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Based on observations and interview, it was determined the facility failed to maintain smoke barriers that would resist the passage of smoke between smoke compartments in accordance with NFPA standards. The deficiency had the potential to affect two (2) of four (4) smoke compartments, patients, staff and visitors. The facility is certified for twenty five (25) beds, with a census of seventeen (17) on the day of the survey. The facility failed to ensure penetrations in the smoke partition were sealed with a material capable of maintaining the smoke resistance rating of the smoke barrier.


The findings include:

Observation, on 11/27/12 at 1:36 PM, with the Director of Maintenance and the Safety and Compliance Officer revealed the smoke partition, extending above the ceiling located next to the information desk had a sleeve of wires penetrating the smoke barrier and the inside of the sleeve was not filled with a material rated to maintain the smoke resistance rating of the wall. The sleeve had been filled with an unrated foam pipe insulation that was designed for insulating water lines.

Interview, on 11/27/12 at 1:36 PM, with the Director of Maintenance and the Safety and Compliance Officer revealed they were aware of the requirements for sealing penetrations in smoke barriers but not aware the sleeve had been improperly sealed.




Reference: NFPA 101 (2000 edition)
19.3.7.3
Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1/2 hour.
Exception No. 1: Where an atrium is used, smoke barriers shall be permitted to terminate at an atrium wall constructed in accordance with Exception No. 2 to 8.2.5.6(1). Not less than two separate smoke compartments shall be provided on each floor.
Exception No. 2*: Dampers shall not be required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air conditioning systems where an approved, supervised automatic sprinkler system in accordance with 19.3.5.3 has been provided for smoke compartments adjacent to the smoke barrier.
Reference: NFPA 101 (2000 Edition).

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:
(a) The space between the penetrating item and the smoke barrier shall
1. Be filled with a material capable of maintaining the smoke resistance of the smoke barrier, or
2. Be protected by an approved device designed for the specific purpose.
(b) 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
1. Be filled with a material capable of maintaining the smoke resistance of the smoke barrier, or
2. Be protected by an approved device designed for the specific purpose.
(c) Where designs take transmission of vibration into consideration, any vibration isolation shall
1. Be made on either side of the smoke barrier, or
2. Be made by an approved device designed for the specific purpose.

19.3.7.4
Not less than 30 net ft2 (2.8 net m2) per patient in a hospital or nursing home, or not less than 15 net ft2 (1.4 net m2) per resident in a limited care facility, shall be provided within the aggregate area of corridors, patient rooms, treatment rooms, lounge or dining areas, and other low hazard areas on each side of the smoke barrier. On stories not housing bed or litterborne patients, not less than 6 net ft2 (0.56 net m2) per occupant shall be provided on each side of the smoke barrier for the total number of occupants in adjoining compartments.
19.3.7.5
Openings in smoke barriers shall be protected by fire-rated glazing; by wired glass panels and steel frames; by substantial doors, such as 13/4-in. (4.4-cm) thick, solid-bonded wood core doors; or by construction that resists fire for not less than 20 minutes. Nonrated factory- or field-applied protective plates extending not more than 48 in. (122 cm) above the bottom of the door shall be permitted.
Exception: Doors shall be permitted to have fixed fire window assemblies in accordance with 8.2.3.2.2.
18.3.7.3
Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1 hour.
Exception No. 1: Where an atrium is used, smoke barriers shall be permitted to terminate at an atrium wall constructed in accordance with Exception No. 2 to 8.2.5.6(1). Not less than two separate smoke compartments shall be provided on each floor.
Exception No. 2*: Dampers shall not be required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air conditioning systems.

18.3.7.1
Buildings containing health care facilities shall be subdivided by smoke barriers as follows:
(1) To divide every story used by inpatients for sleeping or treatment into not less than two smoke compartments
(2) To divide every story having an occupant load of 50 or more persons, regardless of use, into not less than two smoke compartments
(3) To limit the size of each smoke compartment required by (1) and (2) to an area not exceeding 22,500 ft2 (2100 m2)
Exception: The area of an atrium separated in accordance with 8.2.5.6 shall not be limited in size.
(4) To limit the travel distance from any point to reach a door in the required smoke barrier to a distance not exceeding 200 ft (60 m).
Exception No. 1: Stories that do not contain a health care occupancy, located totally above the health care occupancy.
Exception No. 2: Areas that do not contain a health care occupancy and that are separated from the health care occupancy by a fire barrier complying with 7.2.4.3.
Exception No. 3: Stories that do not contain health care occupancies and that are more than one story below the health care occupancy.
Exception No. 4: Open-air parking structures protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.

Based on observation and interview, it was determined the facility failed to ensure cross -corridor doors located in a smoke barrier would resist the passage of smoke in accordance with NFPA standards. The deficiency had the potential to affect two (2) of four (4) smoke compartments, patients, staff and visitors. The facility is certified for twenty five (25) beds with a census of seventeen (17) on the day of the survey.

The findings include:

Observation, on 11/27/12 at 2:00 PM with the Director of Maintenance and the Safety and Compliance Officer, revealed the cross-corridor doors located between the breezeway and the new building would not close completely when tested and would not resist the passage of smoke. The doors would not close all the way due to an air draft blowing the doors open and preventing them from staying closed.

Interview, on 11/27/12 at 2:00 PM, with the Director of Maintenance and the Safety and Compliance Officer revealed they were not aware of the air draft preventing the doors from closing properly.


Reference: NFPA 101 (2000 edition)

8.3.4.1* Doors in smoke barriers shall close the opening leaving
only the minimum clearance necessary for proper operation
and shall be without undercuts, louvers, or grilles.

Reference: NFPA 80 (1999 Edition)
Standard for Fire Doors 2-3.1.7
The clearance between the edge of the door on the pull side shall be 1/8 in. (+/-) 1/16 in. (3.18 mm (+/-) 1.59 mm) for steel doors and shall not exceed 1/8 in. (3.18mm) for wood doors.

Based on observation and interview, it was determined the facility failed to meet the requirements of Protection of Hazards in accordance with NFPA Standards. The deficiency had the potential to affect three (3) of four (4) smoke compartments, patients, staff and visitors. The facility is certified for twenty five (25) beds with a census of seventeen (17) on the day of the survey. the facility failed to ensure staff was knowledgeable of the requirements related to self closing devices for doors protecting hazardous areas.The facility failed to provide self-closing devices for doors protecting hazardous areas. Eight (8) doors were affected.


