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Unsealed openings / penetrations were observed in the fire walls as follows: During the survey, the following is an example of what was observed:

Unsealed penetrations around a section of sheetrock above the fire doors in the two hour fire wall, by North West Hall by Elevator #8.


8.2.2.2* Fire compartments shall be formed with fire barriers that are continuous from outside wall to outside wall, from one fire barrier to another, or a combination thereof, including continuity through all concealed spaces, such as those found above a ceiling, including interstitial spaces. Walls used as fire barriers shall comply with Chapter 3 of NFPA 221, Standard for Fire Walls and Fire Barrier Walls. The NFPA 221 limitation on percentage width of openings shall not apply.

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.

The facility failed to provide complete corridor walls in areas of the facility which did not have sprinkler coverage. Examples are as follows:

The corridor wall in the compartments without complete sprinkler coverage were observed not extending to the deck above at the following locations:

a) Med Room 5336
b) In the corridor between Four North West and Four North


NFPA 101, 19.3.6.2.1 Corridor walls shall be continuous from the floor to the underside of the floor or roof deck above, through any concealed spaces, such as those above suspended ceilings, and through interstitial structural and mechanical spaces, and they shall have a fire resistance rating of not less than 1/2 hour.
Exception No. 1: In smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.2, a corridor shall be permitted to be separated from all other areas by non-fire-rated partitions and shall be permitted to terminate at the ceiling where the ceiling is constructed to limit the transfer of smoke.

The facility failed to provide/maintain corridor doors which would close and resist the passage of smoke. Examples are as follows:

1) The following doors were observed without positive latching hardware:

a) Top half of the Dutch Door to Med Room 5138
b) Office 5351
c) Office 5409

2) The door to Office 4685 was observed held in the open position with a rubber wedge, causing an impediment to closing.

3) A corridor door was not observed to the PACU unit near Male Locker Room 6325.

4) The corridor double doors to the First Floor OR Sterile Processing Room, near Recovery, were observed with an unsealed gap between doors, allowing viewing into the room from the corridor.


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5) The PBX Office door was held open by a wooden stop, located on the Ground Floor.

6) The door for Labor Observation Room failed to latch.

7) Patient Room 4649 door failed to close tight in the frame so as to resist the passage of smoke.


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8) The following First Floor corridor doors did not have positive latching hardware:

a. Dr.s' Lounge room 1404
b. Room 1231
c. The Chapel doors
d. Consult 1 room 1611
e. Room 1110

9) Rooms 3744 (Conference Room) and room 3739 - had self-closing devices on the corridor doors, but the doors were being held open by trash cans.

10) The following corridor doors were impeded from closing by trash cans:

a. Room 3806
b. Room 3805
c. Room 3803
d. Room 3645
e. Room 3301



2000 NFPA 101, 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.
2000 NFPA 101, 19.3.6.3.3 Hold-open devices that release when the door is pushed or pulled shall be permitted.
2000 NFPA 101, 19.3.6.3.4 Door-closing devices shall not be required on doors in corridor wall openings other than those serving required exits, smoke barriers, or enclosures of vertical openings and hazardous areas.
2007 CMS - 2786R There is no impediment to the closing of the corridor doors.

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The facility failed to provide clearly marked access to exits per code. Findings include:
During the survey, the following are examples of what was observed:

The following First Floor stairwells did not have a clearly marked access to the exit:

a. Stairwell 1401
b. Stairwell 1968

2000 NFPA 101, 7.10.1.4 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. Sign placement shall be such that no point in an exit access corridor is in excess of 100 ft (30 m) from the nearest externally illuminated sign and is not in excess of the marked rating for internally illuminated signs.
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The facility failed to maintain smoke barriers that would provide at least a half hour fire resistance rating and restrict the movement of smoke. Examples are as follows:

Unsealed opening/penetrations were observed in smoke walls as follows:

1) Approximately 3 ' X 4 ' piece of sheetrock missing inside room 5333
2) Unsealed opening in corridor over the smoke doors near room 5107


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3) Unsealed penetrations around a group of wiring in the Smoke Barrier G:309.
4) Unsealed penetrations around a group of wiring in the Smoke Barrier by Patient Room 2413.



NFPA 101, 19.3.7.3 and 8.3.1 Smoke walls shall have a fire resistance rating of at least half hour and to be continuous from floor-to-deck and from outside-to-outside.

The facility failed to maintain self-closing doors in smoke barriers. Examples are as follows:

1) The smoke doors near room 4132 were observed not closing/latching with installed hardware when released during fire alarm activation.

2) The smoke doors near the OR Nursing Desk, across from the Procedure Board, failed to release from the magnetic hold-open devices upon fire alarm activation.


NFPA 101, 19.3.7.6, 8.3.4 Doors in smoke barriers to be self-closing. Doors in smoke barriers shall close the opening in the wall leaving only a minimum clearance to allow door(s) to function properly.

The facility failed to provide/maintain smoke-resisting partitions and self-closing/latching doors for hazardous areas. Examples are as follows:

1) The doors to the following rooms with sprinkler coverage were observed not closing/latching with the installed hardware:

a) Storage Room 5406
b) Equipment Tech Office/Storage Room 5408

2) The following rooms were observed without a self-closing device:

a) Trash Collection Room 5203
b) Supply Room 5214
c) Storage Room 4526
d) Trash Collection Room 5415

3) The Trash Room 5338 without sprinkler coverage was observed with flex ducts passing through the walls above the ceiling without fire dampers and the door only twenty minute fire rated, not forty-five minute rated as required.

4) The door to the MICU Storage Room was observed removed.

5) The Soiled Utility Room 4340 without sprinkler coverage was observed with flex ducts passing through the walls above the ceiling.

6) Storage Room 4338 without sprinkler coverage was observed with the walls not extending to the deck above the ceiling.

7) The doors to the Large Bed Storage Room at Four North PT area were observed with the arms of the self-closing devices removed.


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First Floor
8) The Credentials Office/Storage Room - was over 50 sq. ft., sprinklered and contained combustible materials - the corridor door did not have a self-closing device.

9) The Old Kitchen/Storage Room - the corridor door did not have a self-closing device.


2000 NFPA 101, 19.3.2.1 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.

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The facility failed to maintain stairways with at least one hour fire resistance rating. Examples are as follows:

The following stairwells were observed with air supply ducts passing through the walls supplying air into the corridor and stairwell without fire dampers:

1) Near room 5321
2) Near room 5311


NFPA 101, 19.3.1.1 Any vertical opening shall be enclosed or protected in accordance with 8.2.5. Where enclosure is provided, the construction shall have not less than a 1-hour fire resistance rating.

The facility failed to provide readily accessible exit access. Examples are as follows:

1) Double cylinder keyed dead bolt locks were observed on the following room doors which prevent exit from within the rooms:

a. Education Room 5244
b. Supply Room 5214
c. Office 5200

2) Cylinder keyed dead bolt locks, without any way to unlock the lock from within the room, were observed on the following rooms which prevent exit from within the rooms:

a. Office 5102
b. Office 5104
c. Storage Room 5106


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3) First Floor the following delayed egress exit doors did not release when tested:
a. Stairwell #1228
b. Stairwell at the East Air Handling Unit - Door # 4M4 - 43
c. Atrium door # 4M4 - 37

4). Third Floor the following doors were magnetically located on the Rehabilitation Unit, without an emergency door release button at the Nurses' Station:
a. The stairwell door 3831 - only key pad would release this door.
b. The separation doors - the key pad or a button on the phone (only when someone is pressing it) would release these doors.



