HospitalInspections.org

K-18 Not Met.
While inspecting the Thayer Unit CCU corridor with the hospital facilities manager, inspector observed the doors ( both sets) to the CCU area had a gap between them that exceeds the allowable amount allowed for a smoke resistant door. This was confirmed by the facilities manager.

K-29 Not Met.
Findings.
While surveying the Augusta Unit Emergency Room Inspector observed that the soiled utility room did not latch as required. This was confirmed by the Facility maintenance manager.

While surveying the Seton Unit Laundry ,Inspector observed that the middle door to the laundry area was damaged on the edges and would not close and latch as required. This was confirmed by the facility maintenance manager.

K-62 Not Met.
While reviewing the facilities records at the Augusta Unit, Inspector could not determine from the sprinkler reports that the required internal obstruction/investigation testing had been done in the last 5 years as required. Facility Maintenance manager advised that the testing has been scheduled.

K-73 Not Met.
While surveying the inpatient floors of the Augusta Unit this inspector observed that Christmas tree decorations on the trees could not be certified that they were fire retardant as required. This was confirmed by the facility maintenance manager and staff on the units.

K-130 Not Met Offsite locations as defined by the following findings.

Haynes Sleep Center.
1. Boiler room ceiling has penetrations not properly sealed .
2. Electrical junction box on ceiling in boiler room does not have an approved cover ( NFPA 70)

KMD Office site. E.
1. Fire door bottom of stair enclosure was wedged open.
2. Required emergency lights in the first floor corridor were not working.
3. Combustible storage was observed in the North stair tower 2nd floor level landing.

Hathaway Center.
1. Office exits 3rd floor not provided with approved AC/DC illuminated exit signs.
2. Southwest stair tower at 3rd floor level has numerous unsealed penetrations in the wall enclosures.



25654

Harold Alfond Center for Cancer Care:
361 Old Belgrade Road, Augusta
While surveying the Harold Alfond Center for Cancer Care with the facilities manager, the inspector observed the following conditions:
1. The door to the elevator machine room (public elevator by medical oncology) failed to positively latch in the closed position.
2. The soiled utility room located in medical oncology was observed to not have a self-closing device installed on the door.
3. Through review of records the inspector determined that there is potential concern over the water supply available for fire protection at the Alfond Center for Cancer Care. Between October 22, 2009 and November 9, 2010 flow rates according to annual hydrant testing data have declined:
Date: Hydrant: Flow: Date: Hydrant: Flow:
10/22/09 Main entrance 860 GPM 10/22/09 Back entrance 876 GPM
11/9/2010 Main entrance 735 GPM 11/9/2010 Back entrance 675 GPM
Decline: - 125 GPM Decline: - 201 GPM

It should be noted that both fire sprinkler risers located in the facility (one dry system and one wet system) were found by virtue of inspection/testing data to be within the design specifications for the respective systems at this time. The hydrants noted in the above tests are located on the water supply line that also supplies the fire protection systems (fire sprinkler and standpipe for the building). Further investigation into the significant flow declines observed during review of documentation is required.

Physical Therapy and Sports Medicine:
40 Granite Hill Road Suite # 2, Manchester
While surveying the Physical Therapy and Sports Medicine practice with the facilities manager, the inspector observed the following conditions:
1. The curtain in the pool room obstructs fire sprinkler discharge and must be lowered or replaced with a mesh curtain.
2. The outside landing (rear exit) was observed to have landscape materials in the egress path at the bottom of the stairs extending approximately 8 inches above adjacent grade. An even, travel surface must be provided without any tripping hazards.
3. The inspector observed at least two gasoline containers, gas powered machinery, and several flammable/combustible liquid containers being stored in the basement storage area. Flammable/combustible liquids must be removed from the building or appropriately stored in a listed flammable liquids storage cabinet.
4. The inspector examined facility records was not able to find evidence that the required five year internal/obstruction examination had been conducted on the building fire sprinkler system.

