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This Standard is not met as evidenced by:

Based on observations and confirmed by staff, the facility is not separated from other use occupancies as required. This deficient practice could affect all patients, staff and visitors within the improperly separated unit.

Section 19.1.3.1 states multiple occupancies shall be in accordance with section 6.1.14.4 Separated Occupancies

Section 6.1.14.1.1 states multiple occupancies shall comply with the requirements of 6.1.14.1 and one of the following:
(1) Mixed occupancies - 6.1.14.3
(2) Separated occupancies - 6.1.14.4


Section 6.1.14.4.1 states where separated occupancies are provided, each part of the building comprising a distinct occupancy, as described in this chapter, shall be completely separated from other occupancies by fire-resistive assemblies, as specified in 6.1.14.4.2, 6.1.14.4.3, Table 6.1.14.4.1(a), and Table 6.1.14.4.1(b), unless separation is provided by approved existing separations.

Section 6.1.14.4.2 states occupancy separations shall be classified as 3-hour fire resistance-rated, 2-hour fire resistance-rated, or 1-hour fire resistance-rated and shall meet the requirements of Chapter 8.

Section 6.1.14.4.3 states the minimum fire resistance rating specified in Table 6.1.14.4.1(a) and Table 6.1.14.4.1(b) shall be permitted to be reduced by 1 hour, but in no case shall it be reduced to less than 1 hour, where the building is protected throughout by an approved automatic sprinkler system in accordance with 9.7.1.1(1) and supervised in accordance with 9.7.2, unless prohibited by the double-dagger footnote entries in the tables.

Section 6.1.14.4.4 states occupancy separations shall be vertical, horizontal, or both or, when necessary, of such other form as required to provide complete separation between occupancy divisions in the building.

Section 6.1.14.4.1 states where separated occupancies are provided, each part of the building comprising a distinct occupancy, as described in this chapter, shall be completely separated from other occupancies by fire-resistive assemblies, as specified in 6.1.14.4.2, 6.1.14.4.3, Table 6.1.14.4.1(a), and Table 6.1.14.4.1(b), unless separation is provided by approved existing separations.

Table 6.1.14.4.1(a) requires a 2-hour fire separation between Healthcare Occupancies and Business Occupancies.

Findings Include:

During the documentation review and facility tour conducted on 7/15/19 through 7/17/19 , it was observed that the Main Entrance located on the ground floor level was not properly separated from the Hospital's Administrative Area, located in a building classified as an existing Business Occupancy (Chapter 39 of the LSC) .
According to the Engineer's Life Safety Code drawings provided by the hospital's engineering staff , dated April 2019, the Hospital occupancy is enclosed with a 2-hour fire separation from the adjoining Business Occupancy.

However, the hospital's defined 2-hour fire rated enclosure is non-compliant as the following was noted:
- The barrier includes Five (5) 32" x 72" non-rated double hung windows as well as a non-rated 84" x 84" plain glass sliding door and accompanying sidelight. The door is not equipped with a latching mechanism.
- Unsealed penetrations in the defined 2-hour fire rated barrier were noted above the in-lay ceiling tiles separating the volunteer office closet and the pre-operation charting room around electrical metal tubing (EMT), and telecommunications wiring and above the in-lay tiles at the mailroom and the pre-operation corridor, around EMT.

As a result, the facility was not provided with the required 2-hour fire resistance rated separation as defined by the facility's Life Safety Drawings dated April 2019 and as required by Table 6.1.14.4.1(a).

This was acknowledged by the facility's Security Manager / Safety Officer during survey and reviewed with and acknowledged by the Hospital's Leadership Team during the exit interview process.

Based on observation, the facility failed to maintain the stairwells in conformance with NFPA 101, Section 7.2.

NFPA 101 section 7.2.2.5.3.1 states open space within the exit enclosure shall not be used for any purpose that has the potential to interfere with egress. ( An example of a use with the potential to interfere with egress is storage.)

Findings Include:

During the facility tour conducted on 7/15/19 through 7/17/19, it was noted that the bottom landing of stair #4, on the ground floor level outside of the Cafeteria, was utilized to store approximately 40 stacking chairs. These chairs were noted at approximately 2:43 P.M. on 7/16/19, and at 9:03 A.M. on 7/17/19.

As a result, the facility was not compliant with section 7.2.2.5.3.1 .

This was reviewed with and acknowledged by the Hospital's Leadership Team during the exit interview process.

Based on observations, the facility failed to assure that the means of egress is in accordance with Chapter 7.

Section 7.7.3.4 states that stairs and ramps that continue more than one-half story beyond the level of discharge shall be provided with an approved means to prevent or dissuade occupants from traveling past the level of discharge during emergency building
evacuation.

Findings Include:

During the facility tour conducted on 7/15/19 through 7/17/19, it was noted that stair #8 exit discharge level is located one-half a story below the second floor level, and the bottom of the stair enclosure is located on the ground floor level. There was no "guard" in place to dissuade occupants from proceeding more than one-half story beyond the level of exit discharge as required.

