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Based on staff interview and documentation review, the facility failed to substantiate that an emergency preparedness program that meets all of the standards specified within the condition/requirement has been developed. This deficient practice could affect all patients, staff and visitors in the event of an actual emergency where the Emergency Preparedness procedures are activated.

The Findings Include:

A documentation review and staff interview conducted during the morning hours of 03/27/19 indicates that the Main Hospital's Emergency Preparedness Plan does not incorporate all of required components including off-site satellite campuses. The East Boston Neighborhood Health Center identified as Building #09 located at 10 Gove Street, East Boston is not identified in the Main Hospital's Emergency Preparedness Plan. Building #09 was also surveyed as a healthcare facility operating under the Main Hospital's license. When staff within Building #09 were questioned regarding Emergency Preparedness plans, it was stated that the satellite does not utilize the Main Hospital's Emergency Preparedness Plans. When questioned further, the satellite was unable to produce any emergency preparedness manual or information regarding the individual off-site satellite. This healthcare satellite is required to have or be included within an Emergency Preparedness Program. The emergency preparedness program must include an Emergency Plan that must be developed, maintained, evaluated, and updated at least annually.

As a result, the Hospital failed to comply with Emergency Preparedness development and annual review requirements. The East Boston Neighborhood Health Center identified as Building #09 is not incorporated into the Hospital Emergency Preparedness Plans and reviewed annually as such.

The finding was discussed during the survey exit interview with the Hospital President, Hospital Leadership Staff and Facility Engineering.

This Standard is not met as evidenced by:

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

Section 19.1.3.1 states multiple occupancies shall be in accordance with 6.1.14.

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

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

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

THE FINDINGS INCLUDE:

During the documentation review and facility tour conducted on 03/27/19, it was observed that the End Stage Renal Disease Unit (ESRD) located in the basement level of the Menino Building was not properly separated. According to the Life Safety Code drawings provided by the hospital, the unit is enclosed with a 1-hour fire separation from the adjoining Business Occupancy. During an interview with Facilities Management Staff, it was explained that the hospital viewed the ESRD as an Ambulatory Surgical Center (ASC) used for outpatient services, thus requiring a 1-hour fire separation.

However, the ESRD is listed as an inpatient unit on the Hospital's license, and would be surveyed under Healthcare requirements. While surveying the ESRD unit during the morning hours of 03/27/19, the nurse manager was asked if the five current patients receiving treatment were inpatient or outpatient. The manager stated that all five were inpatient and would be transferred back to their respective hospital beds after receiving treatment.

As a result, the facility was not provided with the required 2-hour fire resistance rated separation as required by Table 6.1.14.4.1(a).

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

Based on observations, the facility failed to ensure that the building is of a conforming construction type.
This deficient practice could affect the current patients, as well as an undetermined amount of staff and visitors in the event of an actual fire.

Section 19-1.6.2 requires buildings 3-stories in height to be of at least Type I (443), Type I (332) or Type II (222). If the building is equipped with a complete automatic sprinkler system it may be of Type II (111) construction.

Findings include:

On 03/27/19 the following was noted:

The building is classified as a three-story structure, Type II(000)construction due to non-rated floor/ceiling assemblies throughout the building. This was evidenced by unprotected steel beams and columns. It was noted that the columns were unprotected above the lay in ceiling tiles. The ceiling/roof assembly was also rated for less than the required one-hour fire protection rating.

The building is not equipped with a complete automatic sprinkler system.

As a result of the findings the facility is found to be not compliant with NFPA 19.1.6.2

These items were noted during survey exit interview with the Hospital President, Hospital Leadership Staff and Facility Engineering.

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

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

FINDINGS INCLUDE:During a survey of the facility in the morning hours of 3/28/19, the following items were stored on the landings of the stairways:

1. Stairway #1 - boxes of light fixtures were stored on the basement level landing.
2. Stairway #2 - blowers were stored on the basement level landing.
3. Stairway #5 - life size chess pieces, a chair, and a ladders were stored on the basement level landing.
4. Stairway #6 - A cooler, trash, and a mop bucket were stored on the basement level landing.
5. Glass enclosed stairway - multiple spare confidential paper bins were stored on the basement landing.

As a result, the open space within the exit enclosure was not maintained in accordance with Section 7.2.2.5.3.1.

The facility maintenance representative confirmed the observation during the facility survey walk through.

