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Section 9.6.5 Emergency Control
9.6.5.1: A fire alarm and control system, where required by another section of this Code, shall be arranged to actuate automatically the control functions necessary to make the protected premises safer for building occupants.

9.6.5.2: Where required by another section of this Code, the following functions shall be actuated by the complete fire alarm system:
(1) Release of hold-open devices for doors or other opening protectives
(2) Stairwell or elevator shaft pressurization
(3) Smoke management or smoke control systems
(4) Emergency lighting control
(5) Unlocking of doors.


Based on observation, interview, and document review, the facility failed to ensure doors in smoke barriers automatically closed upon activation of the fire alarm system.

Findings include:

The smoke/fire barriers throughout the facility had cross-corridor doors that were held open with magnetic hold open devices. Upon activation of the fire alarm system by manual pull stations on 3/24/10, 3/25/10, and 3/26/10 on the first floor, second floor, third floor, and fourth floor, the magnetic hold open devices did not automatically release to allow the closure of the doors.

On 3/23/10 through 3/26/10, the Director of Maintenance (Chief Engineer) indicated the fire alarm system was not set up to release the smoke barrier doors upon activation of the manual pull station of the fire alarm system. He further indicated that the system was designed to release the hold open devices with the activation of the smoke detection system and the automatic sprinkler system to allow the smoke barrier doors to close.

On 3/25/10, the Maintenance Director provided an undated, and unknown version, copy of the building plans indicating there was no response with the manual controls of the fire alarm system for the closure of doors held open with hold open devices.

Based on observation, the facility failed to ensure a width of 8 feet was maintained free and clear in corridors within the facility.

Findings include:

1. On 3/23/10, 3/24/10, 3/25/10, and 3/26/10, the Emergency Department had stored soiled linen carts on the corridors, reducing the width to 6 1/2 feet.

2. On 3/25/10, the following areas on the fourth floor had corridors which contained stored equipment, reducing the width of the corridors from the required 8 feet:

a) The corridor by Room #442 had a stored gurney reducing 1 corridor width to 6 feet.

b) The corridor by Room #407 had a stored bed and a scale reducing the corridor width to 4 1/2 feet.

3. On 3/26/10, the following areas had corridors with stored equipment, reducing the width of the corridors from the required 8 feet:

a) The Emergency Department had a gurney stored in the corridor reducing the corridor width to 6 feet.

b) The second floor Labor and Delivery unit had stored soiled linen carts reducing the corridor width to 6 1/2 feet.

Based on document review and interview, the facility failed to ensure fire drills were conducted at least quarterly on each shift and as required for the night shift.

Findings include:

On 3/23/10, the Director of Maintenance indicated the shifts were as follows:

Day Shift = 7:00 AM - 3:30 PM;
Swing Shift = 3:30 PM - 11:30 PM;
Night Shift = 11:30 PM to 7:00 AM.

On 3/23/10, the fire drill records indicated the times and dates of the following fire drills:

3/14/09: 1035 (10:35 AM) (Day Shift);
5/13/09: 0958 (9:58 AM) (Day Shift);
6/2/09: 1825 (6:25 PM) (Swing Shift);
7/8/09: 0040 (12:40 AM) (Night Shift - "Paper Drill");
8/17/09: 2310 (11:10 PM) (Night Shift - "Paper Drill");
9/18/09: 0715 (7:15 AM) (Day Shift);
10/27/09: 0604 (6:04 AM) (Night Shift - "Paper Drill");
11/23/09: 2018 (8:18 PM) (Swing Shift);
12/25/09: 2300 (11:00 PM) (Night Shift - "Paper Drill");
1/25/10: 1309 (1:09 PM) (Swing Shift);
2/16/10: 0959 (9:58 AM) (Day Shift).

1) The Director of Maintenance further indicated that on the Night Shift, a "paper drill" was conducted. He indicated a "paper drill" did not include activation of the audible fire alarm system (allowed for night shift) or a coded announcement (required for night shift if no fire alarm actuation). The Director of Maintenance further indicated the regular practice of the night shift fire drill did not include a simulation by employees of the fire drill. The facility's procedure included a Security Guard walking to the area in which the fire drill was to be conducted and questioning the nursing staff what they would do in the event of a fire emergency (not acceptable).

