HospitalInspections.org

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Based on the observation during the survey on 07/12/2016 the facility failed to provide a complete two hour fire rated barrier separating the main hospital building from the metal building housing the laundry. Findings include:

The two hour fire rated barrier in the Dining Room stopped at the bottom of the "I" beam, the two hour fire barrier does not extend to the roof deck.

The deficiency impacted 1 of the 18 smoke compartments.
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Review of 2000 NFPA 101, 19.1.1.4.1 Additions shall be separated from any existing structure not conforming to the provisions within Chapter 19 by a fire barrier having not less than a 2-hour fire resistance rating and constructed of materials as required for the addition. (See 4.6.11 and 4.6.6.)

Review of 2000 NFPA 101, 8.2.2.2 Fire compartments shall be formed with fire barriers that are continuous from outside wall to outside wall, from one fire barrier to another, or a combination thereof, including continuity through all concealed spaces, such as those found above a ceiling, including interstitial spaces. Walls used as fire barriers shall comply with Chapter 3 of NFPA 221, Standard for Fire Walls and Fire Barrier Walls. The NFPA 221 limitation on percentage width of openings shall not apply.

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Based on the observation during the survey on 07/12/2016 the facility failed to provide a building construction type allowed for partially sprinklered buildings. Findings include:

Per interview and observation the facility has 8 ICU rooms and 1 freezer that does not have automatic sprinkler coverage and the building construction type at the two story is a type II (000) (the old plaster ceiling has deteriorated and/or been removed in areas throughout the original 1958 single story part that connects to the two story without a two hour fire rated barrier, per architectural drawings).

Based on observation during the survey on 07/12/2016 the facility failed to meet a construction type for health care facility. Findings include:
Per observation the facility had constructed a single story unprotected wood frame structure up against the outside wall, right at a window (that is not fire rated) of the two story part of the building (radiology).

The deficiency impacted 9 of the 18 smoke compartments.
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Review of 2000 NFPA 101, 19.1.6.2 Health care occupancies shall be limited to the types of building construction shown in Table 19.1.6.2. (See 8.2.1.)Exception*: Any building of Type I(443), Type I(332), Type II(222), or Type II(111) construction shall be permitted to include roofing systems involving combustible supports, decking, or roofing, provided that the following criteria are met:(a) The roof covering meets Class C requirements in accordance with NFPA 256, Standard Methods of Fire Tests of Roof Coverings.
(b) The roof is separated from all occupied portions of the building by a noncombustible floor assembly that includes not less than 21/2 in. (6.4 cm) of concrete or gypsum fill.
(c) The attic or other space is either unoccupied or protected throughout by an approved automatic
sprinkler system.

Review of Table 19.1.6.2 Construction Type Limitations
Construction Stories
Type
1 2 3 4 or
More
I(443) X X X X
I(332) X X X X
II(222) X X X X
II(111) X X* X* NP
II(000) X* X* NP NP
III(211) X* X* NP NP
III(200) X* NP NP NP
IV(2HH) X* X* NP NP
V(111) X* X* NP NP
V(000) X* NP NP NP
X: Permitted type of construction.
NP: Not permitted.
*Building requires automatic sprinkler protection. (See 19.3.5.1.)

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Based on the observation during the survey on 07/13/2016 the facility failed to maintain the corridor doors. Findings include:

1. The Dining Room corridor double doors were observed without hardware that will keep doors securely latched in the door frame.
2. The Automatic Sprinkler riser room between the Lobby and Radiology was observed with a ventilating louver in the bottom half of it's corridor door.

The deficiency impacted 9 of the 18 smoke compartments.
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Review of 2000 NFPA 101, 19.3.6.3.2 Doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door.

Review of 2000 NFPA 101, 19.3.6.3.1 Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 13/4-in. (4.4-cm) thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke. Compliance with NFPA 80, Standard for Fire Doors and Fire Windows, shall not be required. Clearance between the bottom of the door and the floor covering not exceeding 1 in. (2.5 cm) shall be permitted for corridor doors.
Exception No. 1: Doors to toilet rooms, bathrooms, shower rooms, sink closets, and similar auxiliary spaces that do not contain flammable or combustible materials.
Exception No. 2: In smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.2, the door construction requirements of 19.3.6.3.1 shall not be mandatory, but the doors shall be constructed to resist the passage of smoke.

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Based on observation on 07/13/2016 the facility failed to provide one hour fire resistance rating for the elevator shaft. Findings Include: During the survey, the following is an example of what was observed.

Elevator # 3 was observed with approximately an 8" unsealed opening in the north shaft wall of the elevator.

This deficiency impacted 2 of 18 smoke compartments.
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NFPA 101, 19.3.1.1 Any vertical openings shall be enclosed or protected in accordance with 8.2.5. Where enclosure is provided, the construction shall have not less than a 1-hour fire resistance rating.

