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Based on observation and interview the facility failed to provide a one hour fire rated construction (with 0 hour fire-rated doors) or an approved automatic fire extinguishing system in accordance with 8.4.1 and/or 19.3.5.4 to protect hazardous areas.

The finding is:

During a tour of the Audubon outpatient site on July 19, 2016 at approximately 1:30 pm, it was observed that the facility has a file room containing open shelving which houses a large number of patient files in cardboard file boxes. Upon interview at this time, the Deputy Director of Administration stated that this room, which is not protected by an automatic sprinkler system, is not separated from the rest of the facility by a one hour fire rated wall. NFPA 101, 2012 edition, 39.2.3.3 and 8.7.1 states that in an existing business occupancy, any room that presents a degree of hazard greater than the rest of the building must be protected by an automatic sprinkler system or one hour fire rated separation.

Failure to adequately protect a room containing a large amount of paper and cardboard may negatively impact the safety of patients and staff in the event of a fire emergency.

This finding was verified on July 19, 2016 by the Deputy Director of Administration and the Facilities Planner.

Based on observation and interview, the facility failed to maintain automatic sprinkler systems in reliable operating condition per NFPA 13, 19.7.6 and 4.6.12, NFPA 25 9.7.5.

The findings are:

1) During a tour of the facility on July 18, at approximately 10:15 am, an electrical cable was observed resting on a sprinkler pipe in the corridor near room J4500.
2) On July 18, 2016 at approximately 10:35 am near stairwell 4 on the fourth floor, a twine used to pull electrical wiring was observed to be tied to a sprinkler pipe.
3) On July 18, 2016 at approximately 10:50 am, twine and electrical wires were found to be tied to a sprinkler pipe near stairwell 6 on the fourth floor.

Upon interview on July 18, 2016 at approximately 10:15 am the Plant Superintendent stated that the facility is aware of these issues, and has a plan in place to remove electrical wires from sprinkler pipes throughout the facility.

Failure to maintain the automatic sprinkler system properly may negatively impact the safety of patients and staff in the event of a fire emergency.

These findings were verified on July 18, 2016 by the Plant Superintendent and the Deputy Director of Administration.

Based on observation and interview, the facility failed to maintain fire extinguishers in accordance with NFPA 10, 9.7.4.1.

The findings are:

During a tour of the facility on July 18, 2016 at approximately 11:15 am, portable fire extinguishers throughout the facility were observed to be located in flush mounted cabinets with solid metal doors. The extinguishers were not visible through the cabinet doors, and the cabinets lacked signage indicating the presence of a fire extinguisher. Upon interview at the same date and time, the Deputy Director of Administration stated that the cabinets were previously labeled with the words " Fire Extinguisher " , but the labels had worn off.

Failure to conspicuously mark the location of portable fire extinguishers, may negatively impact the safety of patients and staff in the event of a fire emergency.

These findings were verified on July 18, 2016 by the Deputy Director of Administration.

Based on observation and interview, the facility failed to provide adequate fire protection at the site of the emergency generator.

The finding is:

During a tour of the facility on July 19, 2016 at approximately 2:00 pm it was observed that there was no fire extinguisher at the emergency generator which is located outside the building in separate generator housing. NFPA 37 Standard for the Installation and use of Stationary Combustion Engines and Gas Turbines (referenced in NFPA 110 Standard for Emergency and Standby Power Systems) requires that a fire risk evaluation be performed to determine the level of protection needed based on the type and quantity of combustible materials involved, including engine fuel and lubricating oil. It was also observed at this time that cardboard was stored in the generator housing, increasing the fuel load in the event of a fire. The facility shall perform a fire risk evaluation and provide some form of fire protection at the generator. Upon interview on July 20th at 11:00 am the Deputy Director of Administration stated that there had previously been an extinguisher at the generator and that one was needed.

Failure to adequately protect the generator from fire may result in injury to staff and patients in the event of a fire emergency.

This finding was validated on July 19, 2016 by the Deputy Director of Administration.

Based on document review and interview, the facility did not ensure that electrical wiring and equipment is in accordance with National Electrical Code. 9-1.2 (NFPA 99) 18.9.1, 19.9.1

The finding is:

During a review of documents on July 20, 2016 at approximately 1:00 pm, the facility was found to be lacking documentation for monthly tests of ground fault circuit interrupter (GFCI) electrical receptacles. Upon interview on July 20 at approximately 1:10 pm, the plant superintendent stated that the facility has not been conducting any testing of GFCI receptacles.

Failure to conduct the necessary testing of these receptacles may result in undetected malfunctions, which may cause injury to patients and staff through electrical shock or fire.

This finding was verified on July 20, 2016 by the Deputy Director of Administration and the Plant Superintendent.

