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Based on observation and interview, the facility failed to ensure 1 of 2 fire barriers that separated other occupancies were protected to maintain the one hour fire resistance rating of the fire barrier. NFPA 101 2012 edition 8.3.5.6.1 states membrane penetrations for cables cable trays conduits, pipes, tubes, combustion vents and exhaust vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a membrane of a wall, floor, or floor/ceiling assembly constructed as a fire barrier shall be protected by a firestop system or device. 8.3.5.6.2 The firestop system or device shall be tested in accordance with ASTM E 814, Standard Test Method for Fire Test of Through Penetration Fire stops, or ANSI/UL 1479, Standard for Fire Tests of Through-Penetration Firestops. This deficient practice could affect all occupants.

Findings include:

Based on observations during a tour of the facility with the Maintenance Supervisor and the Vice President of Information Support Operations on 5/09/17 at 2:20 p.m., in the north fire wall that separates the surgery area form an office occupancy contained 10 unsealed one inch penetrations around piping, wires, and conduits. Based on interview at the time of observation, the Maintenance Supervisor and the Vice President of Information Support Operations acknowledged the penetrations.

1. Based on interview, the facility failed to ensure testing for 6 of 6 emergency battery powered lighting units. NFPA 101 in 4.6.12.3 states existing life safety features obvious to the public, if not required by the Code, shall be maintained. LSC 7.9.3.1.1 testing of required emergency lighting systems shall be permitted to be conducted as follows:
(1) Functional testing shall be conducted monthly, with a minimum of 3 weeks and a maximum of 5 weeks between tests, for not less than 30 seconds.
(2) The test interval shall be permitted to be extended beyond 30 days with approval of the authority having jurisdiction
(3) Functional testing shall be conducted annually for a minimum of 1 ½ hours if the emergency lighting is battery powered.
(4) The emergency lighting equipment shall be fully operational for the duration of the test.
(5) Written records of visual inspections and tests shall be kept by the owner for inspection for the authority having jurisdiction
This deficient practice could affect all occupants if the facility were required to evacuate in an emergency during a loss of normal power.

Findings include:

Based on observations during a tour of the facility with the Vice President of Information Support Operations on 5/09/17 between 11:00 a.m. 11:30 am, there were six battery power emergency lights observed in the facility. Based on a records review with the Maintenance Supervisor at 1:15 p.m., no written records of an annual 1 ½ hour functional test or a 30 second month test was available for review. Based on interview at the time of record review, the Maintenance Supervisor acknowledged no documentation was available for review.

2. Based on observation and interview, the facility failed to ensure the corridor door to 1 of 1 hazardous rooms with fuel fired equipment, was provided with a fire rated door. LSC 39.3.2.1 states hazardous areas including, but not limited to, areas used for general storage, boiler or furnace rooms, and maintenance shops shall be protected in accordance with section 8.7. LSC 8.7.1.3 doors in barriers required to have a fire resistant rating shall have a minimum ¾-hour fire protection rating and shall be self-closing in accordance with 7.2.1.8. This deficient practice could affect all occupants of the building.

Findings include:

Based on observations during a tour of the facility with the Vice President of Information Support Operations on 5/09/17 at 11:10 a.m., the door to the furnace room, which contained a fuel fired furnace and was not sprinkled, did not have a fire rated door. Based on interview, this was acknowledged by the Vice President of Information Support Operations at the time of observation.

Based on record review, interview and observation; the facility failed to ensure documentation for the preventative maintenance of 1 of 1 battery operated smoke alarms in the medical office building. NFPA 101 in 4.6.12.3 states existing life safety features obvious to the public, if not required by the Code, shall be maintained. This deficient practice could affect all residents, staff, and visitors.

Findings include:

Based on observations during a tour of the facility with the Vice President of Information Support Operations on 5/09/17 at 10:30 a.m., there was no report available of the battery operated smoke alarm tested for functionality on a monthly basis during the past twelve months. Based on interview, this was acknowledged by the Vice President of Information Support Operations at the time of record review.

1. Based on observation and interview, the facility failed to ensure the corridor door to 1 of 1 hazardous areas such as a combustible storage room over 50 square feet was provided with a self-closing device which would cause the door to automatically close and latch into the door frame. This deficient practice could affect 25 people in the front lobby.

