HospitalInspections.org

Based upon observation and operational testing on 10/25/11 the facility failed to ensure that corridor doors closed and latched securely. This deficient practice allows products of combustion to move freely between rooms and the exit access corridor compromising egress. The facility is licensed for 22 beds and had a census of 20 on the day of the survey.

Findings include:

During the facility tour on 10/25/11 between 8:00 AM and 11:15 PM corridor doors were tested and the following were observed to not close and latch securely; Room 103, Room 107, and Room 108. Testing was conducted by the surveyor and witnessed by the Maintenance Director.

Actual NFPA standard:
LSC 2000
19.3.6.3.2*
Doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door. Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.2.
Exception No. 1: Doors to toilet rooms, bathrooms, shower rooms, sink closets, and similar auxiliary spaces that do not contain flammable or combustible materials.
Exception No. 2: Existing roller latches demonstrated to keep the door closed against a force of 5 lbf (22 N) shall be permitted to be kept in service. Roller latches are prohibited by 42 CFR 482.41

Based upon observation and operational testing the facility failed to ensure hazardous area doors were maintained self closing to prevent the spread of the products of combustion. The facility was licensed for 22 beds and had a census of 20 on the day of the survey.

Findings include:

During the facility tour on 10/25/11 between 8:00 AM and 11:15 AM, observation of operational testing of the storage/clean linen room door inside the shower room failed to have the door self close and latch securely. Testing was conducted by the surveyor and witnessed by the Maintenance Director.

Actual NFPA standard:

101 - 2000 Edition

19.3.2.1 Hazardous Areas.
Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. 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) Soiled linen rooms
(6) Trash collection rooms
(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.
Exception: Doors in rated enclosures shall be permitted to have nonrated, factory- or field-applied protective plates extending not more than 48 in. (122 cm) above the bottom of the door.

Based upon observation and interview on 10/25/11 the facility failed to ensure exit discharge was unobstructed to a public way. Failure to provide accessible exit discharge prevents egress to a safe area by wheelchairs, beds and mobility impaired persons.

Findings include:

During the facility tour on 10/25/11 between 8:00 AM and 11:05 AM observation revealed the hard surfaced exit discharge from the West corridor; North patio, North east corridor and patio, and the East patient wing corridor did not connect to a public way or parking area, there was approximately 20 feet up to 45 feet of grassy surface to cross before a hard surface area was available from each of these exits to the public way. This was observed by the surveyor and acknowledged as a potential problem during snow and wet weather by the Maintenance Director. When questioned about snow removal of the grass covered exit discharge, the Maintenance Director had no policy on snow removal for this area.

Actual NFPA Standard:

19.2.1 General.
Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7.
Exception: As modified by 19.2.2 through 19.2.11.
7.7.1*
Exits shall terminate directly at a public way or at an exterior exit discharge. Yards, courts, open spaces, or other portions of the exit discharge shall be of required width and size to provide all occupants with a safe access to a public way.
Exception No. 1: This requirement shall not apply to interior exit discharge as otherwise provided in 7.7.2.
Exception No. 2: This requirement shall not apply to rooftop exit discharge as otherwise provided in 7.7.6.
Exception No. 3: Means of egress shall be permitted to terminate in an exterior area of refuge as provided in Chapters 22 and 23.

Based upon record review and interview on 10/24/11 the facility failed to ensure the fire alarm system was maintained in a reliable operating condition. Failure to maintain the fire alarm system could result in an increased time to identify and control a fire. The facility was licensed for 22 with a census of 20 on the day of the survey.

Findings include:

During the review of facility records on 10/24/11 at approximately 2:45 PM the facility was unable to produce a record of a sensitivity testing of the system smoke detectors of the fire alarm/detection system. Review of the fire alarm system inspection records indicated the system had a new panel installed in 2005 and the city sign-off was 2008. No record of sensitivity testing could be produced and there was a mix of new and older style smoke detectors throughout the building. When asked about the time span between installation and sign off, the Maintenance Director indicated the installation had not been fully tested upon completion, and it was not discovered until 2008.

