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Based on the observation of all smoke barriers on 3/11/2015, the facility failed to maintain smoke barriers that would provide at least a one hour fire resistance rating. Findings include:

1. Unsealed penetrations at the deck, also around a section of conduit, in the smoke barrier inside the Admissions Office.

2. Unsealed penetrations around a sprinkler line, in the smoke barrier, by the janitor room, across the corridor from Risk Manager Office.

3. Unsealed penetrations at the end of two sleeve's, in the smoke barrier, inside the Therapy Office.

The deficiency impacted 1 of 2 smoke compartments.

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Review of 2000 NFPA 101, 18.3.7.3 Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1 hour.

Review of 2000 NFPA 101, 8.3.2 Smoke barriers required by this Code shall be continuous from an outside wall to an outside wall, from a floor to a floor, or from a smoke barrier to a smoke barrier or a combination thereof. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces.
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Based on the observation of all hazardous rooms, on 3/11/2015, the facility failed to maintain one hour fire rating. Findings include:

Unsealed penetrations at the end of a sleeve, with a single red wire going thru sleeve, in the wall of the janitor room by Group Therapy Office.

This deficiency impacted 1 of 2 smoke compartments.

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NFPA 101, 18.3.2.1 Hazardous areas. Any hazardous area shall be protected in accordance with Section 8.4. The areas described in Table 18.3.2.1 shall be protected as indicated.
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Based on the observation on 03/12/2015 of this facility's means of egress, the facility failed to maintain the means of egress per code. Findings include:

Per observation of the means of egress:
While testing the emergency door release switch all doors released, except for the cross corridor smoke barrier doors that have full time magnetic locks and have exit signs on both sides.

This deficiency impacted 2 of 2 smoke compartments.

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Review of 2000 NFPA 101, 7.5.1.1 Exits shall be located and exit access shall be arranged so that exits are readily accessible at all times.
Review of Alabama Department of Public Health Memo "Exit Door Locking Arrangements in Health Care Facilities" Revised 08/30/2013
2. Locked egress doors: This hardware is locked during all or part of the day.
Requirements:
A. The facility must be protected throughout by either an approved, supervised automatic fire detection system (smoke and/or heat detection) or an approved, supervised automatic sprinkler system.
B. A manual release switch shall be provided on both sides of each locked door (required only on the egress side of exterior doors). This may be a code pad, or key or card switch.
C. An emergency release switch, or "kill switch," shall be provided at each nurse station, to disable locks on doors under control of that station or throughout the facility. This release switch shall be capable of being reset only by key or special knowledge. This switch may release doors by means of a key only in psychiatric and infant units.
D. A sign at each nurse station release switch indicating the purpose of the switch, to read, "EMERGENCY DOOR RELEASE".

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Based on the documentation provided for fire drills on 3/11/2015, the facility failed to conduct the drills according to code. Findings include:

1. A fire drill was not conducted for the second shift, second quarter of 2014.

2. A fire drill was not conducted for the second shift, third quarter of 2014.

3. A fire drill was not conducted for the third shift, fourth quarter of 2014.

This deficiency impacted 2 of 2 smoke compartments.

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NFPA 101, 18.7.1.2 Fire drills shall be conducted at least quarterly on each shift and at unexpected times under varied conditions on all shifts to simulate the unusual conditions occurring in case of fire.

NFPA 101, 18.7.1.2 and 18.7.1.3 Employees of health care occupancies shall be instructed in life safety procedures and devices.
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Based on the interview with maintenance director on 3/11/2015, the facility did not have documentation for sensitivity testing of smoke detectors.

This deficiency impacted 2 of 2 smoke compartments.

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Detector sensitivity shall be checked one year after installation and every alternate year thereafter per 72, 7-3.2.1. (Up to 5 years permitted under certain circumstances. See 7-3.2.1).
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Based on the observation of the fire extinguishers on 3/11/2015, the facility failed to maintain the fire extinguishers. Findings include:

The tag on the fire extinguisher located in the generator set control room did not indicate the year or month maintenance was conducted.

The deficiency impacted 1 of 2 smoke compartments.

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1998 NFPA 10, 4-4.1 Fire extinguishers shall be subjected to maintenance intervals of not more than one year.
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Based on the observation on 3/11/2015, the facility failed to maintain the electrical system. Findings include:

Junction box missing the cover in the ceiling of the generator set control room.

The deficiency impacted 1 of 2 smoke compartments.

