection, test, or maintenance required by the standard.
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Based on the review of documentation on 12/03/2014 of the facility's automatic sprinkler system's quarterly inspections reports, the facility failed to maintain the automatic sprinkler system per code. Findings include:

Per observation the last documented quarterly inspection was conducted on 06/25/2014, no documentation of a quarterly inspection after that date.

This deficiency impacted 3 of 3 smoke compartments of this building.
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Review of 2000 NFPA 101, 9.7.5 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.

Review of 1998 NFPA 25, 1-8* Records.
Records of inspections, tests, and maintenance of the system and its components shall be made available to the authority having jurisdiction upon request. Typical records include, but are not limited to, valve inspections; flow, drain, and pump tests; and trip tests of dry pipe, deluge, and preaction valves.

Review of 1998 NFPA 25, 1-8.1 Records shall indicate the procedure performed (e.g., inspection, test, or maintenance), the organization that performed the work, the results, and the date.
Review of 1998 NFPA 25, 1-8.2 Records shall be maintained by the owner. Original records shall be retained for the life of the system. Subsequent records shall be retained for a period of one year after the next inspection, test, or maintenance required by the standard.
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Based on the observation on 12/03/2014 of this building's smoke dampers, the facility failed to maintain the smoke dampers . Findings include:

The smoke damper at room 203 did not fully close upon activation of the fire alarm.

This deficiency impacted 2 of 2 smoke compartments on the second floor of this building.
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Review of 1999 NFPA 90A, 3-4.5.4 Dampers shall close against the maximum calculated airflow of that portion of the air duct system in which they are installed. Fire dampers shall be tested in accordance with UL 555, Standard for Safety Fire Dampers. Smoke dampers shall be tested in accordance with UL 555S, Standard for Safety Smoke Dampers.
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Based on the observation on 12/03/2014 of this building's Line Isolation Monitors (L.I.M.), the facility failed to maintain 1 of the 2 L.I.M. per code. Findings include:

The L.I.M. for OR #2, the test switch for the monitor in OR #2 was missing and the test switch for the monitor outside OR #2 was not working, the facility was unable to test this L.I.M.

This deficiency impacted 1 of 2 smoke compartments of the first floor of this building.
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Review of 1999 NFPA 99, 3-3.2.2.3 Line Isolation Monitor.
(f) A reliable test switch shall be mounted on the line isolation monitor to test its capability to operate (i.e., cause the alarms to operate and the meter to indicate in the " alarm on " zone). This switch shall transfer the grounding connection of the line isolation monitor from the reference grounding point to a test impedance arrangement connected across the isolated line; the test impedance(s) shall be of the appropriate magnitude to produce a meter reading corresponding to the rated total hazard current at the nominal line voltage, or to a lesser alarm hazard current if the line isolation monitor is so rated. The operation of this switch shall break the grounding connection of the line isolation monitor to the reference grounding point before transferring this grounding connector to the test impedance(s), so that making this test will not add to the hazard of a system in actual use, nor will the test include the effect of the line to ground stray impedance of the system. The test switch shall be of a self-restoring type.

Review of 1999 NFPA 99, 3-3.3.4.2 Line Isolation Monitor Tests.
The proper functioning of each line isolation monitor (LIM) circuit shall be ensured by the following:
(a) The LIM circuit shall be tested after installation, and prior to being placed in service, by successively grounding each line of the energized distribution system through a resistor of 200 V ohms, where V = measured line voltage. The visual and audible alarms [see 3-3.2.2.3(b)] shall be activated.
(b) The LIM circuit shall be tested at intervals of not more than 1 month by actuating the LIM test switch [see 3-3.2.2.3(f)]. For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months. Actuation of the test switch shall activate both visual and audible alarm indicators.
(c) After any repair or renovation to an electrical distribution system and at intervals of not more than 6 months, the LIM circuit shall be tested in accordance with paragraph (a) above and only when the circuit is not otherwise in use. For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months.
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Based on the observation on 12/03/2014 of this building's electrical wiring and equipment, the facility failed to prohibit the use of extension cords per code. Findings include:

1. The Pharmacy had a surge protector (extension cord) plugged into a homemade extension cord by the Narcotics Room.


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2. Room 300 was observed with a refrigerator plugged into a surge protector.

The deficiency impacted 1 of 2 smoke compartments.

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1999 NFPA 70, 400-7 and 400-8, and HCFA Transmittal Notice 22-99 The 1984 edition of the National Electric Code restricts the use of extension cords to temporary short term uses. It is the policy of HCFA to prohibit non-circuit breaker protected extension cords in health care. The limited use of circuit breaker protected power strips is acceptable, provided the current is limited to 15 amps or less, and no major appliances such as air conditioners, refrigerators, or heating units are connected to the power strip.

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Based on the observation of the electrical system on 12/03/2014, the facility failed to maintain the electrical system in the facility. Findings include:

Inside the Oncology Control Room Office, this surveyor observed a refrigerator plugged into a surge protector.

The deficiency impacted 1 of 2 smoke compartments.

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1999 NFPA 70, 400-7 and 400-8, and HCFA Transmittal Notice 22-99 The 1984 edition of the National Electric Code restricts the use of extension cords to temporary short term uses. It is the policy of HCFA to prohibit non-circuit breaker protected extension cords in health care. The limited use of circuit breaker protected power strips is acceptable, provided the current is limited to 15 amps or less, and no major appliances such as air conditioners, refrigerators, or heating units are connected to the power strip.
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