HospitalInspections.org

Based on observation and staff interview, it was determined that the facility failed to arrange and maintain the means of egress in accordance with Life Safety Code Section 19.2 and Chapter 7.

1. Stair 4 Delayed egress egress door 3rd floor (no signage or alarm) (non-compliant IAW NFPA 101) Door corrections need to come in for plan review
2. Stair 4 Delayed egress baby ward (non-compliant IAW NFPA 101)
3. ED department stairway 4 needs an eye to disable the maglock


NFPA 101
19.2.2.2.4
Doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side, unless otherwise permitted by one of the following:
Locks complying with 19.2.2.2.5 shall be permitted.

*Delayed-egress locks complying with 7.2.1.6.1 shall be permitted.

*Access-controlled egress doors complying with 7.2.1.6.2 shall be permitted.

Elevator lobby exit access door locking in accordance with 7.2.1.6.3 shall be permitted.

Approved existing door-locking installations shall be permitted.

19.2.2.2.5 Door-locking arrangements shall be permitted in accordance with either 19.2.2.2.5.1 or 19.2.2.2.5.2.

19.2.2.2.5.1* Door-locking arrangements shall be permitted where the clinical needs of patients require specialized security measures or where patients pose a security threat, provided that staff can readily unlock doors at all times in accordance with 19.2.2.2.6.

These deficiencies have the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Director of Compliance and the Maintenance Director at the exit conference.

Based on observation and staff interview, it was determined that the facility failed to arrange and maintain exit signage in accordance with Life Safety Code Section 7.10.1.2.1 and Chapter 19.
This deficient practice could affect all residents, staff and visitors throughout the facility if an exit cannot be identified during an emergency.

1. Exit signage needed over "Temp door"
2. The staff room 5304 hallway needs an Exit Sign

NFPA 101, 4.5.3.3 Awareness of Egress System. Every exit shall be clearly visible, or the route to reach every exit shall be conspicuously indicated. Each means of egress, in its entirety, shall be arranged or marked so that the way to a place of safety is indicated in a clear manner.

NFPA 101, 7.10.1.2.1* Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign that is readily visible from any direction of exit access.
NFPA 101 7.9.2.5 Unit equipment and battery systems for emergency luminaires shall be listed to ANSI/UL 924, Standard for Emergency Lighting and Power Equipment.

These deficiencies have the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Director of Compliance and the Maintenance Director at the exit conference. .

Through observation during the survey and staff interview, it was determined that the facility failed to meet the exit signage requirements in accordance with NFPA 101, 19.2.10.1. This was evidenced by:

1.Exit signs in the lobby need to be listed: Lobby, Admin, Imaging Hallway
2.Photoluminescent signs need light for charging signs throughout the facility's exits


NFPA 101
7.10.5 Illumination of Signs.
7.10.5.1* General. Every sign required by 7.10.1.2, 7.10.1.5, or 7.10.8.1, other than where operations or processes require low lighting levels, shall be suitably illuminated by a reliable light source. Externally and internally illuminated signs shall be legible in both the normal and emergency lighting mode.

7.10.7 Internally Illuminated Signs.

7.10.7.1 Listing.
Internally illuminated signs shall be listed in accordance with ANSI/UL 924, Standard for Emergency Lighting and Power Equipment, unless they meet one of the following criteria:
(1)They are approved existing signs.

(2)They are existing signs having the required wording in legible letters not less than 4 in. (100 mm) high.

(3)They are signs that are in accordance with 7.10.1.3 and 7.10.1.6.

7.10.7.2* Photoluminescent Signs.

The face of a photoluminescent sign shall be continually illuminated while the building is occupied. The illumination levels on the face of the photoluminescent sign shall be in accordance with its listing. The charging illumination shall be a reliable light source, as determined by the authority having jurisdiction. The charging light source, shall be of a type specified in the product markings.

These deficiencies have the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Director of Compliance and the Maintenance Director at the exit conference.

Based on a record review and staff interview, it was determined that facility did not follow installation and testing requirements for the fire alarm system IAW NFPA 72 for past construction project.

