HospitalInspections.org

The facility failed to ensure that fusible link fire dampers and fire doors were tested and inspected as required by NPFA 80. This deficient practice would allow fire and smoke products to pass through the HVAC systems affecting all occupants in both smoke zones. The facility has a capacity of 12 and a census of 4 at the time of survey.

During the survey on 2/15/18 between 12:30 PM and 4:00 PM and on 2/16/18 between 8:30 AM and 11:00 AM:

Findings include:

1. On 2/15/18 at 1:59 PM: There is no documentation of maintenance of the fusible link fire dampers.

2. On 2/16/18 at 10:15 AM: There is no documentation of fire door testing.

The Administrator and Maintenance Technician were present and acknowledged the finding.

NFPA Standard: NFPA 80, 2010 edition

19.4.1 Each damper shall be tested and inspected 1 year after
installation.

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

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

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

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

19.4.5 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.

19.4.6 The damper frame shall not be penetrated by any foreign
objects that would affect fire damper operations.

19.4.7 The damper shall not be blocked from closure in any
way.

19.4.8 The fusible link shall be reinstalled after testing is
complete.

19.4.8.1 If the link is damaged or painted, it shall be replaced
with a link of the same size, temperature, and load rating.

19.4.9 All inspections and testing shall be documented, indicating
the location of the fire damper or combination fire/
smoke damper, date of inspection, name of inspector, and
deficiencies discovered.

19.4.9.1 The documentation shall have a space to indicate
when and how the deficiencies were corrected.

19.4.10 All documentation shall be maintained and made
available for review by the AHJ.

19.4.11 Periodic inspections and testing of a combination
fire/smoke damper shall also meet the inspection and testing
requirements contained in Chapter 6 of NFPA 105, Standard
for Smoke Door Assemblies and Other Opening Protectives.

"7.2.1.15 Inspection of Door Openings. 7.2.1.15.1* (1) Door leaves equipped with panic hardware or fire exit" hardware in accordance with 7.2.1.7 (2) Door assemblies in exit enclosures (3) Electrically controlled egress doors (4) Door assemblies with special locking arrangements subject to 7.2.1.6
7.2.1.15.2 Fire-rated door assemblies shall be inspected and tested in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Smoke door assemblies shall be inspected and tested in accordance with NFPA 105, Standard for Smoke Door Assemblies and Other Opening Protectives.

7.2.1.15.3 The inspection and testing interval for fire-rated and nonrated door assemblies shall be permitted to exceed 12 months under a written performance-based program in accordance with 5.2.2 of NFPA 80, Standard for Fire Doors and Other Opening Protectives.

7.2.1.15.4 A written record of the inspections and testing shall be signed and kept for inspection by the authority having jurisdiction.

7.2.1.15.5 Functional testing of door assemblies shall be performed by individuals who can demonstrate knowledge and understanding of the operating components of the type of door being subjected to testing.

7.2.1.15.6 Door assemblies shall be visually inspected from both sides of the opening to assess the overall condition of the assembly.

7.2.1.15.7 As a minimum, the following items shall be verified: (1) Floor space on both sides of the openings is clear of obstructions, and door leaves open fully and close freely. (2) Forces required to set door leaves in motion and move to the fully open position do not exceed the requirements in 7.2.1.4.5. (3) Latching and locking devices comply with 7.2.1.5. (4) Releasing hardware devices are installed in accordance with 7.2.1.5.10.1. (5) Door leaves of paired openings are installed in accordance with 7.2.1.5.11. (6) Door closers are adjusted properly to control the closing speed of door leaves in accordance with accessibility requirements. (7) Projection of door leaves into the path of egress does not exceed the encroachment permitted by 7.2.1.4.3. (8) Powered door openings operate in accordance with 7.2.1.9. (9) Signage required by 7.2.1.4.1(3), 7.2.1.5.5, 7.2.1.6, and 7.2.1.9 is intact and legible. (10) Door openings with special locking arrangements function in accordance with 7.2.1.6 (11) Security devices that impede egress are not installed on openings, as required by 7.2.1.5.12.

Based upon observation and staff interview, the facility fails to assure that hazardous areas are separated from other spaces by smoke resisting partitions and doors. The deficient practice fails to provide solid, smoke resisting walls, ceiling, or doors in hazardous areas which would not stop the spread of smoke, affecting all patients and any visitors or staff in one of two smoke zones. The facility has a capacity of 12 with a census of 4 at the time of this survey.