The findings include:

Observation, on 11/27/12 between 1:30 PM and 4:30 PM, with the Director of Maintenance and the Safety and Compliance Officer revealed the doors protecting hazardous rooms located in the following areas did not have a self-closing device.

1) Mechanical Room located in the Surgery Area. This room has a boiler and three (3) doors for access. None of the three doors had a self-closing device.
2) Health Information Office.
3) Health Information Record Storage.
4) Oxygen Storage Room across from the Kitchen.
5) Dark Room.
6) Mammography Room.


Interview, on 11/27/12 between 1:30 PM and 4:30 PM, with the Director of Maintenance and the Safety and Compliance Officer revealed they were not aware of the requirements for protection from hazards. The Safety and Compliance Officer is responsible for maintaining compliance with Life Safety Code requirements, but had only been in her current position for three (3) weeks, and had not had time to make a full assessment of the facility.


18.3.2 Protection from Hazards.
18.3.2.1* Hazardous Areas.
Any hazardous area shall be protected in accordance with Section 8.4. The areas described in Table 18.3.2.1 shall be protected as indicated.



Table 18.3.2.1 Hazardous Area Protection

Hazardous Area Description Separation/Protection
Boiler and fuel-fired heater rooms 1 hour
Central/bulk laundries larger than 100 ft2 (9.3 m2) 1 hour
Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe
hazard See 18.3.6.3.4
Laboratories that use hazardous materials that would be classified as a severe hazard in accordance with NFPA 99, Standard for Health Care Facilities 1 hour
Paint shops employing hazardous substances and materials in quantities less than those that would be classified as a severe hazard 1 hour
Physical plant maintenance shops 1 hour
Soiled linen rooms 1 hour
Storage rooms larger than 50 ft2 (4.6 m2) but not exceeding
100 ft2 (9.3 m2) storing
combustible material See 18.3.6.3.4
Storage rooms larger than 100 ft2 (9.3 m2) storing combustible
material 1 hour
Trash collection rooms 1 hour


8.4.1.3
Doors in barriers required to have a fire resistance rating shall have a 3/4-hour fire protection rating and shall be self-closing or automatic-closing in accordance with 7.2.1.8.










Reference:

NFPA 101 (2000 Edition).

19.3.2 Protection from Hazards.
19.3.2.1 Hazardous Areas. 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 ft2
(9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Soiled linen rooms
(6) Trash collection rooms
(7) Rooms or spaces larger than 50 ft2 (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 nonrated, factory or field-applied
protective plates extending not more than
48 in. (122 cm) above the bottom of the door.

Based on observation and interview, it was determined the facility failed to ensure exits were equipped with lighting in accordance with NFPA standards. The deficiency had the potential to affect one (1) of four (4) smoke compartments, patients, staff and visitors. The facility is certified for twenty five (25) beds with a census of seventeen (17) on the day of the survey. The facility failed to ensure staff was knowledgeable of the requirements for egress illumination. One (1) exit was identified to not meet the requirement for illumination of egress.

The findings include:

Observation, on 11/27/12 at 3:49 PM, with the Director of Maintenance and the Safety and Compliance Officer revealed the exterior exit located in the Old Operating Room area did not have a light outside to light the egress path.

Interview, on 11/27/12 at 3:49 PM, with the Director of Maintenance and the Safety and Compliance Officer revealed they were not aware the exit did not have the required illumination for egress lighting. The Safety and Compliance Officer is responsible for maintaining compliance with the Life Safety Code but has only been in her current position for three (3) weeks and has not had time to make a full assessment of the facility.


Reference: NFPA 101 (2000 Edition)

19.2.8 Illumination of Means of Egress.
Means of egress shall be illuminated in accordance with Section 7.8.


7.8 ILLUMINATION OF MEANS OF EGRESS
7.8.1 General.
7.8.1.1*
Illumination of means of egress shall be provided in accordance with Section 7.8 for every building and structure where required in Chapters 11 through 42. For the purposes of this requirement, exit access shall include only designated stairs, aisles, corridors, ramps, escalators, and passageways leading to an exit. For the purposes of this requirement, exit discharge shall include only designated stairs, aisles, corridors, ramps, escalators, walkways, and exit passageways leading to a public way.
7.8.1.2
Illumination of means of egress shall be continuous during the time that the conditions of occupancy require that the means of egress be available for use. Artificial lighting shall be employed at such locations and for such periods of time as required to maintain the illumination to the minimum criteria values herein specified.
Exception: Automatic, motion sensor-type lighting switches shall be permitted within the means of egress, provided that the switch controllers are equipped for fail-safe operation, the illumination timers are set for a minimum 15-minute duration, and the motion sensor is activated by any occupant movement in the area served by the lighting units.
7.8.1.3*
The floors and other walking surfaces within an exit and within the portions of the exit access and exit discharge designated in 7.8.1.1 shall be illuminated to values of at least 1 ft-candle (10 lux) measured at the floor.
Exception No. 1: In assembly occupancies, the illumination of the floors of exit access shall be at least 0.2 ft-candle (2 lux) during periods of performances or projections involving directed light.
Exception No. 2*: This requirement shall not apply where operations or processes require low lighting levels.
7.8.1.4*
Required illumination shall be arranged so that the failure of any single lighting unit does not result in an illumination level of less than 0.2 ft-candle (2 lux) in any designated area.

Based on observation and interview, it was determined the facility failed to ensure exit signs were maintained in accordance with NFPA standards. The deficiency had the potential to affect one (1) of four (4) smoke compartments, patients, staff and visitors. The facility is certified for twenty five (25) beds with a census of seventeen (17) on the day of the survey. The facility failed to ensure exits were clearly recognizable with proper exit signage. The facility failed to ensure staff was knowledgeable related to proper exit sinage. Three (3) exits were affected.

The findings include:

Observations, on 11/27/12 between 1:30 PM and 4:30 PM, with the Director of Maintenance and the Safety and Compliance Officer revealed the exit doors located in the Kitchen, and the Old Operating Room area exit did not have an exit sign above the door making the path of egress not clearly recognizable.