Actual NFPA standard:

9.6.1.4
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 Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.
9.6.1.5
All systems and components shall be approved for the purpose for which they are installed.
9.6.1.6
Fire alarm system installation wiring or other transmission paths shall be monitored for integrity in accordance with 9.6.1.4.
9.6.1.7*
To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code.

NFPA 72, National Fire Alarm Code, 1999 Edition

7-3.2.1*
Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.
To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method
(2) Manufacturer ' s calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction
Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.
Exception No. 1: Detectors listed as field adjustable shall be permitted to be either adjusted within the listed and marked sensitivity range and cleaned and recalibrated, or they shall be replaced.
Exception No. 2: This requirement shall not apply to single station detectors referenced in 7-3.3 and Table 7-2.2.
The detector sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of smoke or other aerosol into the detector.

Based upon observation, record review and interview on 10/24-25/11 the facility failed to inspect, test and maintain the automatic sprinkler system in a reliable operating condition in accordance with NFPA 25. This deficient practice could result in the system not fully functional during an emergency. The hospital is licensed for 22 and had a census of 20 on the day of the survey.

Findings include:

1) Interview with the Maintenance Director on 10/24/11 revealed no system was in place to conduct quarterly inspections and flow alarm testing of the sprinkler system. Monthly testing of tamper switches were documented, but no records were not available to document quarterly inspection and testing of the alarm activation device (flow switch).

2) During the facility tour on 10/25/11 at 8:45 AM observation revealed a sprinkler head loaded with paint in the bathroom of room 207.

3) During the facility tour on 10/25/11 at approximately 9:00 AM observation of the sprinkler riser room revealed the spare head box to not have a supply of spare heads (two spare heads were painted) proportionally representative of the heads used in the system.

Actual NFPA Standard:

NFPA 25, 1999 Edition
2-1 General.
This chapter provides the minimum requirements for the routine inspection, testing, and maintenance of sprinkler systems. Table 2-1 shall be used to determine the minimum required frequencies for inspection, testing, and maintenance.
Exception: Valves and fire department connections shall be inspected, tested, and maintained in accordance with Chapter 9.
2-2.6 Alarm Devices.
Alarm devices shall be inspected quarterly to verify that they are free of physical damage.
2-2.7* Hydraulic Nameplate.
The hydraulic nameplate, if provided, shall be inspected quarterly to verify that it is attached securely to the sprinkler riser and is legible.
2-3.3* Alarm Devices.
Waterflow alarm devices including, but not limited to, mechanical water motor gongs, vane-type waterflow devices, and pressure switches that provide audible or visual signals shall be tested quarterly.

2-2.1.1*
Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.
Exception No. 1*: Sprinklers installed in concealed spaces such as above suspended ceilings shall not require inspection.
Exception No. 2: Sprinklers installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown.


2-4.1.4
A supply of at least six spare sprinklers shall be stored in a cabinet on the premises for replacement purposes. The stock of spare sprinklers shall be proportionally representative of the types and temperature ratings of the system sprinklers. A minimum of two sprinklers of each type and temperature rating installed shall be provided. The cabinet shall be so located that it will not be exposed to moisture, dust, corrosion, or a temperature exceeding 100?F (38?C).
Exception: Where dry sprinklers of different lengths are installed, spare dry sprinklers shall not be required, provided that a means of returning the system to service is furnished.

Based upon observation, record review and interview on 10/24-25/11 the facility failed to ensure a smoking policy provided a safe environment for patients, staff and visitors of the facility. The facility is licensed for 22 beds and had a census of 20 on the day of the survey.

Findings include:

1) During record review on 10/24/11 the Maintenance Director was asked to provide smoking policy for review and none could be provided. Review of available records and the facilities policy manual revealed no written policy or regulation was available to provide guidance to staff, patients and visitors to ensure smoking safety.

2) During the facility tour on 10/25/11 observation revealed a 32 gallon (or larger) Rubbermaid type trash container in the patient smoking area just outside the nursing station area. A non combustible ashtray was provided but no self closing metal container was available for ashtray disposal.

