HospitalInspections.org

A. Based on observations, the facility failed to ensure that corridor walls are constructed with at least 1/2 hour fire resistance rating as required by Section 19.3.6.2.1.

THE FINDINGS INCLUDE:

Observations while touring the facility on 01/06-09/14 revealed that corridor walls were not constructed with at least 1/2 hour fire resistance rating. The following areas were noted:

1. The corridor sidelights and door to the President's Office is constructed with plain glass vision panels.
2. The Gift Shop has four 3' x 3' plain glass vision panels in addition to plain glass in the corridor doors to the Gift Shop.
3. The Consultation room is constructed with plain glass vision panels.
4. The ICU waiting room is constructed with plain glass vision panels.
5. The OR is constructed with non rated sliding glass doors.
6. The Mother Baby Sitting Unit is constructed with two 60" X 48" glass panels.

NOTE: The areas noted are in smoke compartments which are not protected throughout by an approved, supervised automatic sprinkler system.



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B. Based on observations and confirmed by staff, the facility failed to ensure corridor walls are constructed as required. Exception #6 to 19.3.6.1 states spaces other than patient sleeping rooms, treatment rooms, and hazardous areas shall be permitted to be open to the corridor and unlimited in area, provided that the following criteria are met:
(a) The space and the corridors onto which it opens, where located in the same smoke compartment, are protected by an electrically supervised automatic smoke detection system in accordance with 19.3.4.
(b) Each space is protected by automatic sprinklers, or the furnishings and furniture, in combination with all other combustibles within the area, are of such minimum quantity and arrangement that a fully developed fire is unlikely to occur.
(c) The space does not obstruct access to required exits.

THE FINDINGS INCLUDE:

Observations while touring the facility at approximately 10:00 A.M. on 01/06/14 revealed that the staff Breakroom door on the 4th floor of the Pediatric Unit has been removed. In addition to the missing door, the room is not equipped with a smoke detecting device.

This was acknowledged by facility staff and reviewed during the summary of survey findings.

A. Based on observations during a tour of the building in the afternoon on 01/06/14 and 01/07/14 and confirmed by staff, the facility failed to ensure that corridor doors are maintained as required.

THE FINDINGS INCLUDE:

1. The corridor door to the Med Room on the 1st floor "A" wing is provided with a louver which does not resist the passage of smoke in accordance with Section 19.3.6.3.


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2. The corridor door to the telecommunications closet on the 3rd floor "C" wing, adjacent to room # 325 B, is provided with a louver which is not in compliance with Section 19.3.6.3.

3. The following corridor doors to patient room are not smoke tight: #304, #306, #307, #312, #314, and #316. The facility had installed new corridor door leaf(s), a 36" wide active leaf and a 12' wide inactive leaf, at the above noted locations and failed to maintain a smoke tight seal at the door leaf(s) meeting edges. The space between the meeting edges ranged from 1/4' to 3/8". Facility engineering staff acknowledged the finding and had already installed astragals on several other corridor doors.

4. The corridor doors to patient rooms #324 and #309 have unsealed 1/8" gaps between the top of the door and the door frame header.

5. The corridor door to room #339 A failed to latch in the door frame during the morning hours of 01/06/14.


This was acknowledged by facility staff and reviewed during the summary of survey findings.

Based on observations, the facility failed to ensure that smoke barriers are constructed to resist the passage of smoke and are continuous to floor/roof slabs above suspended ceilings. Section 8.3.2 requires smoke barriers to be continuous from an outside wall to an outside wall, from a floor to a floor, or from a smoke barrier to a smoke barrier or a combination thereof. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces.

THE FINDINGS INCLUDE:

Observations while touring the facility on 01/07/14 revealed voids in smoke barrier walls. Specific areas are noted below, however, voids are not limited to these locations:

1. The smoke barrier wall contains voids around the wire penetrations above the suspended ceiling by the rear door of Interventional on the first floor.

2. The smoke barrier wall has a 12" X 10" hole which penetrates Stair "B" North above the suspended ceiling at the ground level.

3. The smoke barrier wall has a 2" x 4" void around the BX cable located above the suspended ceiling by the exit door by Radiology on the ground floor.

4. The smoke barrier wall has a void around the BX cable located above the suspended ceiling in the Interventional Radiology Clean Storage room on the ground floor.


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5. The smoke barrier contains voids around the data cable penetrations above the suspended ceiling by the Emergency Department room #16.


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6. The smoke barrier near the Lab Registration waiting room contains a 2" x 6" approximate sized penetration located above the suspended ceiling.

7. The smoke barrier located in the Emergency Department corridor across from the vending machine area contains several various sized penetrations above the suspended ceiling.

8. Observations while touring the facility at approximately 1:30 P.M.on 01/07/14 revealed that there are two 1 " holes in the smoke barrier wall, near the stairwell and the elevator, located in the back of the Vascular Lab in the basement level.

9. Observations while touring the facility at approximately 9:30 A.M. on 01/07/14 revealed that there is a 10" X 3" and two 2" x 2" holes around piping and an electrical junction box in the smoke barrier located between the Nursery and the Nurses station on 2 East.

10. Observations while touring the facility at approximately 11:00 A.M. on 01/07/14 revealed that there is a 2" X 2" hole around the duct in the smoke barrier wall to the right of a door identified as "staff only" to the Nursery and the Nurses station on 2 East.

11. Observations while touring the facility at approximately 11:30 A.M. on 01/07/14 revealed that there is no wall above the ceiling in the smoke barrier in 2 East near the staff bathroom, located next to the Nurses station.

This was acknowledged by facility staff and reviewed during the summary of survey findings.

Based on observations and confirmed by staff, the facility failed to ensure that hazardous areas are separated as required.

THE FINDINGS INCLUDE:

Observations while touring the facility at approximately 2:00 P.M. on 01/07/14 revealed that the non-sprinklered basement level mechanical space is not properly separated. According to the floor plans provided by the facility, the wall was constructed to have a 2-hour fire rating. When the wall was observed for compliance, approximately six penetrations were observed as not sealed with any fire rated material. These mainly consist of voids around various conduit and piping which penetrate the wall.
Note: Each of these penetrations were in hard to access locations above air handling equipment along the entire length of the room.

This was acknowledged by facility staff and reviewed during the summary of survey findings.


