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Based on observations, the facility failed to maintain the smoke and fire resistance rating for a 2-hour rated fire barrier wall in accordance with NFPA 101, 2000 Edition, Section 8.2.3.2.4.2. This deficiency could affect 2 of 3 smoke compartments.

Findings include:

1. During an observation on 9/15/15 at 9:24 a.m., the fire barrier above the lab was inspected. There was a large Information Technology (IT) conduit going from the space above the lab through the two-hour barrier into the IT room on the clinic side. The conduit had IT wires running through it, but there was still a large opening inside the conduit through the fire barrier.¹

2. During an observation on 9/15/15 at 9:26 a.m., the fire barrier behind the admissions desk was inspected. There were two penetrations in the fire barrier above the door to the RHC admissions offices. One of the penetrations had IT wires running through it.¹

¹ NFPA 101, 2000 Edition, Section 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 purpose.
(3) * Insulation and coverings for pipes and ducts shall not pass through the fire barrier unless one of the following conditions is met:
a. 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.

Based on observation, the facility failed to maintain the two-hour fire protection of the self-closing doors used as a horizontal exit in accordance with NFPA 101, 2000 Edition, Sections 18.2.2.26, 18.3.6.3.3, and A.18.3.6.3.3. This deficiency could affect 2 of 3 smoke compartments.

Findings include:

During an observation on 9/15/15 at 9:26 a.m., the doors in the two-hour barrier were inspected. The door behind the admissions desk, the door in the lab/blood draw area, and the conference room door were all chocked open.¹ ²

¹ NFPA 101 Life Safety Code, 2000 Edition Section 18.3.6.3.3*; Hold-open devices that release when the door is pushed or pulled shall be permitted.

² NFPA 101, 2000 Edition Section A.18.3.6.3.3; Doors should not be blocked open by furniture, door stops, chocks, tie-backs, drop-down or plunger-type devices, or other devices that necessitate manual unlatching or releasing action to close. Examples of hold-open devices that release when the door is pushed or pulled are friction catches or magnetic catches.

Based on observations, the facility failed to maintain smoke barriers per NFPA 101, 2000 Edition, Section 8.3.6.1. The deficiency could affect 2 of 3 smoke compartments.

Findings include:

1. During an observation on 9/15/15 at 10:50 a.m., the smoke barriers in the patient room area of the CAH were inspected. The smoke wall above the smoke doors next to the radiology work room was found to have a 2-inch penetration with several white IT wires running through the penetration.¹

2. During an observation on 9/15/15 at 10:50 a.m., the smoke wall on the opposite patient corridor was inspected. There were two penetrations found above the smoke doors. The first was a large annular ring around the main sprinkler pipe for the wet system going through the smoke barrier. The second was an inch and a half circular penetration with no pipes or wires running through it.¹

¹ NFPA 101, 2000 Edition, Section 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.
(3) 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 smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Based on observations, the facility failed to protect hazardous areas with a self closing door per NFPA 101, 2000 Edition, Section 19.3.2.1. These deficiencies could affect 1 of 3 smoke compartments.

Findings include:

1. During an observation on 9/14/15 at 4:18 p.m., the x-ray file storage room was inspected. The room is over 50 square feet and had no self-closer on the door.¹

2. During an observation on 9/15/15 at 7:38 a.m., the hospital equipment store room was inspected. The room is over 50 square feet, contained combustibles, and there was no self-closer on the door.¹

¹ NFPA 101, 2000 Edition, Section 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. Hazardous areas shall include, but shall not be restricted to, the following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 square feet (9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Soiled linen rooms
(6) Trash collection rooms
(7) Rooms or spaces larger than 50 square feet (4.6 m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction
(8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard.
Exception: Doors in rated enclosures shall be permitted to have non-rated, factory- or field-applied protective plates extending not more than 48 in. (122 cm) above the bottom of the door.

Based on observation, the facility failed to maintain the automatic sprinkler system in accordance with NFPA 13, 1999 Edition, Section 5-5.1. This deficiency could affect 1 of 3 smoke compartments.

