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Based on observation and interview, the facility failed to maintain their corridor doors to fully close and resist the passage of smoke. This was evidenced by doors that failed to positive latch and by doors that were impeded from closing. This failure could result in the transfer of smoke and fire, resulting in potential harm to the occupants. This effected 4 of 9 smoke compartments.

Findings:

During a tour of the facility with Staff 1, Staff 2, Staff 3, and Staff 4, from June 25 through June 27, 2012, the corridor doors were observed.

June 25, 2012 - Behavioral Medicine Center
At 12:58 p.m., the corridor door to the Pharmacy Office was impeded from closing by a yellow rubber wedge that was placed under the door.

At 1:41 p.m., the corridor door to patient Room 1217 failed to latch when closed. The door latching mechanism was stuck in the closed position.

At 1:42 p.m., during an interview Staff 1 stated "the door latching mechanism sticks."

At 1:58 p.m., the corridor door to patient Room 2412 did not latch when closed. The door latching mechanism was stuck in the closed position.

At 1:59 p.m., during an interview, Staff 2 confirmed the latch in the door was stuck.

At 2:20 p.m., the self-closing corridor door to the Staff Only Isolation Room, near Room 2405, did not latch when closed. The door latching mechanism hit the door frame and the door did not close completely.

At 2:21 p.m., during an interview, Staff 2 reported the door needed to be adjusted."

June 26, 2012
At 8:27 a.m., the entrance door to the kitchen tray line did not latch when closed. The door hit the door frame and was obstructed from closing completely.

At 8:32 a.m., the door to the pantry was tied open with a string that obstructed the door from closing.

At 9:56 a.m., the corridor door the dayroom, (Room 1203), did not latch when closed. The door hit the door frame and failed to close completely.

At 10:14 a.m., the self-closing patio door near, Room 1307, did not close completely and latch.

Based on observation, the facility failed to maintain the smoke barrier walls. This was evidenced by a penetration in the separation wall between smoke compartments in one of three buildings. This could result in the spread of smoke or fire to other areas.

NFPA 101 Life Safety Code, 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:
(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.

Findings:

During the facility tour with Staff 1 and Staff 3, on June 27, 2012, the smoke barrier walls were observed in Building 3.

Partial Hospitalization Program
At 9:34 a.m., there was an approximately 3/4 inch penetration around a ? metal conduit, in the East smoke barrier wall, above the entrance to the suite.

Based on interview, the facility failed to ensure staff were familiar with fire procedures, as evidenced by incorrect staff responses to fire drill questions. This could result in an increased risk of panic and a delay in evacuation, if staff were not trained and familiar with the fire emergency procedures. This effected 2 of 9 smoke compartments.

Findings:

During a tour of the facility with Staff 1, Staff 2, Staff 3, and Staff 4, on June 25, 2012, staff were interviewed during fire alarm testing.

June 25, 2012
At 1:17 p.m., Staff members 5 through 16 were interviewed. They were asked to explain what they would do if they discovered a trash can fire in a patient room, with one patient in the room. Two of sixteen staff members (with greater than 4 months of experience) stated that they would yell fire instead of using the code phrase, (Code Red), for fire.

Based on document review and interview, the facility failed to ensure smoke detectors were provided in accordance NFPA 72. This was evidenced by no documentation of smoke detector sensitivity testing. This could result in a failure of the smoke detectors and potential harm to patients in the event of a fire emergency.

NFPA 72 National Fire Alarm Code 1999 Edition
7.2.2 Fire alarm systems and other systems and equipment that are associated with fire alarm systems and accessory equipment shall be tested according to Table 7-2.2
13. Initiating Devices (g) Smoke Detectors
The detectors shall be tested in place to ensure smoke entry into the sensing chamber and an alarm response. Testing with smoke or listed aerosol approved by the manufacturer shall be permitted as acceptable test methods. Other methods approved by the manufacturer that ensure smoke entry into the sensing chamber shall be permitted.
Additionally any of the following tests shall be performed to ensure that each smoke detector is within its listed and marked sensitivity range:
(a)Calibrated test method
(b) Manufacturer's calibrated sensitivity test instrument
(c)Listed control equipment arranged for the purpose
(d) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit when its sensitivity is outside its listed sensitivity range
(e) Other calibrated sensitivity test method approved by the authority having jurisdiction.
Smoke sensitivity testing is required the first year of installation of the smoke detector, the third year and every five years thereafter.

Findings:

During document review with Staff 1, Staff 2, Staff 3, and Staff 4, from June 25 through June 27, 2012, the smoke sensitivity testing documents were requested.

June 25, 2012 - Building 01, Behavioral Medicine Center
At 4:42 p.m., there was no documented evidence of sensitivity testing for 136 smoke detectors in Building 1.

At 4:43 p.m., during an interview, Staff 3 stated "we do not have any sensitivity test documents for the smoke detectors," for the BMC (Behavioral Medicine Center).

June 26, 2012 - Building 02, Behavioral Health Institute
At 2:16 p.m., there was no documented evidence of sensitivity testing for 6 of 6 smoke detectors in Building 02.

At 2:17 p.m., during an interview, Staff 2 stated "we don't have any sensitivity testing for these smoke detectors."

