HospitalInspections.org

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Based on the observation on 01/29/2015 of the corridor walls in nonsprinklered smoke compartments, the facility failed to maintain the construction Type required by code. Findings include:

Majority of Building 0304 was observed to have the construction type of Type II (111) nonsprinklered, except from the Outpatient Nurses' Station to the four hour rated fire wall at the exam rooms that was observed to be of a Type II (000) construction.

This deficiency impacted 1 of 2 smoke compartments of this building.
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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.)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 on 1/28/2015, the facility failed to maintain corridor walls that would provide at least 30 minute fire resistance. Findings include:

1. Unsealed penetrations around a single blue wire in the corridor wall by 2 North vending machines.

2. Unsealed penetrations at the end of a sleeve in the corridor wall by room 210 South Hall.

This deficiency impacted 2 of 5 smoke compartments on the Second Floor of this building.

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NFPA 101, 19.3.6.1 Corridors in unsprinklered smoke compartments shall be separated from all other areas by partitions having a fire resistance rating of at least 30 minutes.
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Based on the observation on 01/29/2015 of this building's corridor doors, the facility failed to maintain the corridor doors smoke resistive. Findings include:

The 'Medicest Office' corridor door was observed with a hole above the door handle and a hole below the door handle.

This deficiency impacted 1 of 3 smoke compartments on the First Floor of this building.
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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 the observation on 01/28/2015 of this building's exit signs, the facility failed to maintain an exit sign with directional indicator showing the direction of travel. Findings include:

The exit sign with directional indicator at the smoke doors at the Pharmacy indicated that the direction of travel was through the Pharmacy, instead of straight ahead through the smoke doors.

This deficiency impacted 1 of 3 smoke compartments on the First Floor of this building.
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Review of 2000 NFPA 101, 7.10.1.4 Access to exits shall be marked by approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent to the occupants. Sign placement shall be such that no point in an exit access corridor is in excess of 100 ft (30 m) from the nearest externally illuminated sign and is not in excess of the marked rating for internally illuminated signs.
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 on 01/28/2015 of this building's smoke barriers, the facility failed to maintain the smoke barriers smoke resistive and one half hour fire rating. Findings include:

The smoke barrier in the Lab had 1 unsealed 1/2" conduit end.

This deficiency impacted 2 of 3 smoke compartments on the First Floor of this building.
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Review of 2000 NFPA 101, 8.2.4.4.1

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Based on the observation on 01/28/2015 of this building's doors in the smoke barriers, the facility failed to maintain the doors in the smoke barriers. Findings include:

The Janitor's Closet (across from the Dining Room) corridor door was observed in the smoke barrier and did not have self-closing hardware.

This deficiency impacted 2 of 3 smoke compartments on the First Floor of this building.
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Review of 2000 NFPA 101, 19.3.7.6 Doors in smoke barriers shall comply with 8.3.4 and shall be self-closing or automatic-closing in accordance with 19.2.2.2.6.

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Based on the observation on 01/29/2015 of this building's hazardous areas, the facility failed to provide a one hour fire rated enclosure in the nonsprinklered area. Findings include:

The kitchen was observed to be over 50 sq. ft. used for storing all the dietary storage in the kitchen and with gas fueled water heater in the kitchen. The following was observed:
1. The wall between the kitchen and the Serving Area did not continue to the ceiling floor deck above
2. The two doors to the kitchen at serving line and corridor were not 45 minute fire rated
3. The kitchen corridor door did not have a self - closing device
4. The door between the kitchen and Serving Area did not have positive latching hardware
5. The 2 roll down shutter, one in the corridor wall and in the wall between the Vending room and kitchen, for the pass through the shutters were not fire rated and were not connected to the fire alarm system nor did these shutters have fusible links

This deficiency impacted 1 of 3 smoke compartments on the First Floor of this building.
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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 the observation on 1/28/2015, the facility failed to maintain stairwell at least 1 hour fire resistance rating. Findings include:

Unsealed opening around 2 sections of conduit in the South Stairwell by Patient room 221.

This deficiency impacted 1 of 5 smoke compartments on the Second Floor of this building.