Winthrop Family Practice/Winthrop Pediatrics:
149 Main Street, Winthrop
While surveying Winthrop Family Practice with the facilities manager, the inspector observed the following conditions:
1. The dumbwaiter shaft enclosure lacks fire sprinkler coverage in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems section 8.15.2. No fire sprinkler coverage was observed in the dumbwaiter shaft. The shaft is accessible by two doors located on the second and third floors of the building.
2. The storage closet opposite door # 360 (lab door) in the Family Practice lacks fire sprinkler coverage. No fire sprinkler was observed to be located in the closet.
3. The storage closet (left side of the practice coordinators office) lacks fire sprinkler coverage. No fire sprinkler was observed to be located in the closet.
4. The shell space located off room # 334 was observed to have several unprotected openings (holes approximately 4 to 6 inches in diameter) between floor levels.
5. The emergency exit from the orthopedics area was found to lack adequate exit signage in the common space.
6. The building fire sprinkler system is due for the required five year internal/obstruction examination.

Gardiner Family Practice:
152 Dresden Avenue, Gardiner
While surveying Gardiner Family Practice with the facilities manager, the inspector observed the following conditions:
1. The fire door to the medical records storage area (opening into the stairwell) on the lower level does not positively latch in the closed position.
2. Through review of records the inspector did not find any evidence that sensitivity testing of smoke detection devices required by NFPA 72 National Fire Alarm Code had been conducted within the previous two year period. Fire alarm system inspection/test reports for 2009 and 2010 were reviewed.
3. The medical records storage area on the lower level of Gardiner Family Practice was found to store large quantities of paper based medical records from a number of Maine General facilities. The medical record storage area is not fully separated or protected as a hazard area from the rest of the structure as evidenced by the inspectors observations of the following:
a. The ceiling of the room(s) where the medical records were found to be stored was observed to be a suspended ceiling over wood joist construction. The ceiling assembly lacks any recognized fire resistive rating.
b. Medical records were observed to be stored in cardboard boxes on open shelving units.
c. The building/space was not observed to have any automatic fire suppression system present.


Diagnostic/Mammography and Geriatric Centers:
150 Dresden Avenue, Gardiner
While surveying the Diagnostic/Mammography and Geriatric Center with the facilities manager, the inspector observed the following conditions:
1. The exit door in the stairwell serving as a means of egress from the diagnostic center was observed to lack illuminated exit signage.
2. Through review of records the inspector did not find any evidence that sensitivity testing of smoke detection devices required by NFPA 72 National Fire Alarm Code had been conducted within the previous two year period. Fire alarm system inspection/test reports for 2009 and 2010 were reviewed.
3. Through review of facility records the inspector determined that documentation pertaining to the testing and inspection of the generator (EPSS) was insufficient. Documentation of monthly EPSS exercise was found from May of 2009 through September of 2009 only. At a minimum the documentation retained by the facility must meet the following requirements:
NFPA 110 Standard for Emergency and Standby Power Systems
8.3.4 A permanent record of the EPSS inspections, tests, exercising, operation, and repairs shall be maintained and readily available.
8.3.4.1 The permanent record shall include the following:
(1) The date of the maintenance report
(2) Identification of the servicing personnel
(3) Notation of any unsatisfactory condition and the corrective action taken, including parts replaced
(4) Testing of any repair for the time as recommended by the manufacturer


Augusta Family Medicine:
77 Sewell Street, Augusta
While surveying Augusta Family Medicine with the facilities manager, the inspector observed the following conditions:
1. Battery powered emergency lights in the following locations did not function when tested:
a. The waiting area.
b. The checkout area.
c. In the stairwell just outside the practice door opening into the stairwell.
d. The administration area.
2. The building fire sprinkler system is due for the required five year internal/obstruction examination.


