HospitalInspections.org

Based on observations and confirmed by staff, the facility failed to ensure egress routes are properly maintained.
Section 19.1.1.4.4 states construction, repair, and improvement operations shall comply with section 4.6.10.

Section 4.6.10.1 states buildings, or portions of buildings, shall be permitted to be occupied during construction, repair, alterations, or additions only where required means of egress and required fire protection features are in place and continuously maintained for the portion occupied or where alternative life safety measures acceptable to the authority having jurisdiction are in place.

Section 19.3.6.3.5 states that corridor doors shall be provided with a means for keeping the door closed that is acceptable to the authority having jurisdiction, and 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.

THE FINDINGS INCLUDE:

During the afternoon hours of 4/23/18 while touring the 4th floor level, it was observed that the non-occupied 4th floor level of the Fenton Building is in a state of disrepair. According to staff interview, the floor was partially gutted in 2004 to fix exterior leaks and to address mold issues. Each of the rooms adjacent to the main corridor have had walls and ceilings partially removed, exposing exterior concrete walls and interior petition walls. In addition, there is exposed plumbing and electrical boxes throughout this entire unit which are not protected as required. Although the rooms are equipped with doors, some were found to be missing the required latching devices. The egress corridor is required to be properly separated from the rooms per section 19.3.6.3.5 with corridor doors.

Although this unit is non-occupied, it is the required second means of egress from the Pharmacy Suite and must be maintained accordingly.

This finding was confirmed by the Facility's Management Staff during the exit interview conference.

Based on observations and confirmed by staff, the facility is not separated from other tenants in the office occupancy as required. Section 21.3.7.1 Ambulatory health care facilities shall be separated from other tenants and occupancies and shall meet all of the following requirements:
(1) Walls shall have not less than a 1-hour fire resistance rating and shall extend from the floor slab below to the floor
or roof slab above.
(2) Doors shall be constructed of not less than 13.4 in. (44 mm) thick, solid-bonded wood core or the equivalent
and shall be equipped with positive latches.
(3) Doors shall be self-closing and shall be kept in the closed position, except when in use.
(4) Any windows in the barriers shall be of fixed fire window assemblies in accordance with Section 8.3.

FINDINGS INCLUDE:

During the documentation review and survey conducted on 4/24/18, it was noted that the facility's 1-hour wall separating the ASC from other tenants in the office occupancy was not constructed as required. The following deficient items were noted in the 1-hour fire rated wall:

- The surveyor was unable to confirm the fire resistance rating of the wall located behind the approximately 3 foot by 5 foot multi tenant mailboxes.
-The exit door, labeled as ASC-005 , located by Sterile Processing, was not provided with a label indicating the fire resistance rating of the door assembly nor was documentation available to substantiate the fire protection rating.
-The set of cross-corridor doors that were located in the 1-hour wall were not provided with a label indicating the fire resistance rating of the door assembly nor was documentation available to substantiate the fire protection rating

As a result, the facility was not provided with the required 1-hour fire resistance rated separation from other tenants in accordance with Section 21.3.7.1.

This was acknowledged by the Director of Maintenance and the Administrator during the exit interview process.

Based on observations and confirmed by staff the facility failed to ensure compliance with Section 19.2.2.2.7 of the 2012 edition of NFPA 101 "Life Safety Code".

A. Section 19.2.2.2.7 states any door in an exit passageway, stairway enclosure,horizontal exit, smoke barrier, or hazardous area enclosure shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8.2. The automatic sprinkler system, if provided, and the fire alarm system, and the systems required by 7.2.1.8.2, shall be arranged to initiate the closing action of all such doors throughout the smoke compartment or throughout the entire facility.

Findings Include:

While conducting the facility tour on 4/25/18 it was revealed that the following doors were held open with magnetic devices that do not automatically release in accordance with Section 7.2.1.8.2:

- one of the two doors to the 2nd floor File Room
- the door to the 1st floor Medical Records Room

As a result of the findings the facility is found to be non-compliant with Chapter 19 Section 19.2.2.2.7 of the 2012 edition of NFPA 101 "Life Safety Code".

____________________________________________________________
B. Section 7.2.1.8.2 (3) requires that the automatic releasing mechanism or medium is activated by the operation of approved smoke detectors installed in accordance with the requirements for smoke detectors for door leaf release service in NFPA 72 National Fire Alarm and Signaling Code.

-NFPA 72 Section 17.7.5.6.1 states smoke detectors that are part of an open area protection system covering the room, corridor, or enclosed space on each side of the smoke door and that are located and spaced as required by 17.7.3 shall be permitted to accomplish smoke door release service.

-NFPA 72 Section 17.7.3.2.3.1 states in the absence of specific performance-based design criteria, smooth ceiling smoke detector spacing shall be a nominal 30 ft (9.1 m).

-NFPA 72 Section 17.7.5.6.2 states that smoke detectors that are used exclusively for smoke door release service shall be located and spaced as required by 17.7.5.6.

-NFPA 72 Section 17.7.5.6.5 states the number of detectors required shall be determined in accordance with 17.7.5.6.5.1 through 17.7.5.6.5.4.

-NFPA 72 Section 17.7.5.6.5.1 states if doors are to be closed in response to smoke flowing in either direction, the requirements of 17.7.5.6.5.1(A) through 17.7.5.6.5.1(D) shall apply.

-NFPA 72 Section 17.7.5.6.5.1 (A) If the depth of wall section above the door is 24 in. (610 mm) or less, one ceiling-mounted smoke detector shall be required on one side of the doorway only, or two wall-mounted detectors shall be required, one on each side of the doorway.

-NFPA 72 Section 17.7.5.6.5.1 (B) If the depth of wall section above the door is greater than 24 in. (610 mm) on one side only, one ceiling-mounted smoke detector shall be required on the higher side of the doorway only, or one wall-mounted detector shall be required on both sides of the doorway. Figure 17.7.5.6.5.1(A), part D, shall apply.

-NFPA 72 Section 17.7.5.6.6.1 states if ceiling-mounted smoke detectors are to be installed on a smooth ceiling for a single or double doorway, they shall be located as follows:
(1) On the centerline of the doorway
(2) No more than 5 ft (1.5 m), measured along the ceiling and perpendicular to the doorway.

Findings Include:

While conducting the facility tour on 4/23/18, 4/24/18, and 4/25/18 the following doors were observed to be held open by automatic releasing mechanisms compliant with Section 19.2.2.2.7.

- the set of corridor doors to the elevator lobby on the 1st floor
- the cross corridor doors by room #211

However, observations revealed that there were no smoke detectors located within five (5 ') feet of these doors and corridor smoke detectors, comprising an open air protection system, were not provided as defined in NFPA 72 Section 17.7.5.6.1.

As a result of the findings the facility is found to be non-compliant with Section 19.2.2.2.7 of the 2012 edition of NFPA 101.

The findings were discussed and confirmed by the Hospital Administration and the Director of Facilities during the exit conference.

Based on observation, the facility failed to maintain the stairwells in conformance with NFPA 101, Section 7.2.

NFPA 101 section 7.2.2.5.3.1 states open space within the exit enclosure shall not be used for any purpose that has the potential to interfere with egress. ( An example of a use with the potential to interfere with egress is storage.)

FINDINGS INCLUDE:During a survey of the facility in the morning hours of 4/24/18 it was revealed that several pieces of new office furniture were stored on the second floor landing of the stair that exits the rear of the pediatric office space.

As a result, the open space within the exit enclosure was not maintained in accordance with Section 7.2.2.5.3.1.

Based on observation, the facility failed to maintain the stairwells in conformance with NFPA 101, Section 7.2.

Section 7.2.2.5.3 Usable Space, states enclosed usable spaces within exit enclosures shall be prohibited, including under stairs, unless otherwise permitted by 7.2.2.5.3.2.

Section 7.2.2.5.3.1 Open space within the exit enclosure shall not be used for any purpose that has the potential to interfere with egress.

Section 7.2.2.5.3.2 states enclosed, usable space shall be permitted under stairs, provided that both of the following criteria are met:
(1) The space shall be separated from the stair enclosure by the same fire resistance as the exit enclosure.
(2) Entrance to the enclosed, usable space shall not be from within the stair enclosure. (See also 7.1.3.2.3.)