Findings include:

Based on observations during a tour of the facility with the Maintenance Supervisor on 5/09/17 at 12:04 p.m., the door to the gift shop storage room from the volunteer office; which was open to the corridor, contained a large quantity of combustible items, and measured over 50 square feet; was not equipped with a self-closing device. Based on interview, this was acknowledged by the Maintenance Supervisor at the time of observation.

2. Based on observation and interview, the facility failed to ensure the corridor door to 1 of 1 OB soiled utility room doors was provided with a self-closing device which would cause the door to automatically close and latch into the door frame. This deficient practice could affect 10 patients in OB.

Findings include:

Based on observations during a tour of the facility with the Vice President of Information Support Operations on 05/09/17 at 11:00 a.m., the door to the OB soiled utility room, which contained soiled linen and trash greater than 64 gallons, was equipped with a self-closing device but did not latch into the frame. Based on interview, this was acknowledged by the Vice President of Information Support Operations at the time of observation.


3. Based on observation and interview, the facility failed to ensure 1 of 1 soiled utility room in behavioral health were separated from other spaces by smoke resisting partitions and doors. This deficient could affect up to 12 patients in behavior health.

Findings include:

Based on observations during a tour of the facility with the Maintenance Supervisor on 5/09/17 at 11:27 a.m., the behavior health soiled utility room, which contained soiled linen and trash greater than 64 gallons, contained four unsealed half inch penetrations in the ceiling around conduits. Based on an interview at the time of observation, the Maintenance Supervisor acknowledged the penetrations and provided the measurements.

Based on observation and interview, the facility failed to ensure the corridor door to 1 of 1 hazardous soiled Utility rooms were provided with a self-closing device which would cause the door to automatically close and latch into the door frame. This deficient practice could affect 2 patients in the OR.

Findings include:

Based on observations during a tour of the facility with the Maintenance Supervisor on 5/09/17 at 2:00 p.m., the door to soiled utility room; which contained soiled linen, trash, and medical waste; was not equipped with a self-closing device. Based on interview, this was acknowledged by the Maintenance Supervisor at the time of observation.

Based on record review and interview, the facility failed to provide a complete 1 of 1 written policy for the protection of patients indicating procedures to be followed in the event the fire alarm system has to be placed out of service for four hours or more in a twenty four hour period in accordance with LSC, Section 9.6.1.6. This deficient practice affects all occupants.

Findings include:

Based on record review with the Maintenance Supervisor and Vice President of Information Support Operations on 05/09/17 at 9:18 a.m., the facility provided fire watch documentation but it was incomplete due to the following:
a) The fire watch plan did not distinguish between fire alarm outage and sprinkler system outage.
b) The fire watch plan did not state that only trained personnel can conduct a fire watch.
c) The fire watch plan did not indicate the person(s) conducting the fire watch shall be dedicated to the fire watch and have no other duties.
d) The fire watch plan did not list the call to Indiana State Department of Health, the insurance company, hospital leadership, and the fire alarm monitoring company when after the system has been down more than four hours.
Based on an interview record review, the Maintenance Supervisor and Vice President of Information Support Operations acknowledged the aforementioned condition.

Based on record review and interview, the facility failed to provide a complete 1 of 1 written policy for the protection of residents indicating procedures to be followed in the event the fire alarm system has to be placed out of service for four hours or more in a twenty four hour period in accordance with LSC, Section 9.6.1.6. This deficient practice affects all occupants.

Findings include:

Based on record review with the Maintenance Supervisor and Vice President of Information Support Operations on 05/09/17 at 9:18 a.m., the facility provided fire watch documentation but it was incomplete due to the following:
a) The fire watch plan did not distinguish between fire alarm outage and sprinkler system outage.
b) The fire watch plan did not state that only trained personnel can conduct a fire watch.
c) The fire watch plan did not indicate the person(s) conducting the fire watch shall be dedicated to the fire watch and have no other duties.
d) The fire watch plan did not list the call to Indiana State Department of Health, the insurance company, hospital leadership, and the fire alarm monitoring company when after the system has been down more than four hours.
Based on an interview record review, the Maintenance Supervisor and Vice President of Information Support Operations acknowledged the aforementioned condition.

