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A. Based on random observation during the survey walk-through, not all portions of the building are of fire resistive construction to comply with 19.1.6.2 This deficiency could affect patients in the facility, as well as any staff and visitors within three patient wings and two smoke compartments, by not providing these occupants with a safe exit discharge from the building. The finding is:

1. During the afternoon of 06/26/12and the morning of 06/27/12 the surveyor along with the facility representatives observed designated primary exits from the building to the interior courtyards that are covered with a fabric of unknown surface burning characteristics for building material to comply with NFPA 255. The canopies extend approximately 8 feet and are not self supporting. The facility representatives were unable to provide a manufacturer's data sheet noting the flame spread rating or smoke development for the canopy material which does not comply with 19.1.2.4 and 19.1.6.2.

A. Based on random observation during the survey walk-through, not all hazardous areas are separated from the remainder of the building in accordance with 19.3.2.1 and 8.4.1. This deficiency could affect patients, staff and visitors in the gym and cafeteria areas within the same smoke compartment, by allowing smoke and fire to escape from hazardous rooms into the building's exit access corridors.

The finding is:

1. On 06/26/12 the surveyor along with the facility representatives observed the Central Storage room door to be equipped with a non-approved magnetic hold-open device which does not comply with 7.2.1.8.2.

A. Based on random observation during the survey walk-through, not all exit or exit access doors are arranged so that exits are readily accessible at all times in accordance with 19.2.1 and Chapter 7. These deficiencies could affect all patients in the facility, as well as any staff and visitors present, by preventing those occupants from reaching an exit from the building. Findings include:

1. Corridor T1091(as shown on the Life Safety Floor Plan) was observed on the morning of 6/26/12 to be provided with exit signage directing the exit path through a Multipurpose Room # 618. 19.2.5.9 does not permit corridors to exit through an intervening room. The door to the Multipurpose room was locked.

2. Two corridors #T1096 and #T1101 were observed on the morning of 6/26/12 to be provided with exit signage directing the exit path through a day room (open to the corridor and with direct visual observation of the nurse station) to a courtyard. The courtyard did not contain an identified path of egress to an existing locked gate.

3. Exterior egress paths were observed on the morning of 6/27/12 which may not be complete to a public way, to comply with 7.7.2. under certain weather conditions because no stable, maintainable walking surface to a public way is provided. Locations observed include:
a. Egress path from the Adolescent Wing.

b. Egress path from the East Adult Wing.

A. Based on random observation during the survey walk-through, not all patient sleeping room doors are provided with door hardware arranged so that the patient can open the door from the inside in accordance with 19.2.2.2.2. These deficiencies could affect any patients on the floor of the facility, as well as any staff and visitors present, by preventing those occupants from being able to exit the room(s).

The finding is:

1. During the afternoon of 06/26/12 the surveyor accompanied by the facility representatives while in the Food Disorders wing observed patient toilet room doors equipped with locking hardware to prevent toilet room entry. These doors are equipped with an indented thumb turn which allows a person to exit from the toilet. However, when the surveyor demonstrated the function of the lock/thumbturn, it was not possible to allow egress from the room. The thumbturn did not release the locking device which could allow a patient to be locked in the patient toilet room.

A. Based on random observation during the survey walk-through , not all exit discharge locations are provided with illumination to comply with 19.2.8, 7.8 and 7.9. These deficiencies could affect all persons in the facility required to utilize the exit by preventing safe and unimpeded access to the public way. Findings include:

1. On the morning of 6/27/12, the surveyor along with the facility representatives observed an exit discharge location which lacked fixtures/lighting with more than one lamp/fixture equipped with instantaneous type lighting connected to the emergency power system to comply with 7.8.1.4.

a. At the exterior exit discharge from the Gym.

A. Based on record review it was determined that the facility failed to document that fire drills are being conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintainance engineers, and adminsitrative staff) with the signals and emergency action as required. Fire drills are not being conducted, at least quarterly on each shift.

The finding is:

1. On the afternoon of 06/26/12 during a review of the fire drill records with the facility representatives the surveyor found the only available quarterly fire drills were for March, 2012 and June, 2012. There were no available written drills for the previous two quarters in order to obtain a 12 month account of Fire Drills. The surveyor was provided a spread sheet showing previous listed drills however no further documentation was provided. It was determined that quarterly fire drills were not provided throughout the annual cycle to comply with section 19.7.1.2.

A. Based on random observation during the fire alarm test on the afternoon of June 26, 2012, not all areas of the building fire alarm system are installed in accordance with NFPA-72 (1999). This could effect egress for building occupants within four smoke compartments if the fire alarm system does not operate properly during a fire emergency.
Findings include:

1. Pair of cross corridor control doors adjacent to Group Room # 834 did not unlock with a staff provided key upon activation of the fire alarm system.