Section 7.1.3.2.3 states an exit enclosure shall not be used for any purpose that has the potential to interfere with its use as an exit and, if so designated, as an area of refuge. (See also 7.2.2.5.3.)

Findings Include:

On 4/23/18 through 4/26/18 it was noted that the Rodgers Building's stair #2 exit discharge traverses through an interior enclosure, that was formerly the exterior exit discharge. This enclosure also houses the oxygen cylinder storage (greater than 3000 cubic feet) room, accessible from the enclosure and not separated by one-hour construction as required by NFPA 99. See K923.

As a result, the open space within the exit enclosure was not maintained in accordance with Section 7.2.2.5.3.2.

This finding was confirmed by the Facility's Management Staff during the exit interview conference.

Based on observations and confirmed by staff, the facility failed to ensure that two approved egress routes from each compartment are provided as required. Section 19.2.5.4 states every corridor shall provide access to not less than two approved exits in accordance with sections 7.4 and 7.5 without passing through any intervening rooms or spaces other than corridors or lobbies.

THE FINDINGS INCLUDE:

During the afternoon hours of 4/23/18 while touring the 4th floor level, it was observed that only one access route was provided from the corridor leading from the Pharmacy Suite. The Pharmacy Suite (1654 square feet) is equipped with one door which leads into this corridor. Once in this corridor, there is a stairwell (Fenton 1 stairwell) which is accessible to all. The second means of egress from the corridor is a door leading into the 4th floor corridor of the Fenton Building. However, because the 4th floor of the Fenton Building is in disrepair and non-occupied, this required egress door was observed to be locked with a magnetic device prohibiting access. The ID badge access reader was observed to only allow certain personnel to access this area as it is in disrepair. After conversation with the pharmacy staff, it was noted that they do not have access to this area. It was confirmed with security staff that only certain maintenance and security personnel have access to this area.

As a result, the facility failed to comply with section 19.2.5.4 providing at least two approved egress routes from the corridor.

Note 1: After brought to the attention of administrative staff, the pharmacy staff was given badge access to open this locked door during the survey.

Note 2: It was stated by facility staff that the 4th floor of Fenton Building has been closed and non-occupied since 2004.

This finding was confirmed by the Facility's Management Staff during the exit interview conference.

Based on observations and confirmed by staff, the facility failed to ensure that non-sleeping suites are within maximum size limitations. Section 19.2.5.7.3.3 states non-sleeping suites shall not exceed 10,000 ft2 (930 m2) in size.

THE FINDINGS INCLUDE:

During the morning hours of 4/25/18 while touring the Operating Suite, it was observed that the suite is approximately 16,768 square feet (ft2) in size. As configured, the suite currently exceeds the allowable 10,000 ft2 size.

(The surveyor was provided a set of floor plans with a revised suite configuration, adding two additional cross corridor walls/doors to create two separate suites. With the proposed reconfiguration, the new suite sizes would be 9,632 ft2 and 7,136 ft2. It was stated by staff as well as a vendor proposal that the additional walls/doors would be installed by 5/11/18.)

As a result, the facility failed to comply with section 19.2.5.7.3.3 limiting non-sleeping suites to less than 10,000 ft2.

This finding was confirmed by the Facility's Management Staff during the exit interview conference.

Based on observation, the facility's Emergency generator that supplies the Type I emergency electrical system was
not in accordance with NFPA 101, NFPA 70, NFPA 99, and NFPA 110.

NFPA 101, 7.9.2.4 Emergency generators providing power to emergency lighting systems shall be installed, tested, and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. Stored electrical energy systems, where required in this Code, other than battery systems for emergency luminaires
in accordance with 7.9.2.5, shall be installed and tested in accordance with NFPA 111, Standard on Stored Electrical Energy Emergency and Standby Power Systems.

NFPA 70 Article 300.4 Protection Against Physical Damage. Where subject to physical damage, conductors, raceways, and cables shall be protected.

NFPA 70. 700.10 Wiring, Emergency System.
(C) Wiring Design and Location. Emergency wiring circuits shall be designed and located so as to minimize the
hazards that might cause failure due to flooding, fire, icing, vandalism, and other adverse conditions.

NFPA 99, 6.4.1.1.17 Alarm Annunciator. A remote annunciator that is 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 700.12 of NFPA 70, National Electrical Code). The annunciator shall be hard-wired to indicate
alarm conditions of the emergency or auxiliary power source as follows:
(1) Individual visual signals shall indicate the following:
(a) When the emergency or auxiliary power source is operating
to supply power to load
(b) When the battery charger is malfunctioning
(2) Individual visual signals plus a common audible signal to
warn of an engine-generator alarm condition shall indicate
the following:
(a) Low lubricating oil pressure
(b) Low water temperature (below that required in
6.4.1.1.11)
(c) Excessive water temperature
(d) Low fuel when the main fuel storage tank contains
less than a 4-hour operating supply
(e) Overcrank (failed to start)
(f) Overspeed

NFPA 99, 6.4.1.1.17.1* A remote, common audible alarm shall be provided as specified in 6.4.1.1.17.4 that is powered by the storage battery and located outside of the EPS service room at a work site observable by personnel. [110:5.6.6]

NFPA 99, 6.4.1.1.17.2 An alarm-silencing means shall be provided, and the panel shall include repetitive alarm circuitry so that, after the audible alarm has been silenced, it reactivates after the fault condition has been cleared and has to be restored to its normal position to be silenced again. [110:5.6.6.1]

NFPA 99, 6.4.1.1.17.3 In lieu of the requirement of 5.6.6.1 of NFPA 110, a manual alarm-silencing means shall be permitted that silences the audible alarm after the occurrence of the alarm condition, provided such means do not inhibit any subsequent alarms from sounding the audible alarm again without further manual action. [110:5.6.6.2]

NFPA 99, 6.4.1.1.17.4 Individual alarm indication to annunciate any of the conditions listed in Table 6.4.1.1.16.2 shall have the following characteristics:
(1) It shall be battery powered.
(2) It shall be visually indicated.
(3) It shall have additional contacts or circuits for a common audible alarm that signals locally and remotely when any
of the itemized conditions occurs.
(4) It shall have a lamp test

NFPA 110, 4.4.3 All equipment shall be permanently installed.

NFPA 110, 7.1.2* Minimizing the probability of equipment or cable failure within the EPSS shall be a design consideration to reduce the disruption of loads served by the EPSS.

NFPA 110, 7.12.1 The distribution and wiring systems within EPSS shall be installed in accordance with NFPA 70, National Electrical Code.

NFPA 110, 7.12.2 When EPSSs are installed in health care facilities, the installation of the EPSS shall also be in compliance with NFPA 99, Health Care Facilities Code.

FINDINGS INCLUDE:

Observations during the survey on 4/23/18 through 4/25/18 revealed a portable generator that was partially retrofitted to simulate a fixed emergency generator. The portable 800 kW generator was located at the exterior of building in the area of the power plant. The portable unit was provided with a fixed exhaust system that extended above the roof of the power plant and a fixed fuel supply. However, the generator does not meet the following requirements:
- NFPA 110, Section 4.4.3 as the installation is not permanent.
- NFPA 99, 6.4.1.1.17 as a remote annunciator panel is not provided for the emergency generator.
-NFPA 70 Article 300.4 and Article 700.10 as the temporary cables leading from the portable emergency generator to the transfer switch are not provided with protection form physical damage, the weather, vandalism, or other adverse conditions.

As a result, the provided portable emergency generator is not in compliance with the above referenced codes.

The findings were discussed and confirmed by the Hospital Administration and the Director of Facilities during the exit conference.

Based on observations and confirmed by staff interview, the facility failed to ensure that all stairwells are protected with the required 1-hour fire resistance rating.

THE FINDINGS INCLUDE:

During the afternoon hours of 4/25/18 all of the stairwells were viewed for compliance. The following items but not limited to were found to be deficient regarding the maintenance of stairwell components:

1) Goldstein stairwell #1: The door on the 1st floor level was observed to hover in the open position when checked for proper operation. It appears as though the stairwell has an excess of negative air pressure as evident by the strong air flow coming from under and around the door. It was further observed that when a door on another floor level was opened, this 1st floor door closed immediately.

2) Goldstein stairwell #2: The door on the 4th floor level was observed to have a non-sealed 1/2" hole penetrating the door.