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NFPA 101, 19.3.1.1, 8.2.3.2.4, and 7.1.3.2.1 requires a fire resistance rating of 1 hour.
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Based on the observation on 01/28/2015 of this building's horizontal exits, the facility failed to maintain the four hour rated fire barrier, that is a horizontal exit. Findings include:

1. Unsealed penetrations at the end of 2 sleeves in the fire barrier by soiled utility room 200 East Hall.

2. Unsealed penetrations at the end of 2 sleeves in the fire barrier by Patient Room 242 North Hall.

3. Unsealed penetrations at the end of 2 sleeves in the fire barrier by Patient Room 210 South Hall.


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4. The four hour rated fire barrier in Medical Records was observed with 2 3/4" unsealed conduit ends.
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Review of 2000 NFPA 101, 8.2.3.2.4.2

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Based on the observation on 01/29/2015 of this building's fire barriers, the facility failed to maintain the two hour rated fire barrier. Findings include:

The two hour rated fire barrier separating 0204 Building's construction Type, II (000) fully sprinklered from 0104 Building's construction Type II (222) partially sprinklered was observed without the two hour fire rating at the corridor doors on the I.C.U. side.

This deficiency impacted 1 of 1 smoke compartments on the Second Floor of this building.
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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 review of documentation on 01/29/2015 of the facility's fire drill reports, the facility failed to conduct fire drills per code. Findings include:

1. Per documentation provided by maintenance staff, facility failed to document that all facility personnel are familiar with the signals and emergency action required under varied conditions during fire drills. Per interview with facility maintenance staff, staff confirmed that documentation provided of fire drill participation did not include signatures of all staff in the facility at the time of the fire drills.
2. Second Shift fire drills were all within 30 minutes.

3. Weekend Shift fire drills were all within 15 minutes.

Second Shift
10/08/2014 - 6:00 a
07/10/2014 - 6:00 a
04/16/2014 - 6:30 a

Weekend Shift
10/04/2014 - 8:38 a
07/12/2014 - 8:45 a
04/05/2014 - 8:30 a
03/15/2014 - 8:30 a

This deficiency impacted 1 of 1 smoke compartments
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Review of 2000 NFPA 101, 19.7.1.2 Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.

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Based on the review of documentation on 01/29/2015 of the facility's fire drill reports, the facility failed to conduct fire drills per code. Findings include:

1. Per documentation provided by maintenance staff, facility failed to document that all facility personnel are familiar with the signals and emergency action required under varied conditions during fire drills. Per interview with facility maintenance staff, staff confirmed that documentation provided of fire drill participation did not include signatures of all staff in the facility at the time of the fire drills.
2. Second Shift fire drills were all within 30 minutes.

3. Weekend Shift fire drills were all within 15 minutes.

Second Shift
10/08/2014 - 6:00 a
07/10/2014 - 6:00 a
04/16/2014 - 6:30 a

Weekend Shift
10/04/2014 - 8:38 a
07/12/2014 - 8:45 a
04/05/2014 - 8:30 a
03/15/2014 - 8:30 a

This deficiency impacted 2 of 2 smoke compartments
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Review of 2000 NFPA 101, 19.7.1.2 Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.

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Based on the review of documentation on 01/29/2015 of the facility's fire drill reports, the facility failed to conduct fire drills per code. Findings include:

1. Per documentation provided by maintenance staff, facility failed to document that all facility personnel are familiar with the signals and emergency action required under varied conditions during fire drills. Per interview with facility maintenance staff, staff confirmed that documentation provided of fire drill participation did not include signatures of all staff in the facility at the time of the fire drills.
2. Second Shift fire drills were all within 30 minutes.

3. Weekend Shift fire drills were all within 15 minutes.

Second Shift
10/08/2014 - 6:00 a
07/10/2014 - 6:00 a
04/16/2014 - 6:30 a

Weekend Shift
10/04/2014 - 8:38 a
07/12/2014 - 8:45 a
04/05/2014 - 8:30 a
03/15/2014 - 8:30 a

This deficiency impacted 8 of 8 smoke compartments
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Review of 2000 NFPA 101, 19.7.1.2 Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.