3) During the facility tour on 10/25/11 observation of the liquid oxygen storage area was not posted with a sign indicating that smoking was prohibited.

Actual NFPA standard:

NFPA 101 the Life Safety Code

19.7.4* Smoking.
Smoking regulations shall be adopted and shall include not less than the following provisions:
(1) Smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such areas shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking.
Exception: In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required.
(2) Smoking by patients classified as not responsible shall be prohibited.
Exception: The requirement of 19.7.4(2) shall not apply where the patient is under direct supervision.
(3) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted.
(4) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted.

Based upon observation and interview conducted on 10/25/11, the facility failed to ensure portable space heating device elements did not exceed 212 degrees Fahrenheit. This deficient practice is considered a significant risk due to the history of fires caused by space heaters. The facility is licensed for 22 beds and had a census of 20 on the day of the survey.

Findings include:

During the facility tour conducted on 10/25/11 between 8:00 AM and 11:15 AM, observation revealed portable space heating devices located in the following areas: Outpatient room #1, Outpatient room #5, and the Treatment Coordinators office. Interview with the Maintenance Director indicated the facility had no process to initially and annually test portable space heating devices used in non sleeping staff areas to ensure elements are less than 212 degrees F.

Actual NFPA Standard:

NFPA 101, the Life Safety Code, 2000 Edition

19.7.8 Portable Space-Heating Devices.
Portable space-heating devices shall be prohibited in all health care occupancies.
Exception: Portable space-heating devices shall be permitted to be used in nonsleeping staff and employee areas where the heating elements of such devices do not exceed 212?F (100?C).

Based upon observation the facility failed to ensure fire resistance rated separation assembly integrity is maintained at the applicable rating. Failure to seal penetrations could allow products of combustion to migrate through the structure. This observation was made by the surveyor and acknowledged by the Maintenance Director. The facility is licensed for 22 beds and had a census of 20 on the day of the survey.

Findings include:

During the facility tour on 10/25/11 between 8:00 AM and 11:00 AM, observation revealed penetrations of fire rated ceilings in the communications room and bio-hazard storage room. The communications room had two ceiling penetrations; one from cabling approximately 1" in diameter, and another with a 1/2 inch gap encircling a conduit pipe in the 1 hour fire resistive rated ceiling. The bio-hazard room had penetrations around a grouping of conduit in the smoke partition ceiling. This was observed by the surveyor and acknowledged by the Maintenance Director.

Actual NFPA standard:

NFPA 101 the Life Safety Code

8.2.3.2.4.2*
Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through fire barriers shall be protected as follows:
(1) The space between the penetrating item and the fire barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the fire barrier, the sleeve shall be solidly set in the fire barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) * Insulation and coverings for pipes and ducts shall not pass through the fire barrier unless one of the following conditions is met:
a. The material shall be capable of maintaining the fire resistance of the fire barrier.
b. The material shall be protected by an approved device that is designed for the specific purpose.
(4) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the fire barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

8-2.4.4 Penetrations and Miscellaneous Openings in Smoke Partitions.
8.2.4.4.1
Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through smoke partitions shall be protected as follows:
(1) The space between the penetrating item and the smoke partition shall meet one of the following conditions:
a. It shall be filled with a material that is capable of limiting the transfer of smoke.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke partition, the sleeve shall be solidly set in the smoke partition, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of limiting the transfer of smoke.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibrations into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the smoke partitions.
b. It shall be made by an approved device that is designed for the specific purpose.

Based upon observation and staff interview on 10/25/11, the facility failed to ensure adequate electrical safety in accordance with NFPA 70. The facility is licensed for 22 beds and had a census of 20 on the day of the survey.

Findings include:

During the facility tour on 10/25/11 between 8:00 AM and 11:15 AM; observation revealed four (4) relocatable power taps "daisy chained" in the communications room. Relocatable power taps (RPT's) were also in use with significant startup loads including refrigerators, microwaves, and coffee makers in the staff break room, conference room and Outpatient room #5. Interview with the Maintenance Director revealed he was not aware that RPT's were not listed for this type of use.