B. Based on document review and random observation during the test of the fire alarm system on the afternoon of 06/26/12, not all areas of the building fire alarm system are installed in accordance with NFPA-72 (1999). This could effect egress for building occupants within four smoke compartments if the fire alarm system does not operate properly during a fire emergency.
Findings include:

1. During fire drill document review the remarks section of the drill conducted on 6/21/12 in the Adolescent Unit, read "alarm very loud, hard to hear location of code, need to know where we go?"
During the test of the fire alarm system the audible alarm in each of the three "bump out" additions to the patient wings was confirmed to be loud, persons are unable to hear the location of the code, fire origin and therefore the direction of egress. The current condition does not comply with NFPA 72, 1999, 4-3.2.1 and 4-3.1.5 is not complied with concerning the requirement for " messages with voice intelligibility".

A. Based on random observation during the survey walk-through the generator equipment does not meet all requirements of NFPA-110. These deficiencies could affect building occupants because generators would not be able to be shut down remotely in the event of a catastophic failure which may allow damage to extend beyond the generator enclosure.

Findings include:

1. During the afternoon of 6/26/12 the surveyor along with the facility representatives observed that the building emergency generators did not have remote shut down switches to comply with NFPA-110, Section 3-5.5.6.


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B. Based on random observation during the survey walk-through and staff interview, not all components of the type 1 emergency power system are installed in accordance with NFPA 110 1999. The lack of emergency power during a fire emergency may affect all patients, staff and visitors within the building.

The finding is:

1. During the morning of 06/26/12 the surveyor along with the facility representatives observed that the emergency generator location was not equipped with battery powered emergency lighting to comply with NFPA 110 1999, 5-3.1.

Based on random observation during the survey walk-through, document review, and staff interview, the facility is not in compliance with a series of Life Safety and other code requirements that are not documented under other K-Tags.

Findings include:

A. Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.

A. Based on random observation during the survey walk-through the building emergency electrical system is not properly divided into Life Safety, Critical and Equipment branches in accordance with NFPA-99, and NFPA-70, Section 517.

Findings include:

1. During the morning of 06/26/12 the surveyor along with the facility representatives observed, Critical panels CLB, CLB-A-CR, LLB-A-CR, and LLB-B-CR are all serving fire alarm panels that are required to be served by the life safety branch of the emergency power system by NFPA70, Section 517-32.

2. During the morning of 06/26/12 the surveyor along with the facility representatives observed, Panel CHB (observed to be a critical branch panel) is serving the fan coil units. These units should be served by the equipment branch of the emergency power system in accordance with NFPA-70, Section 517-34.

3. During the morning of 06/26/12 the surveyor along with the facility representatives observed Panel LLA serving a mix of loads that need to be moved to the proper branches of the emergency power system as required by NFPA-70, Section 517-30 through 34.

A. Based on random observation during the survey walk-through, not all portions of the building are of fire resistive construction to comply with 19.1.6.2 This deficiency could affect patients in the facility, as well as any staff and visitors within three patient wings and two smoke compartments, by not providing these occupants with a safe exit discharge from the building. The finding is:

1. During the afternoon of 06/26/12and the morning of 06/27/12 the surveyor along with the facility representatives observed designated primary exits from the building to the interior courtyards that are covered with a fabric of unknown surface burning characteristics for building material to comply with NFPA 255. The canopies extend approximately 8 feet and are not self supporting. The facility representatives were unable to provide a manufacturer's data sheet noting the flame spread rating or smoke development for the canopy material which does not comply with 19.1.2.4 and 19.1.6.2.

A. Based on random observation during the survey walk-through, not all hazardous areas are separated from the remainder of the building in accordance with 19.3.2.1 and 8.4.1. This deficiency could affect patients, staff and visitors in the gym and cafeteria areas within the same smoke compartment, by allowing smoke and fire to escape from hazardous rooms into the building's exit access corridors.

The finding is:

1. On 06/26/12 the surveyor along with the facility representatives observed the Central Storage room door to be equipped with a non-approved magnetic hold-open device which does not comply with 7.2.1.8.2.

A. Based on random observation during the survey walk-through, not all exit or exit access doors are arranged so that exits are readily accessible at all times in accordance with 19.2.1 and Chapter 7. These deficiencies could affect all patients in the facility, as well as any staff and visitors present, by preventing those occupants from reaching an exit from the building. Findings include:

1. Corridor T1091(as shown on the Life Safety Floor Plan) was observed on the morning of 6/26/12 to be provided with exit signage directing the exit path through a Multipurpose Room # 618. 19.2.5.9 does not permit corridors to exit through an intervening room. The door to the Multipurpose room was locked.

2. Two corridors #T1096 and #T1101 were observed on the morning of 6/26/12 to be provided with exit signage directing the exit path through a day room (open to the corridor and with direct visual observation of the nurse station) to a courtyard. The courtyard did not contain an identified path of egress to an existing locked gate.

3. Exterior egress paths were observed on the morning of 6/27/12 which may not be complete to a public way, to comply with 7.7.2. under certain weather conditions because no stable, maintainable walking surface to a public way is provided. Locations observed include:
a. Egress path from the Adolescent Wing.

b. Egress path from the East Adult Wing.