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Based on observation on 1/29/2015 the facility failed to maintain the fire alarm system. Findings include:

While reviewing the documentation for the annual fire alarm inspection which was conducted on 11/24/2014. The following items were listed in the comment section as failed during the testing. Based on interview with the Plant Operations Director the items have not been corrected, but are scheduled for correction by the fire alarm service company.

1. One audible / visual signal device.
2. One control panel hard wired.
3. One duct smoke detector.
4. Six heat detectors.
5. Four photo smoke detectors.


This deficiency effects all smoke compartments throughout the facility.



NFPA 101, 9.6.1.4 The fire alarm system to be installed, tested, and maintained in accordance with the requirements of NFPA 70 and NFPA 72.

Based on observation on 1/29/2015 the facility failed to maintain the fire alarm system. Findings include:

While reviewing the documentation for the annual fire alarm inspection which was conducted on 11/24/2014. The following items were listed in the comment section as failed during the testing. Based on interview with the Plant Operations Director the items have not been corrected, but are scheduled for correction by the fire alarm service company.

1. One audible / visual signal device.
2. One control panel hard wired.
3. One duct smoke detector.
4. Six heat detectors.
5. Four photo smoke detectors.


This deficiency effects all smoke compartments throughout the facility.

NFPA 101, 9.6.1.4 The fire alarm system to be installed, tested, and maintained in accordance with the requirements of NFPA 70 and NFPA 72.

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Based on the observation on 1/29/2015, the facility failed to maintain the fire alarm system. Findings include:

While reviewing the documentation for the annual fire alarm inspection which was conducted on 11/24/2014, the following items were listed in the comment section as failed during the testing. Based on the interview with the Plant Operations Director the items have not been corrected, but are scheduled for correction by the fire alarm service company.

1. One audible / visual signal device.
2. One control panel hard wired.
3. One duct smoke detector.
4. Six heat detectors.
5. Four photo smoke detectors.

This deficiency impacted all smoke compartments throughout the facility.

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NFPA 101, 9.6.1.4 The fire alarm system to be installed, tested, and maintained in accordance with the requirements of NFPA 70 and NFPA 72.
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Based on the observation on 1/29/2015, the facility failed to maintain the fire alarm system. Findings include:

While reviewing the documentation for the annual fire alarm inspection which was conducted on 11/24/2014, the following items were listed in the comment section as failed during the testing. Based on the interview with the Plant Operations Director, the items have not been corrected, but are scheduled for correction by the fire alarm service company.

1. One audiol visual signal device.
2. One control panel hard wired.
3. One duct smoke detector.
4. Six heat detectors.
5. Four photo smoke detectors.

This deficiency impacted all smoke compartments throughout the facility.

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NFPA 101, 9.6.1.4 The fire alarm system to be installed, tested, and maintained in accordance with the requirements of NFPA 70 and NFPA 72.
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Based on the observation on 01/28/2015 of the facility's fire alarm system, the facility failed to maintain the smoke detectors in OR's "A" and "B". Findings include:

The smoke detectors in OR's "A" and "B" when tested with smoke in the can did not actuate the fire alarm system.
This deficiency impacted 1 of 3 smoke compartments on the First Floor of this building.
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Review of 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.
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Based on observation on 1/29/2015 the facility failed to maintain the automatic sprinkler system. Findings include:


While reviewing the documentation the following quarterly inspections were conducted on 3/31/2014, 6/25/2014, 9/24/2014. A quarterly inspection was due 12/24/2014, at the time of the survey documentation was not provided. Based on interview with the Plant Operation Director the service company had not conducted the December inspection.



NFPA 101, 4.6.12, and NFPA 25, 2-2 and Table 2-1 Requires an inspection every quarter (three months).

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Based on the observation on 1/29/2015, the facility failed to maintain the automatic sprinkler system. Findings include:

While reviewing the documentation, the following quarterly inspections were conducted on 3/31/2014, 6/25/2014, 9/24/2014. A quarterly inspection was due 12/24/2014, at the time of the survey documentation was not provided. Based on interview with the Plant Operation Director, the service company had not conducted the December sprinkler inspection.

