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Based on document review and staff interview, the facility fails to test and maintain their emergency light systems in accordance with NFPA 101. This deficient practice would affect all patients, visitors, and staff in 3 of 3 smoke zones. The facility has a capacity of 18 with a census of 3 at the time of the survey.

Findings include:

During the survey conducted on 7/18/18 the following deficiency is noted:

1. During document review at 11:02 AM, it is observed that the last annual 90-minute test of the emergency lights was in January 2017 and is past due for an annual test.

Staff A was present and acknowledged the finding.

NFPA Standard: NFPA 101 2012 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, except as otherwise permitted by 7.9.3.1.1(2). (2)*The test interval shall be permitted to be extended beyond 30 days with the approval of the authority having jurisdiction. (3) Functional testing shall be conducted annually for a minimum of 11?2 hours if the emergency lighting system is battery powered. (4) The emergency lighting equipment shall be fully operational for the duration of the tests required by 7.9.3.1.1(1) and (3). (5) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Based on observation and staff interview the facility fails to properly inspect and maintain their exit signs as required in Life Safety Code 101. The deficient practice would affect all patients, visitors and staff in 3 of 3 smoke zones. The facility has a capacity of 18 with a census of 3 at the time of the survey.

Findings include:

During the survey conducted on 7/18/18 the following deficiency is noted:

1. During document review at 11:03 AM it is observed that there is no documentation for any monthly inspections of the exit signs.

Staff A was present and acknowledged the finding.

NFPA Standard: NFPA 101 2012 19.2.10.1 Means of egress shall have signs in accordance with Section 7.10, unless otherwise permitted by 19.2.10.2, 19.2.10.3, or 19.2.10.4. 7.10.1.2.1* Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign that is readily visible from any direction of exit access. 7.10.5.1* General. Every sign required by 7.10.1.2, 7.10.1.5, or 7.10.8.1, other than where operations or processes require low lighting levels, shall be suitably illuminated by a reliable light source. Externally and internally illuminated signs shall be legible in both the normal and emergency lighting mode. 7.10.5.2* Continuous Illumination. 7.10.5.2.1 Every sign required to be illuminated by 7.10.6.3, 7.10.7, and 7.10.8.1 shall be continuously illuminated as required under the provisions of Section 7.8, unless otherwise provided in 7.10.5.2.2. 7.9.3 Periodic Testing of Emergency Lighting Equipment. 7.9.3.1 Required emergency lighting systems shall be tested in accordance with one of the three options offered by 7.9.3.1.1, 7.9.3.1.2, or 7.9.3.1.3.
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, except as otherwise permitted by 7.9.3.1.1(2).
(2)*The test interval shall be permitted to be extended beyond 30 days with the approval of the authority having jurisdiction. (3) Functional testing shall be conducted annually for a minimum
of 11?2 hours if the emergency lighting system is battery powered. (4) The emergency lighting equipment shall be fully operational for the duration of the tests required by 7.9.3.1.1(1) and (3).
(5) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Based on observation and staff interview the facility fails to properly protect and maintain their hazardous areas in accordance with NFPA 101. The deficient practice would affect no patients or visitors, and all staff in 1 of 3 smoke zones. The facility has a capacity of 18 with a census of 3 at the time of the survey.

Findings include:

During the survey conducted on 7/18/18 the following deficiency is noted:

1. During the survey at 12:06 PM it is observed that in the boiler room there are four unsealed approximate 1' by 1' penetrations by gas line supports that would not resist the passage of smoke. There are also unsealed penetrations by conduit and pipes in the ceiling of the boiler room that would not resist the passage of smoke.

Staff A was present and acknowledged the findings.

NFPA Standard: NFPA 101 19.3.2.1.3 The doors shall be self-closing or automatic-closing.
19.3.2.1.5 Hazardous areas shall include, but shall not be restricted to, the following:
(1) Boiler and fuel-fired heater rooms (2) Central/bulk laundries larger than 100 ft2 (9.3 m2)
(3) Paint shops (4) Repair shops (5) Rooms with soiled linen in volume exceeding 64 gal (242 L)
(6) Rooms with collected trash in volume exceeding 64 gal (242 L) (7) Rooms or spaces larger than 50 ft2 (4.6 m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction (8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard
19.3.2.1.2* Where the sprinkler option of 19.3.2.1 is used, the areas shall be separated from other spaces by smoke partitions in accordance with Section 8.4.