Findings include:

During an observation on 9/15/15 at 10:40 a.m., the IT closet in the clinic was inspected. There was a sprinkler head with no escutcheon ring in the closet. There was also a ceiling tile taken down from the ceiling and not replaced.¹

¹ NFPA 13 Standard for the Installation of Sprinkler Systems, 1999 Edition, Section 5-1.1, The requirements for spacing, location, and position of sprinklers shall be based on the following principles:
(1) Sprinklers installed throughout the premises
(2) Sprinklers located so as not to exceed maximum protection area per sprinkler
(3) Sprinklers positioned and located so as to provide satisfactory performance with respect to activation time and distribution
Exception No. 1: For locations permitting omission of sprinklers, see 5-13.1, 5-13.2, and 5-13.9.
Exception No. 2: When sprinklers are specifically tested and test results demonstrate that deviations from clearance requirements to structural members do not impair the ability of the sprinkler to control or suppress a fire, their positioning and locating in accordance with the test results shall be permitted.
Exception No. 3: Clearance between sprinklers and ceilings exceeding the maximum specified in 5-6.4.1, 5-7.4.1, 5-8.4.1, 5-9.4.1, 5-10.4.1, and 5-11.4.1 shall be permitted provided that tests or calculations demonstrate comparable sensitivity and performance of the sprinklers to those installed in conformance with these sections.

Based on observation, the facility failed to place portable fire extinguishers at proper height of 60 inches (5 feet) per NFPA 10, Section 1-6.10. This deficiency could affect 1 of 3 smoke compartments.

Findings include:

During an observation on 9/14/15 at 4:44 p.m., the laundry room was inspected. The fire extinguisher mounted on the wall was mounted 68 inches high, to the top of the extinguisher.¹

¹ NFPA 10 Standard for Portable Fire Extinguishers, 1998 Edition, Section 1-6.10; Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. Fire extinguishers having a gross weight greater than 40 lb (18.14 kg) (except wheeled types) shall be so installed that the top of the fire extinguisher is not more than 31/2 ft (1.07 m) above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 in. (10.2 cm).

Based on observation, the facility failed to maintain the means of egress per NFPA 101, 2000 Edition, Section 7.1.10.1 and Center for Medicare and Medicaid Services (CMS) Policy 13-58-LSC. The deficiency could affect 1 of 3 smoke compartments.

Findings include:

During an observation on 9/15/15 at 7:44 a.m., the patient room corridor was inspected. There were lifts stored in the corridor at the end of the patient hall. The facility was not operating under a categorical waiver to keep wheeled equipment stored in the corridor.¹ ²

¹ NFPA 101 Life Safety Code, 2000 Edition, Section 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.

² CMS Survey & Certification Policy S&C-13-58-LSC 2000 Edition National Fire Protection Association (NFPA) 101® Life Safety Code (LSC) Waivers, Issued 8/30/13.

Based on observation, the facility failed to meet the medical gas storage requirements in accordance with NFPA 50, 1996 Edition, Sections 1-3 and 4-2.1. These deficiencies could affect 1 of 3 smoke compartments.

Findings include:

During an observation on 9/14/15 at 2:00 p.m., the medical gas storeroom was inspected. There were 4, 160 Liter tanks of liquid oxygen or 18,000 ft³, plus 11 "K" sized tanks or 2860 ft³, plus, 10 "E" sized tanks or 240 ft³, equaling 21,100 ft³. The amount of stored oxygen would qualify the area as a bulk oxygen system as it exceeded 20,000 cubic feet. There was no annual inspection of the bulk oxygen system performed by a qualified representative or properly trained employee of the facility.¹ ²

¹ NFPA 50 Standard for Bulk Oxygen Systems at Consumer Sites, 1996 Edition, Section 1-3 Definitions; For the purpose of the standard, the following terms are defined as follows:Bulk Oxygen System. A bulk oxygen system is an assembly of equipment, such as oxygen storage containers, pressure regulators, safety devices, vaporizers, manifolds, and interconnecting piping, that has a storage capacity of more than 20,000 ft3 (566 m3) of oxygen (NTP) including unconnected reserves on hand at the site. The bulk oxygen system terminates at the point where oxygen at service pressure first enters the supply line. The oxygen containers may be stationary or movable, and the oxygen may be stored as gas or liquid.

² NFPA 50, 1996 Edition, Section 4-2.1; Each bulk oxygen system installed on consumer premises shall be inspected annually and maintained by a qualified representative of the equipment owner.