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NFPA 101, 4.6.12, and NFPA 25, 2-2 and Table 2-1 Requires an inspection every quarter (three months).
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Based on the observation on 01/28/2015 of this building's fire barriers, the facility failed to maintain the four hour rated fire barrier. Findings include:

The 4 fire barriers at the Clinical I.T. Manager's Office were observed with an HVAC flex duct penetrating this barrier. The flex duct was observed without a fire damper and did not have a service opening.

This deficiency impacted 2 of 3 smoke compartments on the First Floor of this building.
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Review of 1999 NFPA 90A, 2-3.3.3 Air duct coverings shall not extend through walls or floors that are required to be fire stopped or required to have a fire resistance rating.
Review of 1999 NFPA 90A, 2-3.3.4 Air duct linings shall be interrupted at fire dampers to prevent interference with the operation of devices.
Review of 1999 NFPA 90A, 2-3.3.5 Air duct coverings shall not be installed so as to conceal or prevent the use of any service opening.
Review of 1999 NFPA 90A, 3-3.1.1 Approved fire dampers shall be provided where air ducts penetrate or terminate at openings in walls or partitions required to have a fire resistance rating of 2 hours or more.
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 the observation on 01/28/2015 during the walk thru, the facility failed to maintain the battery-powered emergency lighting. Findings include:

The battery-powered emergency light in OR "B" failed to illuminate when tested.

This deficiency impacted 1 of 3 smoke compartments on the First Floor of this building.
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Review of 1999 NFPA 99, 3-3.2.1.2 All Patient Care Areas.
5. Wiring in Anesthetizing Locations.
e. Battery-Powered Emergency Lighting Units. One or more battery-powered emergency lighting units shall be provided in accordance with NFPA 70, National Electrical Code, Section 700-12(e).

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Based on the observation on 01/29/2015 during the walk around the outside of the building, the facility failed to maintain the fire department connections. Findings include:

The outside fire departmnet connections failed to swivel.

This deficiency impacted 2 of 2 smoke compartments of this building.
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Review of 1995 NFPA 24, 2-6.7 The fire department connection(s) shall have the NH internal threaded swivel fitting(s) having the NH standard thread, at least one of which shall be the 2.5-7.5 NH standard thread, as specified in NFPA 1963, Standard for Fire Hose Connections.
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Based on the observation on 01/29/2015 during the walk thru, the facility failed to maintain the electrical wiring and equipment. Findings include:

1. The D.O.N. Secretary's Office area had a refrigerator plugged into a power strip (extension cord) plugged into a surge protector (extension cord).
2. The Clinical I.T. Manager's Office had a surge protector (extension cord) plugged into another surge protector (extension cord) at the desk.

This deficiency impacted 1 of 2 smoke compartments of this building.
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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 the observation on 01/29/2015 during the walk thru, the facility failed to maintain the electrical wiring and equipment. Findings include:

The Human Resources Office was observed with a lamp plugged into an extension cord.

This deficiency impacted 1 of 3 smoke compartments on the First Floor of this building.
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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 the review of documentation on 01/29/2015 of the facility's policies, the facility failed to provide a fire watch policy. Findings include:

Based on interview the facility was unable to provide a fire watch policy at the time of the survey.

This deficiency impacted 2 of 2 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.
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Based on the review of documentation on 01/29/2015 of the facility's policies, the facility failed to provide a fire watch policy. Findings include:

Based on interview, the facility was unable to provide a fire watch policy at the time of the survey.

This deficiency impacted 1 of 1 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.
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Based on the review of documentation on 01/29/2015 of the facility's policies, the facility failed to provide a fire watch policy. Findings include:

Based on interview, the facility was unable to provide a fire watch policy at the time of the survey.

This deficiency impacted 8 of 8 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.
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Based on the review of documentation on 01/29/2015 of the facility's policies, the facility failed to provide a fire watch policy. Findings include:

Based on interview, the facility was unable to provide a fire watch policy at the time of the survey.

This deficiency impacted 8 of 8 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.

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Based on the review of documentation on 01/29/2015 of the facility's policies, the facility failed to provide a fire watch policy. Findings include:

Based on the interview, the facility was unable to provide a fire watch policy at the time of the survey.

This deficiency impacted 1 of 1 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.