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Based on observations, the facility failed to ensure that exits are separated from other parts of the building as required. Section 7.1.3.2.1 requires an exit to be separated from other parts of the building; the separating construction shall meet the requirements of Section 8.2 and the following:
(a) The separation shall have not less than a 1-hour fire resistance rating where the exit connects three stories or less.
(b) The separation shall have not less than a 2-hour fire resistance rating where the exit connects four or more stories. The separation shall be constructed of an assembly of noncombustible or limited-combustible materials and shall be supported by construction having not less than a 2-hour fire resistance rating.
(c) Openings in the separation shall be protected by fire door assemblies equipped with door closer's complying with 7.2.1.8.
(d) Openings in exit enclosures shall be limited to those necessary for access to the enclosure from normally occupied spaces and corridors and for egress from the enclosure.

THE FINDINGS INCLUDE:

Observations while touring the facility on 01/07/14 revealed that:

1. The third floor level Stair "A West" enclosure is incomplete as the two hour wall, noted on the facility plans dated 10/09/13, has a 1" diameter unsealed penetration where a fire alarm/sprinkler testing module was removed and relocated. The penetration was left unsealed.

2. The ground floor level Stair "B East " stair discharge enclosure is incomplete as the two hour wall, noted on the facility plans dated 10/09/13, has unsealed penetrations above the in-lay ceiling tiles between the stair discharge and the Emergency Department.

3. Two, approximately 10" diameter, ducts penetrate the Stair "B East " stair discharge enclosure to the Emergency department and are neither equipped with access panels nor are they equipped with fire dampers.

This was acknowledged by facility staff and reviewed during the summary of survey findings.

A. Based on observations during the afternoon of 01/07/2014 and confirmed by staff, the facility failed to ensure that exit enclosures are constructed as required. Section 7.1.3.2.1 requires an exit to be separated from other parts of the building, the separating construction shall meet the requirements of Section 8.2 and the following.
(a) * The separation shall have not less than a 1-hour fire resistance rating where the exit connects three stories or less.
(b) * The separation shall have not less than a 2-hour fire resistance rating where the exit connects four or more stories. The separation shall be constructed of an assembly of noncombustible or limited-combustible materials and shall be supported by construction having not less than a 2-hour fire resistance rating.
Exception No. 1: In existing non-high-rise buildings, existing exit stair enclosures shall have not less than a 1-hour fire resistance rating.
Exception No. 2: In existing buildings protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, existing exit stair enclosures shall have not less than a 1-hour fire resistance rating.
Exception No. 3: One-hour enclosures in accordance with 28.2.2.1.2, 29.2.2.1.2, 30.2.2.1.2, and 31.2.2.1.2 shall be permitted as an alternative.
(c) Openings in the separation shall be protected by fire door assemblies equipped with door closers complying with 7.2.1.8.
(d) Openings in exit enclosures shall be limited to those necessary for access to the enclosure from normally occupied spaces and corridors and for egress from the enclosure.
Exception No. 1: Openings in exit passageways in covered mall buildings as provided in Chapters 36 and 37 shall be permitted.
Exception No. 2: In buildings of Type I or Type II construction, existing fire-protection rated doors shall be permitted to interstitial spaces provided that such space meets the following criteria:
(a) The space is used solely for distribution of pipes, ducts, and conduits.
(b) The space contains no storage.
(c) The space is separated from the exit enclosure in accordance with 8.2.3.
(e) Penetrations into and openings through an exit enclosure assembly shall be prohibited except for the following:
(1) Electrical conduit serving the stairway
(2) Required exit doors
(3) Ductwork and equipment necessary for independent stair pressurization
(4) Water or steam piping necessary for the heating or cooling of the exit enclosure
(5) Sprinkler piping
(6) Standpipes
Exception No. 1: Existing penetrations protected in accordance with 8.2.3.2.4 shall be permitted.
Exception No. 2: Penetrations for fire alarm circuits shall be permitted within enclosures where fire alarm circuits are installed in metal conduit and penetrations are protected in accordance with 8.2.3.2.4.
(f) Penetrations or communicating openings shall be prohibited between adjacent exit enclosures.

THE FINDINGS INCLUDE:

1. The entrance to the Telecom room, located on the ground floor of Stair "A" East, is from within the stair enclosure. As per (d) above, this door is not permitted to open into the enclosure.

2. The entrance to the Kitchen Storage closet, located on the ground floor of Stair "B" North, is from within the stair enclosure. As per (d) above, this door is not permitted to open into the enclosure.

3. The entrance to the Bio-Medical Storage, located on the basement level of Stair "B" West, is from within the exit enclosure. As per (d) above, this door is not permitted to open into the enclosure.

4. Observations while touring the facility at approximately 2:50 P.M. on 01/07/14 revealed that the basement level exit route of stairwell "B" is not constructed as required. The following items were observed regarding this stairwell/enclosure:

a. There is a mechanical room (non-occupied space) which has two doors that open into this exit enclosure route. As per (d) above, these doors are not permitted to open into the enclosure.
Note: In addition, this mechanical room is considered sprinklered but is adjacent to another non-sprinklered mechanical room. There are two large openings in the concrete wall between the spaces which are approximately 8' x 3' each in size. These opening have two large ducts approximately 6' x 2' in size passing through into the adjacent space. These ducts are not equipped with fire dampers, therefore the rooms are considered one large area which opens into the exit enclosure.

5. The basement level stairwell adjacent to the telephone room has an approximate 3" non-sealed hole above the stairwell door. This hole has an approximate 20/25 data line cables penetrating the wall at this point.


B. Based on observations, the facility failed to ensure that exit stairways are in accordance with Section 7.2.2.2.1(b) requiring existing stairways to be at least 44" in width, the minimum headroom to be 6 feet 8 inches, and the minimum width clear of al obstructions, except projections not more than 3 1/3 inches at or below handrail height on each side.

THE FINDINGS INCLUDE:

1. The width of Stair "C" at the 1st floor level reduces to 36 inches.

2. The headroom in Stair "C" at the 1st floor level is reduced to 6 foot 5 1/4 inch from the tread to the overhead.

3. The basement level of East Stair reduces to 37 inches in width.

4. The 1st floor level of Stair "C" East reduces to 35 1/2 inch in width due to the radiator which projects 9 inches off the exterior wall between the first and second floor levels. This radiator also reduces the head room to 5 feet 10 inches.