2000 NFPA 101, 7.1.9 Any device or alarm installed to restrict the improper use of a means of egress shall be designed and installed so that it cannot, even in case of failure, impede or prevent emergency use of such means of egress unless otherwise provided in 7.2.1.6 and Chapters 18, 19, 22, and 23.
2000 NFPA 101, 7.1.10.1 Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.
2000 NFPA 101, 7.2.1.5.1 Doors shall be arranged to be opened readily from the egress side whenever the building is occupied. Locks, if provided, shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side.
2000 NFPA 101, 7.2.1.6.1 Approved, listed, delayed-egress locks shall be permitted to be installed on doors serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system in accordance with Section 9.6, or an approved, supervised automatic sprinkler system in accordance with Section 9.7, and where permitted in Chapters 12 through 42, provided that the following criteria are met.
(a) The doors shall unlock upon actuation of an approved, supervised automatic sprinkler system in accordance with Section 9.7 or upon the actuation of any heat detector or activation of not more than two smoke detectors of an approved, supervised automatic fire detection system in accordance with Section 9.6.
(b) The doors shall unlock upon loss of power controlling the lock or locking mechanism.
(c) An irreversible process shall release the lock within 15 seconds upon application of a force to the release device required in 7.2.1.5.4 that shall not be required to exceed 15 lbf (67 N) nor be required to be continuously applied for more than 3 seconds. The initiation of the release process shall activate an audible signal in the vicinity of the door. Once the door lock has been released by the application of force to the releasing device, relocking shall be by manual means only.
Exception: Where approved by the authority having jurisdiction, a delay not exceeding 30 seconds shall be permitted.
(d) * On the door adjacent to the release device, there shall be a readily visible, durable sign in letters not less than 1 in. (2.5 cm) high and not less than 1/8 in. (0.3 cm) in stroke width on a contrasting background that reads as follows:
"PUSH UNTIL ALARM SOUNDS DOOR CAN BE OPENED IN 15 SECONDS"
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.
Alabama Department of Public Health Memo "Exit Door Locking Arrangements in Health Care Facilities" revised 12/19/03, as authority having jurisdiction: an "emergency release switch" or "kill switch" shall be provided at the nearest nurse's station.

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The facility failed to maintain the horizontal exits per code. Findings include:
During the survey, the following are examples of what was observed:

The 1.5 hour fire rated door at the Third Floor Rotary Dining Room leading to Accounting - the right leaf did not latch under the fire alarm.



2000 NFPA 101, 7.2.4.3.8 All fire doors in horizontal exits shall be self-closing or automatic-closing in accordance with 7.2.1.8. Horizontal exit doors located across a corridor shall be automatic-closing in accordance with 7.2.1.8.
1999 NFPA 80, 3-4.1* Closing Devices for Swinging Tin Clad and Sheet Metal Fire Doors. Swinging tin clad and sheet metal fire doors shall be equipped with self-closing or automatic-closing devices to ensure that they are closed and latched at the time of fire. Other arrangements acceptable to the authority having jurisdiction shall be permitted.
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The facility failed to conduct fire drills under varying conditions at unexpected times. Examples are as follows:

1) Based on interview and documentation provided during the survey, all four third shift drills were conducted between 5:00 AM and 5:54 AM.

2) Based on interview and documentation provided during the survey, fire drills conducted between 9:00 PM and 6:00 AM were only an in-service, the fire alarm was not used nor was a coded announcements used at this time.



NFPA 101, 19.7.1.2 and 19.7.1.3 Drills shall include proper procedures, making sure all staff members participate.

NFPA 101, 19.7.1.2 Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of an audible alarm.

Facility failed to maintain the Digital Alarm Communicator Transmitter in the fire alarm system. Findings include: During the survey, the following are examples of what what observed:

1. When the Auto Dialer was tested for phone line 1, failure was not indicated at the protected premise within the allotted four (4) minute time frame.

2. When the Auto Dialer was tested for phone line 2, failure was not indicated at the protected premise within the allotted four (4) minute time frame.

3. When the Auto Dialer was tested for Communication Failure, failure was not indicated at the protected premise within the allotted fifteen (15) minute time frame (5 minimum to 10 maximum attempts for signal transmission).



1999 NFPA 72, Section 1-5.4.6, 5-5.3.2.1.5, and 5-5.3.2.1.6.2. Phone line and communication failure shall be indicated at the facility.

The facility failed to maintain the fire alarm system in proper working order. Examples are as follows:

1) The smoke detector near Node 4 Fire Alarm Control Panel in Ground Northeast G301 Electrical / Mechanical Room was observed mounted approximately four feet from the ceiling.

2) A smoke detector was not provided in the Second Northeast Electrical / Mechanical Room where Node 3 Fire Alarm Control Panel is located. (Drop-in ceiling tiles were observed missing from the grid system which would not allow a smoke detector to function properly)

NFPA 101, 34.1 and 9.6.1.4 1999 NFPA 72, 1-5.6 A smoke detector shall be provided in the location of the fire alarm panel for panels located in areas that are not continuously occupied.

NFPA 101, 9.6.1.4 The fire alarm system to be installed, tested, and maintained in accordance with the requirements of NFPA 70 and NFPA 72.

3) Audible/visual appliances were observed not heard or seen upon fire alarm activation at the following locations:

a) Corridor near room 4637
b) Corridor near room 5637

4) HVAC shutdown upon fire alarm activation could not be verified during fire alarm testing due to medical procedures being conducted.

5) The following exit doors with magnetic locking devices failed to release upon fire alarm activation:

a) Exit doors from MICU
b) Stair exit door from MICU

6) The facility failed to provide documentation of the monthly release of the magnetic locking devices during fire alarm activation.

Alabama Department of Public Health Memo "Exit Door Locking Arrangements in Health Care Facilities" revised 12/19/03, as authority having jurisdiction: as a minimum, documentation shall be maintained of lock operation and deactivation at each door during monthly fire alarm activation.


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7) Audible/visual appliances were observed not heard or seen upon fire alarm activation at the following locations:

a) Audible/Visual in corridor by OR # 5 Out Patient Surgery.
b) Audible/Visual in corridor by Room 1948 Out Patient Surgery.
c) Audible/Visual by G-628.
d) Audible/Visual in the Kitchen located on the wall above the Ice Cream Machine G-6211.


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First Floor
8) The Deli's double doors in the one hour Atrium wall did not close during the testing of the fire alarm system.
9) The following fire alarm audio/visual devices did not strobe:
a) By room 1838
b) At room 1849
c) At room 1807
d) At room 1803
e) At room 16046

Third Floor
10) By room 3636 could not hear the fire alarm when the two sets of fire doors were closed.
11) The following fire alarm audio/visual devices did not strobe:
a) At room 3175
b) At room 3172
12) The Elopement Corridor Doors 3646 at room 3686 did not release under the fire alarm.
Ground Floor
13) The automatic doors 08 025 by elevator 19 did not go to manual operation under the fire alarm.