Interview, on 11/27/12 between 1:30 PM and 4:30 PM, with the Director of Maintenance and the Safety and Compliance Officer revealed they were not aware the exits did not have proper signage. The Safety and Compliance Officer is responsible for compliance with the Life Safety Code but has only been in her current position for three (3) weeks and has not had time to make a full assessment of the facility.



Reference: NFPA 101 (2000 edition)

7.10.1.2* Exits. Exits, other than main exterior exit doors
that obviously and clearly are identifiable as exits, shall be
marked by an approved sign readily visible from any direction
of exit access.

Based on observation and interview it was determined the facility failed to ensure the building had a complete sprinkler system, installed in accordance with NFPA Standards. The deficiency had the potential to affect two (2) of four (4) smoke compartments, patients, staff and visitors. The facility is certified for twenty five (25) beds with a census of seventeen (17) on the day of the survey. The facility failed to ensure sprinkler heads were not blocked by light fixtures on the ceiling, and each room had complete sprinkler coverage. The facility failed to ensure staff was knowledgeable and trained to the requirements.

The findings include:

Observations, on 11/27/12 between 1:30 PM and 4:30 PM with the Director of Maintenance and the Safety and Compliance Officer revealed the sprinkler heads located in Conference Room 1, the Safety and Compliance Office, the corridor by the Chapel, and the Housekeeping Closet in Respiratory Therapy were blocked by light fixtures, within 1 foot of the sprinkler head, extending below the sprinkler heads.

Interview, on 11/27/12 between 1:30 PM and 4:30 PM with the Director of Maintenance and the Safety and Compliance Officer revealed they were unaware that sprinkler heads could have no obstructions below the deflector within 12 inches of the head.

Observation, on 11/27/12 at 3:43 PM, with the Director of Maintenance and the Safety and Compliance Officer revealed a shower room located in the Old Operation Room area did not have adequate sprinkler coverage. The sprinkler head was located outside of the shower stall and could not spray around the wall to cover the shower stall area of the shower room.

Interview, on 11/27/12 at 3:43 PM, with the Director of Maintenance and the Safety and Compliance Officer revealed they had not noticed the inadequate sprinkler coverage but confirmed the sprinkler could not spray around the wall.


Reference: NFPA 13 (1999 Edition)

5-13 8.1 Actual NFPA Standard: NFPA 101, Table 19.1.6.2 and 19.3.5.1. Existing healthcare facilities with construction Type V (111) require complete sprinkler coverage for all parts of a facility.
Actual NFPA Standard: NFPA 101, 19.3.5.1. Where required by 19.1.6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.
Actual NFPA Standard: NFPA 101, 9.7.1.1. Each automatic sprinkler system required by another section of this Code shall be in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.
Actual NFPA Standard: NFPA 13, 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.

Reference: NFPA 13 (1999 edition)

5-6.3.3 Minimum Distance from Walls. Sprinklers shall be located a minimum of 4 in. (102 mm) from a wall.


Reference: NFPA 13 (1999 ed.)
5-5.5.2.2 Sprinklers shall be positioned in accordance with
the minimum distances and special exceptions of Sections 5-6
through 5-11 so that they are located sufficiently away from
obstructions such as truss webs and chords, pipes, columns,
and fixtures.
Table 5-6.5.1.2 Positioning of Sprinklers to Avoid Obstructions to Discharge (SSU/SSP)

Maximum Allowable Distance
Distance from Sprinklers to of Deflector above Bottom of
Side of Obstruction (A) Obstruction (in.) (B
Less than 1 ft 0
1 ft to less than 1 ft 6 in. 21/2
1 ft 6 in. to less than 2 ft 31/2
2 ft to less than 2 ft 6 in. 51/2
2 ft 6 in. to less than 3 ft 71/2
3 ft to less than 3 ft 6 in. 91/2
3 ft 6 in. to less than 4 ft 12
4 ft to less than 4 ft 6 in. 14
4 ft 6 in. to less than 5 ft 161/2
5 ft and greater 18

For SI units, 1 in. = 25.4 mm; 1 ft = 0.3048 m.
Note: For (A) and (B), refer to Figure 5-6.5.1.2(a).

Based on interview and hood cleaning record review, it was determined the facility failed to ensure cooking facilities were protected in accordance with NFPA standards. The deficiency had the potential to affect one (1) of four (4) smoke compartments, patients, staff, and visitors. The facility is certified for twenty five (25) beds with a census of seventeen (17) on the day of the survey. the facility failed to ensure staff was knowledgeable of the hood cleaning requirements. The facility failed to ensure the kitchen exhaust hood had been cleaned routinely.

The findings include:

Hood cleaning record review, on 11/27/12 at 12:10 PM, with the Director of Maintenance and the Safety and Compliance Officer revealed the facility did not have documentation that the exhaust hood located in the Kitchen had ever been cleaned. The Kitchen has been serving the hospital since it was built in 1964.

Interview on 11/27/12 at 12:10 PM, with the Director of Maintenance and the Safety and Compliance Officer revealed they were not aware of the hood cleaning requirements. Further interview revealed the only cleaning they knew the hood received on a regular basis was the filters were removed and washed in the dishwasher. The Safety and Compliance Officer is responsible for maintaining compliance with the requirements of the Life Safety Code but has only been in her current position for three (3) weeks and has not had time to make a full assessment of the facility.


Reference NFPA 101 (2000 Edition)

19.3.2.6 Cooking Facilities.
Cooking facilities shall be protected in accordance with 9.2.3.
Exception*: Where domestic cooking equipment is used for food-warming or limited cooking, protection or segregation of food preparation facilities shall not be required.