5. Stair "B" North reduces to 40 inches by the exit door.

These items are not in compliance with Section 7.2.2.2.1(b).

This was acknowledged by facility staff and reviewed during the summary of survey findings.



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Based on observation the facility failed to assure compliance with section 7-1.10.1 NFPA 101(Life Safety Code) states 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.


THE FINDINGS INCLUDE:

1. During the morning hours of 01/09/14, the stair "C East" enclosure between the first floor (discharge) level and the second floor level had the interior window protective bar unlocked and extended into the stair, rendering the stair impassible. A facility maintenance member immediately pushed the window guard into it's designed position.

2. During the survey on 01/06/14 and 01/09/14, the stair "A East" enclosure between the third floor level and the discharge level (level 1.5) , the facility utilized towels and a boom to maintain leaking water from a radiator. The towels and boom were removed on 01/09/14.

This was acknowledged by facility staff and reviewed during the summary of survey findings.

Based on observations, the facility failed to ensure that smoke detectors are properly installed. NFPA 72, Section 2-3.5.1 requires detectors in spaces served by air-handling systems, not to be located where airflow prevents operation of the detectors. Smoke detectors should be located at least 3 feet from air diffusers.

THE FINDINGS INCLUDE:

Observations while touring the facility on the morning and afternoon of 01/06/14 and 01/07/14 revealed smoke detectors arelocated within 3' of air diffusers in the following but not limited to locations.

1. In the first floor corridor near the stair B North door.
2. In the first floor corridor near the Day Surgery exit.
3. In the first floor soiled utility room located in the Day Surgery area.
4. In the first floor corridor by the stair B West door.

This was acknowledged by facility staff and reviewed during the summary of survey findings.

Based on observations, the facility failed to ensure that an accurate municipal water supply pressure could be monitored. NFPA #13, Sections 4.7.7 requires a listed pressure to be installed immediately below the control valve of each system. NFPA #25, Section 2.2.4.1 requires gauges on wet pipe sprinkler systems to be inspected monthly to ensure that they are in good condition and that normal water supply pressure is being maintained. Section 2.2.4.2 requires gauges on dry pipe sprinkler systems to be inspected weekly to ensure that normal air and water pressures are being maintained.

THE FINDINGS INCLUDE:

Observations while touring the facility on the morning of 01/08/14 revealed that a pressure gauge is not installed where the municipal water supply pressure can accurately be monitored. Pressure gauges are installed immediately below the control valves of each (wet & dry) system, however they are installed on the supply side of the back-flow preventer. Back-flow preventers allow water to pass through them in one direction locking the water pressure on the system (house) side of the device. This prevents the water pressure on the system side from going down when the pressure on the supply side goes down, such as during peak use periods during the day. A pressure gauge must be installed on the supply side of the back-flow preventers.

This was acknowledged by facility staff and reviewed during the summary of survey findings.

Based on observations, the facility failed to ensure that an accurate municipal water supply pressure could be monitored. NFPA #13, Sections 4.7.7 requires a listed pressure to be installed immediately below the control valve of each system. NFPA #25, Section 2.2.4.1 requires gauges on wet pipe sprinkler systems to be inspected monthly to ensure that they are in good condition and that normal water supply pressure is being maintained. Section 2.2.4.2 requires gauges on dry pipe sprinkler systems to be inspected weekly to ensure that normal air and water pressures are being maintained.

THE FINDINGS INCLUDE:

Observations while touring the facility on the morning of 01/08/14 revealed that a pressure gauge is not installed where the municipal water supply pressure can accurately be monitored. Pressure gauges are installed immediately below the control valves of each (wet & dry) system, however they are installed on the supply side of the back-flow preventer. Back-flow preventers allow water to pass through them in one direction locking the water pressure on the system (house) side of the device. This prevents the water pressure on the system side from going down when the pressure on the supply side goes down, such as during peak use periods during the day. A pressure gauge must be installed on the supply side of the back-flow preventers.

This was acknowledged by facility staff and reviewed during the summary of survey findings.

Based on record review, observations, and confirmed by staff interview, the facility failed to assure that the automatic sprinkler system is maintained, tested, and inspected as required by NFPA #25. NFPA #25, Sections 1.9 and 1.10 require system components to be inspected and tested in accordance with the intervals specified in the appropriate chapters. Section 9.4.1.2 and 9.4.2.1 requires alarm valves, and check valves and their associated strainers, filters, and restriction orifices to be inspected internally every 5 years.
NFPA 25, 1998 edition. Section 2-2.4.1 and 2-2.4.2 requires gauges on wet pipe sprinkler systems to be inspected monthly and dry pipe sprinkler system to be inspected weekly, to ensure that they are in good condition and that normal water supply pressure is being maintained.
NFPA #25. Section 2.3.2 requires pressure gauges to be replaced or tested every 5 years.

THE FINDINGS INCLUDE:

Record review on the morning of 01/07/14, and observations made on 01/08/14, while touring the hospital's sprinkler risers, revealed that the automatic sprinkler systems have the following deficiencies.

1. Conference Center Boiler Room sprinkler Main.
-No documented date for the 5 year inspection of the two sprinkler main gauges
-No documented date of the 5 year inspection for the internal inspection of the alarm valve.
2. Hood Building Fire Pump Room.
-No documented date for the 5 year inspection of the fire pump sprinkler gauges.
3. Kitchen Sprinkler Room Main.
-No documented date for the 5 year inspection of the sprinkler main gauge.
-No documented date of the 5 year inspection for the internal inspection of the alarm valve.

This was acknowledged by facility staff and reviewed during the summary of survey findings.

Based on record review, and confirmed by staff, the facility failed to ensure that the heating, ventilating, and air conditioning systems (HVAC) are maintained in accordance with NFPA 90A. NFPA 90A, Section 3.4.7 requires fusible links (where applicable) on fire dampers to be removed; all dampers to be operated to verify that they fully close; the latch, if provided, to be checked; and moving parts to be lubricated as necessary, at least every 4 years. Section 2.3.4.1 requires a service opening to 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. Section 2.3.4.2 requires service openings to be identified with letters having a minimum height of 1/2 in. to indicate the location of the fire protection device(S) within.