2000 NFPA 101, 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.
1999 NFPA 72, 3-9.7.1 Any device or system intended to actuate the locking or unlocking of exits shall be connected to the fire alarm system serving the protected premises.
1999 NFPA 72, 3-9.7.2 All exits connected in accordance with 3-9.7.1 shall unlock upon receipt of any fire alarm signal by means of the fire alarm system serving the protected premises.
NFPA 72, 3-9.7.3 All exits connected in accordance with 3-9.7.1 shall unlock upon loss of the primary power to the fire alarm system serving the protected premises. The secondary power supply shall not be utilized to maintain these doors in the locked condition.
1999 NFPA 72, 4-4.2 Light Pulse Characteristics. The flash rate shall not exceed two flashes per second (2 Hz) nor be less than one flash every second (1 Hz) throughout the listed voltage range of the appliance.

1999 NFPA 72, 4-4.2.1 A maximum pulse duration shall be 0.2 seconds with a maximum duty cycle of 40 percent. The pulse duration shall be defined as the time interval between initial and final points of 10 percent of maximum signal.

1999 NFPA 72, 4-4.2.2* The light source color shall be clear or nominal white and shall not exceed 1000 cd (effective intensity).

1999 NFPA 72, 4-4.3.1 Visible notification appliances used in the public mode shall be located and shall be of a type, size, intensity, and number so that the operating effect of the appliance is seen by the intended viewers regardless of the viewer's orientation.

2000 NFPA 101, 9.6.5.2 Where required by another section of this Code, the following functions shall be actuated by the complete fire alarm system: (1) Release of hold-open devices for doors or other opening protectives (2) Stairwell or elevator shaft pressurization (3) Smoke management or smoke control systems (4) Emergency lighting control (5) Unlocking of doors
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The facility failed to provide sensitivity testing documentation of the smoke detectors. Examples are as follows:

Sensitivity testing documentation of the smoke detectors in the facility was not provided during the survey.


Detector sensitivity shall be checked within one year after installation and every alternate year thereafter per 72, 7-3.2.1.

Sprinkler coverage was observed, during the survey, not adequately provided. Findings include: During the survey, the following are examples of what was observed:

1. Elevator # 15 hoistway not provided with sprinkler coverage.

2. Elevator # 23 hoistway not provided with sprinkler coverage.



1999 NFPA 13, 5-13.6.1 Sidewall spray sprinklers shall be installed at the bottom of each elevator hoistway not more than 2 ft (0.61 m) above the floor of the pit.
Exception: For enclosed, noncombustible elevator shafts that do not contain combustible hydraulic fluids, the sprinklers at the bottom of the shaft are not required.

The facility failed to perform the required maintenance of the facility sprinkler system. Findings include: During the survey, the following are examples of what was observed:

1) The Fire Department Connection (FDC) cap was observed missing in Stairwell 5689 at South North East VIP.

2) The three-way FDC located on the Sixth Floor North East Penthouse on the West Wall was observed without the protective caps.

3) Documentation provided by the facility, during the survey, did not indicate the full trip test of the sprinkler dry system, required every three years.


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3) The connection for the fire department located by the Atrium Entrance failed to rotate smoothly.



NFPA 101,2000 Edition, 9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this code shall be inspected, tested, and maintained in accordance with NFPA 25, Standards for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

NFPA 25, 1998 Edition, 9-7.1 Fire department connections shall be inspected quarterly. The inspection shall verify the following:
(a) The fire department connections are visible and accessible.
(b) Couplings or swivels are not damaged and rotate smoothly.
(c) Plugs or caps are in place and undamaged.
(d) Gaskets are in place and in good condition.
(e) Identification signs are in place.
(f) The check valve is not leaking.
(g) The automatic drain valve is in place and operating properly.

During the survey, the following are examples of what was observed:

Based on observations and interview with the Plant Operation Director, many of the ducts do not have service openings to provide access the dampers in the duct. Work is in progress to correct this throughtout the facility.


NFPA 101, 9.2; NFPA 90A, 2-3.4.1 & 2-3.4.2: Air conditioning, heating, ventilating ductwork, and related equipment shall be in accordance with NFPA 90A. A service opening shall be provided in air ducts adjacent to each fire damper, smoke damper, and smoke detector. The opening shall be large enough to permit maintenance and resetting of the device. Service openings shall be identified with letters having a minimum height of 1/2 in. (1.27 cm) to indicate the location of the fire protection device(s) within.

The facility had improper heating devices. Example is as follows:

1) A portable electric heater was observed in Office 5407.


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2) A portable electrical heater in the Mail Room Ground Floor.


NFPA 101, 19.7.8 Portable space-heating devices shall be prohibited in all health care occupancies.

The facility failed to provide a readily accessible means of egress pathway at all times. Findings include: During the survey, the following is an examples of what was observed:

1) A bed was observed in the corridor by Material Management office at 9:30am 3/22/2011, and was still in corridor when this surveyor was in this area again at 13:00 hours.


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First Floor
2) The following locations had the following items being stored in the corridor (means of egress):
a. A clean linen cart was left outside of room 1511
b. A portable x-ray machine and 2 linen carts were left in the Radiology corridor


2000 NFPA 101, 7.1.10.1 Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.
2000 NFPA 101, 7.1.10.2.1 No furnishings, decorations, or other objects shall obstruct exits, access thereto, egress therefrom, or visibility thereof.
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The facility failed to provide proper storage and use of oxygen. As an example, findings include:

Oxygen storage racks with full and empty cylinders were observed stored in the Corridor/Elevator Lobby at the following locations:

1) Near Elevator #9 on the fifth floor
2) Near Elevator #9 on the fourth floor



CGA g-4, 4.1.1. Cylinders shall be in a definitely assigned location.

Alabama Department of Public Health Memo dated 4/25/03. Health Care Facility Oxygen Storage Requirements, d.1. A single cylinder of any size may be kept indoors, secured to a mobile carrier, where required for emergency use (such as one cylinder at each nurses' station).

The facility failed to provide smoke venting for the ORs per code. Findings include:

During the survey, the following is an example of what was observed:

The 24 windowless ORs, per observation and interview, did not have a smoke venting system.


1999 NFPA 99, 5-4.1.2 Supply and exhaust systems for windowless anesthetizing locations shall be arranged to automatically vent smoke and products of combustion.
1999 NFPA 99, 5-4.1.3 Ventilating systems for anesthetizing locations shall be provided that automatically (a) prevent recirculation of smoke originating within the surgical suite and (b) prevent the circulation of smoke entering the system intake, without in either case interfering with the exhaust function of the system.
1999 NFPA 99, 5-4.1.4 The electric supply to the ventilating system shall be served by the equipment system of the essential electrical system specified in Chapter 3, "Electrical Systems."
1999 NFPA 99, 5-6.1.1 Ventilating and humidifying equipment for anesthetizing locations shall be kept in operable condition and be continually operating during surgical procedures (see A-5-4.1).
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Documentation was not provided for Annual Service of the six observed fire hydrants.