9.2.3 Commercial Cooking Equipment.
Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

Reference: NFPA 96

11.4 Cleaning of Exhaust Systems.
11.4.1 Upon inspection, if found to be contaminated with deposits from grease-laden vapors, the entire exhaust system shall be cleaned by a properly trained, qualified, and certified company or person(s) acceptable to the authority having jurisdiction in accordance with Section 11.3.
11.4.2* Hoods, grease removal devices, fans, ducts, and other appurtenances shall be cleaned to bare metal prior to surfaces becoming heavily contaminated with grease or oily sludge.
11.4.3 At the start of the cleaning process, electrical switches that could be activated accidentally shall be locked out.
11.4.4 Components of the fire suppression system shall not be rendered inoperable during the cleaning process.
11.4.5 Fire-extinguishing systems shall be permitted to be rendered inoperable during the cleaning process where serviced by properly trained and qualified persons in accordance with Section 11.3.
11.4.6 Flammable solvents or other flammable cleaning aids shall not be used.
11.4.7 Cleaning chemicals shall not be applied on fusible links or other detection devices of the automatic extinguishing system.
11.4.8 After the exhaust system is cleaned to bare metal, it shall not be coated with powder or other substance.
11.4.9 All access panels (doors) and cover plates shall be replaced.
11.4.10 Dampers and diffusers shall be positioned for proper airflow.
11.4.11 When cleaning procedures are completed, all electrical switches and system components shall be returned to an operable state.
11.4.12 When a vent cleaning service is used, a certificate showing date of inspection or cleaning shall be maintained on the premises.
11.4.13 After cleaning is completed, the vent cleaning contractor shall place or display within the kitchen area a label indicating the date cleaned and the name of the servicing company, and areas not cleaned.
11.4.14 Where required, certificates of inspection and cleaning shall be submitted to the authority having jurisdiction.


Reference NFPA 96

11.3 Inspection of Exhaust Systems.
The entire exhaust system shall be inspected by a properly trained, qualified, and certified company or person(s) acceptable to the authority having jurisdiction in accordance with Table 11.3.

Table 11.3 Exhaust System Inspection Schedule
Type or Volume of Cooking Frequency Frequency
Systems serving solid fuel cooking operations Monthly
Systems serving high-volume cooking operations such as 24-hour cooking, charbroiling, or wok cooking Quarterly
Systems serving moderate-volume cooking operations Semiannually
Systems serving low-volume cooking operations, such as churches, day camps, seasonal businesses, or senior centers Annually

Based on observation and interview, it was determined the facility failed to ensure, portable space heaters used in the facility were in accordance with NFPA standards. The deficiency had the potential to affect one (1) of four (4) smoke compartments, patients, staff and visitors. The facility is certified for twenty five (25) beds with a census of seventeen (17) on the day of the survey. Two (2) heaters were identified.

This is a repeat deficiency from a survey conducted on 1/20/12.


.
The findings include:

Observation, on 11/27/12 at 4:12 PM, with the Director of Maintenance and the Safety and Compliance Officer revealed two (2) portable space heaters in use located in the Doctor's on-call room. The facility did not have documentation that the heaters did not exceed 212 degrees. The Doctors's on- call room had a couch that doctors would use to sleep.

Interview, on 11/27/12 at 4:12 PM, with the Director of Maintenance and the Safety and Compliance Officer revealed they were aware the heaters could not exceed 212?F in non-sleeping, staff, and employee areas. However, they were not aware the heaters were in use and did not have a plan in place to check for heaters in the building.


Reference: NFPA 101 (2000 edition)
19.7.8 Portable Space-Heating Devices. Portable space-heating
devices shall be prohibited in all health care occupancies.
Exception: Portable space-heating devices shall be permitted to be used
in non-sleeping staff and employee areas where the heating elements of
such devices do not exceed 212?F (100?C).

Based on observation and interview, it was determined the facility failed to ensure fire/smoke dampers were maintained in accordance with NFPA standards. The deficiency had the potential to affect one (1) of four (4) smoke compartments, patients, staff and visitors. The facility is certified for twenty five (25) beds with a census of seventeen (17) on the day of the survey.

The findings include:


Observation, on 11/27/12 at 1:43 PM, with the Director of Maintenance and the Safety and Compliance Officer revealed the fire/smoke damper located in the air duct above the ceiling near the cross corridor doors next to Radiology had been maintained by sealing the air duct around the fire/smoke damper with unrated quick foam.

Interview, on 11/27/12 at 1:43 PM, with the Director of Maintenance and the Safety and Compliance Officer revealed they were not aware of the quick foam and had no idea who would have used unrated quick foam to seal the air duct around the fire/smoke damper.

Reference: NFPA 101 (2000 Edition)

8.3.6 Penetrations and Miscellaneous Openings in Floors and Smoke Barriers.
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.
8.3.6.2
Openings occurring at points where floors or smoke barriers meet the outside walls, other smoke barriers, or fire barriers of a building shall meet one of the following conditions:
(1) It shall be filled with a material that is capable of maintaining the smoke resistance of the floor or smoke barrier.
(2) It shall be protected by an approved device that is designed for the specific purpose.


Reference: NFPA 90A (1999 edition)

3-4.7 Maintenance. At least every 4 years, fusible links (where
applicable) shall be removed; all dampers shall be operated to
verify that they fully close; the latch, if provided, shall be
checked; and moving parts shall be lubricated as necessary.

Based on observation and interview, it was determined the facility failed to ensure electrical wiring was maintained in accordance with NFPA standards. The deficiency had the potential to affect three (3) of four (4) smoke compartments, patients, staff, and visitors. The facility is certified for twenty five (25) beds with a census of seventeen (17) on the day of the survey. The facility failed to ensure the proper use of power strips and extension cords. Three (3) extension cords and three (3) power strips were identified as being misused.

The findings include:

Observation, on 11/27/12 between 1:30 PM and 4:30 PM, with the Director of Maintenance and the Safety and Compliance Officer revealed:

1) An extension cord in use located in the Finance Office.
2) A power strip plugged into an extension cord located in the Business Office.
3) An extension cord in use located in the Health Information Office.
4) A power strip plugged into another power strip located in the Doctor's on-call room.

Interview, on 11/27/12 between 1:30 PM and 4:30 PM, with the Director of Maintenance and the Safety and Compliance Officer revealed they were aware of the proper use of power strips and extension cords, and always looked for misuse during day to day activities. They were not aware any extension cords were being used in building and not aware of whom plugged the power strips together.


Reference: NFPA 101 (2000 Edition)

9.1.2 Electric.
Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

Reference: NFPA 70 400-8
( Extensions Cords) Uses Not Permitted.
Unless specifically permitted in 400.7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces


Reference: NFPA 99 (1999 edition)

3-3.2.1.2 D

Minimum Number of Receptacles. The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters.