THE FINDINGS INCLUDE:

Review of the documentation for the maintenance, testing and inspection of the fire dampers on 01/07/14, revealed that the fire dampers were not tested as required. The vendor's report indicates that some dampers were "inaccessible", "no damper installed" or "no access panels." The facility has no plans to correct the identified deficiencies to be in compliance with NFPA 90A.

This was acknowledged by facility staff and reviewed during the summary of survey findings.

Based on observations, the facility failed to ensure that Utilities comply with the provisions of Section 9-1. Gas equipment shall be installed in accordance with NFPA #54, #90A, and per the manufacturers specifications. NFPA #54, Section 6.4.3 requires that provisions for makeup air be provided with a minimum free area of one square inch for each 1000 British Thermal Unit (Btu) per hour total input rating of the boiler installed. NOTE: A 100 square inch louvered opening provides approximately 75 square inches of free area. NFPA #90A, Section 2.3.11.1 prohibits using corridors as a supply air system to adjoining areas.
LSC 19-5.1, 18-5.1, & 9-1.1

THE FINDINGS INCLUDE:

At approximately 2:45 P.M. on 01/06/14 it was revealed that the laundry room has a gas fired commercial clothes dryer with a total of 165,000 Btu's. The room containing the dryer is not equipped with any make-up air provisions for combustion. As a result of this configuration, the corridor is being used as a plenum and supplying make-up air to the laundry room. The room is required to have minimum free area of 165 square inches of makeup air.

This was acknowledged by facility staff and reviewed during the summary of survey findings.

Based on observations during the building tour on the morning of 01/06/14, and confirmed by staff, the facility failed to ensure compliance with the restrictions of portable space heating devices. Section 9.7.8 states portable space-heating devices shall be prohibited in all health care occupancies.

THE FINDING INCLUDE:

Portable electric space heaters were observed in the following areas:
- in the Medical Records Department/Health Info Management Office,
- in the Medical Records Department Director/Manager's Office, and
- in patient room # 339 B.

Note: The devices in the Medical Records Department were not in use at the time of observation.

This was acknowledged by facility staff and reviewed during the summary of survey findings.


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Based on observations and confirmed by staff, the facility failed to ensure that linen chutes are properly maintained. NFPA 82 Standards for Incinerators and Waste and Linen Handling Systems and Equipment Section 3-2.5.2 states that automatic sprinklers installed in gravity chute service openings shall be recessed out of the chute area through which material travels.

THE FINDINGS INCLUDE:

On 01/06/14 and 01/07/14 a sprinkler pipe and sprinkler head were noted to be installed down the center line of the chute between the fourth and first floor levels.

This was acknowledged by facility staff and reviewed during the summary of survey findings.

Based on observation and confirmed by staff, the facility failed to ensure that smoke dampers were installed as required. LSC Section 8.3.5.1 requires an approved damper designed to resist the passage of smoke to be provided for each air transfer opening or duct penetration of a required smoke barrier. Section 8.3.5.2 requires smoke dampers in ducts penetrating smoke barriers to close upon detection of smoke by approved smoke detectors in accordance with NFPA 72.

THE FINDINGS INCLUDE:

During the morning hours of 01/08/14 while touring the facility, it was observed that the smoke barrier wall on the first floor has duct penetrations above the lay-in tile ceiling that are not equipped with smoke dampers. The following specific ducts are noted but not limited to the following;

- the two ducts which penetrate the first floor corridor wall into the Volunteer Office, and
- the one duct which penetrates the smoke barrier above the smoke barrier doors located in front of the Volunteer Office.

Note: The smoke compartments adjacent to each smoke barrier wall are not fully sprinklered to meet the exception to the code.

This was acknowledged by facility staff and reviewed during the summary of survey findings.

A. Based on record review, the facility failed to ensure that the 1000 gpm @105 psi horizontal electric automatic fire pump is maintained, tested, and inspected as required. LSC Sections 4.6.12.1 & 9.7.5 require automatic sprinkler systems to be continuously maintained in proper operating condition, tested and inspected in accordance with NFPA 25. NFPA #25, Sections 1.9 and 1.10 require system components to be inspected and tested in accordance with the intervals specified in the appropriate chapters. Section 5.3.3.1 requires an annual test of each pump assembly to be conducted under minimum, rated, and peak flows of the fire pump.

THE FINDINGS INCLUDE:

Documentation provided on 01/08/14 was not able to substantiate an annual flow test of the fire pump conducted in accordance with NFPA 25, Section 5.3.3.1.


B. Based on observations during a facility tour on 01/08/14, it was observed that the facility was not in compliance with Section 39.2.4.1. Section 39.2.4.1 requires the number of exits to be in accordance with Section 39.2.4.2. The requirements of 7.4.1.2 shall not apply. Section 39.2.4.2 requires:
Not less than two separate exits shall meet the following criteria:
(1)They shall be provided on every story.
(2)They shall be accessible from every part of every story and mezzanine.

THE FINDINGS INCLUDE:
The Ultrasound Suite, located on the first floor of the Russell Building, Suite 111, is only provided with one exit which is not in compliance with Section 39.2.4.2.


C. Based on observations during a facility tour on 01/08/14, it was observed that the facility is not in compliance with Section 7.1.3.2.. Section 7.1.3.2 Exception No. 2 states 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 which allows existing buildings protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, to allow an existing exit stair enclosures to have not less than a 1-hour fire resistance rating.

THE FINDINGS INCLUDE:The facility is not in compliance with Section 7.1.3.2 due to the 30 minute rated doors on each of the levels to the two exit stairs.


D. Based on observations during a facility tour on 01/08/14, it was observed that the facility is not in compliance with Section 7.1.3.2.3. which requires an exit enclosure to 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.
THE FINDINGS INCLUDE:
The facility is not in compliance with Section 7.1.3.2.3 due to the storage of carpet, boxes of filters, and a metal storage cabinet stored on the ground floor landing of the stair by the Occupational Therapy and Physical Therapy Suite.


This was acknowledged by facility staff and reviewed during the summary of survey findings.



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A. Based on record review and confirmed by staff, it was revealed that the facility failed to ensure compliance with NFPA 101. Section 4.6.12.1 states 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 continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction. NFPA 72 (National Fire Alarm Code). Section 7-1.2 states the owner or the owner's designated representative shall be responsible for inspection, testing, and maintenance of the system and alterations or additions to this system. The delegation of responsibility shall be in writing, with a copy of such delegation provided to the authority having jurisdiction upon request. Table 7-3.2 #20 states Off-Premises Transmission Equipment shall be tested on a quarterly basis. Section 7.3.2 and Table 7.3.2 require systems with sealed batteries to have the battery charger tested annually, replace the battery every 4 years, to conduct a 30 minute battery discharge test annually, and to conduct a load voltage test semi-annually.