2) The following fire drills were either missing or not conducted over the past twelve months:

a) No Night shift drill for the second quarter of 2009.
b) No Swing shift drill for the third quarter of 2009.
c) No Day shift drill for the fourth quarter of 2009.

NFPA 72:

Section 10.4.3 Testing Frequency
10.4.3.2: Sensitivity shall be checked within one year after installation.

10.4.3.2.2: Sensitivity shall be checked every alternate year thereafter unless other permitted by compliance with 10.4.3.2.3.

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

10.4.3.2.4: To ensure that each smoke detector or smoke alarm is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method.
(2) Manufacturer's calibrated sensitivity test instrument.
(3) Listed control equipment arranged for that purpose.
(4) Smoke detector / control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range.
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction.

Based on interview and document review, the facility failed to ensure smoke detectors were tested for sensitivity.

Findings include:

Note: The facility was initially licensed and certified in 2004.

There was no documented evidence of sensitivity testing of the smoke detection system.

On 3/23/10 through 3/26/10, the Director of Maintenance acknowledged there was no sensitivity testing conducted.

NFPA 25 (National Fire Protection Association), Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems:

Chapter 3 Standpipe and Hose Systems
Section 3-1: This chapter provides the minimum requirements for the routine inspection, testing, and maintenance of standpipe and hose systems. Table 3-1 shall be used to determine the minimum required frequencies for inspection, testing, and maintenance.

NFPA 25, Table 3-1 Summary of Standpipe and Hose System Inspection, Testing, and Maintenance.

Hose: Annual Inspections, Test 5 years/3 years;
Hose Nozzle: Annual Test;
Hose Connections: Quarterly Inspections, Annual Maintenance.


Based on observation and interview, the facility failed to maintain the automatic fire sprinkler system.

Findings include:

1. On 3/24/10 and 3/25/10, the following areas had sprinkler heads with foreign matter.

a. On the First Floor, in the pre-op room (pre operating room) there were 13 automatic sprinkler heads with foreign matter.
b. There were 2 automatic sprinkler heads covered with foreign matter located in the hallways by the Operating Rooms.
c. There was 1 automatic sprinkler head covered with foreign matter in the third floor Staff Lounge;
d. There was 1 automatic sprinkler head covered with foreign matter in the third floor Medication Prep (Preparation) Room;
e. There was 1 automatic sprinkler head covered with foreign matter in the fourth floor Staff Lounge;
f. There was 1 automatic sprinkler head covered with foreign matter in the fourth floor Storage Room;
g. There was 1 automatic sprinkler head covered with foreign matter in the fourth floor Soiled Utility Room.

2. The hose stations throughout the facility were equipped with an inspection tag which indicated the most recent testing and inspection by a certified professional was dated December 2003.

On 3/25/10 and 3/26/10, the Director of Maintenance confirmed that the most recent testing and inspections of the hose stations were completed in 2003.

Based on observation and interview, the facility failed to provide metal containers with self-closing cover devices in the designated smoking areas.

Findings include:

On 3/23/10, the Director of Maintenance acknowledged that there were designated smoking areas in the following locations:

a. The smoking patio south of the front entrance was the designated smoking area for employees, visitors, and patients.
b. Rear entrance of the Central Supply Room - smoking area designated for employees;
c. Exterior of the OR (Operating Room) / Recovery Unit; and
d. Outside area at the northeast side of the building.

On 3/23/10, 3/24/10, 3/25/10, and 3/26/10, there were no metal containers with self-closing covers available at the smoking areas at the front entrance, rear entrance at the Central Supply Room, and exterior to the OR and Recovery Unit.

Based on document review and interview, the facility failed to ensure the generator was inspected on a weekly basis.

Findings include:

The maintenance records of the generator testing included testing and inspection on 3/6/09, 4/3/09, 5/1/09, 6/5/09, 7/6/09, 8/7/09, 9/11/09, 10/2/09, 12/11/09, 1/18/10, 2/25/10, and 3/4/10. There was no documented evidence of weekly inspections of the generator.

On 3/23/10, the Director of Maintenance acknowledged it was the regular practice of the facility to inspect the generator only on a monthly basis, and not weekly.