Based on observation and interview the facility failed to provide a one hour fire rated construction (with 0 hour fire-rated doors) or an approved automatic fire extinguishing system in accordance with 8.4.1 and/or 19.3.5.4 to protect hazardous areas.

The finding is:

During a tour of the Audubon outpatient site on July 19, 2016 at approximately 1:30 pm, it was observed that the facility has a file room containing open shelving which houses a large number of patient files in cardboard file boxes. Upon interview at this time, the Deputy Director of Administration stated that this room, which is not protected by an automatic sprinkler system, is not separated from the rest of the facility by a one hour fire rated wall. NFPA 101, 2012 edition, 39.2.3.3 and 8.7.1 states that in an existing business occupancy, any room that presents a degree of hazard greater than the rest of the building must be protected by an automatic sprinkler system or one hour fire rated separation.

Failure to adequately protect a room containing a large amount of paper and cardboard may negatively impact the safety of patients and staff in the event of a fire emergency.

This finding was verified on July 19, 2016 by the Deputy Director of Administration and the Facilities Planner.

Based on observation and interview, the facility failed to maintain automatic sprinkler systems in reliable operating condition per NFPA 13, 19.7.6 and 4.6.12, NFPA 25 9.7.5.

The findings are:

1) During a tour of the facility on July 18, at approximately 10:15 am, an electrical cable was observed resting on a sprinkler pipe in the corridor near room J4500.
2) On July 18, 2016 at approximately 10:35 am near stairwell 4 on the fourth floor, a twine used to pull electrical wiring was observed to be tied to a sprinkler pipe.
3) On July 18, 2016 at approximately 10:50 am, twine and electrical wires were found to be tied to a sprinkler pipe near stairwell 6 on the fourth floor.

Upon interview on July 18, 2016 at approximately 10:15 am the Plant Superintendent stated that the facility is aware of these issues, and has a plan in place to remove electrical wires from sprinkler pipes throughout the facility.

Failure to maintain the automatic sprinkler system properly may negatively impact the safety of patients and staff in the event of a fire emergency.

These findings were verified on July 18, 2016 by the Plant Superintendent and the Deputy Director of Administration.

Based on observation and interview, the facility failed to maintain fire extinguishers in accordance with NFPA 10, 9.7.4.1.

The findings are:

During a tour of the facility on July 18, 2016 at approximately 11:15 am, portable fire extinguishers throughout the facility were observed to be located in flush mounted cabinets with solid metal doors. The extinguishers were not visible through the cabinet doors, and the cabinets lacked signage indicating the presence of a fire extinguisher. Upon interview at the same date and time, the Deputy Director of Administration stated that the cabinets were previously labeled with the words " Fire Extinguisher " , but the labels had worn off.

Failure to conspicuously mark the location of portable fire extinguishers, may negatively impact the safety of patients and staff in the event of a fire emergency.

These findings were verified on July 18, 2016 by the Deputy Director of Administration.

Based on observation and interview, the facility failed to provide adequate fire protection at the site of the emergency generator.

The finding is:

During a tour of the facility on July 19, 2016 at approximately 2:00 pm it was observed that there was no fire extinguisher at the emergency generator which is located outside the building in separate generator housing. NFPA 37 Standard for the Installation and use of Stationary Combustion Engines and Gas Turbines (referenced in NFPA 110 Standard for Emergency and Standby Power Systems) requires that a fire risk evaluation be performed to determine the level of protection needed based on the type and quantity of combustible materials involved, including engine fuel and lubricating oil. It was also observed at this time that cardboard was stored in the generator housing, increasing the fuel load in the event of a fire. The facility shall perform a fire risk evaluation and provide some form of fire protection at the generator. Upon interview on July 20th at 11:00 am the Deputy Director of Administration stated that there had previously been an extinguisher at the generator and that one was needed.

Failure to adequately protect the generator from fire may result in injury to staff and patients in the event of a fire emergency.

This finding was validated on July 19, 2016 by the Deputy Director of Administration.

Based on document review and interview, the facility did not ensure that electrical wiring and equipment is in accordance with National Electrical Code. 9-1.2 (NFPA 99) 18.9.1, 19.9.1

The finding is:

During a review of documents on July 20, 2016 at approximately 1:00 pm, the facility was found to be lacking documentation for monthly tests of ground fault circuit interrupter (GFCI) electrical receptacles. Upon interview on July 20 at approximately 1:10 pm, the plant superintendent stated that the facility has not been conducting any testing of GFCI receptacles.

Failure to conduct the necessary testing of these receptacles may result in undetected malfunctions, which may cause injury to patients and staff through electrical shock or fire.

This finding was verified on July 20, 2016 by the Deputy Director of Administration and the Plant Superintendent.