Based on observation and interview, the facility failed to ensure complete automatic sprinkler system was provided for 2 of 2 closets in and 1 of 1 IT rooms accordance with NFPA 13-2010, Standard for the Installation of Sprinkler Systems, to provide complete coverage for all portions of the building. This deficient practice could affect up to 30 people in two first floor smoke compartments.

Findings include:

Based on observations during a tour of the facility with the Maintenance Supervisor on 05/09/17 between 10:50 a.m. and 1:10 p.m., the following areas lacked sprinkler coverage:
a) The Marketing Office closet that was used for storage did not contain a sprinkler in the closet.
b) The Customer Relations Office closet that was used for storage did not contain a sprinkler in the closet.
c) The back half of the IT room was not covered by the one sprinkler in the room. The one sprinkler head was located near the door would not provide coverage to the back of the room because a little past center of the room there was an IT tower six inches below the bottom of a 11 inch header leaving only a six inch gap for water to pass through.
Based on an interview at the time of observation, the Maintenance Supervisor acknowledged the aforementioned areas lacked sprinkler coverage.

1. Based on record review and interview, the facility failed to provide written documentation or other evidence the sprinkler system gauges and valves had been inspected for 12 of 12 past months. LSC 4.6.12.1 requires any device, equipment or system required for compliance with this code be maintained in accordance with applicable NFPA requirements. Sprinkler systems shall be properly maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. NFPA 25, 4.3.1 requires records shall be made for all inspections, tests, and maintenance of the system components and shall be made available to the authority having jurisdiction upon request. 4.3.2 Requires that records shall indicate the procedure performed (e.g., inspection, test, or maintenance), the organization that performed the work, the results, and the date. NFPA 25, 5.2.4.1 states gauges on wet pipe sprinkler systems shall be inspected monthly to ensure that they are in good condition and that normal supply pressure is being maintained. NFPA 25, 13.3.2.1.1 states valves secured with locks or supervised in accordance with applicable NFPA standards shall be permitted to be inspected monthly. This deficient practice could affect all patients, staff, and visitors in the facility.

Findings include:

Based on record review with the Maintenance Supervisor and Vice President of Information Support Operations on 05/09/17 at 10:11 a.m., there was no monthly inspection of all of the sprinkler system's gauges and valves available for review. Only one gauge out of five were inspected monthly. During an interview at the time of record review, the Maintenance Supervisor and Vice President of Information Support Operations acknowledged there was no written documentation available to show all of the sprinkler system's gauges and valves had been inspected monthly.


2. Based on record review, observation and interview; the facility failed to ensure 1 of 4 sprinkler system gauges were replaced every 5 years or documented as tested every 5 years by comparison with a calibrated gauge. NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition, Section 5.3.2.1 states 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. This deficient practice could affect all patients, visitors and staff in the facility.

Findings include:

Based on observations during a tour of the facility with the Maintenance Supervisor on 5/09/17 at 11:55 a.m., the three sprinkler gauges on the pre-action riser for the imaging center had a date of 2011 listed on the face of the sprinkler gauge. Based on interview at the time of the observation, the Maintenance Supervisor acknowledged the sprinkler gauge was more than five years old.

Based on record review and interview, the facility failed to provide written documentation or other evidence the sprinkler system gauges and valves had been inspected for 12 of 12 past months. LSC 4.6.12.1 requires any device, equipment or system required for compliance with this code be maintained in accordance with applicable NFPA requirements. Sprinkler systems shall be properly maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. NFPA 25, 4.3.1 requires records shall be made for all inspections, tests, and maintenance of the system components and shall be made available to the authority having jurisdiction upon request. 4.3.2 requires that records shall indicate the procedure performed (e.g., inspection, test, or maintenance), the organization that performed the work, the results, and the date. NFPA 25, 5.2.4.1 states gauges on wet pipe sprinkler systems shall be inspected monthly to ensure that they are in good condition and that normal supply pressure is being maintained. NFPA 25, 13.3.2.1.1 states valves secured with locks or supervised in accordance with applicable NFPA standards shall be permitted to be inspected monthly. This deficient practice could affect all residents, staff, and visitors in the facility.

