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Based on observations made and interviews with facility staff, the facility failed to maintain construction, protection, and occupancy features necessary to minimize danger to life from smoke, fumes or panic should a fire or similar emergency occur. The facility failed to maintain existing fire protection and life safety features such as smoke compartments and smoke construction per NFPA 101-2000 , 4.6.12.1-.4, "Features required by the Code...shall be thereafter permanently maintained." Two (2) out of 9 sampled smoke compartments had improperly sealed penetrations.

Findings are:

1. During the life safety tour and observations on October 5, 2011 with the environmental services director and the vice president of security and safety at the Health First Center for Pain Management, the following corridor barrier wall was not maintained to limit the transfer of smoke/heated gases should a fire occur:

2. At 2:20 p.m., observed that the rated cross corridor fire wall that separates the service area from the hyperbaric chamber area was not sealed to limit the transfer of smoke / heated gases. There were three (3) unsealed penetrations (unsealed conduits with communications cables) through this rated fire wall. Note: Penetrations must be resealed with a UL approved fire rated caulking compound. Interview of the maintenance assistant revealed that this area will be properly sealed (on both sides of the wall).

These findings were confirmed during the exit conference with the Manager of Plant Operations, the Vice President of Medical Operations, the VHA Liaison, the Vice President of Security and Safety and the Director of Quality Assurance at 4:45 p.m. on October 5, 2011

NOTE: These examples are not to be considered as the only penetrations of the building's fire/smoke barrier walls / ceilings. A thorough inspection of each fire/smoke barrier must be made along the full length and height of the wall to ensure that all penetrations are found and properly sealed.

59A-3.077/.078/.079, F.A.C.
NFPA 101-2000, 4.6.12.1-.4, 19.3.2, 19.3.3, 19.3.6, 19.3.7, 19.2.2.2.6, 8.3; 19.2.11.5; 7.2.1.8;
Correction Date: 11/05/2011

Based on observations, testing and interviews with facility staff, the facility failed to maintain fire protection and occupancy features necessary to minimize danger to residents from smoke, fumes or panic should a fire occur. The facility did not maintain seven (7) of 50 plus sampled hazardous room doors to prevent impediments to closing them to limit the transfer of smoke / heated gases should a fire occur. NFPA 101-2000, 4.6.12.1 requires that "every...item of equipment / system required by this Code shall be continuously maintained in proper operating condition." Also, per NFPA 101-2000, 19.3.6.3 "must provide a means suitable for keeping the door closed (tightly closed in the frame)." This condition could allow smoke and fire gases to quickly spread, in the event of a fire, endangering building occupants.

Findings are:

During the general life safety tour of the facility on October 4 & 5, 2011 with the manager of plant operations and the vice president of security and safety, observed that each of the following doors had an impediment to self-closing and/or latching:

10/04/2011
1. At 11:05 a.m. - 4 NC 16 - self closing corridor door to respiratory storage room - Rated door would not close and latch upon testing.
2. At 11:12 a.m. - 4 NB 24-soiled utility room's self-closing corridor door did not self-close and latch upon testing.
3. At 1:55 p.m. - 2 ND 53- soiled holding room's self-closing corridor door did not self-close and latch.
4. At 2:45 p.m. - 2 ND 42- soiled holding room's self-closing corridor door did not self-close and latch.
10/05/2011
5. At 8:35 a.m. - Door ACO2 - 8th floor A Tower would not self-close and latch upon testing.
6. At 8:59 a.m. - Corridor door to the patient care room A733 on the 8th floor did not operate as required. It would not close and seal / latch to limit the transfer of smoke / heated gases should a fire occur. This door was equipped with an isolation station that was hung over the top edge. The hanger flanges interfered with the door closure devices and would not allow each door to close and latch per requirements.
7. At 11 a.m. - 3G11- Soiled utility room- self closing door held open with unapproved hold-open device (taped open).
These findings were confirmed during the exit conference with the Manager of Plant Operations, the Vice President of Medical Operations, the VHA Liaison, the Vice President of Security and Safety and the Director of Quality Assurance at 4:45 p.m. on October 5, 2011

59A-3.077/.078/.079, F.A.C.
NFPA 101-2000, 19.3.2.1, 19.3.2.1.5, 19.3.6.3, 7.2.1.8 & 4.6.12.1; NFPA 72; NFPA 90A & NFPA 80
Correction Date: 11/05/2011