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

Based on observations and confirmed by staff, the facility failed to ensure that any required aisle, corridor, or ramp shall be not less than 44 inches (1.2 m)in clear width where serving as means of egress.

39.2.3.2 The clear width of any corridor or passageway serving an occupant load of 50 or more shall be not less than 44 in.
(1120 mm).

Findings Include:

Observations and measurement on 3/28/19 revealed that the second and third floor corridors narrow to 41 inches in width due to the placement of lockers.

As a result of the narrow corridors, the facility failed to comply with section 39.2.3.2.

The facility maintenance representative confirmed the observation during the building survey.

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

This Standard is not met as evidenced by:

Based on observations and confirmed by staff, suites are not separated as required. This deficient practice could affect all patients, staff and visitors within the improperly separated suite.

Section 19.2.5.7.1.2 states suites shall be separated from the remainder of the building, and from other suites, by one
of the following:
(1) Walls and doors meeting the requirements of 19.3.6.2 through 19.3.6.5
(2) Existing approved barriers and doors that limit the transfer of smoke

Section 19.3.6.2.1 states 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, unless otherwise permitted by 19.3.6.2.4 through 19.3.6.2.8.

Section 19.3.6.2.2 states corridor walls shall have a minimum 1/2-hour fire resistance rating.

Section 19.3.6.2.3 states corridor walls shall form a barrier to limit the transfer of smoke.

Section 19.3.6.2.4 states in smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.7, 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.

Section 19.3.6.2.5 states existing corridor partitions shall be permitted to terminate at ceilings that are not an integral part of a floor construction if 60 in. (1525 mm) or more of space exists between the top of the ceiling subsystem and the bottom of the floor or roof above, provided that all the following criteria are met:
(1) The ceiling is part of a fire-rated assembly tested to have a minimum 1-hour fire resistance rating in compliance with the provisions of Section 8.3.
(2) The corridor partitions form smoke-tight joints with the ceilings, and joint filler, if used, is noncombustible.
(3) Each compartment of interstitial space that constitutes a separate smoke area is vented, in a smoke emergency, to
the outside by mechanical means having the capacity to provide not less than two air changes per hour but, in no case, a capacity less than 5000 ft3/min (2.35 m3/s).
(4) The interstitial space is not used for storage.
(5) The space is not used as a plenum for supply, exhaust, or return air, except as noted in 19.3.6.2.5(3).

Section 19.3.6.3.4 states a clearance between the bottom of the door and the floor covering not exceeding 1 in. (25 mm) shall be permitted for corridor doors.

THE FINDINGS INCLUDE:

During the afternoon hours of 03/25/19 while touring the 3rd floor of the Menino Building, the suite identified as the Surgical Intensive Care Unit (SICU) was observed as not having the required windows/walls to limit the transfer of smoke. The corner portion of the unit known as the "fish bowl" is enclosed on two sides with plain glass walls and sliding glass windows. The glass walls which are 10' x 5' and 9' x 5' each have one operational sliding window which is approximately 30" x 30" in size. These operable windows have gaps exceeding 1/4" on three sides and are unable to limit the transfer of smoke.

Hospital staff suggested that the limited gaps around the window units would be comparable to the undercut of a corridor door in square area size. However, the gaps around these windows start at approximately 36" from the floor and extend to approximately 66" above the floor. Undercuts are limited to the space between the door bottom and floor covering.

As a result, the facility failed to comply with section 19.3.6.2.3 to limit the transfer of smoke in corridor walls.

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

Based on surveyor record review, observation and confirmed by the Director of Maintenance (DOM) staff, the facility failed to ensure compliance with section 39.2.9.1 that requires emergency lighting to be provided in accordance with Section 7.9 in any building where any one of the following conditions exists:
(1) The building is three or more stories in height.
(2) The occupancy is subject to 100 or more occupants above
or below the level of exit discharge.
(3) The occupancy is subject to 1000 or more total occupants.

Section 7.8.1.2 requires all illumination in the means of egress be continuous during the time that the conditions of occupancy require that the means of egress be available for use.

Section 7.9.3.1.1, states that testing of required emergency lighting systems shall be permitted to be conducted as follows:
(1) Functional testing shall be conducted monthly, with a minimum of 3 weeks and a maximum of 5 weeks between
tests, for not less than 30 seconds, except as otherwise permitted by 7.9.3.1.1(2).