NPPA 101, 8.2.5 Vertical openings.
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Based on the observation during the survey on 07/13/2016 the facility failed to maintain the exit signs. Findings include:

The exit sign at Bay 9 in Outpatient Surgery was observed without a directional indicator, therefore leading you into Bay 9, not the exit.

The deficiency impacted 1 of the 18 smoke compartments.
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Review of 2000 NFPA 101, 7.10.2 A sign complying with 7.10.3 with a directional indicator showing the direction of travel shall be placed in every location where the direction of travel to reach the nearest exit is not apparent.

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Based on the observation during the survey on 07/13/2016 the facility failed to maintain the hazardous areas. Findings include:

The Medical Records File Room was observed with full automatic sprinkler coverage located in a smoke compartment that has full automatic sprinkler coverage was observed with an approximately 2" hole in one of the ceiling tiles.

The deficiency impacted 1 of the 18 smoke compartments.
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Review of 2000 NFPA 101, 19.3.2.1 Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing.

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Based on observation during the survey on 07/13/2016 the facility failed to provide fire alarm DACT/phone lines with supervision at the facility. Findings include:

1. While testing the fire alarm DACT/phone lines:
a. Line One indicated "dialer trouble"
b. Line Two indicated "dialer trouble"
c. Both Lines indicated "dialer trouble"

The deficiency impacted 18 of the 18 smoke compartments.
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Review of 2000 NFPA 101, 9.6.1.6 Fire alarm system installation wiring or other transmission paths shall be monitored for integrity in accordance with 9.6.1.4.

Review of 1999 NFPA 72, 1-5.2.3 Fire alarm systems shall be provided with at least two independent and reliable power supplies, one primary and one secondary (standby), each of which shall be of adequate capacity for the application.

Review of 1999 NFPA 72, 1-5.4.6 Trouble signals and their restoration to normal shall be indicated within 200 seconds at the locations identified in 1-5.4.6.1 or 1-5.4.6.2. Trouble signals required to indicate at the protected premises shall be indicated by distinctive audible signals. These audible trouble signals shall be distinctive from alarm signals. If an intermittent signal is used, it shall sound at least once every 10 seconds, with a minimum duration of 1/2 second. An audible trouble signal shall be permitted to be common to several supervised circuits. The trouble signal(s) shall be located in an area where it is likely to be heard.

Review of 1999 NFPA 72, 5-5.3.2.1.5*
A DACT shall have means to reset and retry if the first attempt to complete a signal transmission sequence is unsuccessful. A failure to complete connection shall not prevent subsequent attempts to transmit an alarm where such alarm is generated from any other initiating device circuit or signaling line circuit, or both. Additional attempts shall be made until the signal transmission sequence has been completed, up to a minimum of 5 and a maximum of 10 attempts.
If the maximum number of attempts to complete the sequence is reached, an indication of the failure shall be made at the premises.

Review of 1999 NFPA 72, 5-5.3.2.1.6.2
The following requirements shall apply to all combinations in 5-5.3.2.1.6.1:
(1) Both channels shall be supervised in a manner approved for the means of transmission employed.
(2) Both channels shall be tested at intervals not exceeding 24 hours.
Exception No. 1: For public cellular telephone service, a verification (test) signal shall be transmitted at least monthly.
Exception No. 2: Where two telephone lines (numbers) are used, it shall be permitted to test each telephone line (number) at alternating 24-hour intervals.
(3) The failure of either channel shall send a trouble signal on the other channel within 4 minutes.
(4) When one transmission channel has failed, all status change signals shall be sent over the other channel.
Exception: Where used in combination with a DACT, a derived local channel shall not be required to send status change signals other than those indicating that adverse conditions exist on the telephone line (number).
(5) The primary channel shall be capable of delivering an indication to the DACT that the message has been received by the supervising station.
(6) The first attempt to send a status change signal shall use the primary channel.
Exception: Where the primary channel is known to have failed.
(7) Simultaneous transmission over both channels shall be permitted.
(8) Failure of telephone lines (numbers) or cellular service shall be annunciated locally.

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36148

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2. During the testing of the fire alarm system the Radiology Department did not provide audible or visual signals.

3. During the testing of the fire alarm system telephone lines the remote annuciator did not give an audible signal and gave the same visual "dialer trouble" for all three phone line troubles.

The deficiency impacted 18 of the 18 smoke compartments.
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Review of 2000 NFPA 101, 9.6.1.6 Fire alarm system installation wiring or other transmission paths shall be monitored for integrity in accordance with 9.6.1.4.

Review of 1999 NFPA 72 5-4.2.1 Remote supervising station fire alarm systems shall provide an automatic audible and visible indication of alarm and, if required, of supervisory and trouble conditions at a location remote from the protected premises. A manual or automatic permanent record of these conditions shall be provided.
2000 NFPA 101, 9.6.1.4 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.
2000 NFPA 101 9.6.3.2 Notification shall be provided by audible and visible signals in accordance with 9.6.3.3 through 9.6.3.12.
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Based on observation of the post indicator valve on 07/12/2016 the facility failed to maintain the post indicator valve with appropriate identification. Findings include:

1. The post indicator valve located outside behind the maintenance building near the road area was observed with a missing sight glass.
2. The post indicator valve located outside in the front area of the hospital and was not provided with appropriate identification (the sight glass was distorted).