Based on interview and record review, the facility failed to provide documentation of fusible link fire damper testing had been conducted every 4 years per NFPA 90A, 1999 Edition, Section 3-4.7 or proof of use of a catorgorical waiver under CMS S&C Policy . This deficiency could affect 1 of 3 smoke compartments.

The findings include:

During record review on 9/15/15 at 2:00 p.m., the record for fusible link dampers was requested.

In an interview on 9/15/15 at 2:00 p.m., staff member A, maintenance director, said the links have not been changed. The facility was not using any categorical waivers.²

¹ NFPA 90A Standard for the Installation of Air-Conditioning and Ventilating Systems, 1999 Edition, Section 3-4.7; At least every 4 years, fusible links (where applicable) shall be removed from all fire or fire/smoke combination dampers and the dampers shall be operated to verify that they fully close and moving parts shall be lubricated as necessary. Fusible links shall be replaced if they are found to be broken or damaged.

² CMS Survey and Certifcation Policy 10-04-LSC Waiver to Allow Hospitals to Use the NFPA 6-Year Damper Testing Interval, Issued 10/30/09.

Based on observation, the facility failed to maintain the electrical system and/or its components in accordance with the Centers for Medicare and Medicaid Services (CMS) Policy S&C-14-46-LSC. This deficiency could affect 1 of 3 smoke compartments.

Findings include:

During an observation on 9/14/15 at 4:57 p.m., the clinic work area was inspected. There was a refrigerator and a freezer plugged into a power strip.¹

¹ CMS Survey & Certification Policy S&C-14-46-LSC Categorical Waiver for Power Strips Use in Patient Care Areas, Issued 9/26/14.

Based on observation, the facility failed to maintain the electrical system and/or its components in accordance with CMS Policy S&C-14-46-LSC. These deficiencies could affect 1 of 3 smoke compartments.

Findings include:

During an observation on 9/14/15 at 4:09 p.m., emergency room #2 was inspected. There were two power strips in the room, they were not United Laboratories (UL) UL 1363A or UL 60601-1 compliant.¹

¹ CMS Survey & Certification Policy S&C-14-46-LSC Categorical Waiver for Power Strips Use in Patient Care Areas, Issued 9/26/14.

Based on observations, the facility failed to maintain the smoke and fire resistance rating for a 2-hour rated fire barrier wall in accordance with NFPA 101, 2000 Edition, Section 8.2.3.2.4.2. This deficiency could affect 2 of 3 smoke compartments.

Findings include:

1. During an observation on 9/15/15 at 9:24 a.m., the fire barrier above the lab was inspected. There was a large Information Technology (IT) conduit going from the space above the lab through the two-hour barrier into the IT room on the clinic side. The conduit had IT wires running through it, but there was still a large opening inside the conduit through the fire barrier.¹

2. During an observation on 9/15/15 at 9:26 a.m., the fire barrier behind the admissions desk was inspected. There were two penetrations in the fire barrier above the door to the RHC admissions offices. One of the penetrations had IT wires running through it.¹

¹ NFPA 101, 2000 Edition, Section 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 purpose.
(3) * Insulation and coverings for pipes and ducts shall not pass through the fire barrier unless one of the following conditions is met:
a. 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.

Based on observation, the facility failed to maintain the two-hour fire protection of the self-closing doors used as a horizontal exit in accordance with NFPA 101, 2000 Edition, Sections 18.2.2.26, 18.3.6.3.3, and A.18.3.6.3.3. This deficiency could affect 2 of 3 smoke compartments.

Findings include:

During an observation on 9/15/15 at 9:26 a.m., the doors in the two-hour barrier were inspected. The door behind the admissions desk, the door in the lab/blood draw area, and the conference room door were all chocked open.¹ ²

¹ NFPA 101 Life Safety Code, 2000 Edition Section 18.3.6.3.3*; Hold-open devices that release when the door is pushed or pulled shall be permitted.

² NFPA 101, 2000 Edition Section A.18.3.6.3.3; Doors should not be blocked open by furniture, door stops, chocks, tie-backs, drop-down or plunger-type devices, or other devices that necessitate manual unlatching or releasing action to close. Examples of hold-open devices that release when the door is pushed or pulled are friction catches or magnetic catches.

Based on observations, the facility failed to maintain smoke barriers per NFPA 101, 2000 Edition, Section 8.3.6.1. The deficiency could affect 2 of 3 smoke compartments.