(2)*The test interval shall be permitted to be extended beyond 30 days with the approval of the authority having
jurisdiction.

(3) Functional testing shall be conducted annually for a minimum of 1- 1/2 hours if the emergency lighting system is battery
powered.

(4) The emergency lighting equipment shall be fully operational for the duration of the tests required by 7.9.3.1.1(1)
and (3).

(5) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having
jurisdiction.

Findings include:

On 3/28/19, while touring the building and conducting the surveyor record review, it was noted that there were no written records to substantiate that the emergency lighting battery packs were tested annually as required in section 7.9.3.1.1 (3). As a result, the facility failed to comply with section 7.9.3.1.1.

The facility maintenance representative confirmed the finding during the facility survey.

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

This Standard is not met as evidenced by:

Based on record review and confirmed by staff, the facility failed to ensure that emergency lighting is tested as required. This deficient practice could affect an undeterminable amount of patients and staff in the event of actual emergency requiring emergency lighting.

Section 39.2.9.1 states emergency lighting shall be provided in accordance with Section 7.9 in any building where any one of the following conditions exists:
(1) The building is three or more stories in height.
(2) The occupancy is subject to 100 or more occupants above or below the level of exit discharge.
(3) The occupancy is subject to 1000 or more total occupants.

Section 7.9.2.4 emergency generators providing power to emergency lighting systems shall be installed, tested, and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. Stored electrical energy systems, where required in this Code, other than battery systems for emergency luminaires in accordance with 7.9.2.5, shall be installed and tested in accordance with NFPA 111, Standard on Stored Electrical Energy Emergency and Standby Power Systems.

NFPA 110 section 8.3.2.1 states the operational test shall be initiated at an ATS and shall include testing of each EPSS component on which maintenance or repair has been performed, including the transfer of each automatic and manual transfer switch to the alternate power source, for a period of not less than 30 minutes under operating temperature.

NFPA 110 section 8.4.1 states EPSSs, including all appurtenant components, shall be inspected weekly and exercised under load at least monthly.

Section 7.9.3.1 states required emergency lighting systems shall be tested in accordance with one of the three options offered by 7.9.3.1.1, 7.9.3.1.2, or 7.9.3.1.3. 7.9.3.1.1. Testing of required emergency lighting systems
shall be permitted to be conducted as follows:
(1) Functional testing shall be conducted monthly, with a minimum of 3 weeks and a maximum of 5 weeks between
tests, for not less than 30 seconds, except as otherwise permitted by 7.9.3.1.1(2).
(2) The test interval shall be permitted to be extended beyond 30 days with the approval of the authority having
jurisdiction.
(3) Functional testing shall be conducted annually for a minimum of 1-1/2 hours if the emergency lighting system is battery powered.
(4) The emergency lighting equipment shall be fully operational for the duration of the tests required by 7.9.3.1.1(1)
and (3).
(5) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having
jurisdiction.

Section 7.9.3.1.2 states testing of required emergency lighting systems shall be permitted to be conducted as follows:
(1) Self-testing/self-diagnostic battery-operated emergency lighting equipment shall be provided.
(2) Not less than once every 30 days, self-testing/self-diagnostic battery-operated emergency lighting equipment shall automatically perform a test with a duration of a minimum of 30 seconds and a diagnostic routine.
(3) Self-testing/self-diagnostic battery-operated emergency lighting equipment shall indicate failures by a status indicator.
(4) A visual inspection shall be performed at intervals not exceeding 30 days.
(5) Functional testing shall be conducted annually for a minimum of 1-1/2 hours.
(6) Self-testing/self-diagnostic battery-operated emergency lighting equipment shall be fully operational for the duration of the 1-1/2 hour test.
(7) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having
jurisdiction.

Section 7.9.3.1.3 states testing of required emergency lighting systems shall be permitted to be conducted as follows:
(1) Computer-based, self-testing/self-diagnostic battery-operated emergency lighting equipment shall be provided.
(2) Not less than once every 30 days, emergency lighting equipment shall automatically perform a test with a duration of a minimum of 30 seconds and a diagnostic routine.
(3) The emergency lighting equipment shall automatically perform annually a test for a minimum of 11.2 hours.
(4) The emergency lighting equipment shall be fully operational for the duration of the tests required by 7.9.3.1.3(2)
and (3).
(5) The computer-based system shall be capable of providing a report of the history of tests and failures at all times.