The deficiency impacted 18 of 18 smoke compartments.
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2000 NFPA 101, 21.7.6 Maintenance and Testing. (See 4.6.12.)

2000 NFPA 101, 4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction. e 4.6.12.)

1998 NFPA 25, 7-3.7.1 Gate valves, post indicator valves, wall indicator valves, or other control valves for water supply systems shall be inspected to verify that they are in the open position and properly sealed, locked, or supervised. (See Chapter 9 for inspection and maintenance requirements.)

1998 NFPA 25,9-3.3.2* The valve inspection shall verify that the valves are in the following condition: (a) In the normal open or closed position (b) * Properly sealed, locked, or supervised (c) Accessible (d) Provided with appropriate wrenches (e) Free from external leaks (f) Provided with appropriate identification

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Based on observation during the survey on 07/13/2016 the facility failed to maintain the vertical direction of the kitchen hood filters. Findings include:

All of the kitchen hood filters were observed oriented horizontally.

The deficiency impacted 1 of the 18 smoke compartments.
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Review of 1998 NFPA 96, 3-2.7 Grease filters that require a specific orientation to drain grease shall be clearly so designated, or the hood shall be constructed so that filters cannot be installed in the wrong orientation.

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Based on observation during the survey on 07/13/2016 the facility failed to maintain the means of egress. Findings include:

1. First Floor - Crosby's Nurses' Station's desk was built with a place to sit at the end of the desk where a computer station was located that when someone is sitting occupying this spot the individual and chair sticks out into the corridor approximately 2' - 3", one of the staff was observed doing work at this computer station.
2. Second Floor - OB Ward, the following was observed stored in the corridor:
a. One metal shelf
b. Several computers on wheels were being recharged, one had a cover over it

The deficiency impacted 2 of the 18 smoke compartments.
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Review of 2000 NFPA 101, 7.1.10.1 Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

Review of 2000 NFPA 101, 7.1.10.2.1 No furnishings, decorations, or other objects shall obstruct exits, access thereto, egress there from, or visibility thereof.

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Based on review of the documentation during the survey on 07/13/2016 the facility failed to maintain the HVAC dampers. Findings include:

Per documentation from the facility during the facility inspection of the HVAC dampers on 05/03/2016 - 05/08/2016 the following had not been corrected as of the survey:
1. Five dampers failed
2. Twenty-three dampers were non-accessible

The deficiency impacted 18 of the 18 smoke compartments.
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Review of CMS Transmittal S & C-10-04-LSC
After due consideration of State survey agency findings and conclusions of the National Fire Protection Association (NFPA), we are issuing a categorical waiver pursuant to 42 CFR 482.41(b)(2) to permit a testing interval of 6 years rather than 4 years for the maintenance testing of fire and smoke dampers in hospital heating and ventilating systems, so long as the hospital ' s testing system conforms to the requirements under 2007 edition of NFPA 80: Standard for Fire
Doors and Other Opening Protectives and the 2007 edition of NFPA 105: Standard for the Installation of Smoke Door Assemblies. The 6-year testing interval shall commence on the date of the last documented damper test.

Review of 1999 NFPA 90A, 2-3.4.1 A service opening shall be provided in air ducts adjacent to each fire damper, smoke damper, and smoke detector. The opening shall be large enough to permit maintenance and resetting of the device.

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Based on observation during the survey on 07/12/2016 the facility failed to maintain the signs at the liquid oxygen area. Findings include:

The fenced in area for the liquid oxygen container was open to the public on three sides, only one side was observed with a no smoking sign.

The deficiency impacted 1 of the 18 smoke compartments.
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Review of 1999 NFPA 99, 8-6.2.5.2 Transferring of liquid oxygen from one container to another shall be accomplished at a location specifically designated for the transferring that is as follows:
(a) Separated from any portion of a facility wherein patients are housed, examined, or treated by a separation of a fire barrier of 1-hour fire-resistive construction; and
(b) The area is mechanically ventilated, is sprinklered, and has ceramic or concrete flooring; and
(c) The area is posted with signs indicating that transferring is occurring, and that smoking in the immediate area is not permitted.

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Based on observation of all generator equipment on 07/12/2016 the facility failed to
maintain its generator equipment as required. Findings include:

During testing of the level one generators the remote annuciator for the emergency generator # 4 located at the main nurses station did not indicate alarm conditions when the emergency or auxiliary power source was operating to supply power to load.

