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During the survey, unsealed penetrations around a group of wiring, and at the end of a sleeve, were observed in the Fire Wall, by Social Services Office.

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

8.2.3.2.4.2* Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through fire barriers shall be protected as follows:
(1) The space between the penetrating item and the fire barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the fire barrier, the sleeve shall be solidly set in the fire barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) * Insulation and coverings for pipes and ducts shall not pass through the fire barrier unless one of the following conditions is met:
a. The material shall be capable of maintaining the fire resistance of the fire barrier.
b. The material shall be protected by an approved device that is designed for the specific purpose.
(4) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the fire barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

The facility failed to maintain the corridor openings per code. Findings include:

During the survey, the following was observed:
1. Room 304, Office corridor door had a tongue depressor and tape on the doors plunger not allowing the door to be positive latching.
2. The room next to room 304, in back of the Sterilizer Room, showed the corridor door was not positive latching.

2000 NFPA 101, 19.3.6.3.2 Doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door. Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.2.
.

The facility failed to provide smoke barriers that would provide at least a half hour fire resistance rating. Findings include: During the survey, unsealed penetrations were observed around a group of wiring, in the Smoke Barrier, by Rehab Services.

NFPA 101, 19.3.7.3 Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1/2 hour.

NFPA 101, 8.3.2 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 a combination thereof. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces.

The facility failed to maintain the hazardous areas per code. Findings include:

During the survey, the following was observed:
1. The Old O.R. Prep. Room was being used as a Storage Room, the room is over 50 sq. ft. and the corridor door did not have the following: positive latching hardware, a self-closing device, and was not smoke resistive to the corridor.
2. The Janitor Equipment Storage Room corridor door did not have a self-closing device.
3. The Janitor Storage Room by the Fire Alarm Panel Room had a penetration in the ceiling at a sprinkler pipe hanger and a hole in the right wall above the opened door.
4. The Old Hospital Administrative Office was being used as a Storage Room, the room was over
50 sq. ft., the corridor door did not have a self-closing device.
5. The Kitchen Dietary Storage Room, the room was over 50 sq. ft. the corridor door was not positive latching.

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

.

The facility failed to provide a reliable means of egress to the public way. Observation during the survey found the following findings:

The Exit by Patient Room 216 was not provided with an weather surface to the public way.

NFPA 101, 7.1.10.1 Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

NFPA 101, A.7.1.10.1 *A proper means of egress allows unobstructed travel at all times. Any type of barrier including, but not limited to, the accumulations of snow and ice in those climates subject to such accumulations is an impediment to free movement in the means of egress.

The facility failed to conduct fire drills per code. Findings include:

During the survey, per documentation and an interview with the staff, the facility was not getting all staff (that were on site during the fire drill) to sign the Fire Drill Report.

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

The facility failed to maintain a fire alarm system with approved component devices or equipment installed to provide effective warning of fire in any part of the building. Findings include:
During the survey, the fire/smoke damper, in the Smoke Barrier by Out Patient Surgery Registration Office, was observed not to be connected to the fire alarm system and wire for connection to damper was observed by the damper.

NFPA 101, 9.6.1.7 Components of the fire alarm system were not maintained.

NFPA 101 2000, 8.3.5.3 Required smoke dampers in air transfer openings shall close upon detection of smoke by approved smoke detection in accordance with NFPA 72, National Fire Alarm Code.

The facility failed to maintain the fire alarm system per code. Findings include:

During the survey, per observation and an interview with the staff, the facility has two kitchen hoods and two suppression systems. The documentation from the fire alarm company dated 02/22/2010, only lists one.

2000 NFPA 101, 9.6.1.7 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 Code.
.

27382


The facility failed to maintain the automatic sprinkler system per code. Findings include:

During the survey, a hole was observed in the ceiling from a missing light fixture in the Shower Room by the Chapel at the Trauma Entrance.

Missing ceiling tiles in CT Room, and in Radiology Room One.