Section 9.6.5 Emergency Control
9.6.5.1: A fire alarm and control system, where required by another section of this Code, shall be arranged to actuate automatically the control functions necessary to make the protected premises safer for building occupants.

9.6.5.2: Where required by another section of this Code, the following functions shall be actuated by the complete fire alarm system:
(1) Release of hold-open devices for doors or other opening protectives
(2) Stairwell or elevator shaft pressurization
(3) Smoke management or smoke control systems
(4) Emergency lighting control
(5) Unlocking of doors.


Based on observation, interview, and document review, the facility failed to ensure doors in smoke barriers automatically closed upon activation of the fire alarm system.

Findings include:

The smoke/fire barriers throughout the facility had cross-corridor doors that were held open with magnetic hold open devices. Upon activation of the fire alarm system by manual pull stations on 3/24/10, 3/25/10, and 3/26/10 on the first floor, second floor, third floor, and fourth floor, the magnetic hold open devices did not automatically release to allow the closure of the doors.

On 3/23/10 through 3/26/10, the Director of Maintenance (Chief Engineer) indicated the fire alarm system was not set up to release the smoke barrier doors upon activation of the manual pull station of the fire alarm system. He further indicated that the system was designed to release the hold open devices with the activation of the smoke detection system and the automatic sprinkler system to allow the smoke barrier doors to close.

On 3/25/10, the Maintenance Director provided an undated, and unknown version, copy of the building plans indicating there was no response with the manual controls of the fire alarm system for the closure of doors held open with hold open devices.

Based on observation, the facility failed to ensure a width of 8 feet was maintained free and clear in corridors within the facility.

Findings include:

1. On 3/23/10, 3/24/10, 3/25/10, and 3/26/10, the Emergency Department had stored soiled linen carts on the corridors, reducing the width to 6 1/2 feet.

2. On 3/25/10, the following areas on the fourth floor had corridors which contained stored equipment, reducing the width of the corridors from the required 8 feet:

a) The corridor by Room #442 had a stored gurney reducing 1 corridor width to 6 feet.

b) The corridor by Room #407 had a stored bed and a scale reducing the corridor width to 4 1/2 feet.

3. On 3/26/10, the following areas had corridors with stored equipment, reducing the width of the corridors from the required 8 feet:

a) The Emergency Department had a gurney stored in the corridor reducing the corridor width to 6 feet.

b) The second floor Labor and Delivery unit had stored soiled linen carts reducing the corridor width to 6 1/2 feet.

Based on document review and interview, the facility failed to ensure fire drills were conducted at least quarterly on each shift and as required for the night shift.

Findings include:

On 3/23/10, the Director of Maintenance indicated the shifts were as follows:

Day Shift = 7:00 AM - 3:30 PM;
Swing Shift = 3:30 PM - 11:30 PM;
Night Shift = 11:30 PM to 7:00 AM.

On 3/23/10, the fire drill records indicated the times and dates of the following fire drills:

3/14/09: 1035 (10:35 AM) (Day Shift);
5/13/09: 0958 (9:58 AM) (Day Shift);
6/2/09: 1825 (6:25 PM) (Swing Shift);
7/8/09: 0040 (12:40 AM) (Night Shift - "Paper Drill");
8/17/09: 2310 (11:10 PM) (Night Shift - "Paper Drill");
9/18/09: 0715 (7:15 AM) (Day Shift);
10/27/09: 0604 (6:04 AM) (Night Shift - "Paper Drill");
11/23/09: 2018 (8:18 PM) (Swing Shift);
12/25/09: 2300 (11:00 PM) (Night Shift - "Paper Drill");
1/25/10: 1309 (1:09 PM) (Swing Shift);
2/16/10: 0959 (9:58 AM) (Day Shift).

1) The Director of Maintenance further indicated that on the Night Shift, a "paper drill" was conducted. He indicated a "paper drill" did not include activation of the audible fire alarm system (allowed for night shift) or a coded announcement (required for night shift if no fire alarm actuation). The Director of Maintenance further indicated the regular practice of the night shift fire drill did not include a simulation by employees of the fire drill. The facility's procedure included a Security Guard walking to the area in which the fire drill was to be conducted and questioning the nursing staff what they would do in the event of a fire emergency (not acceptable).