Findings include:

1. During an observation on 9/15/15 at 10:50 a.m., the smoke barriers in the patient room area of the CAH were inspected. The smoke wall above the smoke doors next to the radiology work room was found to have a 2-inch penetration with several white IT wires running through the penetration.¹

2. During an observation on 9/15/15 at 10:50 a.m., the smoke wall on the opposite patient corridor was inspected. There were two penetrations found above the smoke doors. The first was a large annular ring around the main sprinkler pipe for the wet system going through the smoke barrier. The second was an inch and a half circular penetration with no pipes or wires running through it.¹

¹ NFPA 101, 2000 Edition, Section 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.
(3) 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 smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Based on observations, the facility failed to protect hazardous areas with a self closing door per NFPA 101, 2000 Edition, Section 19.3.2.1. These deficiencies could affect 1 of 3 smoke compartments.

Findings include:

1. During an observation on 9/14/15 at 4:18 p.m., the x-ray file storage room was inspected. The room is over 50 square feet and had no self-closer on the door.¹

2. During an observation on 9/15/15 at 7:38 a.m., the hospital equipment store room was inspected. The room is over 50 square feet, contained combustibles, and there was no self-closer on the door.¹

¹ NFPA 101, 2000 Edition, Section 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. Hazardous areas shall include, but shall not be restricted to, the following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 square feet (9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Soiled linen rooms
(6) Trash collection rooms
(7) Rooms or spaces larger than 50 square feet (4.6 m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction
(8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard.
Exception: Doors in rated enclosures shall be permitted to have non-rated, factory- or field-applied protective plates extending not more than 48 in. (122 cm) above the bottom of the door.

Based on observation, the facility failed to maintain the automatic sprinkler system in accordance with NFPA 13, 1999 Edition, Section 5-5.1. This deficiency could affect 1 of 3 smoke compartments.

Findings include:

During an observation on 9/15/15 at 10:40 a.m., the IT closet in the clinic was inspected. There was a sprinkler head with no escutcheon ring in the closet. There was also a ceiling tile taken down from the ceiling and not replaced.¹

¹ NFPA 13 Standard for the Installation of Sprinkler Systems, 1999 Edition, Section 5-1.1, The requirements for spacing, location, and position of sprinklers shall be based on the following principles:
(1) Sprinklers installed throughout the premises
(2) Sprinklers located so as not to exceed maximum protection area per sprinkler
(3) Sprinklers positioned and located so as to provide satisfactory performance with respect to activation time and distribution
Exception No. 1: For locations permitting omission of sprinklers, see 5-13.1, 5-13.2, and 5-13.9.
Exception No. 2: When sprinklers are specifically tested and test results demonstrate that deviations from clearance requirements to structural members do not impair the ability of the sprinkler to control or suppress a fire, their positioning and locating in accordance with the test results shall be permitted.
Exception No. 3: Clearance between sprinklers and ceilings exceeding the maximum specified in 5-6.4.1, 5-7.4.1, 5-8.4.1, 5-9.4.1, 5-10.4.1, and 5-11.4.1 shall be permitted provided that tests or calculations demonstrate comparable sensitivity and performance of the sprinklers to those installed in conformance with these sections.

Based on observation, the facility failed to place portable fire extinguishers at proper height of 60 inches (5 feet) per NFPA 10, Section 1-6.10. This deficiency could affect 1 of 3 smoke compartments.

Findings include:

During an observation on 9/14/15 at 4:44 p.m., the laundry room was inspected. The fire extinguisher mounted on the wall was mounted 68 inches high, to the top of the extinguisher.¹

¹ NFPA 10 Standard for Portable Fire Extinguishers, 1998 Edition, Section 1-6.10; Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. Fire extinguishers having a gross weight greater than 40 lb (18.14 kg) (except wheeled types) shall be so installed that the top of the fire extinguisher is not more than 31/2 ft (1.07 m) above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 in. (10.2 cm).

Based on observation, the facility failed to maintain the means of egress per NFPA 101, 2000 Edition, Section 7.1.10.1 and Center for Medicare and Medicaid Services (CMS) Policy 13-58-LSC. The deficiency could affect 1 of 3 smoke compartments.