3) Goldstein stairwell #2: The door on the ground floor level was observed to hover in the open position when checked for proper operation. It appears as though the stairwell has an excess of negative air pressure as evident by the strong air flow coming from under and around the door. It was further observed that when a door on another floor level was opened, this ground floor door closed immediately.

4) Fenton stairwell #1: The door on the sub-ground floor level was observed to hover in the open position when checked for proper operation. It appears as though the stairwell has an excess of negative air pressure as evident by the strong air flow coming from under and around the door. It was further observed that when a door on another floor level was opened, this sub-ground floor door closed immediately.

5) Fenton stairwell #1: The door on the 2nd floor level was observed to have a non-sealed 1/2" hole penetrating the door.

6) Fenton stairwell #1: The door on the 4th floor level was observed to hover in the open position when checked for proper operation. It appears as though the stairwell has an excess of negative air pressure as evident by the strong air flow coming from under and around the door. It was further observed that when a door on another floor level was opened, this 4th floor door closed immediately.

7) Rodgers stairwell #2: The door on the ground floor level was observed to have non-sealed holes penetrating both the door and door frame.

Note: Many of the door holes were sealed during the survey. In addition, an exhaust fan was observed as running at the top level of the Fenton stair #1. When the fan was turned off using the toggle switch, the stair doors were observed to close and latch as required.

As a result, the facility failed to comply with section 19.3.1.1 requiring stairwells to have a minimum of 1-hour fire resistance rating.

This finding was confirmed by the Facility's Management Staff during the exit interview conference.

Based on observations the facility failed to ensure that all hazardous areas are protected in accordance with the 2012 edition of NFPA 101 Life Safety Code.

- Section 19.3.2.1 states any hazardous areas shall be safe-guarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.7.1.

- Section 19.3.2.1.1 states an automatic extinguishing system, where used in
hazardous areas, shall be permitted to be in accordance with 19.3.5.9.

- Section 19.3.2.1.2* states where the sprinkler option of 19.3.2.1 is used, the
areas shall be separated from other spaces by smoke partitions in accordance with Section 8.4.

- Section 19.3.2.1.3 states the doors shall be self-closing or automatic-closing.

- Section 19.3.2.1.5 states hazardous areas shall include, but shall not be restricted
to, the following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 ft2 (9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Rooms with soiled linen in volume exceeding 64 gal (242 L)
(6) Rooms with collected trash in volume exceeding 64 gal (242 L)
(7) Rooms or spaces larger than 50 ft2 (4.6 m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction
(8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard.

- Section 8.4.3.1 states doors in smoke partitions shall comply with 8.4.3.2
through 8.4.3.5.

- Section 8.4.3.2 states doors shall comply with the provisions of 7.2.1.

-Section 7.2.1.8.1* states a door leaf normally required to be kept closed
shall not be secured in the open position at any time and shall be self-closing or automatic-closing in accordance with 7.2.1.8.2, unless otherwise permitted by 7.2.1.8.3.

-Section 7.2.1.8.2 states in any building of low or ordinary hazard contents,
as defined in 6.2.2.2 and 6.2.2.3, or where approved by the authority having jurisdiction, door leaves shall be permitted to be automatic-closing, provided that all of the following criteria
are met:
(1) Upon release of the hold-open mechanism, the leaf becomes self-closing.
(2) The release device is designed so that the leaf instantly releases manually and, upon release, becomes self-closing, or the leaf can be readily closed.
(3) The automatic releasing mechanism or medium is activated by the operation of approved smoke detectors installed in accordance with the requirements for smoke detectors for door leaf release service in NFPA 72, National Fire Alarm and Signaling Code.
(4) Upon loss of power to the hold-open device, the hold open mechanism is released and the door leaf becomes self-closing.

Findings Include:

While conducting the facility tour on 4/25/18 observations revealed the following:
-One of the two doors enclosing the 2nd floor File Room was not equipped with a self-closing device.
-The corridor door to the 1st floor Doctor's Dictating Room, that is open to Medical Records, was equipped with a closing device; however, the closing device had been disconnected.

As a result of the finding the facility is found to be non-compliant with Section 19.3.2.1.3. Doors to hazardous areas must be self-closing or equipped with an automatic closing device compliant with Chapter 7 of the 2012 edition of NFPA 101 Life Safety Code..

The findings were discussed and confirmed by the Hospital Administration and the Director of Facilities during the exit conference.

Based on record review and confirmed by staff, it was revealed that the facility failed to ensure the fire alarm system is maintained as required. NFPA #72 (National Fire Alarm Code) section 14.2.2.1 states the property or building or system owner or the owner's designated representative shall be responsible for inspection, testing, and maintenance of the system and for alterations or additions to this system.

NFPA section 39.3.4.1 states that fire alarm system in accordance with Section
9.6 shall be provided in all business occupancies where any one of the following conditions exists:
(1) The building is three or more stories in height.
(2) The occupancy is subject to 100 or more occupants above
or below the level of exit discharge.
(3) The occupancy is subject to 1000 or more total occupants.

NFPA section 9.6.1.3 states that 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 and Signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use.

Section 14.2.2.2 states the delegation of responsibility shall be in writing, with a copy of such delegation provided to the authority having jurisdiction upon request.

Section 14.4.5.3.1 states sensitivity shall be checked within 1 year after installation.
.
Section 14.4.5.3.2 states sensitivity shall be checked every alternate year thereafter unless otherwise permitted by compliance with 14.4.5.3.3.

Section 14.4.5.3.3 states after the second required calibration test, if sensitivity tests indicate that the device has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years.

THE FINDINGS INCLUDE:

During the morning hours of 04/25/18 while reviewing the fire alarm test/inspection records of the required fire alarm system, it was revealed that documentation was not provided to substantiate smoke detector sensitivity testing had been conducted.

As a result, the facility failed to comply with section 14.4.5.3.3 requiring testing of the detectors at a maximum of 5-year intervals.

Based on record review and confirmed by staff, it was revealed that the facility failed to ensure the fire alarm system is maintained as required. NFPA #72 (National Fire Alarm Code) section 14.2.2.1 states the property or building or system owner or the owner's designated representative shall be responsible for inspection, testing, and maintenance of the system and for alterations or additions to this system.

NFPA section 39.3.4.1 states that fire alarm system in accordance with Section
9.6 shall be provided in all business occupancies where any one of the following conditions exists:
(1) The building is three or more stories in height.
(2) The occupancy is subject to 100 or more occupants above
or below the level of exit discharge.
(3) The occupancy is subject to 1000 or more total occupants.

NFPA section 9.6.1.3 states that 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 and Signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use.

Section 14.2.2.2 states the delegation of responsibility shall be in writing, with a copy of such delegation provided to the authority having jurisdiction upon request.

Section 14.4.5.3.1 states sensitivity shall be checked within 1 year after installation.
.
Section 14.4.5.3.2 states sensitivity shall be checked every alternate year thereafter unless otherwise permitted by compliance with 14.4.5.3.3.

Section 14.4.5.3.3 states after the second required calibration test, if sensitivity tests indicate that the device has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years.

THE FINDINGS INCLUDE:

During the morning hours of 04/25/18 while reviewing the fire alarm test/inspection records of the required fire alarm system, it was revealed that documentation was not provided to substantiate smoke detector sensitivity testing had been conducted.

As a result, the facility failed to comply with section 14.4.5.3.3 requiring testing of the detectors at a maximum of 5-year intervals.

This was acknowledged by the Administrator and Director of Maintenance during the exit interview process.

Based on record review, the facility failed to maintain records of the required tests for the back-up batteries to the fire alarm system.

NFPA 101 (2012 Edition)21.3.4.1. Ambulatory health care facilities shall be provided with fire alarm systems in accordance with Section 9.6, except as modified by 21.3.4.2 through 21.3.4.4.
Section 9.6.1.3 states 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 and Signaling Code, unless it is an approved existing installation, which shall be permitted to be
continued in use.

NFPA 72, 2010 edition, Table 14.4.2.2 requires an annual charger test, a 30 minute annual discharge test, and a semi-annual load test to be conducted of the sealed lead acid batteries.