The deficiency affected 18 of 18 smoke compartments.
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1999 NFPA 99, 3-4.1.1.15 A remote annunciator, storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station (see NFPA 70, National Electrical Code, Section 700-12.)
The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows:
(a) Individual visual signals shall indicate the following:
1. When the emergency or auxiliary power source is operating to supply power to load
2. When the battery charger is malfunctioning
(b) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following:
1. Low lubricating oil pressure
2. Low water temperature (below those required in 3-4.1.1.9)
3. Excessive water temperature
4. Low fuel - when the main fuel storage tank contains less than a 3-hour operating supply
5. Overcrank (failed to start)
6. Overspeed
Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions in 3-4.1.1.15(a) and (b) occur, but need not display these conditions individually. [110: 3-5.5.2]
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A. Based on observation on 07/13/2016 the facility failed to maintain an adequate number and/or location of electrical receptacles. As an example see:
1. A multi outlet device was observed plugged into an electrical outlet at the corridor door to Materials Management & Environmental Services
2. A refrigerator was observed plugged into a power strip in the following locations:
a. The C-Section Room
b. An empty room across from room 168

The deficiency impacted 3 of the 18 smoke compartments.
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36148

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B. Based on observation during the survey on 07/12/2016 the facility failed to maintain the electrical wiring and equipment in accordance with the National Electrical Code (NFPA 70). Findings include:

In the following locations a refrigerator and/or a microwave was observed plugged into a power strip.
a. Hospitalist Office
b. CVCU Med. Room
c. Pharmacy Storage Room
d. Eligibility Screening Services Office

The deficiencies affected 3 of 18 smoke compartments.
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Review of the printed statement on the 2567 for K- 147, Electrical wiring and equipment shall be in accordance with National Electrical Code (NFPA 70).

2000 NFPA 101, 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.

Review of 1999 NFPA 70, 400-7 and 400-8, HCFA Transmittal Notice 22-99, and Interpretative Guidelines for
F 0323 Extension cords should not be used to take the place of adequate wiring in a facility. If extension cords are used, the cords should be properly secured and not be placed overhead, under carpets or rugs, or anywhere that the cord can cause trips, falls, or overheat. Extension cords should be connected to only one device to prevent overloading of the circuit. The cord itself should be of a size and type for the expected electrical load and made of material that will not fray or cut easily. Electrical cords including extension cords should have proper grounding if required and should not have any grounding devices removed or not used if required.
Power strips may not be used as a substitute for adequate electrical outlets in a facility. Power strips may be used for a computer, monitor, and printer. Power strips are not designed to be used with medical devices in patient care areas. Precautions needed if power strips are used include: installing internal ground fault and over-current protection devices; preventing cords from becoming tripping hazards; and using power strips that are adequate for the number and types of devices used. Overload on any circuit can potentially cause overheating and fire. The use of ground fault circuit interruption (GFCIs) may be required in locations near water sources to prevent electrocution of staff or residents.

Review of 1999 NFPA 70, 400-7 and 400-8, and HCFA Transmittal Notice 22-99 The 1984 edition of the National Electric Code restricts the use of extension cords to temporary short term uses. It is the policy of HCFA to prohibit non-circuit breaker protected extension cords in health care. The limited use of circuit breaker protected power strips is acceptable, provided the current is limited to 15 amps or less, and no major appliances such as air conditioners, refrigerators, or heating units are connected to the power strip.
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Based on review of the documentation during the survey on 07/13/2016 the facility failed to provide a fire watch plan with the correct information as adopted by ADPH policy. Findings include:

Per fire watch documentation from the facility:
1. The facility does rounds every hour
2. The documentation did not include sending the report and sign-in logs to Technical Services
3. The documentation did not include that the fire watch person shall be assigned to do nothing other than walking through the facility

The deficiency impacted 18 of the 18 smoke compartments.
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Review of 2000 NFPA 101, 9.7.6.1 Where a required automatic sprinkler system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the sprinkler system has been returned to service.

Review of Alabama Department of Public Health, Technical Services Unit
Fire Watch Procedure Revised 07/23/07
The fire watch person shall be assigned to do nothing other than walking through the facility, checking all rooms and attic spaces for fires, and signing a log every 15 to 30 minutes.
The facility must report the fire watch and sign-in logs to Technical Services.

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Based on review of the documentation during the survey on 07/13/2016 the facility failed to provide a fire watch plan with the correct information as adopted by ADPH policy. Findings include:

Per fire watch documentation from the facility:
1. The facility does rounds every hour
2. The documentation did not include sending the report and sign-in logs to Technical Services
3. The documentation did not include that the fire watch person shall be assigned to do nothing other than walking through the facility

The deficiency impacted 18 of the 18 smoke compartments.
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Review of 2000 NFPA 101, 9.6.1.8 Where a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service.

Review of Alabama Department of Public Health, Technical Services Unit
Fire Watch Procedure Revised 07/23/07
The fire watch person shall be assigned to do nothing other than walking through the facility, checking all rooms and attic spaces for fires, and signing a log every 15 to 30 minutes.
The facility must report the fire watch and sign-in logs to Technical Services.