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Based on the observation on 01/29/2015 of the corridor walls in nonsprinklered smoke compartments, the facility failed to maintain the construction Type required by code. Findings include:

Majority of Building 0304 was observed to have the construction type of Type II (111) nonsprinklered, except from the Outpatient Nurses' Station to the four hour rated fire wall at the exam rooms that was observed to be of a Type II (000) construction.

This deficiency impacted 1 of 2 smoke compartments of this building.
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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.)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 on 1/28/2015, the facility failed to maintain corridor walls that would provide at least 30 minute fire resistance. Findings include:

1. Unsealed penetrations around a single blue wire in the corridor wall by 2 North vending machines.

2. Unsealed penetrations at the end of a sleeve in the corridor wall by room 210 South Hall.

This deficiency impacted 2 of 5 smoke compartments on the Second Floor of this building.

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NFPA 101, 19.3.6.1 Corridors in unsprinklered smoke compartments shall be separated from all other areas by partitions having a fire resistance rating of at least 30 minutes.
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Based on the observation on 01/29/2015 of this building's corridor doors, the facility failed to maintain the corridor doors smoke resistive. Findings include:

The 'Medicest Office' corridor door was observed with a hole above the door handle and a hole below the door handle.

This deficiency impacted 1 of 3 smoke compartments on the First Floor of this building.
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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 the observation on 01/28/2015 of this building's exit signs, the facility failed to maintain an exit sign with directional indicator showing the direction of travel. Findings include:

The exit sign with directional indicator at the smoke doors at the Pharmacy indicated that the direction of travel was through the Pharmacy, instead of straight ahead through the smoke doors.

This deficiency impacted 1 of 3 smoke compartments on the First Floor of this building.
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Review of 2000 NFPA 101, 7.10.1.4 Access to exits shall be marked by approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent to the occupants. Sign placement shall be such that no point in an exit access corridor is in excess of 100 ft (30 m) from the nearest externally illuminated sign and is not in excess of the marked rating for internally illuminated signs.
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 on 01/28/2015 of this building's smoke barriers, the facility failed to maintain the smoke barriers smoke resistive and one half hour fire rating. Findings include:

The smoke barrier in the Lab had 1 unsealed 1/2" conduit end.

This deficiency impacted 2 of 3 smoke compartments on the First Floor of this building.
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Review of 2000 NFPA 101, 8.2.4.4.1

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Based on the observation on 01/28/2015 of this building's doors in the smoke barriers, the facility failed to maintain the doors in the smoke barriers. Findings include:

The Janitor's Closet (across from the Dining Room) corridor door was observed in the smoke barrier and did not have self-closing hardware.

This deficiency impacted 2 of 3 smoke compartments on the First Floor of this building.
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Review of 2000 NFPA 101, 19.3.7.6 Doors in smoke barriers shall comply with 8.3.4 and shall be self-closing or automatic-closing in accordance with 19.2.2.2.6.

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Based on the observation on 01/29/2015 of this building's hazardous areas, the facility failed to provide a one hour fire rated enclosure in the nonsprinklered area. Findings include:

The kitchen was observed to be over 50 sq. ft. used for storing all the dietary storage in the kitchen and with gas fueled water heater in the kitchen. The following was observed:
1. The wall between the kitchen and the Serving Area did not continue to the ceiling floor deck above
2. The two doors to the kitchen at serving line and corridor were not 45 minute fire rated
3. The kitchen corridor door did not have a self - closing device
4. The door between the kitchen and Serving Area did not have positive latching hardware
5. The 2 roll down shutter, one in the corridor wall and in the wall between the Vending room and kitchen, for the pass through the shutters were not fire rated and were not connected to the fire alarm system nor did these shutters have fusible links

This deficiency impacted 1 of 3 smoke compartments on the First Floor of this building.
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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 the observation on 1/28/2015, the facility failed to maintain stairwell at least 1 hour fire resistance rating. Findings include:

Unsealed opening around 2 sections of conduit in the South Stairwell by Patient room 221.

This deficiency impacted 1 of 5 smoke compartments on the Second Floor of this building.