THE FINDINGS INCLUDE:

Record review conducted on 04/23/18 of the vendor inspection/test forms dated 12/08/17, 09/26/17, 06/22/17, and 03/28/17, revealed that the documentation does not indicate the specific required tests of the fire alarm batteries in accordance with NFPA 72. The inspection forms indicate the "Battery- Sealed Lead acid" batteries passed a visual and functional inspection and they are described as "FACP Batteries 12 V 7 AH" ; however, the specific tests cannot be determined by the documentation submitted.

This was acknowledged by the Director of Maintenance and the Administrator during the exit interview process.

Based on observations, the facility failed to ensure compliance with specific requirements of the 2012 edition of NFPA 101 Life Safety Code and the 2010 edition of NFPA 13 Standard for the Installation of Sprinkler Systems.

-Section 19.3.5.7 of the 2012 edition of NFPA Life Safety Code states where this Code permits exceptions for fully sprinklered buildings or smoke compartments, the sprinkler system shall meet all of the following criteria:
(1) It shall be in accordance with Section 9.7.
(2) It shall be installed in accordance with 9.7.1.1(1), unless it is an approved existing system.
(3) It shall be electrically connected to the fire alarm system.
(4) It shall be fully supervised.
(5) In Type I and Type II construction, where the authority having jurisdiction has prohibited sprinklers, approved alternative protection measures shall be permitted to be substituted for sprinkler protection in specified areas without causing a building to be classified as non-sprinklered.

-Section 9.7.1.1 states each automatic sprinkler system required by another section of this code shall be in accordance with the appropriate chapter of NFPA 13 Standard for the Installations of Sprinkler Systems.

- Section 4.1 of the 2010 edition of NFPA 13 Standard for the Installation of Sprinkler states a building, where protected by an automatic sprinkler system installation, shall be provided with sprinklers in all areas except where specific sections of this standard permit the omission of sprinklers.

-Section 8.15.3.2.1 states in noncombustible stair shafts having noncombustible
stairs with noncombustible or limited-combustible finishes, sprinklers shall be installed at the top of the shaft and under the first accessible landing above the bottom of the shaft.

-Section 8.15.10.3 of the 2010 edition of NFPA 13 states sprinklers shall not be required in electrical equipment rooms where all of the following conditions are met:
(1) The room is dedicated to electrical equipment only.
(2) Only dry-type electrical equipment is used.
(3) Equipment is installed in a 2-hour fire-rated enclosure
including protection for penetrations.
(4) No combustible storage is permitted to be stored in the
room.

-Table 8.3.4.2 of the 2010 edition of NFPA 101 requires 2-hour fire-rated enclosures to be provided with an opening protective (Fire Door Assembly) with a 1-1/2 hour fire resistive rating.

Findings Include:

While conducting the facility tour during the morning and afternoon hours of 4/23/18, 4/24/18 and 4/25/18 observations revealed the following:

1. There is a non-sprinklered, non-two hour fire-rated electrical room located in the East B Building adjacent to the Nurses lounge on the hospital's fourth floor. Observations revealed that the room's walls are less than 2-hour fire-resistive, the room's door is non-rated and a non-rated non-fusible link dampered HVAC branch penetrates two walls of the enclosure. The room must either be equipped with automatic sprinkler protection or comply with all requirements of two-hour fire rated enclosures.

2. The IDF closets on 4 west, 4 east, 2 west,and 2 east are not provided with a 2 hour fire protection rating as evidenced by the lack of fire rating tags/labels on the doors nor are they provided with sprinkler protection. The rooms must either be equipped with automatic sprinkler protection or comply with all requirements of two-hour fire rated enclosures.

3. The following closets housing electrical equipment were not provided with a 2 hour fire protection rating as evidenced by the lack of fire rating tags/labels on the doors nor were they provided with sprinkler protection
- the electrical closets on 4 west, 4 east, 2 west, 2 east, 2nd floor main entrance, 1 west, the electrical closet in the X-ray area, and the electrical closet in the men's locker room serving the operating rooms.
- the information technology room located on the 1 west,
- the communications closet on the second floor, and
- the electrical closet located in the facility's intensive care unit.

These rooms must either be equipped with automatic sprinkler protection or comply with all requirements of two-hour fire rated enclosures.

4. The following areas were not provided with sprinkler protection:

-"Stairway A" and "Stairway B" at the top of the shafts which terminate at the roof access level.
-"C Penthouse Stairway"at the bottom of the shaft
-the 3rd floor East B Building "Employee Only Room" and the "Procedure Room"
-the five (5) walk-in coolers/freezer located in the facility's kitchen.
-the storage closet (approximately 16' long by 3.5' wide) in the rear of the second floor "CT Room".
-the alcove used for storage of a chair on the 4th floor corridor across from room 441.
-the 2 west lobby closet housing HVAC equipment.
-the 2nd floor file room
-the vestibule at the lower entrance
-the hallway between the dirty and clean sterile rooms on the first floor
-the area behind the Decontamination Processing unit
-the two closets in the Auditorium
-operating rooms #1 and #2

The findings were discussed and confirmed by the Hospital Administration and the Director of Facilities during the exit conference.

Based on observations and confirmed by staff, the facility failed to ensure that all sprinkler control valves are supervised as required.

Section 19.3.5.3 states where required by 19.1.6, buildings containing hospitals or limited care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 19.3.5.5.

Section 9.7.2.1 states where supervised automatic sprinkler systems are required by another section of this Code, supervisory attachments shall be installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm and Signaling Code, and a distinctive supervisory signal shall be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system. Supervisory signals shall sound and shall be displayed either at a location within the protected building that is constantly attended by qualified personnel or at an approved, remotely located receiving facility.

THE FINDINGS INCLUDE:

During the morning hours of 4/23/18 while touring the 4th floor level, a sprinkler system control valve was observed to be non-supervised. This valve is located on the 4th floor level of Goldstein stair #1.

As a result, the facility failed to comply with section 19.3.5.1 requiring valves to be supervised.

This finding was confirmed by the Facility's Management Staff during the exit interview conference.

Based on observations the facility failed to ensure compliance with the following NFPA regulations.

-Section 19.3.5.7 of the 2012 edition of NFPA Life Safety Code states where this Code permits exceptions for fully sprinklered buildings or smoke compartments, the sprinkler system shall meet all of the following criteria:
(1) It shall be in accordance with Section 9.7.
(2) It shall be installed in accordance with 9.7.1.1(1), unless it is an approved existing system.
(3) It shall be electrically connected to the fire alarm system.
(4) It shall be fully supervised.
(5) In Type I and Type II construction, where the authority having jurisdiction has prohibited sprinklers, approved alternative protection measures shall be permitted to be substituted
for sprinkler protection in specified areas without causing a building to be classified as non-sprinklered.

-Section 9.7.2.1 of the 2012 edition of NFPA 101 Life Safety Code states where supervised automatic sprinkler systems are required by another section of this Code, supervisory attachments shall be installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm and Signaling Code, and a distinctive supervisory signal shall be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system. Supervisory signals shall sound and shall be displayed either at a location within the protected building that is constantly attended by qualified personnel or at an approved, remotely located receiving facility.

-Section 4.16.2 of the 2010 Edition of NFPA 20 Standard for the
Installation of Stationary Pumps for Fire Protection states that fire pump test outlet control valves shall be supervised closed.

Findings Include:

While conducting the facility tour during the afternoon hours of 4/25/18 observations revealed that the test outlet control valve of the facility's diesel fueled fire pump is not equipped with a supervisory device as required by both Section 9.7.2.1 of NFPA 101 and Section 4.16.2 of NFPA 20.

The findings were discussed and confirmed by the Hospital Administration and the Director of Facilities during the exit conference.

Based on observations and confirmed by staff, the facility failed to ensure that sprinkler systems are properly maintained as required.

Section 39.1.1.3 states the provisions of Chapter 4, General, shall apply.

Section 4.1.1 states a goal of this code is to provide an environment for the occupants that is reasonably safe from fire by the following means:
(1) Protection of occupants not intimate with the initial fire development.
(2) Improvement of the survivability of occupants intimate with the initial fire development.

Section 4.2.3 states systems utilized to achieve the goals of Section 4.1 shall be effective in mitigating the hazard or condition for which they are being used, shall be reliable, shall be maintained to the level at which they were designed to operate, and shall remain operational.

Section 4.3.1 states records shall be made for all inspections, tests, and maintenance of the system and its components and shall be made available to the authority having jurisdiction upon request.