Based on observation and interview with staff, the facility did not comply with NFPA standards for the storage and use of combustible liquids that have been adopted to protect the staff, patients and the public from fire and the products of combustion. The facility failed to maintain features of fire protection and occupancy that are necessary to safely handle hazardous materials in a laboratory environment. NFPA 101 Ch. 19.3.2.2, "Laboratories employing quantities of flammable, combustible or hazardous materials that are considered as a severe hazard shall be protected in accordance with NFPA 99, Standard for Health Care Facilities." NFPA 99 Ch. 11.7.2.1 requires that "Flammable and combustible liquids shall be used from and stored in approved containers in accordance with NFPA 30, Flammable and Combustible Liquids Code and NFPA 45, Standard on Fire Protection for Laboratories using Chemicals." Additionally, Ch. 11.8.1.1.4 requires that, "The laboratory safety officer shall prepare and supervise the proper completion of a safety checklist that can be preserved for the record." Also, Ch. 11.8.1.2(4) requires that, "Shelf stocks and storage of flammable and combustible materials . . . .shall be reviewed at appropriate, regular intervals."

Findings include:

Direct observation at 3:15 p.m. on October 5, 2011, in the company of the manager of plant operations, of the first floor's blood cytology prep area revealed that six (6) one gallon containers of reagent solution were stored under the countertop of this working area. Did not observe any NFPA 704 warning labels.

Interview of the technician revealed that these containers were filled with 90 per cent alcohol and are used in her preparation work. Since these containers contained alcohol with a flammability rating of 3 which indicates a liquid that can be ignited under almost all ambient temperature conditions. These one gallon containers were full, or nearly so, and were constructed of plastic. Note: within 10 feet of this location were twenty (20) stored boxes of combustible supplies. Additional investigation discovered an approved type cabinet that is used to store flammable liquids. It was not used to accommodate the quantities of chemicals that were improperly stored under the counter tops. When the technician was asked for the posted guidelines for allowable quantities/safe storage of such flammable liquids, she could not produce same. Further discussion presented no indication of the existence of a safety checklist or a record of periodic inspections.

These findings were confirmed during the exit conference with the Manager of Plant Operations, the Vice President of Medical Operations, the VHA Liaison, the Vice President of Security and Safety and the Director of Quality Assurance at 4:45 p.m. on October 5, 2011

59A-3.077/.078/.079, F.A.C.
NFPA 101-2000, 19.3.2.2 & 4.6.12.1; NFPA 99 (1999), 11.7.2.1; NFPA 30; NFPA 45, 11.8.1.1.4, 11.8.1.2 (4)
Correction Date: 11/05/2011

Based on observations made and interviews with facility staff, the facility failed to maintain construction, protection, and occupancy features necessary to minimize danger to life from smoke, fumes or panic should a fire or similar emergency occur. The facility failed to maintain existing fire protection and life safety features such as smoke compartments and smoke construction per NFPA 101-2000 , 4.6.12.1-.4, "Features required by the Code...shall be thereafter permanently maintained." Two (2) out of 9 sampled smoke compartments had improperly sealed penetrations.

Findings are:

1. During the life safety tour and observations on October 5, 2011 with the environmental services director and the vice president of security and safety at the Health First Center for Pain Management, the following corridor barrier wall was not maintained to limit the transfer of smoke/heated gases should a fire occur:

2. At 2:20 p.m., observed that the rated cross corridor fire wall that separates the service area from the hyperbaric chamber area was not sealed to limit the transfer of smoke / heated gases. There were three (3) unsealed penetrations (unsealed conduits with communications cables) through this rated fire wall. Note: Penetrations must be resealed with a UL approved fire rated caulking compound. Interview of the maintenance assistant revealed that this area will be properly sealed (on both sides of the wall).

These findings were confirmed during the exit conference with the Manager of Plant Operations, the Vice President of Medical Operations, the VHA Liaison, the Vice President of Security and Safety and the Director of Quality Assurance at 4:45 p.m. on October 5, 2011

NOTE: These examples are not to be considered as the only penetrations of the building's fire/smoke barrier walls / ceilings. A thorough inspection of each fire/smoke barrier must be made along the full length and height of the wall to ensure that all penetrations are found and properly sealed.

59A-3.077/.078/.079, F.A.C.
NFPA 101-2000, 4.6.12.1-.4, 19.3.2, 19.3.3, 19.3.6, 19.3.7, 19.2.2.2.6, 8.3; 19.2.11.5; 7.2.1.8;
Correction Date: 11/05/2011

Based on observations, testing and interviews with facility staff, the facility failed to maintain fire protection and occupancy features necessary to minimize danger to residents from smoke, fumes or panic should a fire occur. The facility did not maintain seven (7) of 50 plus sampled hazardous room doors to prevent impediments to closing them to limit the transfer of smoke / heated gases should a fire occur. NFPA 101-2000, 4.6.12.1 requires that "every...item of equipment / system required by this Code shall be continuously maintained in proper operating condition." Also, per NFPA 101-2000, 19.3.6.3 "must provide a means suitable for keeping the door closed (tightly closed in the frame)." This condition could allow smoke and fire gases to quickly spread, in the event of a fire, endangering building occupants.