As a result, the facility was not compliant with section 7.7.3.4 .

This was acknowledged by the facility's Security Manager / Safety Officer during survey and reviewed with and acknowledged by the Hospital's Leadership Team during the exit interview process.

Section 39.2.8 (Illumination of Means of Egress) states that Means of egress shall be illuminated in accordance with Section 7.8.

Section 7.8.1.2 states that Illumination of means of egress shall be continuous during the time that the conditions of occupancy require that the means of egress be available for use, unless otherwise provided in 7.8.1.2.2.

Section 7.8.1.5 states that the equipment or units installed to meet the requirements of Section 7.10 also shall be permitted to serve the function of illumination of means of egress, provided that all requirements of Section 7.8 for such illumination are met.

Section 7.8.2.1 states that Illumination of means of egress shall be from a source considered reliable by the authority having jurisdiction.

Section 7.9.3.1.1, states that 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 1- 1/2 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.

Findings Include:

On 7/17/19, at approximately 1:30 P.M. while conducting the tour of the Building #16, Anna Jaques Cancer Center, two Exit sign(s) emergency lighting battery packs, located adjacent to the stairs, failed to illuminate when the emergency test button was depressed.

As a result, the facility failed to comply with section 7.8.2.1 and section 7.9.3.1.1 (4).

This was acknowledged by the facility's Security Manager / Safety Officer during survey and reviewed with and acknowledged by the Hospital's Leadership Team during the exit interview process.

This Standard is not met as evidenced by:

Based on observations and confirmed by staff, exit signs are not provided as required.

Section 7.10.1.2 (Exits)
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Section 7.10.1.2.1, states that 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.

Section 7.10.1.5.1 states that access to exits shall be marked by approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent to the occupants. Section 7.10.5.2.1 states 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.

Findings Include:

During the facility tour conducted on 7/15/19 through 7/17/19, the following was observed:

1. There was no "Exit" sign at the level of exit discharge of stair # 6.
2. There was no "Exit" sign at the level of exit discharge of stair #4.
3. There was no directional "Exit" sign in stair #8 from the second floor level, where a second path of egress permits re-entry to the second floor level dining/multi-purpose room.

As a result, the facility was not compliant with section 7.10.1.2.1 and section 7.10.1.5.1.

This was acknowledged by the facility's Security Manager / Safety Officer during survey and reviewed with and acknowledged by the Hospital's Leadership Team during the exit interview process.

Based on observations, the facility failed to ensure compliance with specific requirements of the 2012 edition of NFPA 101 Life Safety Code. This facility is licensed for 140-beds. This deficient practice could affect the current residents, as well as an undetermined amount of staff and visitors in the event of an actual fire.

NFPA 101, section 4.5.8 (Maintenance) states that whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be maintained, unless the Code exempts such maintenance.

NFPA 101, Section 19.3.4.1 (General) states health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6.

NFPA 101, Section 9.6.1.3 states a fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use.

NFPA 72, 2010 edition, Table 14.4.2.2 requires an annual charger test, a 30 minute annual discharge test, and a semi-annual load test to be conducted of the sealed lead acid batteries.

NFPA #72 (National Fire Alarm Code) section 14.2.2.1 states the property or building or system owner or the owner's designated representative shall be responsible for inspection, testing, and maintenance of the system and for alterations or additions to this system.

NFPA 72, Section 14.2.2.2 states the delegation of responsibility shall be in writing, with a copy of such delegation provided to the authority having jurisdiction upon request.

NFPA 72, Section 14.6.1.3 states that the system owner shall be responsible for maintaining these records for the life of the system for examination by any authority having jurisdiction. Paper or electronic media shall be permitted.

NFPA 72, Section (14.6.2 Maintenance, Inspection, and Testing Records) 14.6.2.1 states that records shall be retained until the next test and for 1 year thereafter.

Findings include:

While conducting the hospital record review for fire alarm testing during the afternoon hours of 07/15/19, it was revealed that the specific tests required by Table 14.4.2.2: an annual charger test, a 30 minute annual discharge test, and a semi-annual load test were not documented.

As a result, the facility failed to comply with NFPA 101, section 19.3.4.1, section 9.6.1.3, and NFPA 72 Table 14.4.2.2 .

The findings were reviewed with and acknowledged by the Hospital's Leadership Team during the exit interview process.

Based on observations, the facility failed to ensure compliance with specific requirements of the 2012 edition of NFPA 101 Life Safety Code. This facility is licensed for 140-beds. This deficient practice could affect the current residents, as well as an undetermined amount of staff and visitors in the event of an actual fire.

NFPA 101, section 4.6.12.3 states that existing life safety features obvious to the public if not required by the Code, shall be either maintained or removed.

NFPA #72 (National Fire Alarm Code) section 14.2.2.1 states the property or building or system owner or the owner's designated representative shall be responsible for inspection, testing, and maintenance of the system and for alterations or additions to this system.