THE FINDINGS INCLUDE:

The 3-story building is required to have emergency lighting per Section 39.2.9.1.

During the morning hours of 03/28/19 while reviewing the documentation, it was revealed that the facility is equipped with two types of emergency lighting. The roof top 100kW generator provides emergency lighting to the buildings constructed in 1992 and 2000. The building constructed in 2012 is equipped with battery pack emergency lighting units. It was stated by facility maintenance staff that the emergency lighting systems are not tested and documented as required.

The following items were observed regarding testing of the emergency lighting systems:

1) Although the generator is run monthly, it is tested utilizing an automatic timer running the unit in an exercise condition only. It was further stated that the generator is not tested under a load condition utilizing the transfer switch each month as required. In addition, run times of the generator are not provided with the hour-meter which is provided on the unit.

2) The battery equipped emergency lighting is not documented as being tested at all.

As a result, the facility failed to comply with section 39.2.9.1 ensuring emergency lighting is installed and tested as required.

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

A. Based on observations the facility failed to ensure compliance with Chapter 39 "Existing Business Occupancies" of the 2012 Edition of NFPA 101 "Life Safety Code".

39.3.1 Protection of Vertical Openings.
39.3.1.1 Vertical openings shall be enclosed or protected in accordance with Section 8.6, unless otherwise permitted by any of the following:
(1) Unenclosed vertical openings in accordance with 8.6.9.1 or 39.2.4.7 shall be permitted.
(2) Exit access stairs in accordance with 39.2.4.6 or 39.2.4.7 shall be permitted to be unenclosed.
(3) Unprotected vertical openings shall be permitted in buildings complying with all of the following:
(a) Where protected throughout by an approved automatic sprinkler system in accordance with 9.7.1.1(1)
(b) Where no unprotected vertical opening serves as any part of any required means of egress
(c) Where required exits consist of exit doors that discharge directly to the finished ground level in accordance with 7.2.1, outside stairs in accordance with 7.2.2, smokeproof enclosures in accordance with 7.2.3, or horizontal exits in accordance with 7.2.4.

8.6.7* Atriums. Unless prohibited by Chapters 11 through 43, an atrium shall be permitted, provided that the following conditions
are met:
(1) The atrium is separated from the adjacent spaces by fire barriers with not less than a 1-hour fire resistance rating,
with opening protectives for corridor walls, unless one of the following is met:
(a) The requirement of 8.6.7(1) shall not apply to existing, previously approved atriums.
(b) Any number of levels of the building shall be permitted to open directly to the atrium without enclosure,
based on the results of the engineering analysis required in 8.6.7(5).
(c)*Glass walls and inoperable windows shall be permitted in lieu of the fire barriers where all the following
are met:
i. Automatic sprinklers are spaced along both sides of the glass wall and the inoperable windows
at intervals not to exceed 6 ft (1830 mm).
ii. The automatic sprinklers specified in 8.6.7(1)(c)(i) are located at a distance from the glass wall not to exceed 12 in. (305 mm) and
arranged so that the entire surface of the glass is wet upon operation of the sprinklers.
iii. The glass wall is of tempered, wired, or laminated glass held in place by a gasket system that
allows the glass framing system to deflect without breaking (loading) the glass before the sprinklers operate.
iv. The automatic sprinklers required by 8.6.7(1)(c)(i) are not required on the atrium side of the glass wall and the inoperable window
where there is no walkway or other floor area on the atrium side above the main floor level.
v. Doors in the glass walls are of glass or other material that resists the passage of smoke.
vi. Doors in the glass walls are self-closing or automatic-closing upon detection of smoke.
vii. The glass is continuous vertically, without horizontal mullions, window treatments, or other
obstructions that would interfere with the wetting of the entire glass surface.
(2) Access to exits is permitted to be within the atrium, and exit discharge in accordance with 7.7.2 is permitted to be
within the atrium.
(3) The occupancy within the atrium meets the specifications for classification as low or ordinary hazard contents. (See
6.2.2.)
(4) The entire building is protected throughout by an approved, supervised automatic sprinkler system in accordance
with Section 9.7.
(5)*For other than existing, previously approved atriums, an engineering analysis is performed that demonstrates that the
building is designed to keep the smoke layer interface above the highest unprotected opening to adjoining spaces, or 6 ft
(1830 mm) above the highest floor level of exit access open to the atrium, for a period equal to 1.5 times the calculated
egress time or 20 minutes, whichever is greater.
(6)*In other than existing, previously approved atriums, where an engineered smoke control system is installed to
meet the requirements of 8.6.7(5), the system is independently activated by each of the following:
(a) Required automatic sprinkler system
(b) Manual controls that are readily accessible to the fire department

Findings include:

A survey of the building on 3/28/19 revealed a three story vertical shaft at the front of the building. The vertical opening is enclosed with glass on the second and third floors; however, it not enclosed at the first floor level. The vertical opening on the first floor serves as part of the required means of egress from the first floor. In addition, the building was not provided with a complete automatic sprinkler system. Please see K351.

In addition, if the vertical opening were to be identified as an atrium, it does not meet Section 8.6.7 because an engineering analysis was not available and the building was not provided with a complete automatic sprinkler system. Please see K351.

As a result of the deficiency the facility is found to be non-compliant with Chapter 39 Section 39.3.1.


B. Based on observations and confirmed by staff, the facility failed to ensure that the rated stairwell fire doors latch as required.

NFPA 101 section 39.2.2.2.1 Doors complying with 7.2.1 shall be permitted.

7.2.1.1.1 A door assembly in a means of egress shall conform
to the general requirements of Section 7.1 and to the special requirements of Section 7.2.1.

39.2.2.3.1 Stairs complying with 7.2.2 shall be permitted.

Section 7.2.2.1.1 states that stairs used as a component in the means of egress shall conform to the general requirements of Section 7.1.

Section 7.1.3.2.1 states that where this Code requires an exit to be separated from other parts of the building, the separating construction shall meet the requirements of Section 8.2.

Section 8.2.2.2 states fire compartments shall be formed with fire barriers that comply with Section 8.3.

Section 8.3.3.1 states that openings required to have a fire protection rating by Table 8.3.4.2 shall be protected by approved, listed, labeled fire door assemblies and fire window assemblies and their accompanying hardware, including all frames, closing devices, anchorage, and sills in accordance with the requirements of NFPA 80, Standard for Fire Doors and Other Opening Protectives, except as otherwise specified in this Code.

THE FINDINGS INCLUDE:

During a survey of the building on the morning of 3/28/19, the following were observed:

1. The 1st floor stair #2 door to the lab was not provided with a closing device. The closing hardware had been removed from the door as evidenced by holes in the fire door.

2. The door latching mechanism on the second floor of stair #2 was retracted not allowing the door to latch in the closed position. The Director of Maintenance stated that the latch could be released with an Allen screw adjustment.

The facility maintenance representative confirmed the observation during the facility survey walk through.

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

This Standard is not met as evidenced by:

Based on observations and record review, the facility failed to ensure fume hoods are inspected as required. This deficient practice could affect all the staff working within the Hematology Laboratory.

NFPA 45 section 8.12 states special-use chemical fume hoods and special-use local exhaust systems shall be identified to indicate their intended use.

Section 8.12.2 states a sign containing the following information from the last inspection shall be affixed to each hood, or a properly maintained log of all hoods providing the following information shall be maintained:
(1) Inspection interval
(2) Last inspection date
(3) Average face velocity
(4) Location of fan that serves hood
(5) Inspector ' s name

Section 8.13.1 states when installed or modified and at least annually thereafter, chemical fume hoods, chemical fume hood exhaust systems, and laboratory special exhaust systems shall be inspected and tested as applicable, as follows:
(1) Visual inspection of the physical condition of the hood interior, sash, and ductwork (see 7.5.3)
(2) Measuring device for hood airflow
(3) Low airflow and loss-of-airflow alarms at each alarm location
(4) Face velocity
(5) Verification of inward airflow over the entire hood face
(6) Changes in work area conditions that might affect hood performance

THE FINDINGS INCLUDE:

During the morning hours of 03/28/19 while touring the 2nd floor, a fume hood was observed within the Hematology Laboratory. Upon closer examination, the hood was observed as not having an inspection/testing tag attached to the hood. When questioned, maintenance staff stated the hood is tested quarterly by in-house staff, ensuring that the fan motor is working. It was further stated that the facility does not have a certified vendor perform testing or inspection of the fume hood.