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Based on the observation during the survey on 07/12/2016 the facility failed to provide a complete two hour fire rated barrier separating the main hospital building from the metal building housing the laundry. Findings include:

The two hour fire rated barrier in the Dining Room stopped at the bottom of the "I" beam, the two hour fire barrier does not extend to the roof deck.

The deficiency impacted 1 of the 18 smoke compartments.
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Review of 2000 NFPA 101, 19.1.1.4.1 Additions shall be separated from any existing structure not conforming to the provisions within Chapter 19 by a fire barrier having not less than a 2-hour fire resistance rating and constructed of materials as required for the addition. (See 4.6.11 and 4.6.6.)

Review of 2000 NFPA 101, 8.2.2.2 Fire compartments shall be formed with fire barriers that are continuous from outside wall to outside wall, from one fire barrier to another, or a combination thereof, including continuity through all concealed spaces, such as those found above a ceiling, including interstitial spaces. Walls used as fire barriers shall comply with Chapter 3 of NFPA 221, Standard for Fire Walls and Fire Barrier Walls. The NFPA 221 limitation on percentage width of openings shall not apply.

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Based on the observation during the survey on 07/12/2016 the facility failed to provide a building construction type allowed for partially sprinklered buildings. Findings include:

Per interview and observation the facility has 8 ICU rooms and 1 freezer that does not have automatic sprinkler coverage and the building construction type at the two story is a type II (000) (the old plaster ceiling has deteriorated and/or been removed in areas throughout the original 1958 single story part that connects to the two story without a two hour fire rated barrier, per architectural drawings).

Based on observation during the survey on 07/12/2016 the facility failed to meet a construction type for health care facility. Findings include:
Per observation the facility had constructed a single story unprotected wood frame structure up against the outside wall, right at a window (that is not fire rated) of the two story part of the building (radiology).

The deficiency impacted 9 of the 18 smoke compartments.
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Review of 2000 NFPA 101, 19.1.6.2 Health care occupancies shall be limited to the types of building construction shown in Table 19.1.6.2. (See 8.2.1.)Exception*: Any building of Type I(443), Type I(332), Type II(222), or Type II(111) construction shall be permitted to include roofing systems involving combustible supports, decking, or roofing, provided that the following criteria are met:(a) The roof covering meets Class C requirements in accordance with NFPA 256, Standard Methods of Fire Tests of Roof Coverings.
(b) The roof is separated from all occupied portions of the building by a noncombustible floor assembly that includes not less than 21/2 in. (6.4 cm) of concrete or gypsum fill.
(c) The attic or other space is either unoccupied or protected throughout by an approved automatic
sprinkler system.

Review of Table 19.1.6.2 Construction Type Limitations
Construction Stories
Type
1 2 3 4 or
More
I(443) X X X X
I(332) X X X X
II(222) X X X X
II(111) X X* X* NP
II(000) X* X* NP NP
III(211) X* X* NP NP
III(200) X* NP NP NP
IV(2HH) X* X* NP NP
V(111) X* X* NP NP
V(000) X* NP NP NP
X: Permitted type of construction.
NP: Not permitted.
*Building requires automatic sprinkler protection. (See 19.3.5.1.)

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Based on the observation during the survey on 07/13/2016 the facility failed to maintain the corridor doors. Findings include:

1. The Dining Room corridor double doors were observed without hardware that will keep doors securely latched in the door frame.
2. The Automatic Sprinkler riser room between the Lobby and Radiology was observed with a ventilating louver in the bottom half of it's corridor door.

The deficiency impacted 9 of the 18 smoke compartments.
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Review of 2000 NFPA 101, 19.3.6.3.2 Doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door.

Review of 2000 NFPA 101, 19.3.6.3.1 Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 13/4-in. (4.4-cm) thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke. Compliance with NFPA 80, Standard for Fire Doors and Fire Windows, shall not be required. Clearance between the bottom of the door and the floor covering not exceeding 1 in. (2.5 cm) shall be permitted for corridor doors.
Exception No. 1: Doors to toilet rooms, bathrooms, shower rooms, sink closets, and similar auxiliary spaces that do not contain flammable or combustible materials.
Exception No. 2: In smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.2, the door construction requirements of 19.3.6.3.1 shall not be mandatory, but the doors shall be constructed to resist the passage of smoke.

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Based on observation on 07/13/2016 the facility failed to provide one hour fire resistance rating for the elevator shaft. Findings Include: During the survey, the following is an example of what was observed.

Elevator # 3 was observed with approximately an 8" unsealed opening in the north shaft wall of the elevator.

This deficiency impacted 2 of 18 smoke compartments.
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NFPA 101, 19.3.1.1 Any vertical openings shall be enclosed or protected in accordance with 8.2.5. Where enclosure is provided, the construction shall have not less than a 1-hour fire resistance rating.