1.UnPermitted work conducted without AHJ approval/final testing for the MRI remodel project

NFPA 72
14.4.1 System Testing.
14.4.1.1 Initial Acceptance Testing.
14.4.1.1.1 Initial acceptance testing shall be performed as required in 14.4.1.1.1.1 through 14.4.1.1.1.2.

14.4.1.1.1.1 All new systems shall be inspected and tested in accordance with the requirements of Chapter 14.
14.4.1.1.1.2 The authority having jurisdiction shall be notified prior to the initial acceptance test.
14.4.1.2* Reacceptance Testing.
14.4.1.2.1 Reacceptance testing shall be performed as required in 14.4.1.2.1.1 through 14.4.1.2.1.4.

14.4.1.2.1.1 When an initiating device, notification appliance, or control relay is added, it shall be functionally tested.
14.4.1.2.1.2
When an initiating device, notification appliance, or control relay is deleted, another device, appliance, or control relay on the circuit shall be operated.
14.4.1.2.1.3
When modifications or repairs to control equipment hardware are made, the control equipment shall be tested in accordance with Table 14.4.2.2, items 1(a) and 1(d).
14.4.1.2.1.4
When changes are made to site-specific software, the following shall apply:
(1)All functions known to be affected by the change, or identified by a means that indicates changes, shall be 100 percent tested.

(2)In addition, 10 percent of initiating devices that are not directly affected by the change, up to a maximum of 50 devices, also shall be tested and correct system operation shall be verified.

(3)A revised record of completion in accordance with 10.18.2.1 shall be prepared to reflect these changes.

14.4.1.2.2
Changes to all control units connected or controlled by the system executive software shall require a 10 percent functional test of the system, including a test of at least one device on each input and output circuit to verify critical system functions such as notification appliances, control functions, and off-premises reporting.

These deficiencies have the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Director of Compliance and the Maintenance Director.

Based on a record review and staff interview, it was determined that the facility failed to maintain the fire alarm system components and devices in accordance with the Life Safety Code Section 9.6 and NFPA 72.

1. Annual Fire Alarm Report
- Need to clarify if all heat detection was tested for the elevator and elevator pits
- Detectors that were missed during the remodel need to be tested
- Emergency Control Functions need to be tested IAW NFPA 72 (Smoke/Fire Dampers)
- Semi-annual visual inspection not documented on the report

NFPA 101, Section 9.6.1.5* To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of
NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code.

NFPA 72- 14.4.2.2* Systems and associated equipment shall be tested according to Table 14.4.2.2. (15). Alarm notification appliances (a) Audible: Test shall be performed in accordance with the manufacturer ' s published instructions. Appliance locations shall be verified to be per approved layout, and it shall be confirmed that no floor plan changes affect the approved layout. It shall be verified that the candela rating marking agrees with the approved drawing. It shall be confirmed that each appliance flashes.

14.4.2.2*
Systems and associated equipment shall be tested according to Table 14.4.2.2.
23. Emergency control functions
Emergency control functions (i.e., fan control, smoke damper operation, elevator recall, elevator power shutdown, door holder release, shutter release, door unlocking, etc.) shall be tested by operating or simulating alarm signals. Testing frequency for emergency control functions shall be the same as the frequency required for the initiating device that activates the emergency control function.

These deficiencies have the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Director of Compliance and the Maintenance Director at the exit conference.

Based on a record review it was determined that the facility failed to maintain the fire alarm system components and devices in accordance with the Life Safety Code Section 9.6 and NFPA 72.

1. Fire Alarm Report
- Annual report labeled semi-annual
- States semi-annual visual inspection only
- The semi-annual report does not include a visual inspection

NFPA 101, Section 9.6.1.5* To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of
NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code.

NFPA 72- 14.4.2.2* Systems and associated equipment shall be tested according to Table 14.4.2.2. (15). Alarm notification appliances (a) Audible: Test shall be performed in accordance with the manufacturer ' s published instructions. Appliance locations shall be verified to be per approved layout, and it shall be confirmed that no floor plan changes affect the approved layout. It shall be verified that the candela rating marking agrees with the approved drawing. It shall be confirmed that each appliance flashes.


These deficiencies have the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Director of Compliance and the Maintenance Director at the exit conference.

Based on observations and records review, it was determined that the facility failed to maintain the automatic sprinkler system in accordance with National Fire Protection Association NFPA 25 and NFPA 101.