NFPA 25, 4-4.3 Hydrants 4-4.3.1 Hydrants shall be lubricated annually to ensure that all stems, caps, plugs, and threads are in proper operating condition.

During the survey, the following is an example of what was observed:

Documentation provided for the annual inspection of the fire alarm system on 3/16/2011, indicated that AHU # 3, failed to shut down upon activation of the alarm. Based on interveiw with maintenance, this has not been corrected and was sheduled for 3/25/2011.


1999 NFPA 72, 7-5.2.2 and Figure 7-5.2.2 A permanent record of all inspections, testing, and maintenance shall be maintained that includes periodic tests and applicable information.

During the survey, the following are examples of what was observed:

1.Unsealed penetrations at the end of a sleeve, and at the deck, in the Smoke Barrier, by the Transcription Room.

2. Unsealed penetrations at the end of two sleeves, in the Smoke Barrier, by the Reading Room.

Documentation was not provided for the trip test for the dry riser.

NFPA 25,1998 Edition, 9-5.2.3 A partial flow trip test adequate to move the valve from its seat shall be conducted annually.
NFPA 25, 1998 Edition, 9-4.4.2.2.2 Every 3 years and whenever the system is altered, the dry pipe valve shall be trip tested with the control valve fully opened and the quick-opening device, if provided, in service.

Escutcheon plate was missing on a sprinkler in Housekeeping Room.


2000 NFPA 13, 3-2.7.2 Escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly.


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The facility failed to maintain the following systems per code. Findings include:

During the survey, the following are examples of what was observed:

1. The facility failed to perform the weekly generator inspections consistently.
2. The facility failed to perform the monthly load test.
3. The smoke wall at "the writting board" conduit with a black wire not sealed at the end.
4. The facility did not have battery back up lighting at the generator's transfer switches.
5. The facility had the following items being stored in the stairwell:
a. A set of ramps
b. A water extractor
6. The facility failed to provide documentation of a sensitivity test within the last two years.



1999 NFPA 110, 6-4.1 Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.
2000 NFPA 101, 8.3.6.1 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows: (1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions: a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke 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 smoke barrier, the sleeve shall be solidly set in the smoke 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 smoke resistance of the smoke barrier. b. It shall be protected by an approved device that is designed for the specific purpose. (3)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 smoke barrier. b. It shall be made by an approved device that is designed for the specific purpose.
1999 NFPA 110, 5-3.1 The Level 1 or Level 2 EPS equipment location shall be provided with battery-powered emergency lighting. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch.
2000 NFPA 101, 7.1.3.2.2 An exit enclosure shall provide a continuous protected path of travel to an exit discharge.
2000 NFPA 101, 7.1.3.2.3 An exit enclosure shall not be used for any purpose that has the potential to interfere with its use as an exit and, if so designated, as an area of refuge. (See also 7.2.2.5.3.)
1999 NFPA 72, 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.

The facility failed to maintain the following systems per code. Findings include:

During the survey, the following are examples of what was observed:

1) The building was storing the following items in the stairwell: trash can, wheel chair, broken chair, mop, broom, and junk.
2) The facility had a plant blocking the fire extinguisher in the Lobby / Waiting Area.
3) The facillity failed to provide documentation of a sensitivity test within the last two years.
4) The facility failed to provide documentation of a full trip test for the dry system within the last three years.


2000 NFPA 101, 7.1.3.2.2 An exit enclosure shall provide a continuous protected path of travel to an exit discharge.
2000 NFPA 101, 7.1.3.2.3 An exit enclosure shall not be used for any purpose that has the potential to interfere with its use as an exit and, if so designated, as an area of refuge. (See also 7.2.2.5.3.)
1998 NFPA 10, 4-3.2 Periodic inspection of fire extinguishers shall include a check of at least the following items: (a) Location in designated place (b) No obstruction to access or visibility (c) Operating instructions on nameplate legible and facing outward (d) * Safety seals and tamper indicators not broken or missing (e) Fullness determined by weighing or "hefting" (f) Examination for obvious physical damage, corrosion, leakage, or clogged nozzle (g) Pressure gauge reading or indicator in the operable range or position (h) Condition of tires, wheels, carriage, hose, and nozzle checked (for wheeled units) (i) HMIS label in place
1999 NFPA 72, 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.
1998 NFPA 25, 9-4.4.2.2.1 Every 3 years and whenever the system is altered, the dry pipe valve shall be trip tested with the control valve fully open and the quick-opening device, if provided, in service.

The facility failed to maintain the following systems per code. Findings include:

During the survey, the following are examples of what was observed:

1. The six windowless ORs, per observation and interview, did not have a smoke venting system.
2. The following fire alarm audiable and visual devices did not strobe when the fire alarm was tested:

a. At OR 3/room 1953
b. In Out Patient Recovery at the Nurses' Station
c. In the corridor outside of Out Patient Recovery at "the picture board"
3. The facility failed to provide documentation of a sensitivity test within the last two years.

During the survey, the following are examples of what was observed:

1. The battery-powered emergency light was inoperable at Generator Three and Four.
2. The battery-powered emergency light was not provide at Generator One and Two.


1999 NFPA 99, 3-6.1.1 and 3-4.1.1.4, and 1999 NFPA 110, 5-3.1. Emergency generator equipment locations.

The facility failed to provide approved electrical utilities. Findings include:

1) An extension cord without overcurrent protection was observed at Five Northeast Second Nursing Station.

2) Six junction boxes without covers were observed in the corridor above the ceiling near room 5141.

3) The ceiling mounted clock in the corridor near room 5640 was observed with one side opened, leaving exposed electrical wires and connections.

4) A refrigerator and microwave were observed plugged into an overcurrent protected cord in office 5409.


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5) Two junction boxes were missing the covers in the Boiler Room EEU.


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6. First Floor Room 1303 had a refrigerator and a microwave plugged into a surge protector
7. First Floor Room 16035/I.T. :
a. A surge protector was plugged into another surge protector
b. An extension cord was being used
8. First Floor Room 1849/Education Room an extension cord was being used

9. Third Floor Room 3645A/Med. Room had a refrigerator plugged into a surge protector


NFPA 101, 19.5.1 Utilities shall comply with NFPA 101, 9.1.

NFPA 101, 9.1.2 Electrical utilities shall comply with 1999 NFPA 70, National Electrical Code.

1999 NFPA 70, Article 240-4, and HFCA Transmittal Notice 22-99 prohibits the use of extension cords without overcurrent protection.

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

1999 NFPA 70, 400-7 and 400-8, and HCFA Transmittal Notice 22-99 The 1984 edition of the National Electric Code restricts the use of extension cords to temporary short term uses. It is the policy of HCFA to prohibit non-circuit breaker protected extension cords in health care. The limited use of circuit breaker protected power strips is acceptable, provided the current is limited to 15 amps or less, and no major appliances such as air conditioners, refrigerators, or heating units are connected to the power strip.

Appliances, such as air conditioners and refrigerators, shall plug directly into a receptacle. 1999 NFPA 70, 400-7 and 400-8, and HCFA Transmittal Notice 22-99.