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NFPA 101, 19.3.1.1, 8.2.3.2.4, and 7.1.3.2.1 requires a fire resistance rating of 1 hour.
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Based on the observation on 01/28/2015 of this building's horizontal exits, the facility failed to maintain the four hour rated fire barrier, that is a horizontal exit. Findings include:

1. Unsealed penetrations at the end of 2 sleeves in the fire barrier by soiled utility room 200 East Hall.

2. Unsealed penetrations at the end of 2 sleeves in the fire barrier by Patient Room 242 North Hall.

3. Unsealed penetrations at the end of 2 sleeves in the fire barrier by Patient Room 210 South Hall.


27382

4. The four hour rated fire barrier in Medical Records was observed with 2 3/4" unsealed conduit ends.
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Review of 2000 NFPA 101, 8.2.3.2.4.2

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Based on the observation on 01/29/2015 of this building's fire barriers, the facility failed to maintain the two hour rated fire barrier. Findings include:

The two hour rated fire barrier separating 0204 Building's construction Type, II (000) fully sprinklered from 0104 Building's construction Type II (222) partially sprinklered was observed without the two hour fire rating at the corridor doors on the I.C.U. side.

This deficiency impacted 1 of 1 smoke compartments on the Second Floor of this building.
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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 review of documentation on 01/29/2015 of the facility's fire drill reports, the facility failed to conduct fire drills per code. Findings include:

1. Per documentation provided by maintenance staff, facility failed to document that all facility personnel are familiar with the signals and emergency action required under varied conditions during fire drills. Per interview with facility maintenance staff, staff confirmed that documentation provided of fire drill participation did not include signatures of all staff in the facility at the time of the fire drills.
2. Second Shift fire drills were all within 30 minutes.

3. Weekend Shift fire drills were all within 15 minutes.

Second Shift
10/08/2014 - 6:00 a
07/10/2014 - 6:00 a
04/16/2014 - 6:30 a

Weekend Shift
10/04/2014 - 8:38 a
07/12/2014 - 8:45 a
04/05/2014 - 8:30 a
03/15/2014 - 8:30 a

This deficiency impacted 1 of 1 smoke compartments
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Review of 2000 NFPA 101, 19.7.1.2 Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.

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Based on the review of documentation on 01/29/2015 of the facility's fire drill reports, the facility failed to conduct fire drills per code. Findings include:

1. Per documentation provided by maintenance staff, facility failed to document that all facility personnel are familiar with the signals and emergency action required under varied conditions during fire drills. Per interview with facility maintenance staff, staff confirmed that documentation provided of fire drill participation did not include signatures of all staff in the facility at the time of the fire drills.
2. Second Shift fire drills were all within 30 minutes.

3. Weekend Shift fire drills were all within 15 minutes.

Second Shift
10/08/2014 - 6:00 a
07/10/2014 - 6:00 a
04/16/2014 - 6:30 a

Weekend Shift
10/04/2014 - 8:38 a
07/12/2014 - 8:45 a
04/05/2014 - 8:30 a
03/15/2014 - 8:30 a

This deficiency impacted 2 of 2 smoke compartments
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Review of 2000 NFPA 101, 19.7.1.2 Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.

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Based on the review of documentation on 01/29/2015 of the facility's fire drill reports, the facility failed to conduct fire drills per code. Findings include:

1. Per documentation provided by maintenance staff, facility failed to document that all facility personnel are familiar with the signals and emergency action required under varied conditions during fire drills. Per interview with facility maintenance staff, staff confirmed that documentation provided of fire drill participation did not include signatures of all staff in the facility at the time of the fire drills.
2. Second Shift fire drills were all within 30 minutes.

3. Weekend Shift fire drills were all within 15 minutes.

Second Shift
10/08/2014 - 6:00 a
07/10/2014 - 6:00 a
04/16/2014 - 6:30 a

Weekend Shift
10/04/2014 - 8:38 a
07/12/2014 - 8:45 a
04/05/2014 - 8:30 a
03/15/2014 - 8:30 a

This deficiency impacted 8 of 8 smoke compartments
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Review of 2000 NFPA 101, 19.7.1.2 Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.

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Based on observation on 1/29/2015 the facility failed to maintain the fire alarm system. Findings include:

While reviewing the documentation for the annual fire alarm inspection which was conducted on 11/24/2014. The following items were listed in the comment section as failed during the testing. Based on interview with the Plant Operations Director the items have not been corrected, but are scheduled for correction by the fire alarm service company.