Based on observations and interview, it was determined the facility failed to maintain smoke barriers that would resist the passage of smoke between smoke compartments in accordance with NFPA standards. The deficiency had the potential to affect two (2) of four (4) smoke compartments, patients, staff and visitors. The facility is certified for twenty five (25) beds, with a census of seventeen (17) on the day of the survey. The facility failed to ensure penetrations in the smoke partition were sealed with a material capable of maintaining the smoke resistance rating of the smoke barrier.


The findings include:

Observation, on 11/27/12 at 1:36 PM, with the Director of Maintenance and the Safety and Compliance Officer revealed the smoke partition, extending above the ceiling located next to the information desk had a sleeve of wires penetrating the smoke barrier and the inside of the sleeve was not filled with a material rated to maintain the smoke resistance rating of the wall. The sleeve had been filled with an unrated foam pipe insulation that was designed for insulating water lines.

Interview, on 11/27/12 at 1:36 PM, with the Director of Maintenance and the Safety and Compliance Officer revealed they were aware of the requirements for sealing penetrations in smoke barriers but not aware the sleeve had been improperly sealed.




Reference: NFPA 101 (2000 edition)
19.3.7.3
Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1/2 hour.
Exception No. 1: Where an atrium is used, smoke barriers shall be permitted to terminate at an atrium wall constructed in accordance with Exception No. 2 to 8.2.5.6(1). Not less than two separate smoke compartments shall be provided on each floor.
Exception No. 2*: Dampers shall not be required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air conditioning systems where an approved, supervised automatic sprinkler system in accordance with 19.3.5.3 has been provided for smoke compartments adjacent to the smoke barrier.
Reference: NFPA 101 (2000 Edition).

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:
(a) The space between the penetrating item and the smoke barrier shall
1. Be filled with a material capable of maintaining the smoke resistance of the smoke barrier, or
2. Be protected by an approved device designed for the specific purpose.
(b) 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
1. Be filled with a material capable of maintaining the smoke resistance of the smoke barrier, or
2. Be protected by an approved device designed for the specific purpose.
(c) Where designs take transmission of vibration into consideration, any vibration isolation shall
1. Be made on either side of the smoke barrier, or
2. Be made by an approved device designed for the specific purpose.

19.3.7.4
Not less than 30 net ft2 (2.8 net m2) per patient in a hospital or nursing home, or not less than 15 net ft2 (1.4 net m2) per resident in a limited care facility, shall be provided within the aggregate area of corridors, patient rooms, treatment rooms, lounge or dining areas, and other low hazard areas on each side of the smoke barrier. On stories not housing bed or litterborne patients, not less than 6 net ft2 (0.56 net m2) per occupant shall be provided on each side of the smoke barrier for the total number of occupants in adjoining compartments.
19.3.7.5
Openings in smoke barriers shall be protected by fire-rated glazing; by wired glass panels and steel frames; by substantial doors, such as 13/4-in. (4.4-cm) thick, solid-bonded wood core doors; or by construction that resists fire for not less than 20 minutes. Nonrated factory- or field-applied protective plates extending not more than 48 in. (122 cm) above the bottom of the door shall be permitted.
Exception: Doors shall be permitted to have fixed fire window assemblies in accordance with 8.2.3.2.2.
18.3.7.3
Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1 hour.
Exception No. 1: Where an atrium is used, smoke barriers shall be permitted to terminate at an atrium wall constructed in accordance with Exception No. 2 to 8.2.5.6(1). Not less than two separate smoke compartments shall be provided on each floor.
Exception No. 2*: Dampers shall not be required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air conditioning systems.

18.3.7.1
Buildings containing health care facilities shall be subdivided by smoke barriers as follows:
(1) To divide every story used by inpatients for sleeping or treatment into not less than two smoke compartments
(2) To divide every story having an occupant load of 50 or more persons, regardless of use, into not less than two smoke compartments
(3) To limit the size of each smoke compartment required by (1) and (2) to an area not exceeding 22,500 ft2 (2100 m2)
Exception: The area of an atrium separated in accordance with 8.2.5.6 shall not be limited in size.
(4) To limit the travel distance from any point to reach a door in the required smoke barrier to a distance not exceeding 200 ft (60 m).
Exception No. 1: Stories that do not contain a health care occupancy, located totally above the health care occupancy.
Exception No. 2: Areas that do not contain a health care occupancy and that are separated from the health care occupancy by a fire barrier complying with 7.2.4.3.
Exception No. 3: Stories that do not contain health care occupancies and that are more than one story below the health care occupancy.
Exception No. 4: Open-air parking structures protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.

Based on observation and interview, it was determined the facility failed to ensure cross -corridor doors located in a smoke barrier would resist the passage of smoke in accordance with NFPA standards. The deficiency had the potential to affect two (2) of four (4) smoke compartments, patients, staff and visitors. The facility is certified for twenty five (25) beds with a census of seventeen (17) on the day of the survey.

The findings include:

Observation, on 11/27/12 at 2:00 PM with the Director of Maintenance and the Safety and Compliance Officer, revealed the cross-corridor doors located between the breezeway and the new building would not close completely when tested and would not resist the passage of smoke. The doors would not close all the way due to an air draft blowing the doors open and preventing them from staying closed.

Interview, on 11/27/12 at 2:00 PM, with the Director of Maintenance and the Safety and Compliance Officer revealed they were not aware of the air draft preventing the doors from closing properly.


Reference: NFPA 101 (2000 edition)

8.3.4.1* Doors in smoke barriers shall close the opening leaving
only the minimum clearance necessary for proper operation
and shall be without undercuts, louvers, or grilles.

Reference: NFPA 80 (1999 Edition)
Standard for Fire Doors 2-3.1.7
The clearance between the edge of the door on the pull side shall be 1/8 in. (+/-) 1/16 in. (3.18 mm (+/-) 1.59 mm) for steel doors and shall not exceed 1/8 in. (3.18mm) for wood doors.

Based on observation and interview, it was determined the facility failed to meet the requirements of Protection of Hazards in accordance with NFPA Standards. The deficiency had the potential to affect three (3) of four (4) smoke compartments, patients, staff and visitors. The facility is certified for twenty five (25) beds with a census of seventeen (17) on the day of the survey. the facility failed to ensure staff was knowledgeable of the requirements related to self closing devices for doors protecting hazardous areas.The facility failed to provide self-closing devices for doors protecting hazardous areas. Eight (8) doors were affected.