Findings include:

Based on record review with the Maintenance Supervisor and Vice President of Information Support Operations on 05/09/17 at 10:11 a.m., there was no monthly inspection of the sprinkler system's gauges and valves available for review. During an interview at the time of record review, the Maintenance Supervisor and Vice President of Information Support Operations acknowledged there was no written documentation available to show the sprinkler system's gauges and valves had been inspected monthly.

Based on record review and interview, the facility failed to provide a complete 1 of 1 written policy for the protection of patients indicating procedures to be followed in the event the fire sprinkler system has to be placed out of service for ten hours or more in a twenty four hour period in accordance with LSC, Section 9.6.1.6. This deficient practice affects all occupants.

Findings include:

Based on record review with the Maintenance Supervisor and Vice President of Information Support Operations on 05/09/17 at 9:18 a.m., the facility provided fire watch documentation but it was incomplete due to the following:
a) The fire watch plan did not distinguish between fire alarm outage and sprinkler system outage.
b) The fire watch plan did not state that only trained personnel can conduct a fire watch.
c) The fire watch plan did not indicate the person(s) conducting the fire watch shall be dedicated to the fire watch and have no other duties.
d) The fire watch plan did not list the call to Indiana State Department of Health, the insurance company, hospital leadership, and the fire alarm monitoring company when after the system has been down more than 10 hours.
Based on an interview record review, the Maintenance Supervisor and Vice President of Information Support Operations acknowledged the aforementioned condition.

Based on record review and interview, the facility failed to provide a complete 1 of 1 written policy for the protection of residents indicating procedures to be followed in the event the fire sprinkler system has to be placed out of service for ten hours or more in a twenty four hour period in accordance with LSC, Section 9.6.1.6. This deficient practice affects all occupants.

Findings include:

Based on record review with the Maintenance Supervisor and Vice President of Information Support Operations on 05/09/17 at 9:18 a.m., the facility provided fire watch documentation but it was incomplete due to the following:
a) The fire watch plan did not distinguish between fire alarm outage and sprinkler system outage.
b) The fire watch plan did not state that only trained personnel can conduct a fire watch.
c) The fire watch plan did not indicate the person(s) conducting the fire watch shall be dedicated to the fire watch and have no other duties.
d) The fire watch plan did not list the call to Indiana State Department of Health, the insurance company, hospital leadership, and the fire alarm monitoring company when after the system has been down more than 10 hours.
Based on an interview record review, the Maintenance Supervisor and Vice President of Information Support Operations acknowledged the aforementioned condition.

Based on record review and interview, the facility failed to conduct quarterly fire drills for 1 of 4 quarters. LSC 19.7.1.6 requires drills to be conducted quarterly on each shift under varied conditions. This deficient practice affects all staff and patients.

Findings include:

Based on record review with the Maintenance Supervisor and Vice President of Information Support Operations on 05/09/17 at 9:18 a.m., there was no documentation for a second shift fire drill in the third quarter of 2016. Based on interview at the time of record review, the Maintenance Supervisor and Vice President of Information Support Operations acknowledged the aforementioned condition.

Based on observation and interview, the facility failed to ensure there were battery-powered lighting for 2 of 2 anesthesia areas. NFPA 99 2012 edition 6.3.2.2.11.1 states one or more battery-powered lights shall be provided within locations where deep sedation and general anesthesia is administered. 6.3.2.2.11.2 The lighting level of each unit shall be sufficient to terminate procedures intended to be performed within the operating room. This deficient practice could affect two patients, and staff during surgery.

Findings include:

Based on observations during a tour of the facility with the Vice President of Information Support Operations and the Maintenance Supervisor on 5/09/17 at 2:15 p.m., operating rooms one and two did not have battery-powered lighting. Based on interview at the time of observation, the Maintenance Supervisor and the Vice President of Information Support Operations acknowledged both operating rooms that used deep sedation and general anesthesia did not have backup battery-powered lighting.

Based on observation and interview, the facility failed to ensure there were ground-fault circuit interrupters (GFCI) for 2 of 2 wet procedure locations in the O.R. This deficient practice could affect two patients, and staff during surgery.