1. One audible / visual signal device.
2. One control panel hard wired.
3. One duct smoke detector.
4. Six heat detectors.
5. Four photo smoke detectors.


This deficiency effects all smoke compartments throughout the facility.



NFPA 101, 9.6.1.4 The fire alarm system to be installed, tested, and maintained in accordance with the requirements of NFPA 70 and NFPA 72.

Based on observation on 1/29/2015 the facility failed to maintain the fire alarm system. Findings include:

While reviewing the documentation for the annual fire alarm inspection which was conducted on 11/24/2014. The following items were listed in the comment section as failed during the testing. Based on interview with the Plant Operations Director the items have not been corrected, but are scheduled for correction by the fire alarm service company.

1. One audible / visual signal device.
2. One control panel hard wired.
3. One duct smoke detector.
4. Six heat detectors.
5. Four photo smoke detectors.


This deficiency effects all smoke compartments throughout the facility.

NFPA 101, 9.6.1.4 The fire alarm system to be installed, tested, and maintained in accordance with the requirements of NFPA 70 and NFPA 72.

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Based on the observation on 1/29/2015, the facility failed to maintain the fire alarm system. Findings include:

While reviewing the documentation for the annual fire alarm inspection which was conducted on 11/24/2014, the following items were listed in the comment section as failed during the testing. Based on the interview with the Plant Operations Director the items have not been corrected, but are scheduled for correction by the fire alarm service company.

1. One audible / visual signal device.
2. One control panel hard wired.
3. One duct smoke detector.
4. Six heat detectors.
5. Four photo smoke detectors.

This deficiency impacted all smoke compartments throughout the facility.

____________


NFPA 101, 9.6.1.4 The fire alarm system to be installed, tested, and maintained in accordance with the requirements of NFPA 70 and NFPA 72.
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Based on the observation on 1/29/2015, the facility failed to maintain the fire alarm system. Findings include:

While reviewing the documentation for the annual fire alarm inspection which was conducted on 11/24/2014, the following items were listed in the comment section as failed during the testing. Based on the interview with the Plant Operations Director, the items have not been corrected, but are scheduled for correction by the fire alarm service company.

1. One audiol visual signal device.
2. One control panel hard wired.
3. One duct smoke detector.
4. Six heat detectors.
5. Four photo smoke detectors.

This deficiency impacted all smoke compartments throughout the facility.

_________

NFPA 101, 9.6.1.4 The fire alarm system to be installed, tested, and maintained in accordance with the requirements of NFPA 70 and NFPA 72.
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Based on the observation on 01/28/2015 of the facility's fire alarm system, the facility failed to maintain the smoke detectors in OR's "A" and "B". Findings include:

The smoke detectors in OR's "A" and "B" when tested with smoke in the can did not actuate the fire alarm system.
This deficiency impacted 1 of 3 smoke compartments on the First Floor of this building.
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Review of 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.
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Based on observation on 1/29/2015 the facility failed to maintain the automatic sprinkler system. Findings include:


While reviewing the documentation the following quarterly inspections were conducted on 3/31/2014, 6/25/2014, 9/24/2014. A quarterly inspection was due 12/24/2014, at the time of the survey documentation was not provided. Based on interview with the Plant Operation Director the service company had not conducted the December inspection.



NFPA 101, 4.6.12, and NFPA 25, 2-2 and Table 2-1 Requires an inspection every quarter (three months).

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Based on the observation on 1/29/2015, the facility failed to maintain the automatic sprinkler system. Findings include:

While reviewing the documentation, the following quarterly inspections were conducted on 3/31/2014, 6/25/2014, 9/24/2014. A quarterly inspection was due 12/24/2014, at the time of the survey documentation was not provided. Based on interview with the Plant Operation Director, the service company had not conducted the December sprinkler inspection.

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NFPA 101, 4.6.12, and NFPA 25, 2-2 and Table 2-1 Requires an inspection every quarter (three months).
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Based on the observation on 01/28/2015 of this building's fire barriers, the facility failed to maintain the four hour rated fire barrier. Findings include:

The 4 fire barriers at the Clinical I.T. Manager's Office were observed with an HVAC flex duct penetrating this barrier. The flex duct was observed without a fire damper and did not have a service opening.