The findings include:

Observation, on 11/27/12 between 1:30 PM and 4:30 PM, with the Director of Maintenance and the Safety and Compliance Officer revealed the doors protecting hazardous rooms located in the following areas did not have a self-closing device.

1) Mechanical Room located in the Surgery Area. This room has a boiler and three (3) doors for access. None of the three doors had a self-closing device.
2) Health Information Office.
3) Health Information Record Storage.
4) Oxygen Storage Room across from the Kitchen.
5) Dark Room.
6) Mammography Room.


Interview, on 11/27/12 between 1:30 PM and 4:30 PM, with the Director of Maintenance and the Safety and Compliance Officer revealed they were not aware of the requirements for protection from hazards. The Safety and Compliance Officer is responsible for maintaining compliance with Life Safety Code requirements, but had only been in her current position for three (3) weeks, and had not had time to make a full assessment of the facility.


18.3.2 Protection from Hazards.
18.3.2.1* Hazardous Areas.
Any hazardous area shall be protected in accordance with Section 8.4. The areas described in Table 18.3.2.1 shall be protected as indicated.



Table 18.3.2.1 Hazardous Area Protection

Hazardous Area Description Separation/Protection
Boiler and fuel-fired heater rooms 1 hour
Central/bulk laundries larger than 100 ft2 (9.3 m2) 1 hour
Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe
hazard See 18.3.6.3.4
Laboratories that use hazardous materials that would be classified as a severe hazard in accordance with NFPA 99, Standard for Health Care Facilities 1 hour
Paint shops employing hazardous substances and materials in quantities less than those that would be classified as a severe hazard 1 hour
Physical plant maintenance shops 1 hour
Soiled linen rooms 1 hour
Storage rooms larger than 50 ft2 (4.6 m2) but not exceeding
100 ft2 (9.3 m2) storing
combustible material See 18.3.6.3.4
Storage rooms larger than 100 ft2 (9.3 m2) storing combustible
material 1 hour
Trash collection rooms 1 hour


8.4.1.3
Doors in barriers required to have a fire resistance rating shall have a 3/4-hour fire protection rating and shall be self-closing or automatic-closing in accordance with 7.2.1.8.










Reference:

NFPA 101 (2000 Edition).

19.3.2 Protection from Hazards.
19.3.2.1 Hazardous Areas. 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 ft2
(9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Soiled linen rooms
(6) Trash collection rooms
(7) Rooms or spaces larger than 50 ft2 (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 nonrated, factory or field-applied
protective plates extending not more than
48 in. (122 cm) above the bottom of the door.

Based on observation and interview, it was determined the facility failed to ensure exits were equipped with lighting in accordance with NFPA standards. The deficiency had the potential to affect one (1) of four (4) smoke compartments, patients, staff and visitors. The facility is certified for twenty five (25) beds with a census of seventeen (17) on the day of the survey. The facility failed to ensure staff was knowledgeable of the requirements for egress illumination. One (1) exit was identified to not meet the requirement for illumination of egress.

The findings include:

Observation, on 11/27/12 at 3:49 PM, with the Director of Maintenance and the Safety and Compliance Officer revealed the exterior exit located in the Old Operating Room area did not have a light outside to light the egress path.

Interview, on 11/27/12 at 3:49 PM, with the Director of Maintenance and the Safety and Compliance Officer revealed they were not aware the exit did not have the required illumination for egress lighting. The Safety and Compliance Officer is responsible for maintaining compliance with the Life Safety Code but has only been in her current position for three (3) weeks and has not had time to make a full assessment of the facility.


Reference: NFPA 101 (2000 Edition)

19.2.8 Illumination of Means of Egress.
Means of egress shall be illuminated in accordance with Section 7.8.


7.8 ILLUMINATION OF MEANS OF EGRESS
7.8.1 General.
7.8.1.1*
Illumination of means of egress shall be provided in accordance with Section 7.8 for every building and structure where required in Chapters 11 through 42. For the purposes of this requirement, exit access shall include only designated stairs, aisles, corridors, ramps, escalators, and passageways leading to an exit. For the purposes of this requirement, exit discharge shall include only designated stairs, aisles, corridors, ramps, escalators, walkways, and exit passageways leading to a public way.
7.8.1.2
Illumination of means of egress shall be continuous during the time that the conditions of occupancy require that the means of egress be available for use. Artificial lighting shall be employed at such locations and for such periods of time as required to maintain the illumination to the minimum criteria values herein specified.
Exception: Automatic, motion sensor-type lighting switches shall be permitted within the means of egress, provided that the switch controllers are equipped for fail-safe operation, the illumination timers are set for a minimum 15-minute duration, and the motion sensor is activated by any occupant movement in the area served by the lighting units.
7.8.1.3*
The floors and other walking surfaces within an exit and within the portions of the exit access and exit discharge designated in 7.8.1.1 shall be illuminated to values of at least 1 ft-candle (10 lux) measured at the floor.
Exception No. 1: In assembly occupancies, the illumination of the floors of exit access shall be at least 0.2 ft-candle (2 lux) during periods of performances or projections involving directed light.
Exception No. 2*: This requirement shall not apply where operations or processes require low lighting levels.
7.8.1.4*
Required illumination shall be arranged so that the failure of any single lighting unit does not result in an illumination level of less than 0.2 ft-candle (2 lux) in any designated area.

Based on observation and interview, it was determined the facility failed to ensure exit signs were maintained in accordance with NFPA standards. The deficiency had the potential to affect one (1) of four (4) smoke compartments, patients, staff and visitors. The facility is certified for twenty five (25) beds with a census of seventeen (17) on the day of the survey. The facility failed to ensure exits were clearly recognizable with proper exit signage. The facility failed to ensure staff was knowledgeable related to proper exit sinage. Three (3) exits were affected.

The findings include:

Observations, on 11/27/12 between 1:30 PM and 4:30 PM, with the Director of Maintenance and the Safety and Compliance Officer revealed the exit doors located in the Kitchen, and the Old Operating Room area exit did not have an exit sign above the door making the path of egress not clearly recognizable.