A. Based on random observation during the survey walk-through, not all patient sleeping room doors are provided with door hardware arranged so that the patient can open the door from the inside in accordance with 19.2.2.2.2. These deficiencies could affect any patients on the floor of the facility, as well as any staff and visitors present, by preventing those occupants from being able to exit the room(s).

The finding is:

1. During the afternoon of 06/26/12 the surveyor accompanied by the facility representatives while in the Food Disorders wing observed patient toilet room doors equipped with locking hardware to prevent toilet room entry. These doors are equipped with an indented thumb turn which allows a person to exit from the toilet. However, when the surveyor demonstrated the function of the lock/thumbturn, it was not possible to allow egress from the room. The thumbturn did not release the locking device which could allow a patient to be locked in the patient toilet room.

A. Based on random observation during the survey walk-through , not all exit discharge locations are provided with illumination to comply with 19.2.8, 7.8 and 7.9. These deficiencies could affect all persons in the facility required to utilize the exit by preventing safe and unimpeded access to the public way. Findings include:

1. On the morning of 6/27/12, the surveyor along with the facility representatives observed an exit discharge location which lacked fixtures/lighting with more than one lamp/fixture equipped with instantaneous type lighting connected to the emergency power system to comply with 7.8.1.4.

a. At the exterior exit discharge from the Gym.

A. Based on record review it was determined that the facility failed to document that fire drills are being conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintainance engineers, and adminsitrative staff) with the signals and emergency action as required. Fire drills are not being conducted, at least quarterly on each shift.

The finding is:

1. On the afternoon of 06/26/12 during a review of the fire drill records with the facility representatives the surveyor found the only available quarterly fire drills were for March, 2012 and June, 2012. There were no available written drills for the previous two quarters in order to obtain a 12 month account of Fire Drills. The surveyor was provided a spread sheet showing previous listed drills however no further documentation was provided. It was determined that quarterly fire drills were not provided throughout the annual cycle to comply with section 19.7.1.2.

A. Based on random observation during the fire alarm test on the afternoon of June 26, 2012, not all areas of the building fire alarm system are installed in accordance with NFPA-72 (1999). This could effect egress for building occupants within four smoke compartments if the fire alarm system does not operate properly during a fire emergency.
Findings include:

1. Pair of cross corridor control doors adjacent to Group Room # 834 did not unlock with a staff provided key upon activation of the fire alarm system.



B. Based on document review and random observation during the test of the fire alarm system on the afternoon of 06/26/12, not all areas of the building fire alarm system are installed in accordance with NFPA-72 (1999). This could effect egress for building occupants within four smoke compartments if the fire alarm system does not operate properly during a fire emergency.
Findings include:

1. During fire drill document review the remarks section of the drill conducted on 6/21/12 in the Adolescent Unit, read "alarm very loud, hard to hear location of code, need to know where we go?"
During the test of the fire alarm system the audible alarm in each of the three "bump out" additions to the patient wings was confirmed to be loud, persons are unable to hear the location of the code, fire origin and therefore the direction of egress. The current condition does not comply with NFPA 72, 1999, 4-3.2.1 and 4-3.1.5 is not complied with concerning the requirement for " messages with voice intelligibility".

A. Based on random observation during the survey walk-through the generator equipment does not meet all requirements of NFPA-110. These deficiencies could affect building occupants because generators would not be able to be shut down remotely in the event of a catastophic failure which may allow damage to extend beyond the generator enclosure.

Findings include:

1. During the afternoon of 6/26/12 the surveyor along with the facility representatives observed that the building emergency generators did not have remote shut down switches to comply with NFPA-110, Section 3-5.5.6.


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B. Based on random observation during the survey walk-through and staff interview, not all components of the type 1 emergency power system are installed in accordance with NFPA 110 1999. The lack of emergency power during a fire emergency may affect all patients, staff and visitors within the building.

The finding is:

1. During the morning of 06/26/12 the surveyor along with the facility representatives observed that the emergency generator location was not equipped with battery powered emergency lighting to comply with NFPA 110 1999, 5-3.1.

Based on random observation during the survey walk-through, document review, and staff interview, the facility is not in compliance with a series of Life Safety and other code requirements that are not documented under other K-Tags.

Findings include:

A. Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.

A. Based on random observation during the survey walk-through the building emergency electrical system is not properly divided into Life Safety, Critical and Equipment branches in accordance with NFPA-99, and NFPA-70, Section 517.

Findings include:

1. During the morning of 06/26/12 the surveyor along with the facility representatives observed, Critical panels CLB, CLB-A-CR, LLB-A-CR, and LLB-B-CR are all serving fire alarm panels that are required to be served by the life safety branch of the emergency power system by NFPA70, Section 517-32.

2. During the morning of 06/26/12 the surveyor along with the facility representatives observed, Panel CHB (observed to be a critical branch panel) is serving the fan coil units. These units should be served by the equipment branch of the emergency power system in accordance with NFPA-70, Section 517-34.

3. During the morning of 06/26/12 the surveyor along with the facility representatives observed Panel LLA serving a mix of loads that need to be moved to the proper branches of the emergency power system as required by NFPA-70, Section 517-30 through 34.