Findings include:

Based on observations during a tour of the facility with the Maintenance Supervisor and the Vice President of Information Support Operations on 5/09/17 at 2:14 p.m., all of the electrical outlets in O.R. rooms one and two did not have GFCI protection. Based on interview at the time of observation, the Maintenance Supervisor and the Vice President of Information Support Operations acknowledged all outlets were not GFCI protected and stated there was not a risk assessment conducted to show the outlets could be unprotected by a GFCI.

Based on record review and interview, the facility failed to ensure 2 of 2 emergency generators ran 30 minutes under load monthly and was allowed a 5 minute cool down period after a load test. NFPA 99, 2012, Chapter 6.4.4.1.1.4(a), requires monthly testing of the generator serving the emergency electrical system to be in accordance with NFPA 110, 2010. Chapter 8.4.2 states diesel generators sets in service shall be exercised at least once a month for a minimum of 30 minutes and 8.4.2.4 states Spark-ignited generator sets shall be exercised at least once a month with the available EPSS load for 30 minutes. 6.2.10 Time Delay on Engine Shutdown requires that a minimum time delay of 5 minutes shall be provided for unloaded running of the Emergency Power Supply (EPS) prior to shut down. This delay provides additional engine cool down. This time delay shall not be required on small (15 kW or less) air-cooled prime movers. This deficient practice could affect all occupants.

Findings include:

Based on record review with the Maintenance Supervisor and Vice President of Information Support Operations on 05/09/17 at 10:05 a.m., the generator log form documented the spark-ignited generator was tested monthly, however there was no documentation on the form that showed the generator ran for at least 30 minutes under load or had a cool down time of at least 5 minutes following its load test. Based on interview at the time of record review, the Maintenance Supervisor stated the generator did run under load for 30 minutes and had a cool down over five minutes but the times were not documented.

3.1-19(b)

1. Based on observation and interview, the facility failed to ensure a minimum distance of at least five feet separated combustible materials from oxygen storage equipment in 1 of 1 oxygen storage areas. NFPA 99, 11.3.2.3 requires oxidizing gases such as oxygen shall be separated from combustibles by one of the following: (1) a minimum distance of 20 feet. (2) a minimum distance of 5 feet if the required storage location is protected by an automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. (3) Enclosed cabinet of noncombustible construction having a minimum fire protection rating of ½ hour. This deficient practice could affect 20 people in one smoke compartment on the first floor.

Findings include:

Based on observation during a tour of the facility with the Maintenance Supervisor on 05/09/17 at 11:37 p.m., the liquid oxygen containers were stored in the Decontamination room next to and touching plastic barrels filled with decontamination supplies. Based on interview at the time of observation, the Maintenance Supervisor acknowledged combustible materials were stored within five feet of stationary liquid oxygen containers.

3.1-19(b)

2. Based on observation and interview, the facility failed to ensure 1 of 1 oxygen storage/transfer location was provided with a sign indicating that transferring is occurring. NFPA 99 11.5.2.3.1(3) states, the area is posted with signs indicating that trans-filling is occurring and that smoking is the immediate area is not permitted. This deficient practice could affect 20 people in one smoke compartment on the first floor.

Findings include:

Based on observation during a tour of the facility with the Maintenance Supervisor on 05/09/17 at 11:37 p.m., the oxygen storage/transfer room was labeled Decontamination room, which dose have a concert floor and mechanically vented, contained three liquid oxygen containers and one oxygen cylinders. The door to this room lacked a sign indicating that transferring of oxygen occurs in this location and oxygen was stored. Base on interview this was acknowledged by the Maintenance Supervisor at the time of observation.

3.1-19(b)

3. Based on observation and interview, the facility failed to ensure 1 of 1 oxygen trans-filling rooms was protected with a one hour fire-resistive construction by having a self-closing door in accordance with 2012 NFPA 99 11.5.2.3.1(1). This deficient practice could affect 20 people in one smoke compartment on the first floor.

Findings include:

Based on observation during a tour of the facility with the Maintenance Supervisor on 05/09/17 at 11:37 p.m., the oxygen storage/transfer room did have the proper rated door, but the door was not self-closing. Based on interview at the time of observation, the Director of Plant Operations acknowledged the aforementioned condition.