Section 4.3.2 states records shall indicate the procedure performed (e.g., inspection, test, or maintenance), the organization that performed the work, the results, and the date.

Section 4.3.3 states records shall be maintained by the property owner.

Section 4.6.12.4 states any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature requiring periodic testing, inspection, or operation to ensure its maintenance shall be tested, inspected, or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction.

NFPA #25 section 4.1.1 states the property owner or designated representative shall be responsible for properly maintaining a water based fire protection system.

Section 4.1.1.1.1 states inspection, testing, maintenance, and impairment shall be implemented in accordance with procedures meeting those established in this document and in accordance with the manufacturer ' s instructions.

Section 4.1.1.2 states inspection, testing, and maintenance shall be performed by personnel who have developed competence through training and experience.

Section 4.1.4.1 states the property owner or designated representative shall correct or repair deficiencies or impairments that are found during the inspection, test, and maintenance required by this standard.

Section 4.1.4.2 states corrections and repairs shall be performed by qualified maintenance personnel or a qualified contractor.

Section 4.5.1 states all components and systems shall be tested to verify that they function as intended.

Release # 01-201 from Central Sprinkler Corporation announced a voluntary replacement program of recalled sprinkler heads. Central manufactured 33 million "wet" sprinklers with O-rings from 1989 until 2000 that are effected by this recall. The fire sprinkler heads have the words "CENTRAL" or "STAR", the letters "CSC", the letter "G" in triangle, or a star-shaped symbol stamped on either the metal sprinkler frame or on the deflector. The model designation and date may also be stamped on the frame or deflector. The deflector is the flower, or gear-shaped metal piece at one end of the sprinkler head.

THE FINDINGS INCLUDE:

During the afternoon hours of 4/25/18 while touring the MRI Building, numerous sprinkler heads were observed as being on the national list of recalled heads. The sprinkler heads observed were "1998 Central GB" heads. These sprinkler heads were observed in numerous locations of this building on each of the two floor levels.

As a result of the above findings, the facility failed to comply with section 39.1.1.3 requiring systems to be maintained in a proper operating condition.

This finding was confirmed by the Facility's Management Staff during the exit interview conference.

Based on observations and records provided, the facility failed to properly maintain the sprinkler system. NFPA 25 section 4.1.1 states the property owner or designated representative shall be responsible for properly maintaining a water based fire protection system.

Section 5.4.1.1 states replacement sprinklers shall have the proper characteristics for the application intended, which include the following:
(1) Style
(2) Orifice size and K-factor
(3) Temperature rating
(4) Coating, if any
(5) Deflector type (e.g., upright, pendent, sidewall)
(6) Design requirements

NFPA 13 section 8.3.3.2 states where quick-response sprinklers are installed, all sprinklers within a compartment shall be quick-response unless otherwise permitted in 8.3.3.3.

Section 8.6.4.1.1 states under unobstructed construction, the distance between the sprinkler deflector and the ceiling shall be a minimum of 1 in. (25.4 mm) and a maximum of 12 in. (305 mm) throughout the area of coverage of the sprinkler.

THE FINDINGS INCLUDE:

During the facility survey between 4/23/18 and 4/26/18, the following items but not limited to were observed regarding the facility's sprinkler system:

1) It was observed that the Pharmacy Suite is equipped with mixed type sprinkler heads. Both quick response and standard response sprinkler heads were observed within this compartment.

2) While touring the Emergency Department, it was observed that the rear vestibule (ambulance entrance) is equipped with numerous egg crate ceiling tiles for air circulation. Although this vestibule is equipped with sprinkler heads, they are located at the lay-in-ceiling plane level. The space above the lay-in-ceiling tiles is five feet (5') to the decking above. As a result, the sprinkler heads are located too far below the deck, exceeding the 12" allowance. With the current design, the space would be required to be sprinklered above the ceiling as well as below.

3) While touring the ground floor of the Fenton Building, it was observed that the mechanical space behind the MRI room is missing many of the lay-in-ceiling tiles. The space above the lay-in-ceiling tiles is five feet (5') to the deck above. As a result, the sprinkler heads are located too far below the deck, exceeding the 12" allowance.

As a result, the facility failed to comply with NFPA 25 and NFPA 13 requiring sprinkler systems to be installed and maintained as required.

This finding was confirmed by the Facility's Management Staff during the exit interview conference.

Based on observations and documentation review the facility failed to ensure compliance with the 2011 edition of NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

NFPA 101 (2012 edition) 4.6.12.1 states whenever or wherever any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or other feature shall thereafter be continuously maintained. Maintenance shall be provided in accordance with applicable NFPA requirements or requirements developed as part of a performance-based design, or as directed by the authority having jurisdiction.

NFPA 101 section 9.7.5 states that all automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

NFPA 25 (2011 edition), section 5.2.5 states that waterflow alarm and supervisory alarm devices shall be inspected quarterly to verify that they are free of physical damage.

NFPA 25, Section 5.3.3.1 states that mechanical waterflow alarm devices including, but not limited to, water motor gongs, shall be tested quarterly.

NFPA 25, Section 5.3.3.2 states that vane-type and pressure switch-type waterflow alarm devices shall be tested semiannually.

NFPA 25, Section 5.3.3.3 states that testing waterflow alarm devices on wet pipe systems shall be accomplished by opening the inspector 's test connection.

FINDINGS INCLUDE:

On the morning of 04/25/18 the facility's vendor sprinkler report dated 06/14/17 was reviewed. This was the only sprinkler inspection, testing and maintenance document provided for the previous 11 months. As a result, documentation provided was not able to substantiate quarterly sprinkler inspections were conducted during the third and fourth quarters of 2017 and the first quarter of 2018.

Therefore, the facility was not in compliance with the following:
- the requirement to conduct quarterly testing of the mechanical waterflow alarm devices, including, but not limited to, water motor gongs.
- the requirement to conduct semi-annual testing of the vane-type and pressure switch-type waterflow alarm devices.
- the requirement to test waterflow alarm devices on wet pipe systems by opening the inspector 's test connection.

As as result, the facility failed to maintain the sprinkler system in accordance with NFPA 25, Sections 5.3.3.1, 5.3.3.2, 5.3.3.3.


This was acknowledged by the Director of Maintenance and the Administrator during the exit interview process.

Based on observations and documentation review the facility failed to ensure compliance with the 2011 edition of NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

NFPA 101 (2012 edition) 4.6.12.1 states whenever or wherever any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or other feature shall thereafter be continuously maintained. Maintenance shall be provided in accordance with applicable NFPA requirements or requirements developed as part of a performance-based design, or as directed by the authority having jurisdiction.

NFPA 101 section 9.7.5 states that all automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

NFPA 25 (2011 edition), section 5.2.5 states that waterflow alarm and supervisory alarm devices shall be inspected quarterly to verify that they are free of physical damage.

NFPA 25, Section 5.3.3.1 states that mechanical waterflow alarm devices including, but not limited to, water motor gongs, shall be tested quarterly.

NFPA 25, Section 5.3.3.2 states that vane-type and pressure switch-type waterflow alarm devices shall be tested semiannually.

NFPA 25, Section 5.3.3.3 states that testing waterflow alarm devices on wet pipe systems shall be accomplished by opening the inspector 's test connection.

FINDINGS INCLUDE:

On the morning of 04/25/18 the facility's vendor sprinkler report dated 06/14/17 was reviewed. This was the only sprinkler inspection, testing and maintenance document provided for the previous 11 months. As a result, documentation provided was not able to substantiate quarterly sprinkler inspections were conducted during the third and fourth quarters of 2017 and the first quarter of 2018.

Therefore, the facility was not in compliance with the following:
- the requirement to conduct quarterly testing of the mechanical waterflow alarm devices, including, but not limited to, water motor gongs.
- the requirement to conduct semi-annual testing of the vane-type and pressure switch-type waterflow alarm devices.
- the requirement to test waterflow alarm devices on wet pipe systems by opening the inspector 's test connection.

As as result, the facility failed to maintain the sprinkler system in accordance with NFPA 25, Sections 5.3.3.1, 5.3.3.2, 5.3.3.3.

This was acknowledged by the Director of Maintenance and the Administrator during the exit interview process.