During the survey on 2/15/18 between 12:30 PM and 4:00 PM and on 2/16/18 between 8:30 AM and 11:00 AM:

Findings include:

On 2/16/18 at 9:56 AM: There is a 16 inch by 14 inch hole with a metal grate over the hole to allow for venting in the 7 foot by 8 foot combined storage and internet server room.

The Administrator and Maintenance Technician were present and acknowledged the finding.

NFPA Standard: Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4-hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have non-rated or field-applied protective plates that do not exceed 48 inches from the bottom of the door. 2012 NFPA 101 19.3.2.1

Based on observation and record review, the facility failed to provide complete documentation of annual inspection and testing of the fire alarm system as required by NFPA 72. The absence of complete, verifiable documented maintenance and repair history on the fire alarm system fails to ensure reliability of the alarm system in the event of an emergency, affecting all occupants in both smoke zones. The facility has a capacity of 12 patients and census of 4 at the time of the survey.

During the survey on 2/15/18 between 12:30 PM and 4:00 PM and on 2/16/18 between 8:30 AM and 11:00 AM:

Findings include:

On 2/15/18 at 2:48 PM: The annual fire alarm inspection report dated 5/15/17 does not include a complete initiating device testing page. The facility range hood suppression system is missing from the documentation.

The Administrator and Maintenance Technician were present and acknowledged the finding.

Review of the following NFPA Standard revealed: Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6. 2012 NFPA 101, 19.3.4.1

Review of the following NFPA Standard revealed: 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. 2012 NFPA 101, 4.6.12.4.

Review of the following NFPA Standard revealed: 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. 2012 NFPA 101, 9.6.1.5

Review of the following NFPA Standard revealed: 14.6.2.4* A record of all inspections, testing, and maintenance shall be provided that includes the following information regarding tests and all the applicable information requested in Figure 14.6.2.4: (1) Date, (2) Test frequency, (3) Name of property, (4) Address, (5) Name of person performing inspection, maintenance, tests, or combination thereof, and affiliation, business address, and telephone number. (6) Name, address, and representative of approving agency(ies), (7) Designation of the detector(s) tested, (8) Functional test of detectors, (9)Functional test of required sequence of operations, (10) Check of all smoke detectors, (11) Loop resistance for all fixed temperature, line type heat detectors, (12) Functional test of mass notification system control units, (13) Functional test of signal transmission to mass notification systems, (14) Functional test of ability of mass notification system to silence fire alarm notification appliances, (15) Test of intelligibility of mass notification system speakers, (16) Other tests as required by the equipment manufacturer's published instructions, (17) Other tests as required by the authority having jurisdiction, (18) Signatures of tester and approving agency notified, problem corrected/successfully retested, device abandoned in place proved authority representative, (19) Disposition of problems identified during test (e.g., system owner).

Based on record review, observation and staff interview, this facility is not maintaining the sprinkler system in accordance with the 2011 edition of NFPA 25, and the 2010 edition of NFPA 13. This deficient practice could affect the operation of the system delaying the response time or preventing the activation of the alarm system that can compromise the emergency response to a fire, affecting all patients and staff in both smoke zones. The facility has a capacity of 12 with a census of 4 at the time of this survey.

During the survey on 2/15/18 between 12:30 PM and 4:00 PM and on 2/16/18 between 8:30 AM and 11:00 AM:

Findings include:

On 2/16/18 at 8:43 AM: The annual sprinkler test documentation notes that the flow switch was tested manually because the main drain was not plumbed to the outside or a drain. There is an inspectors test on the opposite end of the building that is plumbed to the outside. The vendor was unaware of the inspectors test. When the surveyor checked the monitoring logs, there was no alarm activation received by the monitoring agency on the day of the annual sprinkler inspection. The vendor was not able to recall whether they put the panel into walk test. A test of the flow switch activation and subsequent alarm activation was completed during the survey and the flow switch was activated via the inspector's test alarming the notification devices in 28 seconds.

The Administrator and Maintenance Technician were present and acknowledged the finding.

NFPA Standard: Automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25 per 2012 NFPA 101, 9.7.5.

5.3.3.3 Testing waterflow alarm devices on wet pipe systems
shall be accomplished by opening the inspector ' s test connection.

Based on observation and staff interview the facility fails to maintain smoke barriers to at least one half hour fire resistance. This deficient practice would prevent containment of fire and smoke, affecting all patients and staff in both smoke zones. The facility has a capacity of 12 and census of 4 at the time of the survey.

During the survey on 2/15/18 between 12:30 PM and 4:00 PM and on 2/16/18 between 8:30 AM and 11:00 AM:

Findings include:

On 2/16/18 at 10:12 AM: There is a .75 inch unsealed penetration around a cable that is through the smoke barrier wall viewed above the ceiling in the corridor outside of the cafeteria.