NPPA 101, 8.2.5 Vertical openings.
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Based on the observation during the survey on 07/13/2016 the facility failed to maintain the exit signs. Findings include:

The exit sign at Bay 9 in Outpatient Surgery was observed without a directional indicator, therefore leading you into Bay 9, not the exit.

The deficiency impacted 1 of the 18 smoke compartments.
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Review of 2000 NFPA 101, 7.10.2 A sign complying with 7.10.3 with a directional indicator showing the direction of travel shall be placed in every location where the direction of travel to reach the nearest exit is not apparent.

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Based on the observation during the survey on 07/13/2016 the facility failed to maintain the hazardous areas. Findings include:

The Medical Records File Room was observed with full automatic sprinkler coverage located in a smoke compartment that has full automatic sprinkler coverage was observed with an approximately 2" hole in one of the ceiling tiles.

The deficiency impacted 1 of the 18 smoke compartments.
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Review of 2000 NFPA 101, 19.3.2.1 Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing.

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Based on observation during the survey on 07/13/2016 the facility failed to provide fire alarm DACT/phone lines with supervision at the facility. Findings include:

1. While testing the fire alarm DACT/phone lines:
a. Line One indicated "dialer trouble"
b. Line Two indicated "dialer trouble"
c. Both Lines indicated "dialer trouble"

The deficiency impacted 18 of the 18 smoke compartments.
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Review of 2000 NFPA 101, 9.6.1.6 Fire alarm system installation wiring or other transmission paths shall be monitored for integrity in accordance with 9.6.1.4.

Review of 1999 NFPA 72, 1-5.2.3 Fire alarm systems shall be provided with at least two independent and reliable power supplies, one primary and one secondary (standby), each of which shall be of adequate capacity for the application.

Review of 1999 NFPA 72, 1-5.4.6 Trouble signals and their restoration to normal shall be indicated within 200 seconds at the locations identified in 1-5.4.6.1 or 1-5.4.6.2. Trouble signals required to indicate at the protected premises shall be indicated by distinctive audible signals. These audible trouble signals shall be distinctive from alarm signals. If an intermittent signal is used, it shall sound at least once every 10 seconds, with a minimum duration of 1/2 second. An audible trouble signal shall be permitted to be common to several supervised circuits. The trouble signal(s) shall be located in an area where it is likely to be heard.

Review of 1999 NFPA 72, 5-5.3.2.1.5*
A DACT shall have means to reset and retry if the first attempt to complete a signal transmission sequence is unsuccessful. A failure to complete connection shall not prevent subsequent attempts to transmit an alarm where such alarm is generated from any other initiating device circuit or signaling line circuit, or both. Additional attempts shall be made until the signal transmission sequence has been completed, up to a minimum of 5 and a maximum of 10 attempts.
If the maximum number of attempts to complete the sequence is reached, an indication of the failure shall be made at the premises.

Review of 1999 NFPA 72, 5-5.3.2.1.6.2
The following requirements shall apply to all combinations in 5-5.3.2.1.6.1:
(1) Both channels shall be supervised in a manner approved for the means of transmission employed.
(2) Both channels shall be tested at intervals not exceeding 24 hours.
Exception No. 1: For public cellular telephone service, a verification (test) signal shall be transmitted at least monthly.
Exception No. 2: Where two telephone lines (numbers) are used, it shall be permitted to test each telephone line (number) at alternating 24-hour intervals.
(3) The failure of either channel shall send a trouble signal on the other channel within 4 minutes.
(4) When one transmission channel has failed, all status change signals shall be sent over the other channel.
Exception: Where used in combination with a DACT, a derived local channel shall not be required to send status change signals other than those indicating that adverse conditions exist on the telephone line (number).
(5) The primary channel shall be capable of delivering an indication to the DACT that the message has been received by the supervising station.
(6) The first attempt to send a status change signal shall use the primary channel.
Exception: Where the primary channel is known to have failed.
(7) Simultaneous transmission over both channels shall be permitted.
(8) Failure of telephone lines (numbers) or cellular service shall be annunciated locally.

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2. During the testing of the fire alarm system the Radiology Department did not provide audible or visual signals.

3. During the testing of the fire alarm system telephone lines the remote annuciator did not give an audible signal and gave the same visual "dialer trouble" for all three phone line troubles.

The deficiency impacted 18 of the 18 smoke compartments.
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Review of 2000 NFPA 101, 9.6.1.6 Fire alarm system installation wiring or other transmission paths shall be monitored for integrity in accordance with 9.6.1.4.

Review of 1999 NFPA 72 5-4.2.1 Remote supervising station fire alarm systems shall provide an automatic audible and visible indication of alarm and, if required, of supervisory and trouble conditions at a location remote from the protected premises. A manual or automatic permanent record of these conditions shall be provided.
2000 NFPA 101, 9.6.1.4 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.
2000 NFPA 101 9.6.3.2 Notification shall be provided by audible and visible signals in accordance with 9.6.3.3 through 9.6.3.12.
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Based on observation of the post indicator valve on 07/12/2016 the facility failed to maintain the post indicator valve with appropriate identification. Findings include:

1. The post indicator valve located outside behind the maintenance building near the road area was observed with a missing sight glass.
2. The post indicator valve located outside in the front area of the hospital and was not provided with appropriate identification (the sight glass was distorted).