THE FINDINGS INCLUDE:

During the morning hours of 01/08/14 while performing the record review, it was observed that the facility does not maintain/inspect the fire alarm system as required. The only fire alarm vendor inspection report available for review was dated 12/28/12. As a result of the annual testing, the following items were noted as being deficient:

1. The off-premise testing is not performed quarterly as required.

2. The fire alarm batteries are not dated or documented as being tested as required. There are no line items pertaining to the testing of batteries for either annual or semi-annual tests.


B. NFPA 25, Section 2-3.3 requires waterflow alarm devices including, but not limited to, mechanical water motor gongs, vane-type waterflow devices, and pressure switches that provide audible or visual signals to be tested quarterly. Testing the waterflow alarms on wet pipe systems shall be accomplished by opening the inspector's test connection which simulates activation of a sprinkler head. Section 2-2.4.1 requires gauges on wet pipe sprinkler systems to be inspected monthly to ensure that they are in good condition and that normal water supply pressure is being maintained. Section 9-4.1.2 requires alarm valves and their associated strainers, filters, and restriction orifices to be inspected internally every 5 years unless tests indicate a greater frequency is necessary.

THE FINDINGS INCLUDE:

During the morning hours of 01/08/14 while performing the record review, it was observed that the facility does not maintain/inspect the sprinkler system as required. The only sprinkler vendor inspection report available for review was dated 12/27/12. As a result of the annual testing, the following items were noted as being deficient:

1. The quarterly flow test utilizing the Inspector's Test Valve (ITV) is not performed as required.

2. The facility does not perform monthly pressure readings of the sprinkler system as required.

3. There are no records to substantiate that the 5-year internal check of the main alarm valve was performed.

This was acknowledged by facility staff and reviewed during the summary of survey findings.

A. Based on record review and confirmed by staff, it was revealed that the facility failed to ensure compliance with NFPA 101. Section 4.6.12.1 states 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 continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction. NFPA 72 (National Fire Alarm Code). Section 7-1.2 states the owner or the owner's designated representative shall be responsible for inspection, testing, and maintenance of the system and alterations or additions to this system. The delegation of responsibility shall be in writing, with a copy of such delegation provided to the authority having jurisdiction upon request. Table 7-3.2 #20 states Off-Premises Transmission Equipment shall be tested on a quarterly basis. Section 7.3.2 and Table 7.3.2 require systems with sealed batteries to have the battery charger tested annually, replace the battery every 4 years, to conduct a 30 minute battery discharge test annually, and to conduct a load voltage test semi-annually.

THE FINDINGS INCLUDE:

During the morning hours of 01/08/14 while performing the record review, it was observed that the facility does not maintain/inspect the fire alarm system as required. The only fire alarm vendor inspection report available for review was dated 12/28/12. As a result of the annual testing, the following items were noted as being deficient:

1. The off-premise testing is not performed quarterly as required.

2. The fire alarm batteries are not dated or documented as being tested as required. There are no line items pertaining to the testing of batteries for either annual or semi-annual tests.


B. NFPA 25 section 2-3.3 requires waterflow alarm devices including, but not limited to, mechanical water motor gongs, vane-type waterflow devices, and pressure switches that provide audible or visual signals to be tested quarterly. Testing the waterflow alarms on wet pipe systems shall be accomplished by opening the inspector's test connection which simulates activation of a sprinkler head. Section 2-2.4.1 requires gauges on wet pipe sprinkler systems to be inspected monthly to ensure that they are in good condition and that normal water supply pressure is being maintained. Section 9-4.1.2 requires alarm valves and their associated strainers, filters, and restriction orifices to be inspected internally every 5 years unless tests indicate a greater frequency is necessary.

THE FINDINGS INCLUDE:

During the morning hours of 01/08/14 while performing the record review, it was observed that the facility does not maintain/inspect the sprinkler system as required. The only sprinkler vendor inspection report available for review was dated 12/27/12. As a result of the annual testing, the following items were noted as being deficient:

1. The quarterly flow test utilizing the Inspector's Test Valve (ITV) is not performed as required.

2. The facility does not perform monthly pressure readings of the sprinkler system as required.

3. There are no records to substantiate that the 5-year internal check of the main alarm valve was performed.


C. NFPA 110, Section 6.1.1 requires a routine maintenance and operational testing program of the "Emergency Power Supply System" (EPSS) that is based on the manufacturer's recommendations, instruction manuals, and the minimum requirements of this chapter and the authority having jurisdiction. Section 6.3.3 requires a written schedule for routine maintenance and operational testing of the EPSS to be established. Sections 6.4.1 & 6.4.2 require the EPSS's, including all appurtenant components, to be inspected weekly and to be exercised under load at least monthly for a minimum of 30 minutes.

THE FINDINGS INCLUDE:

Review of the documentation for the hospital maintenance, testing and inspection of the EPSS (generators) on 01/07/14, revealed that the facility was not conducting weekly generator inspections on the two generators as required.


This was acknowledged by facility staff and reviewed during the summary of survey findings.

A. Based on record review, and confirmed by staff, the facility failed to ensure that the heating, ventilating, and air conditioning systems (HVAC) are maintained in accordance with NFPA 90A. NFPA 90A, Section 3.4.7 requires fusible links (where applicable) on fire dampers to be removed; all dampers to be operated to verify that they fully close; the latch, if provided, to be checked; and moving parts to be lubricated as necessary, at least every 4 years.
Section 2.3.4.1 requires a service opening to 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. Section 2.3.4.2 requires service openings to be identified with letters having a minimum height of 1/2 in. to indicate the location of the fire protection device(S) within.

THE FINDINGS INCLUDE:

Review of the documentation for the maintenance, testing and inspection of the fire dampers on 01/07/14, revealed that the fire dampers were not tested as required. The vendor's report indicates that some dampers were "inaccessible", "no damper installed" or "no access panels." The facility has no plans to correct the identified deficiencies to be in compliance with NFPA 90A.


B. Based on record review and confirmed by staff interview, the facility failed to ensure that the "Emergency Power Supply System" (EPSS) is maintained, tested, and inspected in accordance with NFPA 101 and NFPA 110.
NFPA 101 LIFE SAFETY CODE" (LSC), Section 7.9.3 requires written records of visual inspections and tests to be kept by the owner for inspection by the authority having jurisdiction. NFPA 110, Section 6.1.1 requires a routine maintenance and operational testing program of the "Emergency Power Supply System" (EPSS) that is based on the manufacturer's recommendations, instruction manuals, and the minimum requirements of this chapter and the authority having jurisdiction. Section 6.3.3 requires a written schedule for routine maintenance and operational testing of the EPSS to be established. Sections 6.4.1 & 6.4.2 require the EPSS's, including all appurtenant components, to be inspected weekly and to be exercised under load at least monthly for a minimum of 30 minutes.

THE FINDINGS INCLUDE:

Review of the documentation for the hospital maintenance, testing and inspection of the EPSS (generator) on 01/08/14, revealed that the facility was not conducting weekly generator inspections on the generator as required.


C. Based on observations and confirmed by staff, the facility failed to ensure that smoke barrier doors have at least a 20 minute fire protection rating or are at least 1 3/4 inch thick solid bonded wood core or the equivalent in accordance with Section 21.3.7.1.

THE FINDINGS INCLUDE:

During the morning hours of 01/08/14 while touring the facility, it was observed that the smoke barrier door, between the Admitting and Pre-Operation areas, is a non-labeled, non-rated door.

This was acknowledged by facility staff and reviewed during the summary of survey findings.

A. Based on observations, the facility failed to ensure that the automatic sprinkler system is installed per code. NFPA #13, Section 4-1.1 requires a listed pressure gauge conforming to 5-15.3.2 shall be installed in each system riser. Pressure gauges shall be installed above and below each alarm check valve where such devices are present.

THE FINDINGS INCLUDE:

Observations made while conducting the facility tour on the morning of 01/08/14 revealed the automatic sprinkler system to be without pressure gauges.

B. Based on observations the facility failed to ensure that the automatic sprinkler system is inspected and maintained as required per code. NFPA #25, Section 2.2.4.1 requires gauges on wet pipe sprinkler systems to be inspected monthly to ensure that they are in good condition and that normal water supply pressure is being maintained. Section 2.3.3.1 requires alarm devices on wet pipe systems to be tested at least quarterly by opening the inspectors test connection. Section 9.3.4.1 requires each control valve to be operated annually through its full range and returned to its normal position. Section 9.3.5 requires the operating stems of outside screw and yoke valves (OS&Y) to be lubricated annually.

THE FINDINGS INCLUDE:

A review of the automatic sprinkler system records made available on the morning of 01/08/14 revealed the following:

1. The testing of the system's alarm valve by flowing water through the inspector's test connection was conducted once in 2013.

2. There is no documentation to substantiate the annual exercising and lubrication of the system's OS&Y valve.

This was acknowledged by facility staff and reviewed during the summary of survey findings.

A.Based on observations, the facility failed to ensure that an accurate municipal water supply pressure could be monitored. NFPA #13, Sections 4.7.7 requires a listed pressure gauge to be installed immediately below the control valve of each system.

THE FINDINGS INCLUDE:

Observations while touring the facility on the morning of 01/08/14 revealed that a pressure gauge is not installed where the municipal water supply pressure can accurately be monitored. There is no pressure gauge installed on the supply side of the back-flow preventer. Back-flow preventers allow water to pass through them in one direction locking the water pressure on the system (house) side of the device. This prevents the water pressure on the system side from going down when the pressure on the supply side goes down, such as during peak use periods during the day. A pressure gauge must be installed on the supply side of the back-flow preventers.


B. Based on observations the facility failed to ensure that the automatic sprinkler system is inspected and maintained as required per code. NFPA #25, Section 2.2.4.1 requires gauges on wet pipe sprinkler systems to be inspected monthly to ensure that they are in good condition and that normal water supply pressure is being maintained. Section 2.3.3.1 requires alarm devices on wet pipe systems to be tested at least quarterly by opening the inspectors test connection.

THE FINDINGS INCLUDE:

A review of the facilities records conducted on the morning of 01/08/14 revealed the following:

1. There is no documentation to substantiate the monthly reading/inspection of the systems pressure gauges.

2. The automatic sprinkler system is inspected on an annual basis. Quarterly testing of the system's alarm valves via the inspectors test connection is not being performed. Note: Supervisory switches and tamper switches are being tested by the facilities fire alarm contractor at the proper intervals.

This was acknowledged by facility staff and reviewed during the summary of survey findings.

Based on record review and confirmed by staff interview, the facility failed to ensure that the "Emergency Power Supply System" (EPSS) is maintained, tested, and inspected in accordance with NFPA 101 and NFPA 110. NFPA 101 LIFE SAFETY CODE (LSC), Section 7.9.3 requires written records of visual inspections and tests to be kept by the owner for inspection by the authority having jurisdiction. NFPA 110, Section 6.1.1 requires a routine maintenance and operational testing program of the "Emergency Power Supply System" (EPSS) that is based on the manufacturer's recommendations, instruction manuals, and the minimum requirements of this chapter and the authority having jurisdiction. Section 6.3.3 requires a written schedule for routine maintenance and operational testing of the EPSS to be established. Sections 6.4.1 & 6.4.2 require the EPSS's, including all appurtenant components, to be inspected weekly and to be exercised under load at least monthly for a minimum of 30 minutes.

THE FINDINGS INCLUDE:

Review of the documentation for the hospital maintenance, testing and inspection of the EPSS (generators) on 01/07/14 revealed that the facility is not conducting weekly generator inspections on the two generators as required by NFPA 110.

This was acknowledged by facility staff and reviewed during the summary of survey findings.

A. Based on observations and confirmed by staff, the facility failed to ensure that extension cords are used in accordance with NFPA 70. Article 305-3 permits temporary wiring to be used during periods of construction, remodeling, maintenance, and repair of buildings, during emergencies, and for a period not to exceed 90 days. Article 400-8 prohibits flexible cords from being use as a substitute for the fixed wiring of a structure. LSC 19.5.1

THE FINDINGS INCLUDE:

During the morning hours of 01/09/14, strip outlets were mounted on and plugged into wall receptacles on the first floor level "A East" wing corridor wall by patient room #104 and the "C West" corridor walls. These areas were being utilized as charging stations.