As a result, the facility failed to comply with NFPA 45 section 8.12.2 and 8.13.1 requiring fume hoods to be maintained and labeled accordingly.

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

A. Based on observations and confirmed by staff, the facility failed to ensure that all required areas are protected by the automatic sprinkler system. A building is considered to be provided with a complete automatic sprinkler system when the sprinkler system is installed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.

Section 8.6.4.1.1.1 states that under unobstructed construction, the distance between the sprinkler deflector and the ceiling shall be a minimum of 1 in. (25.4 mm) and a maximum of 12 in. (305 mm) throughout the area of coverage of the sprinkler.

Findings Include:

During the afternoon hours of 03/28/19 observations revealed the following areas were not provided with sprinkler protection in accordance with NFPA 13.

1. The closet located across from room #3039 was not provided with sprinkler protection.
2. One side of the Rental Supply Closet was not provided with sprinkler protection.
3. The ceiling tiles in the 1st and 2nd floor IT closets had been removed. As a result, the existing sprinkler heads were located greater than 12 inches from the corrugated metal deck above.

NOTE: The building is required to be completely sprinklered in accordance with NFPA 13. See K311.

As a result the facility failed to comply with NFPA 13.

B. Based on observations and confirmed by staff, the facility failed to ensure that all required areas are protected by the automatic sprinkler system.

-NFPA 13 Chapter 8 "Installation Requirements" Section 8.15.10.3 states sprinklers shall not be required in electrical equipment
rooms where all of the following conditions are met:
(1) The room is dedicated to electrical equipment only.
(2) Only dry-type electrical equipment is used.
(3) Equipment is installed in a 2-hour fire-rated enclosure
including protection for penetrations.
(4) No combustible storage is permitted to be stored in the
room.

-NFPA 101 Chapter 8 "Features of Fire Protection" Table 8.3.4.2 requires 2-hour fire-rated enclosures to be provided with an opening protective (Fire Door Assembly) with a 1-1/2 hour fire resistive rating.

Findings include:

Observations while touring the facility on 3/28/18 revealed the following:

1. The corridor door to the basement elevator machine room, located in the administration wing, was fitted with a louver. The elevator machine room door is required to be rated for 1.5 hours in a two hour non sprinklered fire rated room.

2. A dental chair and four rolling combustible chairs were stored in the basement elevator machine room #0028.

The facility maintenance representative confirmed the observation during the facility survey walk through.

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

Based on record review and confirmed by staff interview, the facility failed to ensure that the automatic sprinkler system is maintained, tested, and inspected as required.

NFPA 101, 2012 edition
39.3.1 Protection of Vertical Openings.
39.3.1.1 Vertical openings shall be enclosed or protected in accordance with Section 8.6, unless otherwise permitted by any of the following:
(1) Unenclosed vertical openings in accordance with 8.6.9.1 or 39.2.4.7 shall be permitted.
(2) Exit access stairs in accordance with 39.2.4.6 or 39.2.4.7 shall be permitted to be unenclosed.
(3) Unprotected vertical openings shall be permitted in buildings complying with all of the following:
(a) Where protected throughout by an approved automatic sprinkler system in accordance with 9.7.1.1(1)
(b) Where no unprotected vertical opening serves as any part of any required means of egress
(c) Where required exits consist of exit doors that discharge directly to the finished ground level in accordance with 7.2.1, outside stairs in accordance with 7.2.2, smokeproof enclosures in accordance with 7.2.3, or horizontal exits in accordance with 7.2.4.

39.1.1.3 General. The provisions of Chapter 4, General, shall
apply.

4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or other feature shall thereafter be continuously maintained. Maintenance shall be provided in accordance with applicable NFPA requirements or requirements developed as part of a performance-based design, or as directed by the authority having jurisdiction.

NFPA 25 (2011 edition),

5.2.4.1* Gauges on wet pipe sprinkler systems shall be inspected monthly to ensure that they are in good condition and that normal water supply pressure is being maintained.

5.2.5 Waterflow Alarm and Supervisory Devices. Waterflow alarm and supervisory alarm devices shall be inspected quarterly
to verify that they are free of physical damage.

5.3.3.1 Mechanical waterflow alarm devices including, but not limited to, water motor gongs, shall be tested quarterly.

5.3.3.2 Vane-type and pressure switch-type waterflow alarm devices shall be tested semiannually.

5.3.3.3 Testing waterflow alarm devices on wet pipe systems shall be accomplished by opening the inspector 's test connection.