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Unsealed openings / penetrations were observed in the fire walls as follows: During the survey, the following is an example of what was observed:

Unsealed penetrations around a section of sheetrock above the fire doors in the two hour fire wall, by North West Hall by Elevator #8.


8.2.2.2* Fire compartments shall be formed with fire barriers that are continuous from outside wall to outside wall, from one fire barrier to another, or a combination thereof, including continuity through all concealed spaces, such as those found above a ceiling, including interstitial spaces. Walls used as fire barriers shall comply with Chapter 3 of NFPA 221, Standard for Fire Walls and Fire Barrier Walls. The NFPA 221 limitation on percentage width of openings shall not apply.

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.

The facility failed to provide complete corridor walls in areas of the facility which did not have sprinkler coverage. Examples are as follows:

The corridor wall in the compartments without complete sprinkler coverage were observed not extending to the deck above at the following locations:

a) Med Room 5336
b) In the corridor between Four North West and Four North


NFPA 101, 19.3.6.2.1 Corridor walls shall be continuous from the floor to the underside of the floor or roof deck above, through any concealed spaces, such as those above suspended ceilings, and through interstitial structural and mechanical spaces, and they shall have a fire resistance rating of not less than 1/2 hour.
Exception No. 1: In smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.2, a corridor shall be permitted to be separated from all other areas by non-fire-rated partitions and shall be permitted to terminate at the ceiling where the ceiling is constructed to limit the transfer of smoke.

The facility failed to provide/maintain corridor doors which would close and resist the passage of smoke. Examples are as follows:

1) The following doors were observed without positive latching hardware:

a) Top half of the Dutch Door to Med Room 5138
b) Office 5351
c) Office 5409

2) The door to Office 4685 was observed held in the open position with a rubber wedge, causing an impediment to closing.

3) A corridor door was not observed to the PACU unit near Male Locker Room 6325.

4) The corridor double doors to the First Floor OR Sterile Processing Room, near Recovery, were observed with an unsealed gap between doors, allowing viewing into the room from the corridor.


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5) The PBX Office door was held open by a wooden stop, located on the Ground Floor.

6) The door for Labor Observation Room failed to latch.

7) Patient Room 4649 door failed to close tight in the frame so as to resist the passage of smoke.


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8) The following First Floor corridor doors did not have positive latching hardware:

a. Dr.s' Lounge room 1404
b. Room 1231
c. The Chapel doors
d. Consult 1 room 1611
e. Room 1110

9) Rooms 3744 (Conference Room) and room 3739 - had self-closing devices on the corridor doors, but the doors were being held open by trash cans.

10) The following corridor doors were impeded from closing by trash cans:

a. Room 3806
b. Room 3805
c. Room 3803
d. Room 3645
e. Room 3301



2000 NFPA 101, 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.
2000 NFPA 101, 19.3.6.3.3 Hold-open devices that release when the door is pushed or pulled shall be permitted.
2000 NFPA 101, 19.3.6.3.4 Door-closing devices shall not be required on doors in corridor wall openings other than those serving required exits, smoke barriers, or enclosures of vertical openings and hazardous areas.
2007 CMS - 2786R There is no impediment to the closing of the corridor doors.

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The facility failed to provide clearly marked access to exits per code. Findings include:
During the survey, the following are examples of what was observed:

The following First Floor stairwells did not have a clearly marked access to the exit:

a. Stairwell 1401
b. Stairwell 1968

2000 NFPA 101, 7.10.1.4 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. Sign placement shall be such that no point in an exit access corridor is in excess of 100 ft (30 m) from the nearest externally illuminated sign and is not in excess of the marked rating for internally illuminated signs.
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The facility failed to maintain smoke barriers that would provide at least a half hour fire resistance rating and restrict the movement of smoke. Examples are as follows:

Unsealed opening/penetrations were observed in smoke walls as follows:

1) Approximately 3 ' X 4 ' piece of sheetrock missing inside room 5333
2) Unsealed opening in corridor over the smoke doors near room 5107


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3) Unsealed penetrations around a group of wiring in the Smoke Barrier G:309.
4) Unsealed penetrations around a group of wiring in the Smoke Barrier by Patient Room 2413.



NFPA 101, 19.3.7.3 and 8.3.1 Smoke walls shall have a fire resistance rating of at least half hour and to be continuous from floor-to-deck and from outside-to-outside.

The facility failed to maintain self-closing doors in smoke barriers. Examples are as follows:

1) The smoke doors near room 4132 were observed not closing/latching with installed hardware when released during fire alarm activation.

2) The smoke doors near the OR Nursing Desk, across from the Procedure Board, failed to release from the magnetic hold-open devices upon fire alarm activation.


NFPA 101, 19.3.7.6, 8.3.4 Doors in smoke barriers to be self-closing. Doors in smoke barriers shall close the opening in the wall leaving only a minimum clearance to allow door(s) to function properly.

The facility failed to provide/maintain smoke-resisting partitions and self-closing/latching doors for hazardous areas. Examples are as follows:

1) The doors to the following rooms with sprinkler coverage were observed not closing/latching with the installed hardware:

a) Storage Room 5406
b) Equipment Tech Office/Storage Room 5408

2) The following rooms were observed without a self-closing device:

a) Trash Collection Room 5203
b) Supply Room 5214
c) Storage Room 4526
d) Trash Collection Room 5415

3) The Trash Room 5338 without sprinkler coverage was observed with flex ducts passing through the walls above the ceiling without fire dampers and the door only twenty minute fire rated, not forty-five minute rated as required.

4) The door to the MICU Storage Room was observed removed.

5) The Soiled Utility Room 4340 without sprinkler coverage was observed with flex ducts passing through the walls above the ceiling.

6) Storage Room 4338 without sprinkler coverage was observed with the walls not extending to the deck above the ceiling.

7) The doors to the Large Bed Storage Room at Four North PT area were observed with the arms of the self-closing devices removed.


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First Floor
8) The Credentials Office/Storage Room - was over 50 sq. ft., sprinklered and contained combustible materials - the corridor door did not have a self-closing device.

9) The Old Kitchen/Storage Room - the corridor door did not have a self-closing device.


2000 NFPA 101, 19.3.2.1 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.

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The facility failed to maintain stairways with at least one hour fire resistance rating. Examples are as follows:

The following stairwells were observed with air supply ducts passing through the walls supplying air into the corridor and stairwell without fire dampers:

1) Near room 5321
2) Near room 5311


NFPA 101, 19.3.1.1 Any vertical opening shall be enclosed or protected in accordance with 8.2.5. Where enclosure is provided, the construction shall have not less than a 1-hour fire resistance rating.

The facility failed to provide readily accessible exit access. Examples are as follows:

1) Double cylinder keyed dead bolt locks were observed on the following room doors which prevent exit from within the rooms:

a. Education Room 5244
b. Supply Room 5214
c. Office 5200

2) Cylinder keyed dead bolt locks, without any way to unlock the lock from within the room, were observed on the following rooms which prevent exit from within the rooms:

a. Office 5102
b. Office 5104
c. Storage Room 5106


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3) First Floor the following delayed egress exit doors did not release when tested:
a. Stairwell #1228
b. Stairwell at the East Air Handling Unit - Door # 4M4 - 43
c. Atrium door # 4M4 - 37

4). Third Floor the following doors were magnetically located on the Rehabilitation Unit, without an emergency door release button at the Nurses' Station:
a. The stairwell door 3831 - only key pad would release this door.
b. The separation doors - the key pad or a button on the phone (only when someone is pressing it) would release these doors.