Actual NFPA reference:

NFPA 101 the Life Safety Code
9.1.2 Electric.
Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction. NFPA 70, National Electrical Code, 1999 Edition

NFPA 70 - 110.3 Examination, Identification, Installation, and Use of Equipment.
(A) Examination. In judging equipment, considerations such as the following shall be evaluated:
(1) Suitability for installation and use in conformity with the provisions of this Code
FPN: Suitability of equipment use may be identified by a description marked on or provided with a product to identify the suitability of the product for a specific purpose, environment, or application. Suitability of equipment may be evidenced by listing or labeling.
(2) Mechanical strength and durability, including, for parts designed to enclose and protect other equipment, the adequacy of the protection thus provided
(3) Wire-bending and connection space
(4) Electrical insulation
(5) Heating effects under normal conditions of use and also under abnormal conditions likely to arise in service
(6) Arcing effects
(7) Classification by type, size, voltage, current capacity, and specific use
(8) Other factors that contribute to the practical safeguarding of persons using or likely to come in contact with the equipment
(B) Installation and Use. Listed or labeled equipment shall be installed and used in accordance with any instructions included in the listing or labeling.

See UL listing 1363 and UL XBYS.GuideInfo Relocatable Power Taps

Based upon record review and staff interview on 10/24/11 the facility failed to ensure a policy was in place to evacuate or safeguard occupants in the event of required fire protection systems being out of service. The facility is licensed for 22 beds and had a census of 20 on the day of the survey.

Findings include:

During the review of records portion of the survey, interview with the Maintenance Director revealed there was no policy in place to conduct a fire watch in the event of a fire alarm or sprinkler system being out of service for greater than four hours. When the Maintenance Director was asked about such a policy he was was unaware of the requirements for a fire watch or a policy.

Actual NFPA standards:

NFPA 101 the Life Safety Code

9.6.1.8*
Where a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service.

9.7.6.1
Where a required automatic sprinkler system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the sprinkler system has been returned to service.

Based upon observation and operational testing on 10/25/11 the facility failed to ensure that corridor doors closed and latched securely. This deficient practice allows products of combustion to move freely between rooms and the exit access corridor compromising egress. The facility is licensed for 22 beds and had a census of 20 on the day of the survey.

Findings include:

During the facility tour on 10/25/11 between 8:00 AM and 11:15 PM corridor doors were tested and the following were observed to not close and latch securely; Room 103, Room 107, and Room 108. Testing was conducted by the surveyor and witnessed by the Maintenance Director.

Actual NFPA standard:
LSC 2000
19.3.6.3.2*
Doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door. Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.2.
Exception No. 1: Doors to toilet rooms, bathrooms, shower rooms, sink closets, and similar auxiliary spaces that do not contain flammable or combustible materials.
Exception No. 2: Existing roller latches demonstrated to keep the door closed against a force of 5 lbf (22 N) shall be permitted to be kept in service. Roller latches are prohibited by 42 CFR 482.41

Based upon observation and operational testing the facility failed to ensure hazardous area doors were maintained self closing to prevent the spread of the products of combustion. The facility was licensed for 22 beds and had a census of 20 on the day of the survey.

Findings include:

During the facility tour on 10/25/11 between 8:00 AM and 11:15 AM, observation of operational testing of the storage/clean linen room door inside the shower room failed to have the door self close and latch securely. Testing was conducted by the surveyor and witnessed by the Maintenance Director.

Actual NFPA standard:

101 - 2000 Edition

19.3.2.1 Hazardous Areas.
Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. 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) Soiled linen rooms
(6) Trash collection rooms
(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.
Exception: Doors in rated enclosures shall be permitted to have nonrated, factory- or field-applied protective plates extending not more than 48 in. (122 cm) above the bottom of the door.

Based upon observation and interview on 10/25/11 the facility failed to ensure exit discharge was unobstructed to a public way. Failure to provide accessible exit discharge prevents egress to a safe area by wheelchairs, beds and mobility impaired persons.