Findings are:

During the general life safety tour of the facility on October 4 & 5, 2011 with the manager of plant operations and the vice president of security and safety, observed that each of the following doors had an impediment to self-closing and/or latching:

10/04/2011
1. At 11:05 a.m. - 4 NC 16 - self closing corridor door to respiratory storage room - Rated door would not close and latch upon testing.
2. At 11:12 a.m. - 4 NB 24-soiled utility room's self-closing corridor door did not self-close and latch upon testing.
3. At 1:55 p.m. - 2 ND 53- soiled holding room's self-closing corridor door did not self-close and latch.
4. At 2:45 p.m. - 2 ND 42- soiled holding room's self-closing corridor door did not self-close and latch.
10/05/2011
5. At 8:35 a.m. - Door ACO2 - 8th floor A Tower would not self-close and latch upon testing.
6. At 8:59 a.m. - Corridor door to the patient care room A733 on the 8th floor did not operate as required. It would not close and seal / latch to limit the transfer of smoke / heated gases should a fire occur. This door was equipped with an isolation station that was hung over the top edge. The hanger flanges interfered with the door closure devices and would not allow each door to close and latch per requirements.
7. At 11 a.m. - 3G11- Soiled utility room- self closing door held open with unapproved hold-open device (taped open).
These findings were confirmed during the exit conference with the Manager of Plant Operations, the Vice President of Medical Operations, the VHA Liaison, the Vice President of Security and Safety and the Director of Quality Assurance at 4:45 p.m. on October 5, 2011

59A-3.077/.078/.079, F.A.C.
NFPA 101-2000, 19.3.2.1, 19.3.2.1.5, 19.3.6.3, 7.2.1.8 & 4.6.12.1; NFPA 72; NFPA 90A & NFPA 80
Correction Date: 11/05/2011

Based on observation and interview with staff, the facility did not comply with NFPA standards for the storage and use of combustible liquids that have been adopted to protect the staff, patients and the public from fire and the products of combustion. The facility failed to maintain features of fire protection and occupancy that are necessary to safely handle hazardous materials in a laboratory environment. NFPA 101 Ch. 19.3.2.2, "Laboratories employing quantities of flammable, combustible or hazardous materials that are considered as a severe hazard shall be protected in accordance with NFPA 99, Standard for Health Care Facilities." NFPA 99 Ch. 11.7.2.1 requires that "Flammable and combustible liquids shall be used from and stored in approved containers in accordance with NFPA 30, Flammable and Combustible Liquids Code and NFPA 45, Standard on Fire Protection for Laboratories using Chemicals." Additionally, Ch. 11.8.1.1.4 requires that, "The laboratory safety officer shall prepare and supervise the proper completion of a safety checklist that can be preserved for the record." Also, Ch. 11.8.1.2(4) requires that, "Shelf stocks and storage of flammable and combustible materials . . . .shall be reviewed at appropriate, regular intervals."

Findings include:

Direct observation at 3:15 p.m. on October 5, 2011, in the company of the manager of plant operations, of the first floor's blood cytology prep area revealed that six (6) one gallon containers of reagent solution were stored under the countertop of this working area. Did not observe any NFPA 704 warning labels.

Interview of the technician revealed that these containers were filled with 90 per cent alcohol and are used in her preparation work. Since these containers contained alcohol with a flammability rating of 3 which indicates a liquid that can be ignited under almost all ambient temperature conditions. These one gallon containers were full, or nearly so, and were constructed of plastic. Note: within 10 feet of this location were twenty (20) stored boxes of combustible supplies. Additional investigation discovered an approved type cabinet that is used to store flammable liquids. It was not used to accommodate the quantities of chemicals that were improperly stored under the counter tops. When the technician was asked for the posted guidelines for allowable quantities/safe storage of such flammable liquids, she could not produce same. Further discussion presented no indication of the existence of a safety checklist or a record of periodic inspections.

These findings were confirmed during the exit conference with the Manager of Plant Operations, the Vice President of Medical Operations, the VHA Liaison, the Vice President of Security and Safety and the Director of Quality Assurance at 4:45 p.m. on October 5, 2011

59A-3.077/.078/.079, F.A.C.
NFPA 101-2000, 19.3.2.2 & 4.6.12.1; NFPA 99 (1999), 11.7.2.1; NFPA 30; NFPA 45, 11.8.1.1.4, 11.8.1.2 (4)
Correction Date: 11/05/2011