Based on staff interview and observation, the facility fails to install and maintain their Alcohol Based Hand Rub dispensers in accordance with NFPA 101. The deficient practice would no patients or visitors, and all staff in 1 of 3 smoke zones. The facility has a capacity of 18 with a census of 3 at the time of the survey.

Findings include:

During the survey conducted on 7/18/18 the following deficiency is noted:

1. During the survey at 12:18 PM, it is observed that the alcohol based hand rub dispenser in the laundry room is mounted over an electrical outlet.

Staff A was present and acknowledged the finding.

NFPA Standards: Life Safety Code 101 2012 19.3.2.6* Alcohol-Based Hand-Rub Dispensers. Alcohol-based hand-rub dispensers shall be protected in accordance with 8.7.3.1, unless all of the following conditions are met: (8) Dispensers shall not be installed in the following locations: (a) Above an ignition source within a 1 in. (25 mm) horizontal distance from each side of the ignition source (b) To the side of an ignition source within a 1 in. (25mm) horizontal distance from the ignition source (c) Beneath an ignition source within a 1 in. (25 mm) vertical distance from the ignition source.

Based on observation and staff interview the facility fails to properly install and maintain the fire extinguishers as required by NFPA 10. The deficient practice would affect no patients, and all visitors and staff in 1 of 3 smoke zones. The facility has a capacity of 18 with a census of 3 at the time of the survey.

Findings include:

During the survey conducted on 7/18/18 the following deficiency is noted:

1. During the survey at 12:49 PM, it is observed that the class K fire extinguisher in the kitchen is mounted higher than 5' on the wall.

Staff A was present and acknowledged the finding.

NFPA Standard: NFPA 101 9.7.4.1* Where required by the provisions of another section of this Code, portable fire extinguishers shall be selected, installed, inspected, and maintained in accordance with
NFPA 10, Standard for Portable Fire Extinguishers.
Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. In no case shall the clearance between the bottom of the hand portable fire extinguisher and the floor be less than 4 in. (102 mm). 2010 NFPA 10 6.1.3.8

Based upon observation, document review, and staff interview the facility is not inspecting and maintaining their rated door assemblies in compliance with NFPA 80. This deficient practice could prevent the ability of the facility to properly confine smoke and prevent fire from spreading to other zones. This deficient practice would affect all patients, visitors, and staff in 3 of 3 smoke zones. The facility has a capacity of 18 with a census of 3 at the time of this survey.

Findings include:

During the survey conducted on 7/18/18 the following deficiency is noted:

1. During document review at 10:40 AM, it is observed that the annual service report for the rated door assemblies showed deficiencies on 29 of 31 doors. There is no documentation at the time of survey that these have been corrected.

Staff A was present and acknowledged the finding.

NFPA Standard: NFPA 80 2010 5.2.1 Fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for inspection by the AHJ. 5.2.3.1 Functional testing of fire door and window assemblies shall be performed by individuals with knowledge and understanding of the operating components of the type of door being subject to testing. 5.2.4.2 As a minimum, the following items shall be verified: (1) No open holes or breaks exist in the surfaces of either the door or frame. (2) Glazing, vision light frames, and glazing beads are intact and securely fastened in place, if so equipped. (3) The door, frame, hinges, hardware, and non combustible threshold are secured, aligned, and in working order with no visible signs of damage. (4) No parts are missing or broken. (5) Door clearances do not exceed clearances listed in 4.8.4 and 6.3.1.7 (6) The self-closing device is operational; that is, the active door completely closes when operated from the open position. (7) If a coordinator is installed, the inactive leaf closes before the active leaf. (8) Latching hardware operates and secures the door when it is in the closed position. (9) Auxiliary hardware items that interfere or prohibit operation are not installed on the door or frame. (10) No field modifications to the door assembly have been performed that void the label. (11) Gasketing and edge seals, where required, are inspected to verify their presence and integrity. 3.3.95 Qualified Person. A person who, by possession of a recognized degree, certificate, professional standing, or skill, and who by knowledge, training, and experience, has demonstrated the ability to deal with the subject matter, the work, or the project.