Findings include:

During the facility tour on 10/25/11 between 8:00 AM and 11:05 AM observation revealed the hard surfaced exit discharge from the West corridor; North patio, North east corridor and patio, and the East patient wing corridor did not connect to a public way or parking area, there was approximately 20 feet up to 45 feet of grassy surface to cross before a hard surface area was available from each of these exits to the public way. This was observed by the surveyor and acknowledged as a potential problem during snow and wet weather by the Maintenance Director. When questioned about snow removal of the grass covered exit discharge, the Maintenance Director had no policy on snow removal for this area.

Actual NFPA Standard:

19.2.1 General.
Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7.
Exception: As modified by 19.2.2 through 19.2.11.
7.7.1*
Exits shall terminate directly at a public way or at an exterior exit discharge. Yards, courts, open spaces, or other portions of the exit discharge shall be of required width and size to provide all occupants with a safe access to a public way.
Exception No. 1: This requirement shall not apply to interior exit discharge as otherwise provided in 7.7.2.
Exception No. 2: This requirement shall not apply to rooftop exit discharge as otherwise provided in 7.7.6.
Exception No. 3: Means of egress shall be permitted to terminate in an exterior area of refuge as provided in Chapters 22 and 23.

Based upon record review and interview on 10/24/11 the facility failed to ensure the fire alarm system was maintained in a reliable operating condition. Failure to maintain the fire alarm system could result in an increased time to identify and control a fire. The facility was licensed for 22 with a census of 20 on the day of the survey.

Findings include:

During the review of facility records on 10/24/11 at approximately 2:45 PM the facility was unable to produce a record of a sensitivity testing of the system smoke detectors of the fire alarm/detection system. Review of the fire alarm system inspection records indicated the system had a new panel installed in 2005 and the city sign-off was 2008. No record of sensitivity testing could be produced and there was a mix of new and older style smoke detectors throughout the building. When asked about the time span between installation and sign off, the Maintenance Director indicated the installation had not been fully tested upon completion, and it was not discovered until 2008.

Actual NFPA standard:

9.6.1.4
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 Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.
9.6.1.5
All systems and components shall be approved for the purpose for which they are installed.
9.6.1.6
Fire alarm system installation wiring or other transmission paths shall be monitored for integrity in accordance with 9.6.1.4.
9.6.1.7*
To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code.

NFPA 72, National Fire Alarm Code, 1999 Edition

7-3.2.1*
Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.
To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method
(2) Manufacturer ' s calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction
Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.
Exception No. 1: Detectors listed as field adjustable shall be permitted to be either adjusted within the listed and marked sensitivity range and cleaned and recalibrated, or they shall be replaced.
Exception No. 2: This requirement shall not apply to single station detectors referenced in 7-3.3 and Table 7-2.2.
The detector sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of smoke or other aerosol into the detector.

Based upon observation, record review and interview on 10/24-25/11 the facility failed to inspect, test and maintain the automatic sprinkler system in a reliable operating condition in accordance with NFPA 25. This deficient practice could result in the system not fully functional during an emergency. The hospital is licensed for 22 and had a census of 20 on the day of the survey.

Findings include:

1) Interview with the Maintenance Director on 10/24/11 revealed no system was in place to conduct quarterly inspections and flow alarm testing of the sprinkler system. Monthly testing of tamper switches were documented, but no records were not available to document quarterly inspection and testing of the alarm activation device (flow switch).

2) During the facility tour on 10/25/11 at 8:45 AM observation revealed a sprinkler head loaded with paint in the bathroom of room 207.

3) During the facility tour on 10/25/11 at approximately 9:00 AM observation of the sprinkler riser room revealed the spare head box to not have a supply of spare heads (two spare heads were painted) proportionally representative of the heads used in the system.

Actual NFPA Standard:

NFPA 25, 1999 Edition
2-1 General.
This chapter provides the minimum requirements for the routine inspection, testing, and maintenance of sprinkler systems. Table 2-1 shall be used to determine the minimum required frequencies for inspection, testing, and maintenance.
Exception: Valves and fire department connections shall be inspected, tested, and maintained in accordance with Chapter 9.
2-2.6 Alarm Devices.
Alarm devices shall be inspected quarterly to verify that they are free of physical damage.
2-2.7* Hydraulic Nameplate.
The hydraulic nameplate, if provided, shall be inspected quarterly to verify that it is attached securely to the sprinkler riser and is legible.
2-3.3* Alarm Devices.
Waterflow alarm devices including, but not limited to, mechanical water motor gongs, vane-type waterflow devices, and pressure switches that provide audible or visual signals shall be tested quarterly.

2-2.1.1*
Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.
Exception No. 1*: Sprinklers installed in concealed spaces such as above suspended ceilings shall not require inspection.
Exception No. 2: Sprinklers installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown.


2-4.1.4
A supply of at least six spare sprinklers shall be stored in a cabinet on the premises for replacement purposes. The stock of spare sprinklers shall be proportionally representative of the types and temperature ratings of the system sprinklers. A minimum of two sprinklers of each type and temperature rating installed shall be provided. The cabinet shall be so located that it will not be exposed to moisture, dust, corrosion, or a temperature exceeding 100?F (38?C).
Exception: Where dry sprinklers of different lengths are installed, spare dry sprinklers shall not be required, provided that a means of returning the system to service is furnished.

Based upon observation, record review and interview on 10/24-25/11 the facility failed to ensure a smoking policy provided a safe environment for patients, staff and visitors of the facility. The facility is licensed for 22 beds and had a census of 20 on the day of the survey.

Findings include:

1) During record review on 10/24/11 the Maintenance Director was asked to provide smoking policy for review and none could be provided. Review of available records and the facilities policy manual revealed no written policy or regulation was available to provide guidance to staff, patients and visitors to ensure smoking safety.

2) During the facility tour on 10/25/11 observation revealed a 32 gallon (or larger) Rubbermaid type trash container in the patient smoking area just outside the nursing station area. A non combustible ashtray was provided but no self closing metal container was available for ashtray disposal.

3) During the facility tour on 10/25/11 observation of the liquid oxygen storage area was not posted with a sign indicating that smoking was prohibited.

Actual NFPA standard:

NFPA 101 the Life Safety Code

19.7.4* Smoking.
Smoking regulations shall be adopted and shall include not less than the following provisions:
(1) Smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such areas shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking.
Exception: In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required.
(2) Smoking by patients classified as not responsible shall be prohibited.
Exception: The requirement of 19.7.4(2) shall not apply where the patient is under direct supervision.
(3) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted.
(4) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted.

Based upon observation and interview conducted on 10/25/11, the facility failed to ensure portable space heating device elements did not exceed 212 degrees Fahrenheit. This deficient practice is considered a significant risk due to the history of fires caused by space heaters. The facility is licensed for 22 beds and had a census of 20 on the day of the survey.

Findings include:

During the facility tour conducted on 10/25/11 between 8:00 AM and 11:15 AM, observation revealed portable space heating devices located in the following areas: Outpatient room #1, Outpatient room #5, and the Treatment Coordinators office. Interview with the Maintenance Director indicated the facility had no process to initially and annually test portable space heating devices used in non sleeping staff areas to ensure elements are less than 212 degrees F.

Actual NFPA Standard:

NFPA 101, the Life Safety Code, 2000 Edition

19.7.8 Portable Space-Heating Devices.
Portable space-heating devices shall be prohibited in all health care occupancies.
Exception: Portable space-heating devices shall be permitted to be used in nonsleeping staff and employee areas where the heating elements of such devices do not exceed 212?F (100?C).

Based upon observation the facility failed to ensure fire resistance rated separation assembly integrity is maintained at the applicable rating. Failure to seal penetrations could allow products of combustion to migrate through the structure. This observation was made by the surveyor and acknowledged by the Maintenance Director. The facility is licensed for 22 beds and had a census of 20 on the day of the survey.

Findings include:

During the facility tour on 10/25/11 between 8:00 AM and 11:00 AM, observation revealed penetrations of fire rated ceilings in the communications room and bio-hazard storage room. The communications room had two ceiling penetrations; one from cabling approximately 1" in diameter, and another with a 1/2 inch gap encircling a conduit pipe in the 1 hour fire resistive rated ceiling. The bio-hazard room had penetrations around a grouping of conduit in the smoke partition ceiling. This was observed by the surveyor and acknowledged by the Maintenance Director.

Actual NFPA standard:

NFPA 101 the Life Safety Code

8.2.3.2.4.2*
Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through fire barriers shall be protected as follows:
(1) The space between the penetrating item and the fire barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the fire barrier, the sleeve shall be solidly set in the fire barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) * Insulation and coverings for pipes and ducts shall not pass through the fire barrier unless one of the following conditions is met:
a. The material shall be capable of maintaining the fire resistance of the fire barrier.
b. The material shall be protected by an approved device that is designed for the specific purpose.
(4) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the fire barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

8-2.4.4 Penetrations and Miscellaneous Openings in Smoke Partitions.
8.2.4.4.1
Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through smoke partitions shall be protected as follows:
(1) The space between the penetrating item and the smoke partition shall meet one of the following conditions:
a. It shall be filled with a material that is capable of limiting the transfer of smoke.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke partition, the sleeve shall be solidly set in the smoke partition, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of limiting the transfer of smoke.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibrations into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the smoke partitions.
b. It shall be made by an approved device that is designed for the specific purpose.

Based upon observation and staff interview on 10/25/11, the facility failed to ensure adequate electrical safety in accordance with NFPA 70. The facility is licensed for 22 beds and had a census of 20 on the day of the survey.

Findings include:

During the facility tour on 10/25/11 between 8:00 AM and 11:15 AM; observation revealed four (4) relocatable power taps "daisy chained" in the communications room. Relocatable power taps (RPT's) were also in use with significant startup loads including refrigerators, microwaves, and coffee makers in the staff break room, conference room and Outpatient room #5. Interview with the Maintenance Director revealed he was not aware that RPT's were not listed for this type of use.

Actual NFPA reference:

NFPA 101 the Life Safety Code
9.1.2 Electric.
Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction. NFPA 70, National Electrical Code, 1999 Edition

NFPA 70 - 110.3 Examination, Identification, Installation, and Use of Equipment.
(A) Examination. In judging equipment, considerations such as the following shall be evaluated:
(1) Suitability for installation and use in conformity with the provisions of this Code
FPN: Suitability of equipment use may be identified by a description marked on or provided with a product to identify the suitability of the product for a specific purpose, environment, or application. Suitability of equipment may be evidenced by listing or labeling.
(2) Mechanical strength and durability, including, for parts designed to enclose and protect other equipment, the adequacy of the protection thus provided
(3) Wire-bending and connection space
(4) Electrical insulation
(5) Heating effects under normal conditions of use and also under abnormal conditions likely to arise in service
(6) Arcing effects
(7) Classification by type, size, voltage, current capacity, and specific use
(8) Other factors that contribute to the practical safeguarding of persons using or likely to come in contact with the equipment
(B) Installation and Use. Listed or labeled equipment shall be installed and used in accordance with any instructions included in the listing or labeling.

See UL listing 1363 and UL XBYS.GuideInfo Relocatable Power Taps

Based upon record review and staff interview on 10/24/11 the facility failed to ensure a policy was in place to evacuate or safeguard occupants in the event of required fire protection systems being out of service. The facility is licensed for 22 beds and had a census of 20 on the day of the survey.

Findings include:

During the review of records portion of the survey, interview with the Maintenance Director revealed there was no policy in place to conduct a fire watch in the event of a fire alarm or sprinkler system being out of service for greater than four hours. When the Maintenance Director was asked about such a policy he was was unaware of the requirements for a fire watch or a policy.

Actual NFPA standards:

NFPA 101 the Life Safety Code

9.6.1.8*
Where a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service.

9.7.6.1
Where a required automatic sprinkler system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the sprinkler system has been returned to service.