Interview, on 11/27/12 between 1:30 PM and 4:30 PM, with the Director of Maintenance and the Safety and Compliance Officer revealed they were not aware the exits did not have proper signage. The Safety and Compliance Officer is responsible for compliance with the Life Safety Code but has only been in her current position for three (3) weeks and has not had time to make a full assessment of the facility.



Reference: NFPA 101 (2000 edition)

7.10.1.2* Exits. Exits, other than main exterior exit doors
that obviously and clearly are identifiable as exits, shall be
marked by an approved sign readily visible from any direction
of exit access.

Based on observation and interview it was determined the facility failed to ensure the building had a complete sprinkler system, installed in accordance with NFPA Standards. The deficiency had the potential to affect two (2) of four (4) smoke compartments, patients, staff and visitors. The facility is certified for twenty five (25) beds with a census of seventeen (17) on the day of the survey. The facility failed to ensure sprinkler heads were not blocked by light fixtures on the ceiling, and each room had complete sprinkler coverage. The facility failed to ensure staff was knowledgeable and trained to the requirements.

The findings include:

Observations, on 11/27/12 between 1:30 PM and 4:30 PM with the Director of Maintenance and the Safety and Compliance Officer revealed the sprinkler heads located in Conference Room 1, the Safety and Compliance Office, the corridor by the Chapel, and the Housekeeping Closet in Respiratory Therapy were blocked by light fixtures, within 1 foot of the sprinkler head, extending below the sprinkler heads.

Interview, on 11/27/12 between 1:30 PM and 4:30 PM with the Director of Maintenance and the Safety and Compliance Officer revealed they were unaware that sprinkler heads could have no obstructions below the deflector within 12 inches of the head.

Observation, on 11/27/12 at 3:43 PM, with the Director of Maintenance and the Safety and Compliance Officer revealed a shower room located in the Old Operation Room area did not have adequate sprinkler coverage. The sprinkler head was located outside of the shower stall and could not spray around the wall to cover the shower stall area of the shower room.

Interview, on 11/27/12 at 3:43 PM, with the Director of Maintenance and the Safety and Compliance Officer revealed they had not noticed the inadequate sprinkler coverage but confirmed the sprinkler could not spray around the wall.


Reference: NFPA 13 (1999 Edition)

5-13 8.1 Actual NFPA Standard: NFPA 101, Table 19.1.6.2 and 19.3.5.1. Existing healthcare facilities with construction Type V (111) require complete sprinkler coverage for all parts of a facility.
Actual NFPA Standard: NFPA 101, 19.3.5.1. Where required by 19.1.6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.
Actual NFPA Standard: NFPA 101, 9.7.1.1. Each automatic sprinkler system required by another section of this Code shall be in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.
Actual NFPA Standard: NFPA 13, 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.

Reference: NFPA 13 (1999 edition)

5-6.3.3 Minimum Distance from Walls. Sprinklers shall be located a minimum of 4 in. (102 mm) from a wall.


Reference: NFPA 13 (1999 ed.)
5-5.5.2.2 Sprinklers shall be positioned in accordance with
the minimum distances and special exceptions of Sections 5-6
through 5-11 so that they are located sufficiently away from
obstructions such as truss webs and chords, pipes, columns,
and fixtures.
Table 5-6.5.1.2 Positioning of Sprinklers to Avoid Obstructions to Discharge (SSU/SSP)

Maximum Allowable Distance
Distance from Sprinklers to of Deflector above Bottom of
Side of Obstruction (A) Obstruction (in.) (B
Less than 1 ft 0
1 ft to less than 1 ft 6 in. 21/2
1 ft 6 in. to less than 2 ft 31/2
2 ft to less than 2 ft 6 in. 51/2
2 ft 6 in. to less than 3 ft 71/2
3 ft to less than 3 ft 6 in. 91/2
3 ft 6 in. to less than 4 ft 12
4 ft to less than 4 ft 6 in. 14
4 ft 6 in. to less than 5 ft 161/2
5 ft and greater 18

For SI units, 1 in. = 25.4 mm; 1 ft = 0.3048 m.
Note: For (A) and (B), refer to Figure 5-6.5.1.2(a).

Based on interview and hood cleaning record review, it was determined the facility failed to ensure cooking facilities were protected in accordance with NFPA standards. The deficiency had the potential to affect one (1) of four (4) smoke compartments, patients, staff, and visitors. The facility is certified for twenty five (25) beds with a census of seventeen (17) on the day of the survey. the facility failed to ensure staff was knowledgeable of the hood cleaning requirements. The facility failed to ensure the kitchen exhaust hood had been cleaned routinely.

The findings include:

Hood cleaning record review, on 11/27/12 at 12:10 PM, with the Director of Maintenance and the Safety and Compliance Officer revealed the facility did not have documentation that the exhaust hood located in the Kitchen had ever been cleaned. The Kitchen has been serving the hospital since it was built in 1964.

Interview on 11/27/12 at 12:10 PM, with the Director of Maintenance and the Safety and Compliance Officer revealed they were not aware of the hood cleaning requirements. Further interview revealed the only cleaning they knew the hood received on a regular basis was the filters were removed and washed in the dishwasher. The Safety and Compliance Officer is responsible for maintaining compliance with the requirements of the Life Safety Code but has only been in her current position for three (3) weeks and has not had time to make a full assessment of the facility.


Reference NFPA 101 (2000 Edition)

19.3.2.6 Cooking Facilities.
Cooking facilities shall be protected in accordance with 9.2.3.
Exception*: Where domestic cooking equipment is used for food-warming or limited cooking, protection or segregation of food preparation facilities shall not be required.