Based on observation and interview, the facility failed to maintain their corridor doors to fully close and resist the passage of smoke. This was evidenced by doors that failed to positive latch and by doors that were impeded from closing. This failure could result in the transfer of smoke and fire, resulting in potential harm to the occupants. This effected 4 of 9 smoke compartments.

Findings:

During a tour of the facility with Staff 1, Staff 2, Staff 3, and Staff 4, from June 25 through June 27, 2012, the corridor doors were observed.

June 25, 2012 - Behavioral Medicine Center
At 12:58 p.m., the corridor door to the Pharmacy Office was impeded from closing by a yellow rubber wedge that was placed under the door.

At 1:41 p.m., the corridor door to patient Room 1217 failed to latch when closed. The door latching mechanism was stuck in the closed position.

At 1:42 p.m., during an interview Staff 1 stated "the door latching mechanism sticks."

At 1:58 p.m., the corridor door to patient Room 2412 did not latch when closed. The door latching mechanism was stuck in the closed position.

At 1:59 p.m., during an interview, Staff 2 confirmed the latch in the door was stuck.

At 2:20 p.m., the self-closing corridor door to the Staff Only Isolation Room, near Room 2405, did not latch when closed. The door latching mechanism hit the door frame and the door did not close completely.

At 2:21 p.m., during an interview, Staff 2 reported the door needed to be adjusted."

June 26, 2012
At 8:27 a.m., the entrance door to the kitchen tray line did not latch when closed. The door hit the door frame and was obstructed from closing completely.

At 8:32 a.m., the door to the pantry was tied open with a string that obstructed the door from closing.

At 9:56 a.m., the corridor door the dayroom, (Room 1203), did not latch when closed. The door hit the door frame and failed to close completely.

At 10:14 a.m., the self-closing patio door near, Room 1307, did not close completely and latch.

Based on observation, the facility failed to maintain the smoke barrier walls. This was evidenced by a penetration in the separation wall between smoke compartments in one of three buildings. This could result in the spread of smoke or fire to other areas.

NFPA 101 Life Safety Code, 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:
(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.

Findings:

During the facility tour with Staff 1 and Staff 3, on June 27, 2012, the smoke barrier walls were observed in Building 3.

Partial Hospitalization Program
At 9:34 a.m., there was an approximately 3/4 inch penetration around a ? metal conduit, in the East smoke barrier wall, above the entrance to the suite.

Based on interview, the facility failed to ensure staff were familiar with fire procedures, as evidenced by incorrect staff responses to fire drill questions. This could result in an increased risk of panic and a delay in evacuation, if staff were not trained and familiar with the fire emergency procedures. This effected 2 of 9 smoke compartments.

Findings:

During a tour of the facility with Staff 1, Staff 2, Staff 3, and Staff 4, on June 25, 2012, staff were interviewed during fire alarm testing.

June 25, 2012
At 1:17 p.m., Staff members 5 through 16 were interviewed. They were asked to explain what they would do if they discovered a trash can fire in a patient room, with one patient in the room. Two of sixteen staff members (with greater than 4 months of experience) stated that they would yell fire instead of using the code phrase, (Code Red), for fire.

Based on document review and interview, the facility failed to ensure smoke detectors were provided in accordance NFPA 72. This was evidenced by no documentation of smoke detector sensitivity testing. This could result in a failure of the smoke detectors and potential harm to patients in the event of a fire emergency.

NFPA 72 National Fire Alarm Code 1999 Edition
7.2.2 Fire alarm systems and other systems and equipment that are associated with fire alarm systems and accessory equipment shall be tested according to Table 7-2.2
13. Initiating Devices (g) Smoke Detectors
The detectors shall be tested in place to ensure smoke entry into the sensing chamber and an alarm response. Testing with smoke or listed aerosol approved by the manufacturer shall be permitted as acceptable test methods. Other methods approved by the manufacturer that ensure smoke entry into the sensing chamber shall be permitted.
Additionally any of the following tests shall be performed to ensure that each smoke detector is within its listed and marked sensitivity range:
(a)Calibrated test method
(b) Manufacturer's calibrated sensitivity test instrument
(c)Listed control equipment arranged for the purpose
(d) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit when its sensitivity is outside its listed sensitivity range
(e) Other calibrated sensitivity test method approved by the authority having jurisdiction.
Smoke sensitivity testing is required the first year of installation of the smoke detector, the third year and every five years thereafter.

Findings:

During document review with Staff 1, Staff 2, Staff 3, and Staff 4, from June 25 through June 27, 2012, the smoke sensitivity testing documents were requested.

June 25, 2012 - Building 01, Behavioral Medicine Center
At 4:42 p.m., there was no documented evidence of sensitivity testing for 136 smoke detectors in Building 1.

At 4:43 p.m., during an interview, Staff 3 stated "we do not have any sensitivity test documents for the smoke detectors," for the BMC (Behavioral Medicine Center).

June 26, 2012 - Building 02, Behavioral Health Institute
At 2:16 p.m., there was no documented evidence of sensitivity testing for 6 of 6 smoke detectors in Building 02.

At 2:17 p.m., during an interview, Staff 2 stated "we don't have any sensitivity testing for these smoke detectors."