Kennebec Pediatrics:
263 Water Street, Augusta
While surveying Kennebec Pediatrics with the facilities manager, the inspector observed the following conditions:
1. Through review of documentation pertaining to the facility fire sprinkler system, the following deficiencies were observed in the fire sprinkler system:
a. Recalled fire sprinkler heads (designated " GB " in the fire sprinkler inspection/test report) need to be replaced.
b. The building fire sprinkler system is due for the required five year internal/obstruction examination.
2. The lab processing area lacks fire sprinkler coverage. The lab processing area is separated from the adjacent space by means of a lintel 36 inches in depth.
3. The egress stair door at ground level was found to not positively latch in the closed position.
4. The egress stair door from the adolescent area was found to not positively latch in the closed position and was not capable of fully closing with the force applied by the self-closing device on the door.
5. The egress stair door from the adolescent area was found to open with excessive force.


Ervin Pediatric Center:
271 Water Street (Vickery Building), Augusta
While surveying the Ervin Pediatric Center with the facilities manager, the inspector observed the following conditions:
1. Through review of documentation pertaining to the facility fire sprinkler system, the following deficiencies were observed in the fire sprinkler system:
a. The date of the last main drain test is unknown.
b. Heads over 50 years old are present in the fire sprinkler system.
c. The building fire sprinkler system is due for the required five year internal/obstruction examination.
2. No self-closing device was observed on the door at the top of the stairs leading to the basement level of the building.
3. The drop from the exit to ground level at the exit from the rear of the building was observed at 12 inches with no intermediate step in place.
4. No self-closing device or mechanical means of latching were observed on the door at the top of the stairs to the rear exit stairwell of the building from the storage area.


Specialty Center:
157 Capitol Street, Augusta
While surveying the Speciality Center with the facilities manager, the inspector observed the following conditions:
1. The battery powered emergency light by the staff entrance to suite # 201 (Diabetes) did not function when tested.
2. One door panel in the double doors at the top of the front stair was found to not positively latch in the closed position.
3. No self-closing device was observed on the door at the top of the stairs leading to the basement level of the building.

K-18 Not Met.
While inspecting the Thayer Unit CCU corridor with the hospital facilities manager, inspector observed the doors ( both sets) to the CCU area had a gap between them that exceeds the allowable amount allowed for a smoke resistant door. This was confirmed by the facilities manager.

K-29 Not Met.
Findings.
While surveying the Augusta Unit Emergency Room Inspector observed that the soiled utility room did not latch as required. This was confirmed by the Facility maintenance manager.

While surveying the Seton Unit Laundry ,Inspector observed that the middle door to the laundry area was damaged on the edges and would not close and latch as required. This was confirmed by the facility maintenance manager.

K-62 Not Met.
While reviewing the facilities records at the Augusta Unit, Inspector could not determine from the sprinkler reports that the required internal obstruction/investigation testing had been done in the last 5 years as required. Facility Maintenance manager advised that the testing has been scheduled.

K-73 Not Met.
While surveying the inpatient floors of the Augusta Unit this inspector observed that Christmas tree decorations on the trees could not be certified that they were fire retardant as required. This was confirmed by the facility maintenance manager and staff on the units.

K-130 Not Met Offsite locations as defined by the following findings.

Haynes Sleep Center.
1. Boiler room ceiling has penetrations not properly sealed .
2. Electrical junction box on ceiling in boiler room does not have an approved cover ( NFPA 70)

KMD Office site. E.
1. Fire door bottom of stair enclosure was wedged open.
2. Required emergency lights in the first floor corridor were not working.
3. Combustible storage was observed in the North stair tower 2nd floor level landing.

Hathaway Center.
1. Office exits 3rd floor not provided with approved AC/DC illuminated exit signs.
2. Southwest stair tower at 3rd floor level has numerous unsealed penetrations in the wall enclosures.