1999 NFPA 13, 5-8.4.2 Deflectors of sprinklers shall be aligned parallel to ceilings or roofs.
.

Documentation of the calibration test for the sprinkler system gauges was not provided.

NFPA 25, Table 2-1 Summary of Sprinkler System Inspection, Testing, and Maintenance

NFPA 25, 9-2.8.2: Gauges shall be replaced every 5 years or tested every
5 years by comparison with a calibrated gauge. Gauges not accurate to within
3 percent of the full scale shall be recalibrated or replaced.

NFPA 25, 9-2.8.1: Gauges shall be inspected monthly to verify that they are in good condition and that normal pressure is being maintained. Exception: When other sections of this standard have different frequency requirements for specific gauges.

The facility failed to maintain the curtains/draperies per code. Findings include:

During the survey, the facility could not provide flame resistance documantation on the curtains/draperies.

2000 NFPA 101, 10.3.1 Where required by the applicable provisions of this Code, draperies, curtains, and other similar loosely hanging furnishings and decorations shall be flame resistant as demonstrated by testing in accordance with NFPA 701, Standard Methods of Fire Tests for Flame Propagation of Textiles and Films.
.

During the survey, the following was observed:

Seven cylinders were observed unsecured.

1999 NFPA 99, 8-3.1.11.2(g) Cylinders shall be secured from mechanical shock.

Appropriate signage to indicate full/empty cylinders were not provided.

CGA G-4, 4.1.10, and 1999 NFPA 99, 4-3.5.2.2(b)2 and 4-5.5.2.2(b)2 Full and empty cylinders shall be stored separately with appropriate signage.

The facility failed to provide access panels at fire/smoke dampers. Findings include: During the survey, access panel was not provided for the smoke/fire damper in the smoke barrier by Out Patient Surgery Registration Office.

1999 NFPA 90A, 2-3.4.1 A service opening shall be provided in air ducts adjacent to each fire damper, smoke damper, and smoke detector. The opening shall be large enough to permit maintenance and resetting of the device.
1999 NFPA 90A, 3-3.5.1 Smoke dampers shall be installed at or adjacent to the point where air ducts pass through required smoke barriers, but in no case shall a smoke damper be installed more than 2 ft (0.6 m) from the barrier or after the first air duct inlet or outlet, whichever is closer to the smoke barrier.

During the survey, the Battery-Powered Light in the Generator Set, and Control Room was observed to be inoperable.

1999 NFPA 99, 3-6.1.1 and 3-4.1.1.4, and 1999 NFPA 110, 5-3.1. Emergency generator equipment locations

During the survey, the generator was observed not to have met the requirements to transfer from normal to emergency power within 10 seconds. The facility Maintenance Staff was observed to have made one attempt with the following time noted to transfer from normal to emergency power. The time was observed to be 12 seconds.

NFPA 101, 7.9.2.3, and 1999 NFPA 99, 3-4.1.1.8, 3-5.3.1 and 3-6.3.1.2 Emergency generator shall start/crank and transfer from normal to emergency power within ten seconds.

1) The facility utilized extension cord without overcurrent protection. Findings include:

a) During the survey, an extension cord was observed connected to a free standing light, in the OR Equipment Room, which according to maintenance staff, was used to provide better lighting while working in this room.

1999 NFA 70, Article 240-4, and HFCA Transmittal Notice 22-99 prohibit the use of extension cords without overcurrent protection.

b) Junction box was missing the cover, above the ceiling by Rehab Services.

1999 NFPA 70, 370-25 and 410-12. Each box in completed installations to have a cover, face plate, or fixture canopy.


27382


2) The facility failed to maintain the electrical system per code. Findings include:

During the survey, the Fire Alarm Panel Room was observed with 5 electrical junction boxes without cover plates.

1999 NFPA 70, 370-28. Pull and Junction Boxes Boxes and conduit bodies used as pull or junction boxes shall comply with (a) through (d). (c) Covers. All pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use. Where metal covers are used, they shall comply with the grounding requirements of Section 250-110. An extension from the cover of an exposed box shall comply with Section 370-22, Exception.