9.2.3 Commercial Cooking Equipment.
Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

Reference: NFPA 96

11.4 Cleaning of Exhaust Systems.
11.4.1 Upon inspection, if found to be contaminated with deposits from grease-laden vapors, the entire exhaust system shall be cleaned by a properly trained, qualified, and certified company or person(s) acceptable to the authority having jurisdiction in accordance with Section 11.3.
11.4.2* Hoods, grease removal devices, fans, ducts, and other appurtenances shall be cleaned to bare metal prior to surfaces becoming heavily contaminated with grease or oily sludge.
11.4.3 At the start of the cleaning process, electrical switches that could be activated accidentally shall be locked out.
11.4.4 Components of the fire suppression system shall not be rendered inoperable during the cleaning process.
11.4.5 Fire-extinguishing systems shall be permitted to be rendered inoperable during the cleaning process where serviced by properly trained and qualified persons in accordance with Section 11.3.
11.4.6 Flammable solvents or other flammable cleaning aids shall not be used.
11.4.7 Cleaning chemicals shall not be applied on fusible links or other detection devices of the automatic extinguishing system.
11.4.8 After the exhaust system is cleaned to bare metal, it shall not be coated with powder or other substance.
11.4.9 All access panels (doors) and cover plates shall be replaced.
11.4.10 Dampers and diffusers shall be positioned for proper airflow.
11.4.11 When cleaning procedures are completed, all electrical switches and system components shall be returned to an operable state.
11.4.12 When a vent cleaning service is used, a certificate showing date of inspection or cleaning shall be maintained on the premises.
11.4.13 After cleaning is completed, the vent cleaning contractor shall place or display within the kitchen area a label indicating the date cleaned and the name of the servicing company, and areas not cleaned.
11.4.14 Where required, certificates of inspection and cleaning shall be submitted to the authority having jurisdiction.


Reference NFPA 96

11.3 Inspection of Exhaust Systems.
The entire exhaust system shall be inspected by a properly trained, qualified, and certified company or person(s) acceptable to the authority having jurisdiction in accordance with Table 11.3.

Table 11.3 Exhaust System Inspection Schedule
Type or Volume of Cooking Frequency Frequency
Systems serving solid fuel cooking operations Monthly
Systems serving high-volume cooking operations such as 24-hour cooking, charbroiling, or wok cooking Quarterly
Systems serving moderate-volume cooking operations Semiannually
Systems serving low-volume cooking operations, such as churches, day camps, seasonal businesses, or senior centers Annually

Based on observation and interview, it was determined the facility failed to ensure, portable space heaters used in the facility were in accordance with NFPA standards. The deficiency had the potential to affect one (1) of four (4) smoke compartments, patients, staff and visitors. The facility is certified for twenty five (25) beds with a census of seventeen (17) on the day of the survey. Two (2) heaters were identified.

This is a repeat deficiency from a survey conducted on 1/20/12.


.
The findings include:

Observation, on 11/27/12 at 4:12 PM, with the Director of Maintenance and the Safety and Compliance Officer revealed two (2) portable space heaters in use located in the Doctor's on-call room. The facility did not have documentation that the heaters did not exceed 212 degrees. The Doctors's on- call room had a couch that doctors would use to sleep.

Interview, on 11/27/12 at 4:12 PM, with the Director of Maintenance and the Safety and Compliance Officer revealed they were aware the heaters could not exceed 212?F in non-sleeping, staff, and employee areas. However, they were not aware the heaters were in use and did not have a plan in place to check for heaters in the building.


Reference: NFPA 101 (2000 edition)
19.7.8 Portable Space-Heating Devices. Portable space-heating
devices shall be prohibited in all health care occupancies.
Exception: Portable space-heating devices shall be permitted to be used
in non-sleeping staff and employee areas where the heating elements of
such devices do not exceed 212?F (100?C).

Based on observation and interview, it was determined the facility failed to ensure fire/smoke dampers were maintained in accordance with NFPA standards. The deficiency had the potential to affect one (1) of four (4) smoke compartments, patients, staff and visitors. The facility is certified for twenty five (25) beds with a census of seventeen (17) on the day of the survey.

The findings include:


Observation, on 11/27/12 at 1:43 PM, with the Director of Maintenance and the Safety and Compliance Officer revealed the fire/smoke damper located in the air duct above the ceiling near the cross corridor doors next to Radiology had been maintained by sealing the air duct around the fire/smoke damper with unrated quick foam.

Interview, on 11/27/12 at 1:43 PM, with the Director of Maintenance and the Safety and Compliance Officer revealed they were not aware of the quick foam and had no idea who would have used unrated quick foam to seal the air duct around the fire/smoke damper.

Reference: NFPA 101 (2000 Edition)

8.3.6 Penetrations and Miscellaneous Openings in Floors and Smoke Barriers.
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.
8.3.6.2
Openings occurring at points where floors or smoke barriers meet the outside walls, other smoke barriers, or fire barriers of a building shall meet one of the following conditions:
(1) It shall be filled with a material that is capable of maintaining the smoke resistance of the floor or smoke barrier.
(2) It shall be protected by an approved device that is designed for the specific purpose.


Reference: NFPA 90A (1999 edition)

3-4.7 Maintenance. At least every 4 years, fusible links (where
applicable) shall be removed; all dampers shall be operated to
verify that they fully close; the latch, if provided, shall be
checked; and moving parts shall be lubricated as necessary.

Based on observation and interview, it was determined the facility failed to ensure electrical wiring was maintained in accordance with NFPA standards. The deficiency had the potential to affect three (3) of four (4) smoke compartments, patients, staff, and visitors. The facility is certified for twenty five (25) beds with a census of seventeen (17) on the day of the survey. The facility failed to ensure the proper use of power strips and extension cords. Three (3) extension cords and three (3) power strips were identified as being misused.

The findings include:

Observation, on 11/27/12 between 1:30 PM and 4:30 PM, with the Director of Maintenance and the Safety and Compliance Officer revealed:

1) An extension cord in use located in the Finance Office.
2) A power strip plugged into an extension cord located in the Business Office.
3) An extension cord in use located in the Health Information Office.
4) A power strip plugged into another power strip located in the Doctor's on-call room.

Interview, on 11/27/12 between 1:30 PM and 4:30 PM, with the Director of Maintenance and the Safety and Compliance Officer revealed they were aware of the proper use of power strips and extension cords, and always looked for misuse during day to day activities. They were not aware any extension cords were being used in building and not aware of whom plugged the power strips together.


Reference: NFPA 101 (2000 Edition)

9.1.2 Electric.
Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

Reference: NFPA 70 400-8
( Extensions Cords) Uses Not Permitted.
Unless specifically permitted in 400.7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces


Reference: NFPA 99 (1999 edition)

3-3.2.1.2 D

Minimum Number of Receptacles. The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters.