HospitalInspections.org

One-story Existing Health Care Occupancy buildings of Type III (200) construction are required to be protected throughout with an automatic sprinkler system.

Observation determined the structrual walls are concrete block and the roof assembly is constructed of combustible wood supports and wood boards. The building is not protected throughout with an automatic sprinkler system. The Life Safety Code does not allow this type of construction for Existing Health Care Occupancies without a complete automatic sprinkler system.

The facility failed to separate hazardous areas from other spaces with one-hour fire resistive rated partitions and self-closing fire-rated door assemblies.

Observation determined the Medical Records Storage Room door was not a 45-minute fire rated door assembly.

Observation determined the facility failed to ensure that exit stairways are enclosed with construction having a fire resistance rating of at least one-hour to provide a continuous path of escape with protection provided against fire or smoke from other parts of the building.

The north and south exit stairs from the basement discharge onto the main floor and are not arranged to provide a continuous fire resistant enclosure to the exterior of the building.

The facility failed to ensure the fire alarm system is maintained, inspected and tested in accordance with the manufacturer's specifications and NFPA 72. NFPA 72 requires the fire alarm system to be inspected and tested annually.

Review of annual fire alarm system test records indicated the fire alarm system was not inspected and tested since 2008.

1) Listed grease filters, baffles, or other approved grease removal devices for use with commercial cooking equipment must be provided. Listed grease filters must be tested in accordance with UL 1046, Grease Filters for Exhaust Ducts. Mesh filters can not be used. NFPA 96 Section 3-1

The facility failed to ensure the commercial cooking equipment was in compliance with NFPA 96. Observation determined the kitchen exhaust hood mesh filters were not UL 1046 listed filters.

2) Fire extinguishing systems must meet NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations. Review of documentation indicated the service company's inspection check lists for the commercial kitchen hood fire-extinguishing system did not indicate the fire-extinguishing system met UL 300 requirements.

1) Transfer switches must be subjected to a maintenance program including connections, inspection or testing for evidence of overheating and excessive contact erosion, removal of dust and dirt, and replacement of contacts when required. NFPA 110, Standard for Emergency and Standby Power Systems

The facility failed to provide documentation of a preventive maintenance program for the emergency generator electrical transfer switch.

2) A functional test must be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test must be conducted on every required battery-powered emergency lighting system for not less than 1 1/2-hours. Equipment must be fully operational for the duration of the test. Written records of visual inspection and tests must be kept by the owner for inspection. 7.9.3

The facility failed to assure maintenance and testing of emergency lighting. Review of records could not verify the 1 1/2-hour continuous annual test of the battery-powered lighting for the emergency generator and the Ambulance Bay.

3) Records review indicated the facility failed to maintain fire dampers in a reliable operating condition as required by NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems. Maintenance of fire dampers is required at least every 6 years. Maintenance of fire dampers includes:

(a) Fusible links shall be removed.
(b) All dampers shall be operated to verify that they close fully.
(c) The latch, if provided, shall be checked.
(d) Moving parts shall be lubricated as necessary.

4) The emergency generator must be inspected weekly. Maintenance free batteries are not permitted. NFPA 110, 3-5.4.5

Review of records determined documentation of the weekly inspections did not include the battery fluid. Inspection of the battery revealed a maintenance free type without removeable caps was in use.