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1999 NFPA 70, 370-25 and 410-12. Each box in completed installations to have a cover, face plate, or fixture canopy.
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Based on the observation of all smoke barriers on 3/11/2015, the facility failed to maintain smoke barriers that would provide at least a one hour fire resistance rating. Findings include:

1. Unsealed penetrations at the deck, also around a section of conduit, in the smoke barrier inside the Admissions Office.

2. Unsealed penetrations around a sprinkler line, in the smoke barrier, by the janitor room, across the corridor from Risk Manager Office.

3. Unsealed penetrations at the end of two sleeve's, in the smoke barrier, inside the Therapy Office.

The deficiency impacted 1 of 2 smoke compartments.

__________


Review of 2000 NFPA 101, 18.3.7.3 Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1 hour.

Review of 2000 NFPA 101, 8.3.2 Smoke barriers required by this Code shall be continuous from an outside wall to an outside wall, from a floor to a floor, or from a smoke barrier to a smoke barrier or a combination thereof. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces.
.

.
Based on the observation of all hazardous rooms, on 3/11/2015, the facility failed to maintain one hour fire rating. Findings include:

Unsealed penetrations at the end of a sleeve, with a single red wire going thru sleeve, in the wall of the janitor room by Group Therapy Office.

This deficiency impacted 1 of 2 smoke compartments.

________


NFPA 101, 18.3.2.1 Hazardous areas. Any hazardous area shall be protected in accordance with Section 8.4. The areas described in Table 18.3.2.1 shall be protected as indicated.
.

.
Based on the observation on 03/12/2015 of this facility's means of egress, the facility failed to maintain the means of egress per code. Findings include:

Per observation of the means of egress:
While testing the emergency door release switch all doors released, except for the cross corridor smoke barrier doors that have full time magnetic locks and have exit signs on both sides.

This deficiency impacted 2 of 2 smoke compartments.

___________

Review of 2000 NFPA 101, 7.5.1.1 Exits shall be located and exit access shall be arranged so that exits are readily accessible at all times.
Review of Alabama Department of Public Health Memo "Exit Door Locking Arrangements in Health Care Facilities" Revised 08/30/2013
2. Locked egress doors: This hardware is locked during all or part of the day.
Requirements:
A. The facility must be protected throughout by either an approved, supervised automatic fire detection system (smoke and/or heat detection) or an approved, supervised automatic sprinkler system.
B. A manual release switch shall be provided on both sides of each locked door (required only on the egress side of exterior doors). This may be a code pad, or key or card switch.
C. An emergency release switch, or "kill switch," shall be provided at each nurse station, to disable locks on doors under control of that station or throughout the facility. This release switch shall be capable of being reset only by key or special knowledge. This switch may release doors by means of a key only in psychiatric and infant units.
D. A sign at each nurse station release switch indicating the purpose of the switch, to read, "EMERGENCY DOOR RELEASE".

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Based on the documentation provided for fire drills on 3/11/2015, the facility failed to conduct the drills according to code. Findings include:

1. A fire drill was not conducted for the second shift, second quarter of 2014.

2. A fire drill was not conducted for the second shift, third quarter of 2014.

3. A fire drill was not conducted for the third shift, fourth quarter of 2014.

This deficiency impacted 2 of 2 smoke compartments.

_________


NFPA 101, 18.7.1.2 Fire drills shall be conducted at least quarterly on each shift and at unexpected times under varied conditions on all shifts to simulate the unusual conditions occurring in case of fire.

NFPA 101, 18.7.1.2 and 18.7.1.3 Employees of health care occupancies shall be instructed in life safety procedures and devices.
.

.
Based on the interview with maintenance director on 3/11/2015, the facility did not have documentation for sensitivity testing of smoke detectors.

This deficiency impacted 2 of 2 smoke compartments.

________


Detector sensitivity shall be checked one year after installation and every alternate year thereafter per 72, 7-3.2.1. (Up to 5 years permitted under certain circumstances. See 7-3.2.1).
.

.
Based on the observation of the fire extinguishers on 3/11/2015, the facility failed to maintain the fire extinguishers. Findings include:

The tag on the fire extinguisher located in the generator set control room did not indicate the year or month maintenance was conducted.

The deficiency impacted 1 of 2 smoke compartments.

_________


1998 NFPA 10, 4-4.1 Fire extinguishers shall be subjected to maintenance intervals of not more than one year.
.

.
Based on the observation on 3/11/2015, the facility failed to maintain the electrical system. Findings include:

Junction box missing the cover in the ceiling of the generator set control room.

The deficiency impacted 1 of 2 smoke compartments.

_________


1999 NFPA 70, 370-25 and 410-12. Each box in completed installations to have a cover, face plate, or fixture canopy.
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