This was acknowledged by facility staff and reviewed during the summary of survey findings.


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B. Based on record review and confirmed by staff interview, the facility failed to assure that the operating rooms line isolation monitors are tested as required. NFPA 99 section 3-3.3.4.2 , line isolation monitor tests, states that the proper functioning of each line isolation monitor (LIM) circuit shall be ensured by the following:
(a) The LIM circuit shall be tested after installation, and prior to being placed in service, by successively grounding each line of the energized distribution system through a resistor of 200 V ohms, where V = measured line voltage. The visual and audible alarms [see 3-3.2.2.3(b)] shall be activated.
(b) The LIM circuit shall be tested at intervals of not more than 1 month by actuating the LIM test switch [see 3-3.2.2.3(f)]. For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months. Actuation of the test switch shall activate both visual and audible alarm indicators.
(c) After any repair or renovation to an electrical distribution system and at intervals of not more than 6 months, the LIM circuit shall be tested in accordance with paragraph (a) above and only when the circuit is not otherwise in use. For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months.

THE FINDINGS INCLUDE:

Documentation was not available to substantiate the required testing of the Line Isolation Monitors which are located outside each of the Operating Rooms. This was confirmed by interview with the Facility Director.

This was acknowledged by facility staff and reviewed during the summary of survey findings.

A. Based on observations, the facility failed to ensure that corridor walls are constructed with at least 1/2 hour fire resistance rating as required by Section 19.3.6.2.1.

THE FINDINGS INCLUDE:

Observations while touring the facility on 01/06-09/14 revealed that corridor walls were not constructed with at least 1/2 hour fire resistance rating. The following areas were noted:

1. The corridor sidelights and door to the President's Office is constructed with plain glass vision panels.
2. The Gift Shop has four 3' x 3' plain glass vision panels in addition to plain glass in the corridor doors to the Gift Shop.
3. The Consultation room is constructed with plain glass vision panels.
4. The ICU waiting room is constructed with plain glass vision panels.
5. The OR is constructed with non rated sliding glass doors.
6. The Mother Baby Sitting Unit is constructed with two 60" X 48" glass panels.

NOTE: The areas noted are in smoke compartments which are not protected throughout by an approved, supervised automatic sprinkler system.



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B. Based on observations and confirmed by staff, the facility failed to ensure corridor walls are constructed as required. Exception #6 to 19.3.6.1 states spaces other than patient sleeping rooms, treatment rooms, and hazardous areas shall be permitted to be open to the corridor and unlimited in area, provided that the following criteria are met:
(a) The space and the corridors onto which it opens, where located in the same smoke compartment, are protected by an electrically supervised automatic smoke detection system in accordance with 19.3.4.
(b) Each space is protected by automatic sprinklers, or the furnishings and furniture, in combination with all other combustibles within the area, are of such minimum quantity and arrangement that a fully developed fire is unlikely to occur.
(c) The space does not obstruct access to required exits.

THE FINDINGS INCLUDE:

Observations while touring the facility at approximately 10:00 A.M. on 01/06/14 revealed that the staff Breakroom door on the 4th floor of the Pediatric Unit has been removed. In addition to the missing door, the room is not equipped with a smoke detecting device.

This was acknowledged by facility staff and reviewed during the summary of survey findings.

A. Based on observations during a tour of the building in the afternoon on 01/06/14 and 01/07/14 and confirmed by staff, the facility failed to ensure that corridor doors are maintained as required.

THE FINDINGS INCLUDE:

1. The corridor door to the Med Room on the 1st floor "A" wing is provided with a louver which does not resist the passage of smoke in accordance with Section 19.3.6.3.


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2. The corridor door to the telecommunications closet on the 3rd floor "C" wing, adjacent to room # 325 B, is provided with a louver which is not in compliance with Section 19.3.6.3.

3. The following corridor doors to patient room are not smoke tight: #304, #306, #307, #312, #314, and #316. The facility had installed new corridor door leaf(s), a 36" wide active leaf and a 12' wide inactive leaf, at the above noted locations and failed to maintain a smoke tight seal at the door leaf(s) meeting edges. The space between the meeting edges ranged from 1/4' to 3/8". Facility engineering staff acknowledged the finding and had already installed astragals on several other corridor doors.

4. The corridor doors to patient rooms #324 and #309 have unsealed 1/8" gaps between the top of the door and the door frame header.

5. The corridor door to room #339 A failed to latch in the door frame during the morning hours of 01/06/14.


This was acknowledged by facility staff and reviewed during the summary of survey findings.

Based on observations, the facility failed to ensure that smoke barriers are constructed to resist the passage of smoke and are continuous to floor/roof slabs above suspended ceilings. Section 8.3.2 requires smoke barriers to be continuous from an outside wall to an outside wall, from a floor to a floor, or from a smoke barrier to a smoke barrier or a combination thereof. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces.

THE FINDINGS INCLUDE:

Observations while touring the facility on 01/07/14 revealed voids in smoke barrier walls. Specific areas are noted below, however, voids are not limited to these locations:

1. The smoke barrier wall contains voids around the wire penetrations above the suspended ceiling by the rear door of Interventional on the first floor.

2. The smoke barrier wall has a 12" X 10" hole which penetrates Stair "B" North above the suspended ceiling at the ground level.

3. The smoke barrier wall has a 2" x 4" void around the BX cable located above the suspended ceiling by the exit door by Radiology on the ground floor.

4. The smoke barrier wall has a void around the BX cable located above the suspended ceiling in the Interventional Radiology Clean Storage room on the ground floor.


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5. The smoke barrier contains voids around the data cable penetrations above the suspended ceiling by the Emergency Department room #16.


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6. The smoke barrier near the Lab Registration waiting room contains a 2" x 6" approximate sized penetration located above the suspended ceiling.

7. The smoke barrier located in the Emergency Department corridor across from the vending machine area contains several various sized penetrations above the suspended ceiling.

8. Observations while touring the facility at approximately 1:30 P.M.on 01/07/14 revealed that there are two 1 " holes in the smoke barrier wall, near the stairwell and the elevator, located in the back of the Vascular Lab in the basement level.