Based on observations and documentation review the facility failed to ensure compliance with the 2011 edition of NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

NFPA 101 (2012 edition) 4.6.12.1 states whenever or wherever any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or other feature shall thereafter be continuously maintained. Maintenance shall be provided in accordance with applicable NFPA requirements or requirements developed as part of a performance-based design, or as directed by the authority having jurisdiction.

NFPA 25 (2011 edition) Chapter 8 Section 8.3.3.1* states an annual test of each pump assembly shall be conducted by qualified personnel under minimum, rated, and peak flows of the fire pump by controlling the quantity of water discharged through approved test devices.

8.3.1.2 states that electric motor-driven fire pumps shall be operated monthly.

8.3.2.1 states that a test of fire pump assemblies shall be conducted without flowing water.

8.3.2.2 states that the test shall be conducted by starting the pump automatically.

8.3.2.3 states that the electric pump shall run a minimum of 10 minutes.

Findings Include:

A review of automatic fire sprinkler inspection documentation, conducted during the morning hours of 04/25/18 indicates the following two (2) deficiencies:

1. Annual testing of the facility's 500 gpm electric fire pumps was not conducted during the calendar year of 2017.

2. The monthly 10 minute run test was not conducted during the calendar year of 2017.

As a result, sprinkler inspection documentation presented during the survey does not indicate that the fire pump was tested monthly or annually in accordance with NFPA 25.

The findings were discussed with the Maintenance Supervisor and the Director of Nursing during the exit conference.

Based on observations and documentation review the facility failed to ensure compliance with the 2011 edition of NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

NFPA 101 (2012 edition) 4.6.12.1 states whenever or wherever any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or other feature shall thereafter be continuously maintained. Maintenance shall be provided in accordance with applicable NFPA requirements or requirements developed as part of a performance-based design, or as directed by the authority having jurisdiction.

NFPA 25 (2011 edition) Chapter 8 Section 8.3.3.1* states an annual test of each pump assembly shall be conducted by qualified personnel under minimum, rated, and peak flows of the fire pump by controlling the quantity of water discharged through approved test devices.

8.3.1.2* states that electric motor-driven fire pumps shall be operated monthly.

8.3.2.1 states that a test of fire pump assemblies shall be conducted without flowing water.

8.3.2.2 states that the test shall be conducted by starting the pump automatically.

8.3.2.3 states that the electric pump shall run a minimum of 10 minutes.

Findings Include:

A review of the automatic fire sprinkler inspection documentation conducted during the morning hours of 04/25/18 indicated the following two (2) deficiencies:

1. Annual testing of the facility's 500 gpm electric fire pump was not conducted during the calendar year of 2017.

2. The monthly 10 minute run test was not conducted during the calendar year of 2017.

As a result, sprinkler inspection documentation presented during the survey does not indicate that the fire pump was tested monthly or annually in accordance with NFPA 25.

This finding was confirmed by the Facility's Management Staff during the exit interview conference.

Based on observations and confirmed by staff, the facility failed to ensure that corridor walls are maintained to be smoke resistant. Section 19.3.6.2.3 states corridor walls shall form a barrier to limit the transfer of smoke.

Section 19.3.6.4.1 states that transfer grilles, regardless of whether they are protected by fusible link-operated dampers, shall not be used in corridor walls or doors.

Findings include:

On 4/24/18 and 4/25/18 the following was observed:

1. The corridor wall at the Fenton Building's ground floor level mechanical room (on the in-house MRI unit) has an unsealed 4" x 18" space around electrical conduit on the room side below the exposed concrete floor/ceiling assembly.

2. There were three (3) 24" x 24" transfer grilles in the Rogers Building sub-grade level corridor wall. They were located behind the Emergency Department, in the corridor wall to the two electrical rooms and the morgue.

As a result of the finding the facility is found to be non-compliant with the LSC, section 19.3.6.2.3 and section 19.3.6.4.1.

The finding was confirmed by facility staff and reviewed at the exit conference.

Based on observations and confirmed by staff the facility failed to ensure compliance with Chapter 19

Section 19.3.6.3.1 states Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be doors constructed to resist the passage of smoke and shall be constructed of materials such as the following:
(1) 1 3/4 in. 44 mm) thick, solid-bonded core wood
(2) Material that resists fire for a minimum of 20 minutes

Section 19.3.6.3.2 states that the requirements of 19.3.6.3.1 shall not apply where otherwise permitted by either of the following:
(1) Doors to toilet rooms, bathrooms, shower rooms, sink closets, and similar auxiliary spaces that do not contain flammable or combustible materials shall not be required to comply with 19.3.6.3.1.
(2) In smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.7, the door construction materials requirements of 19.3.6.3.1 shall not be mandatory, but the doors shall be constructed to resist the passage of smoke.

Section 19.3.6.3.5 states that corridor doors shall be provided with a means for keeping the door closed that is acceptable to the authority having jurisdiction, and 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.

Section 4.6.10.1 states that buildings, or portions of buildings, shall be permitted to be occupied during construction, repair, alterations, or additions only where required means of egress and required fire protection features are in place and continuously maintained for the portion occupied or where alternative life safety measures acceptable to the authority having jurisdiction are in place.

Findings Include:

On 4/23/18 and 4/24/18 the following was noted:

1. The corridor doors located on the Cushing Building's third floor level unoccupied rooms: #252, #254, #256, #258 and oxygen storage room did not latch in their respective frames. The door latch mechanisms were removed from the doors.

Note: Prior to the survey exit (4/26/18, the latch mechanisms were installed in the doors noted above.

2. One Medication Room corridor door located on the Goldstein Building's third floor level unit is equipped with a 21" wide pass through door/window. When in the closed position, there is a 1/4" gap along the bottom of the pass through rendering the door less than resistant to the passage of smoke.

3. One Medication Room corridor door located on the Goldstein Building's third floor level unit is a 48" wide dutch door. When in the closed position, there is a 1/4" gap at the meeting edges of the upper and lower door leaf rendering the door less than resistant to the passage of smoke.

4. Many of the corridor doors located on the Goldstein Building's second floor level unit are equipped with pins in the header and the floor, allowing the doors to swing into the room and into the corridor. These doors, including all the sleeping rooms, are not capable of resisting the passage of smoke because there is a gap along the door frames' header, latch side, and hinge side. When in the closed and latched position, there is an approximate 1/2" gap along three sides of each door, rendering each door less than resistant to the passage of smoke.

5. The corridor doors to resident rooms #340 and #343 on the St. Michael's Psych Unit, Goldstein Building's 3rd floor were not smoke tight as a gap between the door and the frame existed while the door was in the latched position.

6. The corridor door to resident room #150 on the Russell Hall Medical Surgical Unit, in the Cushing Building's 1st floor was not smoke tight as a gap between the door and the frame existed while the door was in the latched position.

As a result of the finding the facility is found to be non-compliant with section 19.3.6.3.1 and section 19.3.6.3.5.

The finding was confirmed by facility staff and reviewed at the exit conference.

Based on observations and confirmed by staff, the facility failed to ensure that smoke assemblies are maintained as required. Section 19.3.7.3 states any required smoke barrier shall be constructed in accordance with Section 8.5.

Section 8.5.2.1 states smoke barriers required by this Code shall be continuous from an outside wall to an outside wall, from a floor to a floor, or from a smoke barrier to a smoke barrier, or by use of a combination thereof.

THE FINDINGS INCLUDE:

During the morning hours of 4/25/18 while touring the Operating Suite, it was observed that the plastered ceiling within the closet of the scrub room for OR #5 is missing. It was stated by facility staff that there was a steam leak above the ceiling in this location and that the ceiling had to be removed to access the piping. The ceiling in this location acts as a barrier for smoke containment within the OR Suite protecting the interstitial space above the ceilings.

As a result, the facility failed to ensure the smoke barriers assemblies are maintained as required per section 8.5.2.1.

This finding was confirmed by the Facility's Management Staff during the exit interview conference.

Based on observations and confirmed by staff the facility failed to ensure compliance with Chapter 21 "Existing Ambulatory Health Care Occupancies" of the 2012 edition of NFPA 101 "Life Safety Code".