1. Sprinkler in OR area not flush with the ceiling
2. Woman ' s imaging sprinkler head damaged
3. Missing sprinkler cover in office 123
4. Sprinkler in freezer missing escutcheon
5. Hydro sign blank for sprinkler riser in basement
6. Sprinkler pipe in the basement has wires attached
7. Sprinkler coverage needs to be evaluated in the basement, multiple sprinkler heads obstructed by HVAC work, Records storage room: protection and sprinkler not in compliance with NFPA 99 15.10 and 15.11
8. Stairwell between 3rd floor of the hospital and the leased space is not sprinklered IAW NFPA 13
9. ATS room bump out not sprinklered in accordance with NFPA 13 and facility's life safety plans
10. Penthouse area not protected with an approved sprinkler system

NFPA 101: 4.6.12.1 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 5.2.6* Hydraulic Design Information Sign. The hydraulic design information sign for hydraulically designed systems shall be inspected quarterly to verify that it is attached securely to the sprinkler riser and is legible.

NFPA 13
8.15.3.2 Noncombustible Construction.
8.15.3.2.1
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.

NFPA 101
19.3.5 Extinguishment Requirements.
19.3.5.3
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.

NFPA 99
15.10* Compact Storage.
Compact storage shall be protected by sprinklers in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.

15.11 Compact Mobile Storage.
15.11.1 Rooms with compact mobile storage units greater than 50 ft2 (4.65 m2) shall be protected as a hazardous area in accordance with the applicable building code, NFPA 101, Life Safety Code, or fire code.

15.11.2 Smoke detection shall be installed above compact mobile storage units greater than 50 ft2 (4.65 m2) in accordance with NFPA 72.

15.11.3* Compact mobile storage units greater than 50 ft2 (465 m2) shall be protected by automatic sprinklers in accordance with NFPA 13.

These deficiencies have the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Director of Compliance and the Maintenance Director at the exit conference.

Based on observation and staff interview, it was determined that the facility failed to maintain corridor doors in accordance with NFPA 101.

1. Room 2112 doors need to be self-closers and on mag locks if they want to be held open. Staff area door should be a rated door
2. The drop-down door in the admin area needs to be maintained or removed

NFPA 101, 8.3.3.1
Openings required to have a fire protection rating by Table 8.3.4.2 shall be protected by approved, listed, labeled fire door assemblies and fire window assemblies and their accompanying hardware, including all frames, closing devices, anchorage, and sills in accordance with the requirements of NFPA 80, Standard for Fire Doors and Other Opening Protectives, except as otherwise specified in this Code.

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 doors constructed to resist the passage of smoke and shall be constructed of materials such as the following:
(1) 13/4 in. (44 mm) thick, solid-bonded core wood

(2) Material that resists fire for a minimum of 20 minutes

NFPA 101, 19.3.6.3.5*
Doors shall be provided with a means for keeping the door closed that is acceptable to the authority having jurisdiction, and the following requirements also shall apply:
(1) 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.

(2)Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.7.

NFPA 101
4.6.12.3*
Existing life safety features obvious to the public, if not required by the Code, shall be either maintained or removed.

These deficiencies have the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Director of Compliance and the Maintenance Director at the exit conference.

Based on observation and staff interview during the course of the survey it was determined the facility failed to maintain fire/smoke barriers in accordance with NFPA 101.

1. Penetration in the electrical room 350
2. Seal the floor area by the riser under the admin area
3. Fire Barrier inspection revealed that all fire barriers inspected had multiple penetrations (approx 10 locations)

NFPA 101
8.3.1.2*

Fire barriers shall comply with one of the following:
(1) The fire barriers are continuous from outside wall to outside wall or 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.

(2)The fire barriers are continuous from outside wall to outside wall or from one fire barrier to another, and from the floor to the bottom of the interstitial space, provided that the construction assembly forming the bottom of the interstitial space has a fire resistance rating not less than that of the fire barrier.

8.3.4 Opening Protectives.

8.3.4.1
Every opening in a fire barrier shall be protected to limit the spread of fire and restrict the movement of smoke from one side of the fire barrier to the other.