During the survey, unsealed penetrations around a group of wiring, and at the end of a sleeve, were observed in the Fire Wall, by Social Services Office.

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

8.2.3.2.4.2* Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through fire barriers shall be protected as follows:
(1) The space between the penetrating item and the fire barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the fire barrier, the sleeve shall be solidly set in the fire barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) * Insulation and coverings for pipes and ducts shall not pass through the fire barrier unless one of the following conditions is met:
a. The material shall be capable of maintaining the fire resistance of the fire barrier.
b. The material shall be protected by an approved device that is designed for the specific purpose.
(4) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the fire barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

The facility failed to maintain the corridor openings per code. Findings include:

During the survey, the following was observed:
1. Room 304, Office corridor door had a tongue depressor and tape on the doors plunger not allowing the door to be positive latching.
2. The room next to room 304, in back of the Sterilizer Room, showed the corridor door was not positive latching.

2000 NFPA 101, 19.3.6.3.2 Doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door. Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.2.
.

The facility failed to provide smoke barriers that would provide at least a half hour fire resistance rating. Findings include: During the survey, unsealed penetrations were observed around a group of wiring, in the Smoke Barrier, by Rehab Services.

NFPA 101, 19.3.7.3 Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1/2 hour.

NFPA 101, 8.3.2 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 a combination thereof. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces.

The facility failed to maintain the hazardous areas per code. Findings include:

During the survey, the following was observed:
1. The Old O.R. Prep. Room was being used as a Storage Room, the room is over 50 sq. ft. and the corridor door did not have the following: positive latching hardware, a self-closing device, and was not smoke resistive to the corridor.
2. The Janitor Equipment Storage Room corridor door did not have a self-closing device.
3. The Janitor Storage Room by the Fire Alarm Panel Room had a penetration in the ceiling at a sprinkler pipe hanger and a hole in the right wall above the opened door.
4. The Old Hospital Administrative Office was being used as a Storage Room, the room was over
50 sq. ft., the corridor door did not have a self-closing device.
5. The Kitchen Dietary Storage Room, the room was over 50 sq. ft. the corridor door was not positive latching.

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

.

The facility failed to provide a reliable means of egress to the public way. Observation during the survey found the following findings:

The Exit by Patient Room 216 was not provided with an weather surface to the public way.

NFPA 101, 7.1.10.1 Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

NFPA 101, A.7.1.10.1 *A proper means of egress allows unobstructed travel at all times. Any type of barrier including, but not limited to, the accumulations of snow and ice in those climates subject to such accumulations is an impediment to free movement in the means of egress.

The facility failed to conduct fire drills per code. Findings include:

During the survey, per documentation and an interview with the staff, the facility was not getting all staff (that were on site during the fire drill) to sign the Fire Drill Report.

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

The facility failed to maintain a fire alarm system with approved component devices or equipment installed to provide effective warning of fire in any part of the building. Findings include:
During the survey, the fire/smoke damper, in the Smoke Barrier by Out Patient Surgery Registration Office, was observed not to be connected to the fire alarm system and wire for connection to damper was observed by the damper.

NFPA 101, 9.6.1.7 Components of the fire alarm system were not maintained.

NFPA 101 2000, 8.3.5.3 Required smoke dampers in air transfer openings shall close upon detection of smoke by approved smoke detection in accordance with NFPA 72, National Fire Alarm Code.

The facility failed to maintain the fire alarm system per code. Findings include:

During the survey, per observation and an interview with the staff, the facility has two kitchen hoods and two suppression systems. The documentation from the fire alarm company dated 02/22/2010, only lists one.

2000 NFPA 101, 9.6.1.7 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 Code.
.

27382


The facility failed to maintain the automatic sprinkler system per code. Findings include:

During the survey, a hole was observed in the ceiling from a missing light fixture in the Shower Room by the Chapel at the Trauma Entrance.

Missing ceiling tiles in CT Room, and in Radiology Room One.