Findings include:

During an observation on 9/15/15 at 7:44 a.m., the patient room corridor was inspected. There were lifts stored in the corridor at the end of the patient hall. The facility was not operating under a categorical waiver to keep wheeled equipment stored in the corridor.¹ ²

¹ NFPA 101 Life Safety Code, 2000 Edition, Section 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.

² CMS Survey & Certification Policy S&C-13-58-LSC 2000 Edition National Fire Protection Association (NFPA) 101® Life Safety Code (LSC) Waivers, Issued 8/30/13.

Based on observation, the facility failed to meet the medical gas storage requirements in accordance with NFPA 50, 1996 Edition, Sections 1-3 and 4-2.1. These deficiencies could affect 1 of 3 smoke compartments.

Findings include:

During an observation on 9/14/15 at 2:00 p.m., the medical gas storeroom was inspected. There were 4, 160 Liter tanks of liquid oxygen or 18,000 ft³, plus 11 "K" sized tanks or 2860 ft³, plus, 10 "E" sized tanks or 240 ft³, equaling 21,100 ft³. The amount of stored oxygen would qualify the area as a bulk oxygen system as it exceeded 20,000 cubic feet. There was no annual inspection of the bulk oxygen system performed by a qualified representative or properly trained employee of the facility.¹ ²

¹ NFPA 50 Standard for Bulk Oxygen Systems at Consumer Sites, 1996 Edition, Section 1-3 Definitions; For the purpose of the standard, the following terms are defined as follows:Bulk Oxygen System. A bulk oxygen system is an assembly of equipment, such as oxygen storage containers, pressure regulators, safety devices, vaporizers, manifolds, and interconnecting piping, that has a storage capacity of more than 20,000 ft3 (566 m3) of oxygen (NTP) including unconnected reserves on hand at the site. The bulk oxygen system terminates at the point where oxygen at service pressure first enters the supply line. The oxygen containers may be stationary or movable, and the oxygen may be stored as gas or liquid.

² NFPA 50, 1996 Edition, Section 4-2.1; Each bulk oxygen system installed on consumer premises shall be inspected annually and maintained by a qualified representative of the equipment owner.

Based on interview and record review, the facility failed to provide documentation of fusible link fire damper testing had been conducted every 4 years per NFPA 90A, 1999 Edition, Section 3-4.7 or proof of use of a catorgorical waiver under CMS S&C Policy . This deficiency could affect 1 of 3 smoke compartments.

The findings include:

During record review on 9/15/15 at 2:00 p.m., the record for fusible link dampers was requested.

In an interview on 9/15/15 at 2:00 p.m., staff member A, maintenance director, said the links have not been changed. The facility was not using any categorical waivers.²

¹ NFPA 90A Standard for the Installation of Air-Conditioning and Ventilating Systems, 1999 Edition, Section 3-4.7; At least every 4 years, fusible links (where applicable) shall be removed from all fire or fire/smoke combination dampers and the dampers shall be operated to verify that they fully close and moving parts shall be lubricated as necessary. Fusible links shall be replaced if they are found to be broken or damaged.

² CMS Survey and Certifcation Policy 10-04-LSC Waiver to Allow Hospitals to Use the NFPA 6-Year Damper Testing Interval, Issued 10/30/09.

Based on observation, the facility failed to maintain the electrical system and/or its components in accordance with the Centers for Medicare and Medicaid Services (CMS) Policy S&C-14-46-LSC. This deficiency could affect 1 of 3 smoke compartments.

Findings include:

During an observation on 9/14/15 at 4:57 p.m., the clinic work area was inspected. There was a refrigerator and a freezer plugged into a power strip.¹

¹ CMS Survey & Certification Policy S&C-14-46-LSC Categorical Waiver for Power Strips Use in Patient Care Areas, Issued 9/26/14.

Based on observation, the facility failed to maintain the electrical system and/or its components in accordance with CMS Policy S&C-14-46-LSC. These deficiencies could affect 1 of 3 smoke compartments.

Findings include:

During an observation on 9/14/15 at 4:09 p.m., emergency room #2 was inspected. There were two power strips in the room, they were not United Laboratories (UL) UL 1363A or UL 60601-1 compliant.¹

¹ CMS Survey & Certification Policy S&C-14-46-LSC Categorical Waiver for Power Strips Use in Patient Care Areas, Issued 9/26/14.