Section 21.3.7.2 Every story of an ambulatory health care facility shall be divided into not less than two smoke compartments, unless otherwise permitted by one of the following:
(1) This requirement shall not apply to facilities of less than 5000 ft2 (465 m2) that are protected by an approved automatic smoke detection system.
(2) This requirement shall not apply to facilities of less than 10,000 ft2 (929 m2) that are protected throughout by an approved, supervised automatic sprinkler system installed in accordance with Section 9.7.
(3) An area in an adjoining occupancy shall be permitted to serve as a smoke compartment for an ambulatory health care facility if all of the following criteria are met:
(a) The separating wall and both compartments meet the requirements of 21.3.7.
(b) The ambulatory health care facility is less than 22,500 ft2 (2100 m2).
(c) Access from the ambulatory health care facility to the other occupancy is unrestricted.

Section 21.3.7.9 Doors in smoke barriers shall be not less than 1 3/4 in. (44 mm) thick, solid-bonded wood core or the equivalent and shall be self-closing or automatic-closing in accordance with 21.2.2.4.

Findings Include:

While conducting a facility tour during the morning hours of 4/24/18 documentation review and observations revealed a one hour smoke barrier. Upon confirmation of the 1 hour smoke barrier wall, it was noted that the 1 3/4 inch thick door to the Specimen Room was not provided with an self-closing device as required by Section 21.3.7.9.

As a result of the finding the facility is found to be non-compliant with Section 21.3.7.2

This was acknowledged by the Director of Maintenance and the Administrator during the exit interview process.

Based on observations, record review and confirmed by staff, the facility failed to ensure compliance with section 9.2 requiring the maintenance of Heating Ventilation and Air Conditioning (HVAC) Systems.

Section 9.2.1 states air-conditioning, heating, ventilating ductwork, and related equipment shall be in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, or NFPA 90B, Standard for the Installation of Warm Air Heating and Air-Conditioning Systems, as applicable, unless such installations are approved existing installations, which shall be permitted to be continued in service.

NFPA 90A section 5.4.8.1 states fire dampers and ceiling dampers shall be maintained in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives.

NFPA 80 section 19.4.1 states each damper shall be tested and inspected 1 year after installation.

Section 19.4.1.1 states the test and inspection frequency shall then be every 4 years, except in hospitals, where the frequency shall be every 6 years.

Section 19.4.2 states all tests shall be completed in a safe manner by personnel wearing personal protective equipment.

Section 19.4.3 states full unobstructed access to the fire or combination fire/ smoke damper shall be verified and corrected as required.

Section 19.4.4 states if the damper is equipped with a fusible link, the link shall be removed for testing to ensure full closure and lock-inplace if so equipped.

Section 19.4.5 states the operational test of the damper shall verify that there is no damper interference due to rusted, bent, misaligned, or damaged frame or blades, or defective hinges or other moving parts.

Findings Include:

On 4/23/18 after reviewing the smoke/fire damper vendor inspection report dated 9/1/17, it was observed that not all of the fire dampers are inspected as required. The report indicates that seven (7) fire dampers were unable to be accessed due to pre-existing conditions.

Fire dampers, labeled F-2-20, F-2-21, F-2-22, F-2-26, F-3-15 and F-3-16 had utilities and pipes present preventing access to the dampers. The fire damper labeled R-1-18 was noted to have asbestos present and was not safe to access.

There is no documentation to substantiate that these items have been addressed.

As a result, the facility failed to comply with section 9.2 requiring the maintenance of Heating Ventilation and Air Conditioning (HVAC) Systems.

This was reviewed with facility staff and reviewed at the exit conference.

Based on observations and confirmed by staff, the facility failed to ensure linen chutes are maintained as required.

Section 9.5.2 states rubbish chutes, laundry chutes, and incinerators shall be installed and maintained in accordance with NFPA 82, Standard on Incinerators and Waste and Linen Handling Systems and Equipment, unless such installations are approved existing installations, which shall be permitted to be continued in service.

NFPA 82 section 5.2.3.2.1 states the bottom of a waste chute shall be protected by an approved automatic closing or self-closing door of construction that resists fire in accordance with 5.2.3.1.

Section 5.2.3.1.2 states the walls of the enclosure shall have a fire resistance rating of not less than 2 hours if the building is four or more stories in height and not less than 1 hour if the building is less than four stories in height.

Section 5.2.3.1.3 states openings in the fire-rated enclosure shall be as follows:
(1) 11/2-hour fire resistance rating for 2 hour-rated enclosures
(2) 1-hour fire resistance rating for 1 hour-rated enclosures

Section 5.2.3.2.2 states the bottom of a linen chute shall be protected by a listed automatic closing or self-closing door in accordance with 5.2.3.

Findings Include:

On 4/25/18 the Cushing Building's ground floor level linen chute door frame had a 1/2" gap between the top of the frame and the vertical shaft it is installed into.

On 4/25/18 the Goldstein Building's linen chute service opening doors on the ground, second, third, and fourth floor levels did not self-close when opened to their widest position. The sides of each chute door had been altered so that each chute door remained open when extended too far. The chute doors can manually be returned to the closed position. In addition, the fourth floor level chute door didn't latch when in the closed position.

As a result, the facility failed to comply with section 9.5.2 requiring linen chutes to be properly maintained.

The finding was confirmed by facility staff and reviewed at the exit conference.

Based on observations and confirmed by staff the facility failed to ensure compliance with Chapter 19 Section 19.7.8 of the 2012 edition of NFPA 101 " Life Safety Code " .

Section 19.7.8 " Portable Space Heating Devices " states the following. Portable space heating-devices shall be prohibited in all health care occupancies, unless both of the following criteria are met:
(1)Such devices are used only in non-sleeping staff and employee areas.
(2)The heating elements of such devices do not exceed 212 degrees F (100 degrees C).

Findings Include:

While conducting the facility tour on 4/24/18, a portable electric space heater with heating elements capable of exceeding 212 degrees F (100 degrees C) was observed in the Psychiatric In-take office located on the third floor level of the Cancer Management Center (CMC).

(The Cancer Management Center (CMC) was classified as a healthcare occupancy due to the presence of the sleep lab in the compartment.)

As a result, the facility failed to comply with section 19.7.8 in regard to the use of portable electric heaters.

The finding was confirmed by facility staff and reviewed at the exit conference.

Based on observations and confirmed by staff, the facility failed to ensure medical air supply systems are install as required.

NFPA 99 section 5.1.3.6.3.12 states compressor intake air for medical compressors shall meet the following:
(A) The medical air compressors shall draw their air from a source of clean air.
(B) The medical air intake shall be located a minimum of 7.6 m (25 ft) from ventilating system exhausts, fuel storage vents, combustion vents, plumbing vents, vacuum and WAGD discharges, or areas that can collect vehicular exhausts or other noxious fumes.
(C) The medical air intake shall be located a minimum of 6m (20 ft) above ground level.
(D) The medical air intake shall be located a minimum of 3.0m (10 ft) from any door, window, or other opening in the building.
(E) If an air source equal to or better than outside air (e.g., air already filtered for use in operating room ventilating systems) is available, it shall be permitted to be used for the medical air compressors with the following provisions:
(1) This alternate source of supply air shall be available on a continuous 24-hour-per-day, 7-day-per-week basis.
(2) Ventilating systems having fans with motors or drive belts located in the airstream shall not be used as a source of medical air intake.
(F) Compressor intake piping shall be permitted to be made of materials and use a jointing technique as permitted under 5.1.10.2.
(G) Air intakes for separate compressors shall be permitted to be joined together to one common intake where the following conditions are met:
(1) The common intake is sized to minimize back pressure in accordance with the manufacturer ' s recommendations.
(2) Each compressor can be isolated by manual or check valve, blind flange, or tube cap to prevent open inlet piping when the compressor(s) is removed for service from the consequent
backflow of room air into the other compressor(s).
(H) The end of the intake shall be turned down and screened or otherwise be protected against the entry of vermin, debris, or precipitation by screening fabricated or composed of a non-corroding material.

Section 5.1.3.7.7.2 states vacuum exhaust shall be located as follows:
(1) Outdoors.
(2) At least 3.05 m (10 ft) from any door, window, air intake, or other openings in buildings or places of public assembly.
(3) At a level different from air intakes.
(4) Where prevailing winds, adjacent buildings, topography, or other influences will not divert the exhaust into occupied areas or prevent dispersion of the exhaust.