5.2.4.1* Gauges on wet pipe sprinkler systems shall be inspected monthly to ensure that they are in good condition and that normal water supply pressure is being maintained.

FINDINGS INCLUDE:

On the morning of 3/27/19 the health center was surveyed. Sprinkler system vendor inspection and testing information was provided after completion of the health center tour.

The valve tag and the vendor inspection report both indicated the most recent inspection of the sprinkler system had been conducted on 1/19/18. A period of nearly 14-months has passed since the last sprinkler inspection, exceeding the quarterly allowance. In addition, the sprinkler pressures of this wet type system were not documented and maintained monthly.

As a result of the lack of the required testing and inspection of the wet type sprinkler system, the health center is deficient in their testing and maintenance of the wet type sprinkler system in accordance with NFPA 101 and NFPA 25.

Note :This sprinkler system is a required sprinkler system for the business occupancy as there is a three story unenclosed vertical opening that requires the building to be completely sprinklered in accordance with NFPA 101, Section 39.3.1(3).

The facility maintenance representative confirmed the observation during the facility survey walk through.

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

Based on observations and confirmed by staff, the facility failed to ensure compliance with Chapter 19, Section 19.3.6.2 of the 2012 edition of NFPA 101 "Life Safety Code".

This deficient practice could affect the current patients, as well as an undetermined amount of staff and visitors in the event of an actual fire.

Section 19.3.6.2.2 states corridor walls shall have a minimum 1/2-hour fire resistance rating.

In smoke compartments equipped with a complete automatic sprinkler system, partitions are only required to resist the transfer of smoke.
In smoke compartments not equipped with a complete automatic sprinkler system, corridor walls must extend to the underside of the floor or roof deck above the ceiling.

Corridor walls may terminate at the underside of ceilings where specifically permitted by Code.

Section 19.3.6.2.7 states fixed fire window assemblies in accordance with Section 8.3 shall be permitted in corridor walls, unless otherwise permitted in 19.3.6.2.8.

Section 19.3.6.2.8 states there shall be no restrictions in area and fire resistance of glass and frames in smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.7.

Section 19.3.5.7 states where this Code permits exceptions for fully sprinklered buildings or smoke compartments, the sprinkler system shall meet all of the following criteria:
(1) It shall be in accordance with Section 9.7.
(2) It shall be installed in accordance with 9.7.1.1(1), unless it is an approved existing system.
(3) It shall be electrically connected to the fire alarm system.
(4) It shall be fully supervised.
(5) In Type I and Type II construction, where the authority having jurisdiction has prohibited sprinklers, approved alternative protection measures shall be permitted to be substituted for sprinkler protection in specified areas without causing a
building to be classified as nonsprinklered.

Findings Include:

Observations made throughout the nonsprinklered Emergency Department on 03/27/19 revealed that the corridor walls terminated 4 inches above the ceiling. In addition non-rated plain glass visions panel were utilized in the corridor walls throughout the Emergency Department.

As a result, the corridor walls were not constructed in accordance with Section 19.3.6.2.2.

These items were noted during survey exit interview with the Hospital President, Hospital Leadership Staff and Facility Engineering.

Based on surveyor observations the facility failed to ensure that all doors protecting corridor openings are in compliance with the 2012 edition of NFPA 101 Life Safety Code.

This deficient practice could affect the current patients, as well as an undetermined amount of staff and visitors in the event of an actual fire.

Section 19.3.6.3.10 states that corridor doors shall not be held open by devices other than those that release when the door is pushed or pulled.

Findings Include:

While conducting the facility tour on 03/27/19, surveyor observations revealed that the corridor door(s) to the patients treatment rooms were all held open utilizing a step-on type door stop.

Step-on type door stops are not considered approved hold open devices.

As a result of the finding, the facility is found to be non-compliant with section 19.3.6.3.10.

These items were noted during survey exit interview with the Hospital President, Hospital Leadership Staff and Facility Engineering.

Based on documentation review and staff interview, the facility failed to ensure that quarterly fire drills are conducted utilizing various shift times and conditions.

This deficient practice could affect the current patients, as well as an undetermined amount of staff and visitors in the event of an actual fire.

Section 19.7.1.6 states that fire drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions.