The deficiency impacted 18 of 18 smoke compartments.
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2000 NFPA 101, 21.7.6 Maintenance and Testing. (See 4.6.12.)

2000 NFPA 101, 4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction. e 4.6.12.)

1998 NFPA 25, 7-3.7.1 Gate valves, post indicator valves, wall indicator valves, or other control valves for water supply systems shall be inspected to verify that they are in the open position and properly sealed, locked, or supervised. (See Chapter 9 for inspection and maintenance requirements.)

1998 NFPA 25,9-3.3.2* The valve inspection shall verify that the valves are in the following condition: (a) In the normal open or closed position (b) * Properly sealed, locked, or supervised (c) Accessible (d) Provided with appropriate wrenches (e) Free from external leaks (f) Provided with appropriate identification

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Based on observation during the survey on 07/13/2016 the facility failed to maintain the vertical direction of the kitchen hood filters. Findings include:

All of the kitchen hood filters were observed oriented horizontally.

The deficiency impacted 1 of the 18 smoke compartments.
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Review of 1998 NFPA 96, 3-2.7 Grease filters that require a specific orientation to drain grease shall be clearly so designated, or the hood shall be constructed so that filters cannot be installed in the wrong orientation.

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Based on observation during the survey on 07/13/2016 the facility failed to maintain the means of egress. Findings include:

1. First Floor - Crosby's Nurses' Station's desk was built with a place to sit at the end of the desk where a computer station was located that when someone is sitting occupying this spot the individual and chair sticks out into the corridor approximately 2' - 3", one of the staff was observed doing work at this computer station.
2. Second Floor - OB Ward, the following was observed stored in the corridor:
a. One metal shelf
b. Several computers on wheels were being recharged, one had a cover over it

The deficiency impacted 2 of the 18 smoke compartments.
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Review of 2000 NFPA 101, 7.1.10.1 Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

Review of 2000 NFPA 101, 7.1.10.2.1 No furnishings, decorations, or other objects shall obstruct exits, access thereto, egress there from, or visibility thereof.

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Based on review of the documentation during the survey on 07/13/2016 the facility failed to maintain the HVAC dampers. Findings include:

Per documentation from the facility during the facility inspection of the HVAC dampers on 05/03/2016 - 05/08/2016 the following had not been corrected as of the survey:
1. Five dampers failed
2. Twenty-three dampers were non-accessible

The deficiency impacted 18 of the 18 smoke compartments.
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Review of CMS Transmittal S & C-10-04-LSC
After due consideration of State survey agency findings and conclusions of the National Fire Protection Association (NFPA), we are issuing a categorical waiver pursuant to 42 CFR 482.41(b)(2) to permit a testing interval of 6 years rather than 4 years for the maintenance testing of fire and smoke dampers in hospital heating and ventilating systems, so long as the hospital ' s testing system conforms to the requirements under 2007 edition of NFPA 80: Standard for Fire
Doors and Other Opening Protectives and the 2007 edition of NFPA 105: Standard for the Installation of Smoke Door Assemblies. The 6-year testing interval shall commence on the date of the last documented damper test.

Review of 1999 NFPA 90A, 2-3.4.1 A service opening shall be provided in air ducts adjacent to each fire damper, smoke damper, and smoke detector. The opening shall be large enough to permit maintenance and resetting of the device.

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Based on observation during the survey on 07/12/2016 the facility failed to maintain the signs at the liquid oxygen area. Findings include:

The fenced in area for the liquid oxygen container was open to the public on three sides, only one side was observed with a no smoking sign.

The deficiency impacted 1 of the 18 smoke compartments.
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Review of 1999 NFPA 99, 8-6.2.5.2 Transferring of liquid oxygen from one container to another shall be accomplished at a location specifically designated for the transferring that is as follows:
(a) Separated from any portion of a facility wherein patients are housed, examined, or treated by a separation of a fire barrier of 1-hour fire-resistive construction; and
(b) The area is mechanically ventilated, is sprinklered, and has ceramic or concrete flooring; and
(c) The area is posted with signs indicating that transferring is occurring, and that smoking in the immediate area is not permitted.

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Based on observation of all generator equipment on 07/12/2016 the facility failed to
maintain its generator equipment as required. Findings include:

During testing of the level one generators the remote annuciator for the emergency generator # 4 located at the main nurses station did not indicate alarm conditions when the emergency or auxiliary power source was operating to supply power to load.