1999 NFPA 13, 5-8.4.2 Deflectors of sprinklers shall be aligned parallel to ceilings or roofs.
.

Documentation of the calibration test for the sprinkler system gauges was not provided.

NFPA 25, Table 2-1 Summary of Sprinkler System Inspection, Testing, and Maintenance

NFPA 25, 9-2.8.2: Gauges shall be replaced every 5 years or tested every
5 years by comparison with a calibrated gauge. Gauges not accurate to within
3 percent of the full scale shall be recalibrated or replaced.

NFPA 25, 9-2.8.1: Gauges shall be inspected monthly to verify that they are in good condition and that normal pressure is being maintained. Exception: When other sections of this standard have different frequency requirements for specific gauges.

The facility failed to maintain the curtains/draperies per code. Findings include:

During the survey, the facility could not provide flame resistance documantation on the curtains/draperies.

2000 NFPA 101, 10.3.1 Where required by the applicable provisions of this Code, draperies, curtains, and other similar loosely hanging furnishings and decorations shall be flame resistant as demonstrated by testing in accordance with NFPA 701, Standard Methods of Fire Tests for Flame Propagation of Textiles and Films.
.

During the survey, the following was observed:

Seven cylinders were observed unsecured.

1999 NFPA 99, 8-3.1.11.2(g) Cylinders shall be secured from mechanical shock.

Appropriate signage to indicate full/empty cylinders were not provided.

CGA G-4, 4.1.10, and 1999 NFPA 99, 4-3.5.2.2(b)2 and 4-5.5.2.2(b)2 Full and empty cylinders shall be stored separately with appropriate signage.

The facility failed to provide access panels at fire/smoke dampers. Findings include: During the survey, access panel was not provided for the smoke/fire damper in the smoke barrier by Out Patient Surgery Registration Office.

1999 NFPA 90A, 2-3.4.1 A service opening shall be provided in air ducts adjacent to each fire damper, smoke damper, and smoke detector. The opening shall be large enough to permit maintenance and resetting of the device.
1999 NFPA 90A, 3-3.5.1 Smoke dampers shall be installed at or adjacent to the point where air ducts pass through required smoke barriers, but in no case shall a smoke damper be installed more than 2 ft (0.6 m) from the barrier or after the first air duct inlet or outlet, whichever is closer to the smoke barrier.

During the survey, the Battery-Powered Light in the Generator Set, and Control Room was observed to be inoperable.

1999 NFPA 99, 3-6.1.1 and 3-4.1.1.4, and 1999 NFPA 110, 5-3.1. Emergency generator equipment locations

During the survey, the generator was observed not to have met the requirements to transfer from normal to emergency power within 10 seconds. The facility Maintenance Staff was observed to have made one attempt with the following time noted to transfer from normal to emergency power. The time was observed to be 12 seconds.

NFPA 101, 7.9.2.3, and 1999 NFPA 99, 3-4.1.1.8, 3-5.3.1 and 3-6.3.1.2 Emergency generator shall start/crank and transfer from normal to emergency power within ten seconds.

1) The facility utilized extension cord without overcurrent protection. Findings include:

a) During the survey, an extension cord was observed connected to a free standing light, in the OR Equipment Room, which according to maintenance staff, was used to provide better lighting while working in this room.

1999 NFA 70, Article 240-4, and HFCA Transmittal Notice 22-99 prohibit the use of extension cords without overcurrent protection.

b) Junction box was missing the cover, above the ceiling by Rehab Services.

1999 NFPA 70, 370-25 and 410-12. Each box in completed installations to have a cover, face plate, or fixture canopy.


27382


2) The facility failed to maintain the electrical system per code. Findings include:

During the survey, the Fire Alarm Panel Room was observed with 5 electrical junction boxes without cover plates.

1999 NFPA 70, 370-28. Pull and Junction Boxes Boxes and conduit bodies used as pull or junction boxes shall comply with (a) through (d). (c) Covers. All pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use. Where metal covers are used, they shall comply with the grounding requirements of Section 250-110. An extension from the cover of an exposed box shall comply with Section 370-22, Exception.