2) The following fire drills were either missing or not conducted over the past twelve months:

a) No Night shift drill for the second quarter of 2009.
b) No Swing shift drill for the third quarter of 2009.
c) No Day shift drill for the fourth quarter of 2009.

NFPA 72:

Section 10.4.3 Testing Frequency
10.4.3.2: Sensitivity shall be checked within one year after installation.

10.4.3.2.2: Sensitivity shall be checked every alternate year thereafter unless other permitted by compliance with 10.4.3.2.3.

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

10.4.3.2.4: To ensure that each smoke detector or smoke alarm is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method.
(2) Manufacturer's calibrated sensitivity test instrument.
(3) Listed control equipment arranged for that purpose.
(4) Smoke detector / control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range.
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction.

Based on interview and document review, the facility failed to ensure smoke detectors were tested for sensitivity.

Findings include:

Note: The facility was initially licensed and certified in 2004.

There was no documented evidence of sensitivity testing of the smoke detection system.

On 3/23/10 through 3/26/10, the Director of Maintenance acknowledged there was no sensitivity testing conducted.

NFPA 25 (National Fire Protection Association), Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems:

Chapter 3 Standpipe and Hose Systems
Section 3-1: This chapter provides the minimum requirements for the routine inspection, testing, and maintenance of standpipe and hose systems. Table 3-1 shall be used to determine the minimum required frequencies for inspection, testing, and maintenance.

NFPA 25, Table 3-1 Summary of Standpipe and Hose System Inspection, Testing, and Maintenance.

Hose: Annual Inspections, Test 5 years/3 years;
Hose Nozzle: Annual Test;
Hose Connections: Quarterly Inspections, Annual Maintenance.


Based on observation and interview, the facility failed to maintain the automatic fire sprinkler system.

Findings include:

1. On 3/24/10 and 3/25/10, the following areas had sprinkler heads with foreign matter.

a. On the First Floor, in the pre-op room (pre operating room) there were 13 automatic sprinkler heads with foreign matter.
b. There were 2 automatic sprinkler heads covered with foreign matter located in the hallways by the Operating Rooms.
c. There was 1 automatic sprinkler head covered with foreign matter in the third floor Staff Lounge;
d. There was 1 automatic sprinkler head covered with foreign matter in the third floor Medication Prep (Preparation) Room;
e. There was 1 automatic sprinkler head covered with foreign matter in the fourth floor Staff Lounge;
f. There was 1 automatic sprinkler head covered with foreign matter in the fourth floor Storage Room;
g. There was 1 automatic sprinkler head covered with foreign matter in the fourth floor Soiled Utility Room.

2. The hose stations throughout the facility were equipped with an inspection tag which indicated the most recent testing and inspection by a certified professional was dated December 2003.

On 3/25/10 and 3/26/10, the Director of Maintenance confirmed that the most recent testing and inspections of the hose stations were completed in 2003.

Based on observation and interview, the facility failed to provide metal containers with self-closing cover devices in the designated smoking areas.

Findings include:

On 3/23/10, the Director of Maintenance acknowledged that there were designated smoking areas in the following locations:

a. The smoking patio south of the front entrance was the designated smoking area for employees, visitors, and patients.
b. Rear entrance of the Central Supply Room - smoking area designated for employees;
c. Exterior of the OR (Operating Room) / Recovery Unit; and
d. Outside area at the northeast side of the building.

On 3/23/10, 3/24/10, 3/25/10, and 3/26/10, there were no metal containers with self-closing covers available at the smoking areas at the front entrance, rear entrance at the Central Supply Room, and exterior to the OR and Recovery Unit.

Based on document review and interview, the facility failed to ensure the generator was inspected on a weekly basis.

Findings include:

The maintenance records of the generator testing included testing and inspection on 3/6/09, 4/3/09, 5/1/09, 6/5/09, 7/6/09, 8/7/09, 9/11/09, 10/2/09, 12/11/09, 1/18/10, 2/25/10, and 3/4/10. There was no documented evidence of weekly inspections of the generator.

On 3/23/10, the Director of Maintenance acknowledged it was the regular practice of the facility to inspect the generator only on a monthly basis, and not weekly.