The deficiency affected 18 of 18 smoke compartments.
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1999 NFPA 99, 3-4.1.1.15 A remote annunciator, storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station (see NFPA 70, National Electrical Code, Section 700-12.)
The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows:
(a) Individual visual signals shall indicate the following:
1. When the emergency or auxiliary power source is operating to supply power to load
2. When the battery charger is malfunctioning
(b) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following:
1. Low lubricating oil pressure
2. Low water temperature (below those required in 3-4.1.1.9)
3. Excessive water temperature
4. Low fuel - when the main fuel storage tank contains less than a 3-hour operating supply
5. Overcrank (failed to start)
6. Overspeed
Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions in 3-4.1.1.15(a) and (b) occur, but need not display these conditions individually. [110: 3-5.5.2]
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A. Based on observation on 07/13/2016 the facility failed to maintain an adequate number and/or location of electrical receptacles. As an example see:
1. A multi outlet device was observed plugged into an electrical outlet at the corridor door to Materials Management & Environmental Services
2. A refrigerator was observed plugged into a power strip in the following locations:
a. The C-Section Room
b. An empty room across from room 168

The deficiency impacted 3 of the 18 smoke compartments.
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B. Based on observation during the survey on 07/12/2016 the facility failed to maintain the electrical wiring and equipment in accordance with the National Electrical Code (NFPA 70). Findings include:

In the following locations a refrigerator and/or a microwave was observed plugged into a power strip.
a. Hospitalist Office
b. CVCU Med. Room
c. Pharmacy Storage Room
d. Eligibility Screening Services Office

The deficiencies affected 3 of 18 smoke compartments.
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Review of the printed statement on the 2567 for K- 147, Electrical wiring and equipment shall be in accordance with National Electrical Code (NFPA 70).

2000 NFPA 101, 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.

Review of 1999 NFPA 70, 400-7 and 400-8, HCFA Transmittal Notice 22-99, and Interpretative Guidelines for
F 0323 Extension cords should not be used to take the place of adequate wiring in a facility. If extension cords are used, the cords should be properly secured and not be placed overhead, under carpets or rugs, or anywhere that the cord can cause trips, falls, or overheat. Extension cords should be connected to only one device to prevent overloading of the circuit. The cord itself should be of a size and type for the expected electrical load and made of material that will not fray or cut easily. Electrical cords including extension cords should have proper grounding if required and should not have any grounding devices removed or not used if required.
Power strips may not be used as a substitute for adequate electrical outlets in a facility. Power strips may be used for a computer, monitor, and printer. Power strips are not designed to be used with medical devices in patient care areas. Precautions needed if power strips are used include: installing internal ground fault and over-current protection devices; preventing cords from becoming tripping hazards; and using power strips that are adequate for the number and types of devices used. Overload on any circuit can potentially cause overheating and fire. The use of ground fault circuit interruption (GFCIs) may be required in locations near water sources to prevent electrocution of staff or residents.

Review of 1999 NFPA 70, 400-7 and 400-8, and HCFA Transmittal Notice 22-99 The 1984 edition of the National Electric Code restricts the use of extension cords to temporary short term uses. It is the policy of HCFA to prohibit non-circuit breaker protected extension cords in health care. The limited use of circuit breaker protected power strips is acceptable, provided the current is limited to 15 amps or less, and no major appliances such as air conditioners, refrigerators, or heating units are connected to the power strip.
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Based on review of the documentation during the survey on 07/13/2016 the facility failed to provide a fire watch plan with the correct information as adopted by ADPH policy. Findings include:

Per fire watch documentation from the facility:
1. The facility does rounds every hour
2. The documentation did not include sending the report and sign-in logs to Technical Services
3. The documentation did not include that the fire watch person shall be assigned to do nothing other than walking through the facility

The deficiency impacted 18 of the 18 smoke compartments.
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Review of 2000 NFPA 101, 9.7.6.1 Where a required automatic sprinkler system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the sprinkler system has been returned to service.

Review of Alabama Department of Public Health, Technical Services Unit
Fire Watch Procedure Revised 07/23/07
The fire watch person shall be assigned to do nothing other than walking through the facility, checking all rooms and attic spaces for fires, and signing a log every 15 to 30 minutes.
The facility must report the fire watch and sign-in logs to Technical Services.

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Based on review of the documentation during the survey on 07/13/2016 the facility failed to provide a fire watch plan with the correct information as adopted by ADPH policy. Findings include:

Per fire watch documentation from the facility:
1. The facility does rounds every hour
2. The documentation did not include sending the report and sign-in logs to Technical Services
3. The documentation did not include that the fire watch person shall be assigned to do nothing other than walking through the facility

The deficiency impacted 18 of the 18 smoke compartments.
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Review of 2000 NFPA 101, 9.6.1.8 Where a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service.

Review of Alabama Department of Public Health, Technical Services Unit
Fire Watch Procedure Revised 07/23/07
The fire watch person shall be assigned to do nothing other than walking through the facility, checking all rooms and attic spaces for fires, and signing a log every 15 to 30 minutes.
The facility must report the fire watch and sign-in logs to Technical Services.