NFPA 72, Section 14.2.2.2 states the delegation of responsibility shall be in writing, with a copy of such delegation provided to the authority having jurisdiction upon request.

NFPA 72, 2010 edition, Table 14.4.2.2 requires an annual charger test, a 30 minute annual discharge test, and a semi-annual load test to be conducted of the sealed lead acid batteries.

NFPA 72, Section 14.6.1.3 states that the system owner shall be responsible for maintaining these records for the life of the system for examination by any authority having jurisdiction. Paper or electronic media shall be permitted.

NFPA 72, Section (14.6.2 Maintenance, Inspection, and Testing Records) 14.6.2.1 states that records shall be retained until the next test and for 1 year thereafter.

Findings include:

While conducting the hospital record review for fire alarm testing during the afternoon hours of 07/16/19, it was revealed the specific tests required by Table 14.4.2.2: an annual charger test, a 30 minute annual discharge test, and a semi-annual load test are not documented.

As a result, the facility failed to comply with NFPA 72 Table 14.4.2.2 .

The findings were reviewed with and acknowledged by the Hospital's Leadership Team during the exit interview process.

Based on observations the facility failed to ensure compliance with Section 5.3.2.1 and Section 5.3.1.1.1.6 of the 2011 edition of NFPA 25 Standard for the Inspection, Testing and Maintenance of Water-based Fire Protection Systems.
-Section 5.3.2.1 states gages shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gage.

Findings Include:

While conducting the facility tour during the morning hours of 07/17/19 observations and documentation review revealed the facility's automatic sprinkler systems' pressure gages are date stamped 01/2013.

As a result of the findings the facility is found to be non-compliant with Section 5.3.2.1 which requires pressure gages to be replaced or calibrated every five (5) years,

Based on observations the facility failed to ensure compliance with Section 5.3.2.1 and Section 5.3.1.1.1.6 of the 2011 edition of NFPA 25 Standard for the Inspection, Testing and Maintenance of Water-based Fire Protection Systems.
-Section 5.3.2.1 states gages shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gage.

Findings Include:

While conducting the facility tour during the morning hours of 07/17/19 observations and documentation review revealed the facility's automatic sprinkler systems' pressure gages are date stamped 1994.

As a result of the findings the facility is found to be non-compliant with Section 5.3.2.1 which requires pressure gages to be replaced or calibrated every five (5) years,

Based on observations the facility failed to ensure compliance with Section 5.3.2.1 and Section 5.3.1.1.1.6 of the 2011 edition of NFPA 25 Standard for the Inspection, Testing and Maintenance of Water-based Fire Protection Systems.
-Section 5.3.2.1 states gages shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gage.

Findings Include:

While conducting the facility tour during the morning hours of 07/17/19 observations and documentation review revealed the facility's automatic sprinkler systems' pressure gages are date stamped 2012.

As a result of the findings the facility is found to be non-compliant with Section 5.3.2.1 which requires pressure gages to be replaced or calibrated every five (5) years,

Based on observations and confirmed by staff, the facility failed to ensure that corridor doors are constructed in accordance with Section 19.3.6.3.5.

Section 19.3.6.3.1 states that doors protecting corridor openings shall be constructed to resist the passage of smoke, and the following also shall apply:
(1) Compliance with NFPA 80, Standard for Fire Doors and Other Opening Protective's, shall not be required.
(2) A clearance between the bottom of the door and the floor covering not exceeding 1 in. (25 mm) shall be permitted for corridor doors.
(3) Doors to toilet rooms, bathrooms, shower rooms, sink closets, and similar auxiliary spaces that do not contain flammable or combustible material shall not be required to be constructed to resist the passage of smoke.

19.3.6.3.5 Doors shall be self-latching and provided with positive latching hardware.

19.3.6.3.6 Doors to toilet rooms, bathrooms, shower rooms, sink closets, and similar auxiliary spaces that do not contain flammable or combustible materials shall not be required to meet the latching requirements of 19.3.6.3.5.

19.3.6.3.8 Corridor doors utilizing an inactive leaf shall have automatic flush bolts on the inactive leaf to provide positive latching.

Findings Include:

During survey on 07/15/19 and 07/16/19 while touring the facility, the following was observed:

1. The following patient room doors in the Psychiatric unit on the 2nd floor, #201, #202, #203, #205, #206, #207, #208, #210, and #211 were not equipped with working latching hardware as required by NFPA 101, Section 19.3.6.3.5.

2. All of the patient room corridor doors in the Psychiatric unit on the 2nd floor are protected with a double door consisting of a 44" leaf and a 23" leaf. The 23" inactive door leaf is equipped with a manual flush bolt that is covered by a gasket that was previously added to resist the passage of smoke between the two doors. The inactive leaf is required to be provided with an automatic flush bolt in accordance with NFPA 101, Section 19.3.6.3.8.

As a result, the facility failed to comply with section 19.3.6.3.2 requiring corridor doors to resist the passage of smoke.

The findings were reviewed with and acknowledged by the Hospital's Leadership Team during the exit interview process.