Section 5.1.3.7.7.3 states the end of the exhaust shall be turned down and screened or otherwise be protected against the entry of vermin, debris, or precipitation by screening fabricated or composed of a non-corroding material.

THE FINDINGS INCLUDE:

During the morning hours of 4/24/18, the medical air intake and vacuum exhaust for the Hospital were viewed for compliance. The following items were observed regarding the installation of this intake and exhaust piping:

1) The medical air intake point is located approximately 14'-8" above the ground level.

2) The air intake point is located approximately 6' from a plumbing vent pipe.

3) Two of four air intake elbows were not observed to have any screening protecting it from vermin and/or debris.

4) Both vacuum exhaust elbows were not observed to have any screening protecting it from vermin and/or debris.

As a result, the facility failed to comply with NFPA 99 requiring medical air piping and vacuum exhaust piping to be installed as required.

This finding was confirmed by the Facility's Management Staff during the exit interview conference.

Based on observations and record review and confirmed by staff interview, the facility failed to ensure that the medical gas systems are maintained, tested, and inspected in accordance with NFPA 99 and NFPA 101.

NFPA 99, Section 5.1.14.2.1 states General. Health care facilities with installed medical gas, vacuum,WAGD, or medical support gas systems, or combinations thereof, shall develop and document periodic maintenance programs for these systems and their subcomponents as appropriate to the equipment installed.

NFPA 101, Section 4.5.8 states 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 maintained, unless the Code exempts such maintenance.

Findings Include:

During the survey on 4/25/18, the facility's documentation regarding the inspection and maintenance of the medical gas systems was reviewed for code compliance. The testing report dated 2/7/18 identified numerous non compliant items in the Summary of Maintenance Discrepancies and the Summary of Compliance Discrepancies. Review of the documentation with staff revealed that the corrections are necessary to reestablish the proper functions of the medical gas systems.

This finding was confirmed with the Director of Facilities and Facilities Manager at the exit interview process.

Based on observations and confirmed by staff, the Hospital failed to ensure that piped medical gas valves are installed and maintained in compliance with the requirements of the 2012 edition of NFPA 99 "Health Care Facility Code".

Section 5.1.4.1 Gas and Vacuum Shutoff Valves. Shutoff valves shall be provided to isolate sections or portions of the piped distribution system for maintenance, repair, or planned future expansion need and to facilitate periodic testing.

Section 5.1.4.2 Accessibility. All valves, except valves in zone valve box assemblies, shall be located in secured areas such as locked piped chases, or be locked or latched in their operating position, and be labeled as to gas supplied and the area(s) controlled.

FINDINGS INCLUDE:

During the morning hours of 4/25/18 isolation shutoff valves were observed in the 2nd floor room housing the linen chute, located off the corridor by Surgical Daycare. The shutoffs were not located in a secured area or locked or latched in their operating position as required by Section 5.1.4.2.

As a result of the finding the facility is found to be non-compliant with Section 5.1.4.2.

The findings were discussed and confirmed by the Hospital Administration and the Director of Facilities during the exit conference.

Based on documentation review the facility failed to ensure that the facility's emergency generator is tested in accordance with NFPA requirements.

-Section 8.4.9* of the 2010 edition of NFPA 110 Standard for Emergency and Standby Power Systems states Level 1 EPSS shall be tested at least once within every 36 months.

-Section 8.4.9.1 states Level 1 EPSS shall be tested continuously for the duration of its assigned class (see Section 4.2).

-Section 4.2 Table 4.1(a) Classification of EPSSs Class Minimum Time:
Class 0.083 0.083 hr (5 min)
Class 0.25 0.25 hr (15 min)
Class 2 2 hr
Class 6 6 hr
Class 48 48 hr
Class X Other time, in hours, as required by
the application, code, or user

-Section 8.4.9.2 Where the assigned class is greater than 4 hours, it shall be permitted to terminate the test after 4 continuous hours.

Findings Include:

A review of the facility's diesel fueled, Level 1, Type X emergency generator testing documentation conducted during the morning hours of 4/23/18 revealed the following.

There was no documentation confirming that a four hour building load, as required for a Level 1 Type X EPSS, had been conducted within the past three years.

As a result of the finding the facility is found to be non-compliant with Section 8.4.9 of NFPA 110.

The findings were discussed and confirmed with the the facility's office manager during the exit conference.

Based on observations and confirmed by staff the facility failed to ensure compliance with Section 19.3.2.4 of the 2012 edition of NFPA 101 "Life Safety Code".

-Section 19.3.2.4 " Medical Gas " states medical gas storage and administration areas shall be in accordance with section 8.7 and the provisions of NFPA 99 " Health Care Facilities Code " applicable to administration, maintenance and testing.

NFPA 99 section 11.3 Cylinder and Container Storage Requirements.
Section 11.3.1 states that storage for nonflammable gases equal to or greater than 85 m3 (3000 ft3) at STP shall comply with 5.1.3.3.2 and 5.1.3.3.3.

Section 5.1.3.3.2 Design and Construction., states that locations for central supply systems and the storage of positive-pressure gases shall meet the following requirements:
(1) They shall be constructed with access to move cylinders, equipment, and so forth, in and out of the location on hand trucks complying with 11.4.3.1.1.
(2) They shall be secured with lockable doors or gates or otherwise secured.
(3) If outdoors, they shall be provided with an enclosure (wall or fencing) constructed of noncombustible materials with a minimum of two entry/exits.
(4) If indoors, they shall be constructed and use interior finishes of noncombustible or limited-combustible materials such that all walls, floors, ceilings, and doors are of a minimum 1-hour fire resistance rating.
(5)*They shall be compliant with NFPA 70, National Electrical Code, for ordinary locations.
(6) They shall be heated by indirect means (e.g., steam, hot water) if heat is required.
(7) They shall be provided with racks, chains, or other fastenings to secure all cylinders from falling, whether connected, unconnected, full, or empty.
(8)*They shall be supplied with electrical power compliant with the requirements for essential electrical systems as described in Chapter 6.
(9) They shall have racks, shelves, and supports, where provided, constructed of noncombustible materials or limited-combustible materials.
(10) They shall protect electrical devices from physical damage.

Section 5.1.3.3.3 Ventilation.
Section 5.1.3.3.3.1 Venting of Relief Valves states that indoor supply systems shall have all relief valves vented per 5.1.3.5.6.1(4) through (9).

5.1.3.3.3.2 Ventilation for Motor-Driven Equipment. The following source locations shall be adequately ventilated to prevent accumulation of heat:
(1) Medical air sources (see 5.1.3.6)
(2) Medical-surgical vacuum sources (see 5.1.3.7)
(3) Waste anesthetic gas disposal (WAGD) sources (see 5.1.3.8.1)
(4) Instrument air sources (see 5.1.3.9)

Section 5.1.3.3.3.3 Ventilation for Outdoor Locations.
(A) Outdoor locations surrounded by impermeable walls shall have protected ventilation openings located at the base of each wall to allow free circulation of air within the enclosure.
(B) Walls that are shared with other enclosures or with buildings shall be permitted to not have openings.

Section 5.1.3.3.4 Storage.
Section 5.1.3.3.4.1 Full or empty medical gas cylinders, when not connected, shall be stored in locations complying with 5.1.3.3.2 through 5.1.3.3.3 and shall be permitted to be in the same rooms or enclosures as their respective central supply systems.

Section 5.1.3.3.4.2 Cylinders, whether full or empty, shall not be stored in enclosures containing motor-driven machinery, with the exception of cylinders intended for instrument air reserve headers complying with 5.1.3.9.5, which shall be permitted to be placed in the same location containing an instrument air compressor when it is the only motor-driven machinery located within the room. Only cylinders intended for instrument air reserve headers complying with 5.1.3.9.5 shall be permitted to be stored in enclosures containing instrument air compressors.

Findings Include:

On 4/25/18, it was revealed that the facility's oxygen cylinder storage room, located in the Rogers Building's stair #2 discharge, housed 10 "H"/"K" type cylinders and 88 "E"- type cylinders. The oxygen cylinder storage room is enclosed in a room rated for less than one-hour fire rated construction. In addition, the configuration of the room with the door accessible to the stair discharge fails to meet the requirements noted under tag K 225.

This finding was confirmed by the Facility's Management Staff during the exit interview conference.