25654

Harold Alfond Center for Cancer Care:
361 Old Belgrade Road, Augusta
While surveying the Harold Alfond Center for Cancer Care with the facilities manager, the inspector observed the following conditions:
1. The door to the elevator machine room (public elevator by medical oncology) failed to positively latch in the closed position.
2. The soiled utility room located in medical oncology was observed to not have a self-closing device installed on the door.
3. Through review of records the inspector determined that there is potential concern over the water supply available for fire protection at the Alfond Center for Cancer Care. Between October 22, 2009 and November 9, 2010 flow rates according to annual hydrant testing data have declined:
Date: Hydrant: Flow: Date: Hydrant: Flow:
10/22/09 Main entrance 860 GPM 10/22/09 Back entrance 876 GPM
11/9/2010 Main entrance 735 GPM 11/9/2010 Back entrance 675 GPM
Decline: - 125 GPM Decline: - 201 GPM

It should be noted that both fire sprinkler risers located in the facility (one dry system and one wet system) were found by virtue of inspection/testing data to be within the design specifications for the respective systems at this time. The hydrants noted in the above tests are located on the water supply line that also supplies the fire protection systems (fire sprinkler and standpipe for the building). Further investigation into the significant flow declines observed during review of documentation is required.

Physical Therapy and Sports Medicine:
40 Granite Hill Road Suite # 2, Manchester
While surveying the Physical Therapy and Sports Medicine practice with the facilities manager, the inspector observed the following conditions:
1. The curtain in the pool room obstructs fire sprinkler discharge and must be lowered or replaced with a mesh curtain.
2. The outside landing (rear exit) was observed to have landscape materials in the egress path at the bottom of the stairs extending approximately 8 inches above adjacent grade. An even, travel surface must be provided without any tripping hazards.
3. The inspector observed at least two gasoline containers, gas powered machinery, and several flammable/combustible liquid containers being stored in the basement storage area. Flammable/combustible liquids must be removed from the building or appropriately stored in a listed flammable liquids storage cabinet.
4. The inspector examined facility records was not able to find evidence that the required five year internal/obstruction examination had been conducted on the building fire sprinkler system.

Winthrop Family Practice/Winthrop Pediatrics:
149 Main Street, Winthrop
While surveying Winthrop Family Practice with the facilities manager, the inspector observed the following conditions:
1. The dumbwaiter shaft enclosure lacks fire sprinkler coverage in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems section 8.15.2. No fire sprinkler coverage was observed in the dumbwaiter shaft. The shaft is accessible by two doors located on the second and third floors of the building.
2. The storage closet opposite door # 360 (lab door) in the Family Practice lacks fire sprinkler coverage. No fire sprinkler was observed to be located in the closet.
3. The storage closet (left side of the practice coordinators office) lacks fire sprinkler coverage. No fire sprinkler was observed to be located in the closet.
4. The shell space located off room # 334 was observed to have several unprotected openings (holes approximately 4 to 6 inches in diameter) between floor levels.
5. The emergency exit from the orthopedics area was found to lack adequate exit signage in the common space.
6. The building fire sprinkler system is due for the required five year internal/obstruction examination.

Gardiner Family Practice:
152 Dresden Avenue, Gardiner
While surveying Gardiner Family Practice with the facilities manager, the inspector observed the following conditions:
1. The fire door to the medical records storage area (opening into the stairwell) on the lower level does not positively latch in the closed position.
2. Through review of records the inspector did not find any evidence that sensitivity testing of smoke detection devices required by NFPA 72 National Fire Alarm Code had been conducted within the previous two year period. Fire alarm system inspection/test reports for 2009 and 2010 were reviewed.
3. The medical records storage area on the lower level of Gardiner Family Practice was found to store large quantities of paper based medical records from a number of Maine General facilities. The medical record storage area is not fully separated or protected as a hazard area from the rest of the structure as evidenced by the inspectors observations of the following:
a. The ceiling of the room(s) where the medical records were found to be stored was observed to be a suspended ceiling over wood joist construction. The ceiling assembly lacks any recognized fire resistive rating.
b. Medical records were observed to be stored in cardboard boxes on open shelving units.
c. The building/space was not observed to have any automatic fire suppression system present.