2000 NFPA 101, 7.1.9 Any device or alarm installed to restrict the improper use of a means of egress shall be designed and installed so that it cannot, even in case of failure, impede or prevent emergency use of such means of egress unless otherwise provided in 7.2.1.6 and Chapters 18, 19, 22, and 23.
2000 NFPA 101, 7.1.10.1 Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.
2000 NFPA 101, 7.2.1.5.1 Doors shall be arranged to be opened readily from the egress side whenever the building is occupied. Locks, if provided, shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side.
2000 NFPA 101, 7.2.1.6.1 Approved, listed, delayed-egress locks shall be permitted to be installed on doors serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system in accordance with Section 9.6, or an approved, supervised automatic sprinkler system in accordance with Section 9.7, and where permitted in Chapters 12 through 42, provided that the following criteria are met.
(a) The doors shall unlock upon actuation of an approved, supervised automatic sprinkler system in accordance with Section 9.7 or upon the actuation of any heat detector or activation of not more than two smoke detectors of an approved, supervised automatic fire detection system in accordance with Section 9.6.
(b) The doors shall unlock upon loss of power controlling the lock or locking mechanism.
(c) An irreversible process shall release the lock within 15 seconds upon application of a force to the release device required in 7.2.1.5.4 that shall not be required to exceed 15 lbf (67 N) nor be required to be continuously applied for more than 3 seconds. The initiation of the release process shall activate an audible signal in the vicinity of the door. Once the door lock has been released by the application of force to the releasing device, relocking shall be by manual means only.
Exception: Where approved by the authority having jurisdiction, a delay not exceeding 30 seconds shall be permitted.
(d) * On the door adjacent to the release device, there shall be a readily visible, durable sign in letters not less than 1 in. (2.5 cm) high and not less than 1/8 in. (0.3 cm) in stroke width on a contrasting background that reads as follows:
"PUSH UNTIL ALARM SOUNDS DOOR CAN BE OPENED IN 15 SECONDS"
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.
Alabama Department of Public Health Memo "Exit Door Locking Arrangements in Health Care Facilities" revised 12/19/03, as authority having jurisdiction: an "emergency release switch" or "kill switch" shall be provided at the nearest nurse's station.

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The facility failed to maintain the horizontal exits per code. Findings include:
During the survey, the following are examples of what was observed:

The 1.5 hour fire rated door at the Third Floor Rotary Dining Room leading to Accounting - the right leaf did not latch under the fire alarm.



2000 NFPA 101, 7.2.4.3.8 All fire doors in horizontal exits shall be self-closing or automatic-closing in accordance with 7.2.1.8. Horizontal exit doors located across a corridor shall be automatic-closing in accordance with 7.2.1.8.
1999 NFPA 80, 3-4.1* Closing Devices for Swinging Tin Clad and Sheet Metal Fire Doors. Swinging tin clad and sheet metal fire doors shall be equipped with self-closing or automatic-closing devices to ensure that they are closed and latched at the time of fire. Other arrangements acceptable to the authority having jurisdiction shall be permitted.
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The facility failed to conduct fire drills under varying conditions at unexpected times. Examples are as follows:

1) Based on interview and documentation provided during the survey, all four third shift drills were conducted between 5:00 AM and 5:54 AM.

2) Based on interview and documentation provided during the survey, fire drills conducted between 9:00 PM and 6:00 AM were only an in-service, the fire alarm was not used nor was a coded announcements used at this time.



NFPA 101, 19.7.1.2 and 19.7.1.3 Drills shall include proper procedures, making sure all staff members participate.

NFPA 101, 19.7.1.2 Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of an audible alarm.

Facility failed to maintain the Digital Alarm Communicator Transmitter in the fire alarm system. Findings include: During the survey, the following are examples of what what observed:

1. When the Auto Dialer was tested for phone line 1, failure was not indicated at the protected premise within the allotted four (4) minute time frame.

2. When the Auto Dialer was tested for phone line 2, failure was not indicated at the protected premise within the allotted four (4) minute time frame.

3. When the Auto Dialer was tested for Communication Failure, failure was not indicated at the protected premise within the allotted fifteen (15) minute time frame (5 minimum to 10 maximum attempts for signal transmission).



1999 NFPA 72, Section 1-5.4.6, 5-5.3.2.1.5, and 5-5.3.2.1.6.2. Phone line and communication failure shall be indicated at the facility.

The facility failed to maintain the fire alarm system in proper working order. Examples are as follows:

1) The smoke detector near Node 4 Fire Alarm Control Panel in Ground Northeast G301 Electrical / Mechanical Room was observed mounted approximately four feet from the ceiling.

2) A smoke detector was not provided in the Second Northeast Electrical / Mechanical Room where Node 3 Fire Alarm Control Panel is located. (Drop-in ceiling tiles were observed missing from the grid system which would not allow a smoke detector to function properly)

NFPA 101, 34.1 and 9.6.1.4 1999 NFPA 72, 1-5.6 A smoke detector shall be provided in the location of the fire alarm panel for panels located in areas that are not continuously occupied.

NFPA 101, 9.6.1.4 The fire alarm system to be installed, tested, and maintained in accordance with the requirements of NFPA 70 and NFPA 72.

3) Audible/visual appliances were observed not heard or seen upon fire alarm activation at the following locations:

a) Corridor near room 4637
b) Corridor near room 5637

4) HVAC shutdown upon fire alarm activation could not be verified during fire alarm testing due to medical procedures being conducted.

5) The following exit doors with magnetic locking devices failed to release upon fire alarm activation:

a) Exit doors from MICU
b) Stair exit door from MICU

6) The facility failed to provide documentation of the monthly release of the magnetic locking devices during fire alarm activation.

Alabama Department of Public Health Memo "Exit Door Locking Arrangements in Health Care Facilities" revised 12/19/03, as authority having jurisdiction: as a minimum, documentation shall be maintained of lock operation and deactivation at each door during monthly fire alarm activation.


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7) Audible/visual appliances were observed not heard or seen upon fire alarm activation at the following locations:

a) Audible/Visual in corridor by OR # 5 Out Patient Surgery.
b) Audible/Visual in corridor by Room 1948 Out Patient Surgery.
c) Audible/Visual by G-628.
d) Audible/Visual in the Kitchen located on the wall above the Ice Cream Machine G-6211.


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First Floor
8) The Deli's double doors in the one hour Atrium wall did not close during the testing of the fire alarm system.
9) The following fire alarm audio/visual devices did not strobe:
a) By room 1838
b) At room 1849
c) At room 1807
d) At room 1803
e) At room 16046

Third Floor
10) By room 3636 could not hear the fire alarm when the two sets of fire doors were closed.
11) The following fire alarm audio/visual devices did not strobe:
a) At room 3175
b) At room 3172
12) The Elopement Corridor Doors 3646 at room 3686 did not release under the fire alarm.
Ground Floor
13) The automatic doors 08 025 by elevator 19 did not go to manual operation under the fire alarm.