Based upon document review and staff interview, the facility fails to properly maintain their gas and vacuum piped systems. The deficient practice reduces the reliability of the medical gas systems, affecting all patients, visitors, and staff in 3 of 3 smoke zones. The facility has a capacity of 18 with a census of 3 at the time of this survey.

Findings include:

During the survey conducted on 7/18/18 the following deficiency is noted:

-- 1. During document review at 11:35 AM it is observed that the there is no documentation available for the last annual service of the piped in gas system.

Maintenance Staff was present and acknowledged the finding.

NFPA Standard: Medical gas, vacuum, WAGD, or support gas systems have documented maintenance programs. The program includes an inventory of all source systems, control valves, alarms, manufactured assemblies, and outlets. Inspection and maintenance schedules are established through risk assessment considering manufacturer recommendations. Inspection procedures and testing methods are established through risk assessment. Persons maintaining systems are qualified as demonstrated by training and certification or credentialing to the requirements of AASE 6030 or 6040.
5.1.14.2.1, 5.1.14.2.2, 5.1.15, 5.2.14, 5.3.13.4.2 (NFPA 99)

Based on staff interview and document review, the facility failed to maintain and test their electrical receptacles and systems in accordance with NFPA 99. This deficient practice would affect all residents, visitors, and staff in 3 of 3 smoke zones. The facility has a capacity of 18 with a census of 3 at the time of the survey.

Findings include:

During the survey conducted on 7/18/18 the following deficiency is noted:

1. During document review at 11:38 AM, it is observed that there is no documentation at the time of survey for any testing of the electrical receptacles or electrical systems.

Staff A was present and acknowledged finding.

NFPA Standard: NFPA 99 2012 6.3.3.2 Receptacle Testing in Patient Care Rooms 6.3.3.2.1 The physical integrity of each receptacle shall be confirmed by visual inspection. 6.3.3.2.2 The continuity of the grounding circuit in each electrical receptacle shall be verified. 6.3.3.2.3 correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed. 6.3.4.1 Maintenance and testing of Electrical System 6.3.4.1. 1 Where hospital-grade receptacles are required at patient bed location and in location where deep sedation or general anesthesia is administered, testing shall be performed after initial installation, replacement, or servicing of the device. 6.3.4.1.2 Additional testing of receptacles in patient care rooms shall be performed at intervals defined by documented performance data. 6.3.4.1.3 Receptacles not listed as hospital-grade, at patient bed locations and in locations where deep sedation or general anesthesia is administered, shall be tested at intervals not exceeding 12 months. 6.3.4.1.4 The LIM circuit shall be tested at intervals of not more than 1 month by actuating the LIM test switch (see 6.3.2.6.3.6). For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months. Actuation of the test switch shall activate both visual and audible alarm indicators. 6.3.4.1.5 After any repair or renovation to an electrical distribution system, the LIM circuit shall be tested in accordance with 6.3.3.3.2 6.4.4.1.2.1* Circuit Breakers. Main and feeder circuit breakers shall be inspected annually, and a program for periodically exercising the components shall be established according to manufacturer's recommendations. 6.3.4.2.1.1 A record shall be maintained of the tests required by this chapter and associated repairs or modification. 6.3.4.2.1.2 At a minimum, the record shall contain the date, the rooms or areas tested, and an indication of which items have met, or have failed to meet, the performance requirements of this chapter. 6.3.4.2.2 Isolated Power System (Where Installed). A permanent record shall be kept of the results of each of the tests.

Based on staff interview and document review, the facility failed to maintain and test the emergency generator power supply as required. The deficient practice would affect all patients, visitors, and staff in 3 of 3 smoke zones. The facility has a capacity of 18 with a census of 3 at the time of the survey.

Findings include:

During the survey conducted on 7/18/18 the following deficiency is noted:

1. During document review at 11:15 AM, it is observed that there was a missed weekly inspection of the generator in July of 2018.

Staff A was present and acknowledged the finding.