Findings Include:

On 3/27/19, surveyor review of fire drill documentation provided indicated that the facility conducted only two fire drills per year for the Emergency Department.

As a result of the finding the facility failed to ensure compliance with Chapter 19 Section 19.7.1.6.

These items were noted during survey exit interview with the Hospital President, Hospital Leadership Staff and Facility Engineering.

Based on record review and confirmed by staff, the facility failed to ensure that the emergency natural gas generator serving this three story building is run monthly under a load condition for the required 30-minutes.

NFPA 101, 2012 edition

4.5.8 Maintenance. Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be maintained, unless the Code exempts such maintenance.

39.2.9.1 Emergency lighting shall be provided in accordance with Section 7.9 in any building where any one of the following conditions exists:
(1) The building is three or more stories in height.
(2) The occupancy is subject to 100 or more occupants above or below the level of exit discharge.
(3) The occupancy is subject to 1000 or more total occupants.

39.2.9.2 Emergency lighting in accordance with Section 7.9 shall be provided for all underground and limited access structures, as defined in 3.3.271.11 and 3.3.271.3, respectively.

7.9.2.4 Emergency generators providing power to emergency lighting systems shall be installed, tested, and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. Stored electrical energy systems, where required in this Code, other than battery systems for emergency luminaires in accordance with 7.9.2.5, shall be installed and tested in accordance with NFPA 111, Standard on Stored Electrical Energy Emergency and Standby Power Systems.

7.9.3 Periodic Testing of Emergency Lighting Equipment.
7.9.3.1 Required emergency lighting systems shall be tested in accordance with one of the three options offered by 7.9.3.1.1, 7.9.3.1.2, or 7.9.3.1.3.

7.9.3.1.1 Testing of required emergency lighting systems shall be permitted to be conducted as follows:
(1) Functional testing shall be conducted monthly, with a minimum of 3 weeks and a maximum of 5 weeks between tests, for not less than 30 seconds, except as otherwise permitted by 7.9.3.1.1(2).
(2)*The test interval shall be permitted to be extended beyond 30 days with the approval of the authority having jurisdiction.
(3) Functional testing shall be conducted annually for a minimum of 1 1/2 hours if the emergency lighting system is battery powered.
(4) The emergency lighting equipment shall be fully operational for the duration of the tests required by 7.9.3.1.1(1) and (3).
(5) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having
jurisdiction.

NFPA 110, 2010 edition
8.4.2.4 Spark-ignited generator sets shall be exercised at least once a month with the available EPSS load for 30 minutes or until the water temperature and the oil pressure have stabilized.
8.4.2.4.1 The date and time of day for required testing shall be decided by the owner, based on facility operations.
8.4.2.4.2 Equivalent loads used for testing shall be automatically replaced with the emergency loads in case of failure of the primary source.
8.4.3 The EPS test shall be initiated by simulating a power outage using the test switch(es) on the ATSs or by opening a normal breaker. Opening a normal breaker shall not be required.
8.4.4 Load tests of generator sets shall include complete cold starts.
8.4.5 Time delays shall be set as follows:
(1) Time delay on start:
(a) 1 second minimum
(b) 0.5 second minimum for gas turbine units
(2) Time delay on transfer to emergency: no minimum required
(3) Time delay on restoration to normal: 5 minutes minimum
(4) Time delay on shutdown: 5 minutes minimum

8.4.6 Transfer switches shall be operated monthly.

8.4.6.1 The monthly test of a transfer switch shall consist of electrically operating the transfer switch from the standard position to the alternate position and then a return to the standard position.

FINDINGS INCLUDE:

During the morning hours of 3/27/19, records of the generator maintenance and testing were requested. Although maintenance of the 100 kW natural gas emergency generator was documented as occurring on 1/29/19, documentation was not available to substantiate monthly testing of the emergency generator and associated transfer switch on a monthly basis as required by NFPA 101, Section 7.9.2.4 and NFPA 110, Sections 8.4.2.4 and 8.4.6.

In addition, it was noted on the morning of 3/27/19 that the generator alarm panel was indicating an alarm for "Low Engine Temperature". No further information for this alarm condition was available. As a result of the alarm, the emergency generator was not maintained in proper operating condition in accordance with NFPA 101, Section 4.5.8.

The facility maintenance representative confirmed the observation during the facility survey walk through.

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