2000 NFPA 101, 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.
1999 NFPA 72, 3-9.7.1 Any device or system intended to actuate the locking or unlocking of exits shall be connected to the fire alarm system serving the protected premises.
1999 NFPA 72, 3-9.7.2 All exits connected in accordance with 3-9.7.1 shall unlock upon receipt of any fire alarm signal by means of the fire alarm system serving the protected premises.
NFPA 72, 3-9.7.3 All exits connected in accordance with 3-9.7.1 shall unlock upon loss of the primary power to the fire alarm system serving the protected premises. The secondary power supply shall not be utilized to maintain these doors in the locked condition.
1999 NFPA 72, 4-4.2 Light Pulse Characteristics. The flash rate shall not exceed two flashes per second (2 Hz) nor be less than one flash every second (1 Hz) throughout the listed voltage range of the appliance.

1999 NFPA 72, 4-4.2.1 A maximum pulse duration shall be 0.2 seconds with a maximum duty cycle of 40 percent. The pulse duration shall be defined as the time interval between initial and final points of 10 percent of maximum signal.

1999 NFPA 72, 4-4.2.2* The light source color shall be clear or nominal white and shall not exceed 1000 cd (effective intensity).

1999 NFPA 72, 4-4.3.1 Visible notification appliances used in the public mode shall be located and shall be of a type, size, intensity, and number so that the operating effect of the appliance is seen by the intended viewers regardless of the viewer's orientation.

2000 NFPA 101, 9.6.5.2 Where required by another section of this Code, the following functions shall be actuated by the complete fire alarm system: (1) Release of hold-open devices for doors or other opening protectives (2) Stairwell or elevator shaft pressurization (3) Smoke management or smoke control systems (4) Emergency lighting control (5) Unlocking of doors
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The facility failed to provide sensitivity testing documentation of the smoke detectors. Examples are as follows:

Sensitivity testing documentation of the smoke detectors in the facility was not provided during the survey.


Detector sensitivity shall be checked within one year after installation and every alternate year thereafter per 72, 7-3.2.1.

Sprinkler coverage was observed, during the survey, not adequately provided. Findings include: During the survey, the following are examples of what was observed:

1. Elevator # 15 hoistway not provided with sprinkler coverage.

2. Elevator # 23 hoistway not provided with sprinkler coverage.



1999 NFPA 13, 5-13.6.1 Sidewall spray sprinklers shall be installed at the bottom of each elevator hoistway not more than 2 ft (0.61 m) above the floor of the pit.
Exception: For enclosed, noncombustible elevator shafts that do not contain combustible hydraulic fluids, the sprinklers at the bottom of the shaft are not required.

The facility failed to perform the required maintenance of the facility sprinkler system. Findings include: During the survey, the following are examples of what was observed:

1) The Fire Department Connection (FDC) cap was observed missing in Stairwell 5689 at South North East VIP.

2) The three-way FDC located on the Sixth Floor North East Penthouse on the West Wall was observed without the protective caps.

3) Documentation provided by the facility, during the survey, did not indicate the full trip test of the sprinkler dry system, required every three years.


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3) The connection for the fire department located by the Atrium Entrance failed to rotate smoothly.



NFPA 101,2000 Edition, 9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this code shall be inspected, tested, and maintained in accordance with NFPA 25, Standards for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

NFPA 25, 1998 Edition, 9-7.1 Fire department connections shall be inspected quarterly. The inspection shall verify the following:
(a) The fire department connections are visible and accessible.
(b) Couplings or swivels are not damaged and rotate smoothly.
(c) Plugs or caps are in place and undamaged.
(d) Gaskets are in place and in good condition.
(e) Identification signs are in place.
(f) The check valve is not leaking.
(g) The automatic drain valve is in place and operating properly.

During the survey, the following are examples of what was observed:

Based on observations and interview with the Plant Operation Director, many of the ducts do not have service openings to provide access the dampers in the duct. Work is in progress to correct this throughtout the facility.


NFPA 101, 9.2; NFPA 90A, 2-3.4.1 & 2-3.4.2: Air conditioning, heating, ventilating ductwork, and related equipment shall be in accordance with NFPA 90A. A service opening shall be provided in air ducts adjacent to each fire damper, smoke damper, and smoke detector. The opening shall be large enough to permit maintenance and resetting of the device. Service openings shall be identified with letters having a minimum height of 1/2 in. (1.27 cm) to indicate the location of the fire protection device(s) within.

The facility had improper heating devices. Example is as follows:

1) A portable electric heater was observed in Office 5407.


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2) A portable electrical heater in the Mail Room Ground Floor.


NFPA 101, 19.7.8 Portable space-heating devices shall be prohibited in all health care occupancies.

The facility failed to provide a readily accessible means of egress pathway at all times. Findings include: During the survey, the following is an examples of what was observed:

1) A bed was observed in the corridor by Material Management office at 9:30am 3/22/2011, and was still in corridor when this surveyor was in this area again at 13:00 hours.


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First Floor
2) The following locations had the following items being stored in the corridor (means of egress):
a. A clean linen cart was left outside of room 1511
b. A portable x-ray machine and 2 linen carts were left in the Radiology corridor


2000 NFPA 101, 7.1.10.1 Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.
2000 NFPA 101, 7.1.10.2.1 No furnishings, decorations, or other objects shall obstruct exits, access thereto, egress therefrom, or visibility thereof.
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The facility failed to provide proper storage and use of oxygen. As an example, findings include:

Oxygen storage racks with full and empty cylinders were observed stored in the Corridor/Elevator Lobby at the following locations:

1) Near Elevator #9 on the fifth floor
2) Near Elevator #9 on the fourth floor



CGA g-4, 4.1.1. Cylinders shall be in a definitely assigned location.

Alabama Department of Public Health Memo dated 4/25/03. Health Care Facility Oxygen Storage Requirements, d.1. A single cylinder of any size may be kept indoors, secured to a mobile carrier, where required for emergency use (such as one cylinder at each nurses' station).

The facility failed to provide smoke venting for the ORs per code. Findings include:

During the survey, the following is an example of what was observed:

The 24 windowless ORs, per observation and interview, did not have a smoke venting system.


1999 NFPA 99, 5-4.1.2 Supply and exhaust systems for windowless anesthetizing locations shall be arranged to automatically vent smoke and products of combustion.
1999 NFPA 99, 5-4.1.3 Ventilating systems for anesthetizing locations shall be provided that automatically (a) prevent recirculation of smoke originating within the surgical suite and (b) prevent the circulation of smoke entering the system intake, without in either case interfering with the exhaust function of the system.
1999 NFPA 99, 5-4.1.4 The electric supply to the ventilating system shall be served by the equipment system of the essential electrical system specified in Chapter 3, "Electrical Systems."
1999 NFPA 99, 5-6.1.1 Ventilating and humidifying equipment for anesthetizing locations shall be kept in operable condition and be continually operating during surgical procedures (see A-5-4.1).
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Documentation was not provided for Annual Service of the six observed fire hydrants.