Diagnostic/Mammography and Geriatric Centers:
150 Dresden Avenue, Gardiner
While surveying the Diagnostic/Mammography and Geriatric Center with the facilities manager, the inspector observed the following conditions:
1. The exit door in the stairwell serving as a means of egress from the diagnostic center was observed to lack illuminated exit signage.
2. Through review of records the inspector did not find any evidence that sensitivity testing of smoke detection devices required by NFPA 72 National Fire Alarm Code had been conducted within the previous two year period. Fire alarm system inspection/test reports for 2009 and 2010 were reviewed.
3. Through review of facility records the inspector determined that documentation pertaining to the testing and inspection of the generator (EPSS) was insufficient. Documentation of monthly EPSS exercise was found from May of 2009 through September of 2009 only. At a minimum the documentation retained by the facility must meet the following requirements:
NFPA 110 Standard for Emergency and Standby Power Systems
8.3.4 A permanent record of the EPSS inspections, tests, exercising, operation, and repairs shall be maintained and readily available.
8.3.4.1 The permanent record shall include the following:
(1) The date of the maintenance report
(2) Identification of the servicing personnel
(3) Notation of any unsatisfactory condition and the corrective action taken, including parts replaced
(4) Testing of any repair for the time as recommended by the manufacturer


Augusta Family Medicine:
77 Sewell Street, Augusta
While surveying Augusta Family Medicine with the facilities manager, the inspector observed the following conditions:
1. Battery powered emergency lights in the following locations did not function when tested:
a. The waiting area.
b. The checkout area.
c. In the stairwell just outside the practice door opening into the stairwell.
d. The administration area.
2. The building fire sprinkler system is due for the required five year internal/obstruction examination.


Kennebec Pediatrics:
263 Water Street, Augusta
While surveying Kennebec Pediatrics with the facilities manager, the inspector observed the following conditions:
1. Through review of documentation pertaining to the facility fire sprinkler system, the following deficiencies were observed in the fire sprinkler system:
a. Recalled fire sprinkler heads (designated " GB " in the fire sprinkler inspection/test report) need to be replaced.
b. The building fire sprinkler system is due for the required five year internal/obstruction examination.
2. The lab processing area lacks fire sprinkler coverage. The lab processing area is separated from the adjacent space by means of a lintel 36 inches in depth.
3. The egress stair door at ground level was found to not positively latch in the closed position.
4. The egress stair door from the adolescent area was found to not positively latch in the closed position and was not capable of fully closing with the force applied by the self-closing device on the door.
5. The egress stair door from the adolescent area was found to open with excessive force.


Ervin Pediatric Center:
271 Water Street (Vickery Building), Augusta
While surveying the Ervin Pediatric Center with the facilities manager, the inspector observed the following conditions:
1. Through review of documentation pertaining to the facility fire sprinkler system, the following deficiencies were observed in the fire sprinkler system:
a. The date of the last main drain test is unknown.
b. Heads over 50 years old are present in the fire sprinkler system.
c. The building fire sprinkler system is due for the required five year internal/obstruction examination.
2. No self-closing device was observed on the door at the top of the stairs leading to the basement level of the building.
3. The drop from the exit to ground level at the exit from the rear of the building was observed at 12 inches with no intermediate step in place.
4. No self-closing device or mechanical means of latching were observed on the door at the top of the stairs to the rear exit stairwell of the building from the storage area.


Specialty Center:
157 Capitol Street, Augusta
While surveying the Speciality Center with the facilities manager, the inspector observed the following conditions:
1. The battery powered emergency light by the staff entrance to suite # 201 (Diabetes) did not function when tested.
2. One door panel in the double doors at the top of the front stair was found to not positively latch in the closed position.
3. No self-closing device was observed on the door at the top of the stairs leading to the basement level of the building.