The Administrator and Maintenance Technician were present and acknowledged the finding.

Review of the following NFPA Standard revealed: Any required smoke barrier shall be constructed in accordance with Section 8.5 and shall have a minimum ½ hour fire resistance rating, unless otherwise permitted by one of the following:

(1) This requirement shall not apply where an atrium is used, and both of the following criteria also shall apply: (a) Smoke barriers shall be permitted to terminate at an atrium wall constructed in accordance with 8.6.7 (1) (c). (b) Not less than two separate smoke compartments shall be provided on each floor.

(2) Smoke dampers shall not be required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air conditioning systems where an approved, supervised automatic sprinkler system in accordance with 19.3.5.8 has been provided for smoke compartments adjacent to the smoke barrier. 2012 NFPA 101, 19.3.7.3

Review of the following NFPA Standard revealed: 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. Smoke barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces. 2012 NFPA 101, 8.5.2.1 and 8.5.2.2

Review of the following NFPA Standard revealed: The provisions of 8.5.6 shall govern the materials and methods of construction used to protect through penetrations and membrane penetrations of smoke barriers. Penetrations for cables, cable trays, conduits, pipes, tubes, vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a smoke barrier, or through the ceiling membrane of the roof/ceiling of a smoke barrier assembly, shall be protected by a system or material capable of restricting the transfer of smoke. Where a smoke barrier is also constructed as a fire barrier, the penetrations shall be protected in accordance with the requirements of 8.3.5 to limit the spread of fire for a time period equal to the fire resistance rating of the assembly and 8.5.6 to restrict the transfer of smoke, unless the requirements of 8.5.6.4 are met. Where sprinklers penetrate a single membrane of a fire resistance rated assembly in buildings equipped throughout with an approved automatic fire sprinkler system, noncombustible escutcheon plates shall be permitted, provided that the space around each sprinkler penetration does not exceed 112 in. (13 mm), measured between the edge of the membrane and the sprinkler. Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be securely set in the smoke barrier, and the space between the item and the sleeve shall be filled with a material capable of restricting the transfer of smoke. 2012 NFPA 101, 8.5.6.1 through 8.5.6.5.

Based on observation and staff interview, the facility did not ensure that electrical wiring and equipment is installed and maintained in accordance with NFPA 99, Health Care Facility Code. This deficient practice does not ensure prevention of an electrical fire or electric shock hazard, affecting all occupants in both smoke zone. This facility has a capacity of 12 and a census of 4.

During the survey on 2/15/18 between 12:30 PM and 4:00 PM and on 2/16/18 between 8:30 AM and 11:00 AM:

Findings include:

1. On 2/16/18 at 10:18 AM: There are (2) non-approved power strips powering patient care related electrical equipment in the sonogram/treatment room.

2. On 2/16/18 at 9:35 AM: There are (3) non-approved power strips powering non-patient care related electrical equipment in the physical therapy room.

The Administrator and Maintenance Technician were present and acknowledged the finding.


Review of the following NFPA Standard revealed: Two or more power receptacles supplied by a flexible cord shall be permitted to be used to supply power to plug-connected components of a movable equipment assembly that is rack-, table-, pedestal-, or cartmounted, provided that all of the following conditions are met:

(1) The receptacles are permanently attached to the equipment assembly.

(2)The sum of the ampacity of all appliances connected to the outlets does not exceed 75 percent of the ampacity of the flexible cord supplying the outlets.

(3) The ampacity of the flexible cord is in accordance with NFPA 70, National Electrical Code.

(4) The electrical and mechanical integrity of the assembly is regularly verified and documented.

(5) Means are employed to ensure that additional devices or nonmedical equipment cannot be connected to the multiple outlet extension cord after leakage currents have been verified as safe. (NFPA 99) 10.2.3.6 Power strips would not be permitted for beds & chair lifts as these applications would not meet the general precautions as they could subject power strips to damage and overload. In addition, an oxygen concentrator would be considered an appliance for therapeutic purposes and therefore it would be considered line-operated medical equipment.

NFPA Standard: NFPA 70 2011, 400.8 Uses Not Permitted. Unless specifically permitted in 400.7, flexible cords and cables shall not be used for the following: (1) As a substitute for the fixed wiring of a structure (2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors (3) Where run through doorways, windows, or similar openings (4) Where attached to building surfaces Exception to (4): Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of 368.56(B) (5) Where concealed by walls, floors, or ceilings or located above suspended or dropped ceilings (6) Where installed in raceways, except as otherwise permitted in this Code (7) Where subject to physical damage