NFPA 25, 4-4.3 Hydrants 4-4.3.1 Hydrants shall be lubricated annually to ensure that all stems, caps, plugs, and threads are in proper operating condition.

During the survey, the following is an example of what was observed:

Documentation provided for the annual inspection of the fire alarm system on 3/16/2011, indicated that AHU # 3, failed to shut down upon activation of the alarm. Based on interveiw with maintenance, this has not been corrected and was sheduled for 3/25/2011.


1999 NFPA 72, 7-5.2.2 and Figure 7-5.2.2 A permanent record of all inspections, testing, and maintenance shall be maintained that includes periodic tests and applicable information.

During the survey, the following are examples of what was observed:

1.Unsealed penetrations at the end of a sleeve, and at the deck, in the Smoke Barrier, by the Transcription Room.

2. Unsealed penetrations at the end of two sleeves, in the Smoke Barrier, by the Reading Room.

Documentation was not provided for the trip test for the dry riser.

NFPA 25,1998 Edition, 9-5.2.3 A partial flow trip test adequate to move the valve from its seat shall be conducted annually.
NFPA 25, 1998 Edition, 9-4.4.2.2.2 Every 3 years and whenever the system is altered, the dry pipe valve shall be trip tested with the control valve fully opened and the quick-opening device, if provided, in service.

Escutcheon plate was missing on a sprinkler in Housekeeping Room.


2000 NFPA 13, 3-2.7.2 Escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly.


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The facility failed to maintain the following systems per code. Findings include:

During the survey, the following are examples of what was observed:

1. The facility failed to perform the weekly generator inspections consistently.
2. The facility failed to perform the monthly load test.
3. The smoke wall at "the writting board" conduit with a black wire not sealed at the end.
4. The facility did not have battery back up lighting at the generator's transfer switches.
5. The facility had the following items being stored in the stairwell:
a. A set of ramps
b. A water extractor
6. The facility failed to provide documentation of a sensitivity test within the last two years.



1999 NFPA 110, 6-4.1 Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.
2000 NFPA 101, 8.3.6.1 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows: (1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions: a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke 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 smoke barrier, the sleeve shall be solidly set in the smoke 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 smoke resistance of the smoke barrier. b. It shall be protected by an approved device that is designed for the specific purpose. (3)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 smoke barrier. b. It shall be made by an approved device that is designed for the specific purpose.
1999 NFPA 110, 5-3.1 The Level 1 or Level 2 EPS equipment location shall be provided with battery-powered emergency lighting. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch.
2000 NFPA 101, 7.1.3.2.2 An exit enclosure shall provide a continuous protected path of travel to an exit discharge.
2000 NFPA 101, 7.1.3.2.3 An exit enclosure shall not be used for any purpose that has the potential to interfere with its use as an exit and, if so designated, as an area of refuge. (See also 7.2.2.5.3.)
1999 NFPA 72, 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.

The facility failed to maintain the following systems per code. Findings include:

During the survey, the following are examples of what was observed:

1) The building was storing the following items in the stairwell: trash can, wheel chair, broken chair, mop, broom, and junk.
2) The facility had a plant blocking the fire extinguisher in the Lobby / Waiting Area.
3) The facillity failed to provide documentation of a sensitivity test within the last two years.
4) The facility failed to provide documentation of a full trip test for the dry system within the last three years.


2000 NFPA 101, 7.1.3.2.2 An exit enclosure shall provide a continuous protected path of travel to an exit discharge.
2000 NFPA 101, 7.1.3.2.3 An exit enclosure shall not be used for any purpose that has the potential to interfere with its use as an exit and, if so designated, as an area of refuge. (See also 7.2.2.5.3.)
1998 NFPA 10, 4-3.2 Periodic inspection of fire extinguishers shall include a check of at least the following items: (a) Location in designated place (b) No obstruction to access or visibility (c) Operating instructions on nameplate legible and facing outward (d) * Safety seals and tamper indicators not broken or missing (e) Fullness determined by weighing or "hefting" (f) Examination for obvious physical damage, corrosion, leakage, or clogged nozzle (g) Pressure gauge reading or indicator in the operable range or position (h) Condition of tires, wheels, carriage, hose, and nozzle checked (for wheeled units) (i) HMIS label in place
1999 NFPA 72, 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.
1998 NFPA 25, 9-4.4.2.2.1 Every 3 years and whenever the system is altered, the dry pipe valve shall be trip tested with the control valve fully open and the quick-opening device, if provided, in service.

The facility failed to maintain the following systems per code. Findings include:

During the survey, the following are examples of what was observed:

1. The six windowless ORs, per observation and interview, did not have a smoke venting system.
2. The following fire alarm audiable and visual devices did not strobe when the fire alarm was tested:

a. At OR 3/room 1953
b. In Out Patient Recovery at the Nurses' Station
c. In the corridor outside of Out Patient Recovery at "the picture board"
3. The facility failed to provide documentation of a sensitivity test within the last two years.

During the survey, the following are examples of what was observed:

1. The battery-powered emergency light was inoperable at Generator Three and Four.
2. The battery-powered emergency light was not provide at Generator One and Two.


1999 NFPA 99, 3-6.1.1 and 3-4.1.1.4, and 1999 NFPA 110, 5-3.1. Emergency generator equipment locations.

The facility failed to provide approved electrical utilities. Findings include:

1) An extension cord without overcurrent protection was observed at Five Northeast Second Nursing Station.

2) Six junction boxes without covers were observed in the corridor above the ceiling near room 5141.

3) The ceiling mounted clock in the corridor near room 5640 was observed with one side opened, leaving exposed electrical wires and connections.

4) A refrigerator and microwave were observed plugged into an overcurrent protected cord in office 5409.


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5) Two junction boxes were missing the covers in the Boiler Room EEU.


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6. First Floor Room 1303 had a refrigerator and a microwave plugged into a surge protector
7. First Floor Room 16035/I.T. :
a. A surge protector was plugged into another surge protector
b. An extension cord was being used
8. First Floor Room 1849/Education Room an extension cord was being used

9. Third Floor Room 3645A/Med. Room had a refrigerator plugged into a surge protector


NFPA 101, 19.5.1 Utilities shall comply with NFPA 101, 9.1.

NFPA 101, 9.1.2 Electrical utilities shall comply with 1999 NFPA 70, National Electrical Code.

1999 NFPA 70, Article 240-4, and HFCA Transmittal Notice 22-99 prohibits the use of extension cords without overcurrent protection.

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

1999 NFPA 70, 400-7 and 400-8, and HCFA Transmittal Notice 22-99 The 1984 edition of the National Electric Code restricts the use of extension cords to temporary short term uses. It is the policy of HCFA to prohibit non-circuit breaker protected extension cords in health care. The limited use of circuit breaker protected power strips is acceptable, provided the current is limited to 15 amps or less, and no major appliances such as air conditioners, refrigerators, or heating units are connected to the power strip.

Appliances, such as air conditioners and refrigerators, shall plug directly into a receptacle. 1999 NFPA 70, 400-7 and 400-8, and HCFA Transmittal Notice 22-99.

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