NFPA Standard: A permanent record of the EPSS inspections, tests, exercising, operation, and repairs shall be maintained and readily available. 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. 2010 NFPA 110, 8.3.4, 8.3.4.1 NFPA 99 6.4.4.1.1.4 Inspection and Testing. Criteria, conditions, and personnel requirements shall be in accordance with 6.4.4.1.1.4(A) through 6.4.4.1.1.4(C). (A)* Test Criteria. Generator sets shall be tested 12 times a year, with testing intervals of not less than 20 days nor more than 40 days. Generator sets serving essential electrical systems shall be tested in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 8. (B) Test Conditions. The scheduled test under load conditions shall include a complete simulated cold start and appropriate automatic and manual transfer of all essential electrical system loads. (C) Test Personnel. The scheduled tests shall be conducted by competent personnel to keep the machines ready to function and, in addition, serve to detect causes of malfunction and to train personnel in operating procedures. NFPA 99 6.4.4.1.1.4

NFPA Standard: Diesel generator sets in service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods: (1)Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer (2) Under Operating temperature conditions and at not less than 30 percent of the EPS nameplate kW rating NPFA 110 8.4.2
NFPA Standard: Diesel-powered EPS installations that do not meet the requirements of 8.4.2 shall be exercised monthly with the available EPSS load and shall be exercised annually with supplemental loads of not less than 50 percent of the EPS nameplate kW rating for 30 continuous minutes and at not less than 75 percent of the EPS nameplate kW rating for 1 continuous hour for a total test duration of not less than 1.5 continuous hours.

Based on observation and staff interview, the facility failed to properly protect and store compressed gasses as required by NFPA 99. The deficient practice would affect no patients or visitors, and all staff in 1 of 3 smoke zones. The facility has a capacity of 18 with a census of 3 at the time of the survey.

Findings include:

During the survey conducted on 7/18/18 the following deficiency is noted:

1. During the survey at 1:45 PM, it is observed that there is an unsecured O2 cylinder in the exterior liquid oxygen storage room.

Staff A was present and acknowledged the finding.

NFPA Standard: NFPA 99 2012 11.3.2.8 Cylinder valve protection caps shall comply with 11.6.2.3 11.6.2.3 Cylinders shall be protected from damage by means of the following specific procedures: (1) Oxygen cylinders shall be protected from abnormal mechanical shock, which is liable to damage the cylinder, valve, or safety device. (2) Oxygen cylinders shall not be stored near elevators or gangways or in locations where heavy moving objects will strike them or fall on them. (3) Cylinders shall be protected from tampering by unauthorized individuals. (4) Cylinders or cylinder valves shall not be repaired,
painted, or altered. (5) Safety relief devices in valves or cylinders shall not be tampered with. (6) Valve outlets clogged with ice shall be thawed with warm - not boiling - water. (7) A torch flame shall not be permitted, under any circumstances, to come in contact with a cylinder, cylinder valve, or safety device. (8) Sparks and flame shall be kept away from cylinders. (9) Even if they are considered to be empty, cylinders shall not be used as rollers, supports, or for any purpose other than that for which the supplier intended them. (10) Large cylinders (exceeding size E) and containers larger than 45 kg (100 lb) weight shall be transported on a proper hand truck or cart complying with 11.4.3.1. (11) Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart. (12) Cylinders shall not be supported by radiators, steam pipes, or heat ducts.

Based on staff interview and document review the facility fails to properly train and document their staff on the proper handling of compressed gas equipment in accordance with NFPA 99. The deficient practice would affect all patients, visitors, and staff in 3 of 3 smoke zones. The facility has a capacity of 18 with a census of 3 at the time of the survey.

Findings include:

During the survey conducted on 7/18/18 the following deficiency is noted:

1. During document review at 11:33 AM, it is observed that there is no documentation available for the education or training of facility staff on the risk, safety guidelines, and usage requirements of compressed gas at the time of survey.

Staff A was present and acknowledged finding.


NFPA Standard: NFPA 99 11.5.2 Gases in Cylinders and Liquefied Gases in Containers.
11.5.2.1 Qualification and Training of Personnel. 11.5.2.1.1* Personnel concerned with the application and maintenance of medical gases and others who handle medical gases and the cylinders that contain the medical gases shall be trained on the risks associated with their handling and use. 11.5.2.1.2 Health care facilities shall provide programs of continuing education for their personnel. 11.5.2.1.3 Continuing education programs shall include periodic review of safety guidelines and usage requirements for
medical gases and their cylinders. 11.5.2.1.4 Equipment shall be serviced only by personnel trained in the maintenance and operation of the equipment. 11.5.2.1.5 If a bulk cryogenic system is present, the supplier shall provide annual training on its operation.