8.3.4.2*
The fire protection rating for opening protectives in fire barriers, fire-rated smoke barriers, and fire-rated smoke partitions shall be in accordance with Table 8.3.4.2, except as otherwise permitted in 8.3.4.3 or 8.3.4.4. Table 8.3.4.2 was revised by a tentative interim amendment (TIA).

These deficiencies have the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Director of Compliance and the Maintenance Director at the exit conference.

Based on observation and staff interview during the course of the survey it was determined the facility failed to maintain fire/smoke barriers in accordance with NFPA 101.

1.Ortho Electrical Closet Penetrations in closet (Need to know listing of material used in closet)

NFPA 101
8.3.1.2*

Fire barriers shall comply with one of the following:
(1) The fire barriers are continuous from outside wall to outside wall or 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.

(2)The fire barriers are continuous from outside wall to outside wall or from one fire barrier to another, and from the floor to the bottom of the interstitial space, provided that the construction assembly forming the bottom of the interstitial space has a fire resistance rating not less than that of the fire barrier.

8.3.4 Opening Protectives.

8.3.4.1
Every opening in a fire barrier shall be protected to limit the spread of fire and restrict the movement of smoke from one side of the fire barrier to the other.

8.3.4.2*
The fire protection rating for opening protectives in fire barriers, fire-rated smoke barriers, and fire-rated smoke partitions shall be in accordance with Table 8.3.4.2, except as otherwise permitted in 8.3.4.3 or 8.3.4.4. Table 8.3.4.2 was revised by a tentative interim amendment (TIA).

These deficiencies have the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Director of Compliance and the Maintenance Director at the exit conference.

Based on observation and staff interview, it was determined that the facility failed to maintain smoke dampers in accordance with Life Safety Code and NFPA 105

1. Fire Damper report showed multiple dampers not reachable or failed, with no repair reports available (invoice available but no repair report)


NFPA 105, 6.5.1 Smoke dampers for dedicated and non-dedicated smoke control systems shall be inspected and tested in accordance with NFPA 92A, Standard for Smoke-Control Systems Utilizing Barriers and Pressure Differences.
6.5.2* Each damper shall be tested and inspected one year after installation. The test and inspection frequency shall then be every 4 years, except in hospitals, where the frequency shall
be every 6 years.
6.5.3 Care shall be exercised that all tests are completed in a safe manner wearing the appropriate personal protective equipment.
6.5.4 Full unobstructed access to the damper shall be verified and corrected as required.

These deficiencies have the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Director of Compliance and the Maintenance Director at the exit conference.

Based on a record review and staff interview, it was determined that the facility failed to maintain the elevator components and devices in accordance with NFPA 101.

1.No Elevator monthly com checks (Facility working on plan to update system)

NFPA 101
9.4.6 Elevator Testing.
9.4.6.1
Elevators shall be subject to periodic inspections and tests as specified in ASME A17.1/CSA B44, Safety Code for Elevators and Escalators.

9.4.6.2
All elevators equipped with fire fighters ' emergency operations in accordance with 9.4.3 shall be subject to a monthly operation with a written record of the findings made and kept on the premises as required by ASME A17.1/CSA B44, Safety Code for Elevators and Escalators.

9.4.6.3
The elevator inspections and tests required by 9.4.6.1 shall be performed at frequencies complying with one of the following:
(1)Inspection and test frequencies specified in Appendix N of ASME A17.1/CSA B44, Safety Code for Elevators and Escalators

(2) Inspection and test frequencies specified by the authority having jurisdiction

These deficiencies have the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Director of Compliance and the Maintenance Director at the exit conference.

Based on a record review and staff interview, it was determined that the facility failed to maintain the Rooftop Landing Facilities in accordance with the Life Safety Code NFPA 418.

Two portable foam extinguishers, each having a rating of 20-A:160-B, not available in lieu of foam suppression system
Unable to provide training documentation for firefighting operations

NFPA 418
7.7 Fire Protection.The fire protection requirements in Section 7.7 shall be permitted to be modified where a fire risk assessment, as outlined in Chapter 4, identifies that an alternative means of protection is acceptable as outlined in the fire risk assessment.