This deficiency impacted 2 of 3 smoke compartments on the First Floor of this building.
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Review of 1999 NFPA 90A, 2-3.3.3 Air duct coverings shall not extend through walls or floors that are required to be fire stopped or required to have a fire resistance rating.
Review of 1999 NFPA 90A, 2-3.3.4 Air duct linings shall be interrupted at fire dampers to prevent interference with the operation of devices.
Review of 1999 NFPA 90A, 2-3.3.5 Air duct coverings shall not be installed so as to conceal or prevent the use of any service opening.
Review of 1999 NFPA 90A, 3-3.1.1 Approved fire dampers shall be provided where air ducts penetrate or terminate at openings in walls or partitions required to have a fire resistance rating of 2 hours or more.
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 the observation on 01/28/2015 during the walk thru, the facility failed to maintain the battery-powered emergency lighting. Findings include:

The battery-powered emergency light in OR "B" failed to illuminate when tested.

This deficiency impacted 1 of 3 smoke compartments on the First Floor of this building.
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Review of 1999 NFPA 99, 3-3.2.1.2 All Patient Care Areas.
5. Wiring in Anesthetizing Locations.
e. Battery-Powered Emergency Lighting Units. One or more battery-powered emergency lighting units shall be provided in accordance with NFPA 70, National Electrical Code, Section 700-12(e).

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Based on the observation on 01/29/2015 during the walk around the outside of the building, the facility failed to maintain the fire department connections. Findings include:

The outside fire departmnet connections failed to swivel.

This deficiency impacted 2 of 2 smoke compartments of this building.
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Review of 1995 NFPA 24, 2-6.7 The fire department connection(s) shall have the NH internal threaded swivel fitting(s) having the NH standard thread, at least one of which shall be the 2.5-7.5 NH standard thread, as specified in NFPA 1963, Standard for Fire Hose Connections.
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Based on the observation on 01/29/2015 during the walk thru, the facility failed to maintain the electrical wiring and equipment. Findings include:

1. The D.O.N. Secretary's Office area had a refrigerator plugged into a power strip (extension cord) plugged into a surge protector (extension cord).
2. The Clinical I.T. Manager's Office had a surge protector (extension cord) plugged into another surge protector (extension cord) at the desk.

This deficiency impacted 1 of 2 smoke compartments of this building.
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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 the observation on 01/29/2015 during the walk thru, the facility failed to maintain the electrical wiring and equipment. Findings include:

The Human Resources Office was observed with a lamp plugged into an extension cord.

This deficiency impacted 1 of 3 smoke compartments on the First Floor of this building.
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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 the review of documentation on 01/29/2015 of the facility's policies, the facility failed to provide a fire watch policy. Findings include:

Based on interview the facility was unable to provide a fire watch policy at the time of the survey.

This deficiency impacted 2 of 2 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.
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Based on the review of documentation on 01/29/2015 of the facility's policies, the facility failed to provide a fire watch policy. Findings include:

Based on interview, the facility was unable to provide a fire watch policy at the time of the survey.

This deficiency impacted 1 of 1 smoke compartments
___________________

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.
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Based on the review of documentation on 01/29/2015 of the facility's policies, the facility failed to provide a fire watch policy. Findings include:

Based on interview, the facility was unable to provide a fire watch policy at the time of the survey.

This deficiency impacted 8 of 8 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.
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Based on the review of documentation on 01/29/2015 of the facility's policies, the facility failed to provide a fire watch policy. Findings include:

Based on interview the facility was unable to provide a fire watch policy at the time of the survey.

This deficiency impacted 2 of 2 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.

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Based on the review of documentation on 01/29/2015 of the facility's policies, the facility failed to provide a fire watch policy. Findings include:

Based on interview, the facility was unable to provide a fire watch policy at the time of the survey.

This deficiency impacted 8 of 8 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.

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Based on the review of documentation on 01/29/2015 of the facility's policies, the facility failed to provide a fire watch policy. Findings include:

Based on the interview, the facility was unable to provide a fire watch policy at the time of the survey.

This deficiency impacted 1 of 1 smoke compartments
___________________

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.