7.7.1 General.
A foam fire protection system with either a fixed discharge outlet(s) in accordance with 7.7.2 or a hose line(s) in accordance with 7.7.3 shall be designed and installed to protect the rooftop landing pad, unless otherwise permitted by the following:
(1) A foam fire protection system shall not be required for heliports, helistops, vertiports, or vertistops, located on open parking structures or buildings that are not normally occupied.
(2) For A-1 heliports, helistops, vertiports, and vertistops, two portable foam extinguishers, each having a rating of 20-A:160-B, shall be permitted to be used to satisfy the requirement of 7.7.1.
(3) Where foam extinguishers per 7.7.1(2) are not available, approved extinguishers with a 20-A:160B:C rating shall be permitted.
(4) Where approved, alternative fire protection systems shall be provided in accordance with Chapter 4.

7.7.1.1 Where trained personnel are not available, fixed fire protection outlet(s) shall be provided.

These deficiencies have the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Director of Compliance and the Maintenance Director.

Based on documentation review and staff interview, it was determined that the facility did not maintain proper electrical practices in accordance with NFPA 99 Health Care Facilities Code (2012). This was evidenced by:

1.No documentation available to show hospital grade receptacles have been inspected IAW with performance data

NFPA Standard: NFPA 99 Health Care Facilities Code (2012)
6.3.4.1 Maintenance and Testing of Electrical System.

6.3.4.1.1
Where hospital-grade receptacles are required at patient bed locations and in locations where deep sedation or general anesthesia is administered, testing shall be performed after initial installation, replacement, or servicing of the device.

6.3.4.1.2
Additional testing of receptacles in patient care rooms shall be performed at intervals defined by documented performance data.

These deficiencies have the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Director of Compliance and the Maintenance Director at the exit conference.

Based on observation and record review during the survey, it was determined that the facility failed to maintain the back-up emergency generator in accordance with National Fire Protection Association (NFPA) Standard 110. This was evidenced by the following:

1. Generator
- Docs show specific gravity testing. However, batteries are sealed.
- Not tracking monthly transfer switch time

8.1.1 The routine Maintenance and operational testing program shall be based on all of the following:

Manufacturers recommendations
Instruction manuals
Minimum requirements of this chapter
The authority having jurisdiction


8.3.7.1 Maintenance of lead-acid batteries shall include the monthly testing and recording of electrolyte specific gravity. Battery conductance testing shall be permitted in lieu of the testing of specific gravity when applicable or warranted.

These deficiencies have the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Director of Compliance and the Maintenance Director at the exit conference.

Based on observation and record review during the survey, it was determined that the facility failed to maintain the back-up emergency generator in accordance with National Fire Protection Association (NFPA) Standard 110. This was evidenced by the following:

1. Generator Documentation Missing
- No weekly Inspections documented
- Documents state specific gravity testing; however, batteries are sealed
- Monthly transfer switch time is not logged


8.1.1 The routine Maintenance and operational testing program shall be based on all of the following:

Manufacturers recommendations
Instruction manuals
Minimum requirements of this chapter
The authority having jurisdiction


8.3.7.1 Maintenance of lead-acid batteries shall include the monthly testing and recording of electrolyte specific gravity. Battery conductance testing shall be permitted in lieu of the testing of specific gravity when applicable or warranted.

These deficiencies have the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Director of Compliance and the Maintenance Director at the exit conference.

Based on a record review and staff interview, it was determined that the facility failed to maintain the fire alarm system components and devices in accordance with the Life Safety Code and NFPA 99.

1. Med Gas: Shows deficiencies on report (Recommend reaching out to MedGas to get a documented response for what these affect, DFPC is unable to determine distinct life hazard based on the report)
2. Oxygen outside needs coverage

NFPA 99
5.1.1.4
An existing system that is not in strict compliance with the provisions of this code shall be permitted to be continued in use as long as the authority having jurisdiction has determined that such use does not constitute a distinct hazard to life.

11.6.5.4
Cylinders stored in the open shall be protected as follows:
(1)Against extremes of weather and from the ground beneath to prevent rusting
(2)During winter, against accumulations of ice or snow
(3)During summer, screened against continuous exposure to direct rays of the sun in those localities where extreme temperatures prevail

These deficiencies have the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Director of Compliance and the Maintenance Director at the exit conference.