9. Observations while touring the facility at approximately 9:30 A.M. on 01/07/14 revealed that there is a 10" X 3" and two 2" x 2" holes around piping and an electrical junction box in the smoke barrier located between the Nursery and the Nurses station on 2 East.

10. Observations while touring the facility at approximately 11:00 A.M. on 01/07/14 revealed that there is a 2" X 2" hole around the duct in the smoke barrier wall to the right of a door identified as "staff only" to the Nursery and the Nurses station on 2 East.

11. Observations while touring the facility at approximately 11:30 A.M. on 01/07/14 revealed that there is no wall above the ceiling in the smoke barrier in 2 East near the staff bathroom, located next to the Nurses station.

This was acknowledged by facility staff and reviewed during the summary of survey findings.

Based on observations and confirmed by staff, the facility failed to ensure that hazardous areas are separated as required.

THE FINDINGS INCLUDE:

Observations while touring the facility at approximately 2:00 P.M. on 01/07/14 revealed that the non-sprinklered basement level mechanical space is not properly separated. According to the floor plans provided by the facility, the wall was constructed to have a 2-hour fire rating. When the wall was observed for compliance, approximately six penetrations were observed as not sealed with any fire rated material. These mainly consist of voids around various conduit and piping which penetrate the wall.
Note: Each of these penetrations were in hard to access locations above air handling equipment along the entire length of the room.

This was acknowledged by facility staff and reviewed during the summary of survey findings.


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Based on observations, the facility failed to ensure that exits are separated from other parts of the building as required. Section 7.1.3.2.1 requires an exit to be separated from other parts of the building; the separating construction shall meet the requirements of Section 8.2 and the following:
(a) The separation shall have not less than a 1-hour fire resistance rating where the exit connects three stories or less.
(b) The separation shall have not less than a 2-hour fire resistance rating where the exit connects four or more stories. The separation shall be constructed of an assembly of noncombustible or limited-combustible materials and shall be supported by construction having not less than a 2-hour fire resistance rating.
(c) Openings in the separation shall be protected by fire door assemblies equipped with door closer's complying with 7.2.1.8.
(d) Openings in exit enclosures shall be limited to those necessary for access to the enclosure from normally occupied spaces and corridors and for egress from the enclosure.

THE FINDINGS INCLUDE:

Observations while touring the facility on 01/07/14 revealed that:

1. The third floor level Stair "A West" enclosure is incomplete as the two hour wall, noted on the facility plans dated 10/09/13, has a 1" diameter unsealed penetration where a fire alarm/sprinkler testing module was removed and relocated. The penetration was left unsealed.

2. The ground floor level Stair "B East " stair discharge enclosure is incomplete as the two hour wall, noted on the facility plans dated 10/09/13, has unsealed penetrations above the in-lay ceiling tiles between the stair discharge and the Emergency Department.

3. Two, approximately 10" diameter, ducts penetrate the Stair "B East " stair discharge enclosure to the Emergency department and are neither equipped with access panels nor are they equipped with fire dampers.

This was acknowledged by facility staff and reviewed during the summary of survey findings.

A. Based on observations during the afternoon of 01/07/2014 and confirmed by staff, the facility failed to ensure that exit enclosures are constructed as required. Section 7.1.3.2.1 requires an exit to be separated from other parts of the building, the separating construction shall meet the requirements of Section 8.2 and the following.
(a) * The separation shall have not less than a 1-hour fire resistance rating where the exit connects three stories or less.
(b) * The separation shall have not less than a 2-hour fire resistance rating where the exit connects four or more stories. The separation shall be constructed of an assembly of noncombustible or limited-combustible materials and shall be supported by construction having not less than a 2-hour fire resistance rating.
Exception No. 1: In existing non-high-rise buildings, existing exit stair enclosures shall have not less than a 1-hour fire resistance rating.
Exception No. 2: In existing buildings protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, existing exit stair enclosures shall have not less than a 1-hour fire resistance rating.
Exception No. 3: One-hour enclosures in accordance with 28.2.2.1.2, 29.2.2.1.2, 30.2.2.1.2, and 31.2.2.1.2 shall be permitted as an alternative.
(c) Openings in the separation shall be protected by fire door assemblies equipped with door closers complying with 7.2.1.8.
(d) Openings in exit enclosures shall be limited to those necessary for access to the enclosure from normally occupied spaces and corridors and for egress from the enclosure.
Exception No. 1: Openings in exit passageways in covered mall buildings as provided in Chapters 36 and 37 shall be permitted.
Exception No. 2: In buildings of Type I or Type II construction, existing fire-protection rated doors shall be permitted to interstitial spaces provided that such space meets the following criteria:
(a) The space is used solely for distribution of pipes, ducts, and conduits.
(b) The space contains no storage.
(c) The space is separated from the exit enclosure in accordance with 8.2.3.
(e) Penetrations into and openings through an exit enclosure assembly shall be prohibited except for the following:
(1) Electrical conduit serving the stairway
(2) Required exit doors
(3) Ductwork and equipment necessary for independent stair pressurization
(4) Water or steam piping necessary for the heating or cooling of the exit enclosure
(5) Sprinkler piping
(6) Standpipes
Exception No. 1: Existing penetrations protected in accordance with 8.2.3.2.4 shall be permitted.
Exception No. 2: Penetrations for fire alarm circuits shall be permitted within enclosures where fire alarm circuits are installed in metal conduit and penetrations are protected in accordance with 8.2.3.2.4.
(f) Penetrations or communicating openings shall be prohibited between adjacent exit enclosures.

THE FINDINGS INCLUDE:

1. The entrance to the Telecom room, located on the ground floor of Stair "A" East, is from within the stair enclosure. As per (d) above, this door is not permitted to open into the enclosure.

2. The entrance to the Kitchen Storage closet, located on the ground floor of Stair "B" North, is from within the stair enclosure. As per (d) above, this door is not permitted to open into the enclosure.

3. The entrance to the Bio-Medical Storage, located on the basement level of Stair "B" West, is from within the exit enclosure. As per (d) above, this door is not permitted to open into the enclosure.

4. Observations while touring the facility at approximately 2:50 P.M. on 01/07/14 revealed that the basement level exit route of stairwell "B" is not constructed as required. The following items were observed regarding this stairwell/enclosure:

a. There is a mechanical room (non-occupied space) which has two doors that open into this exit enclosure route. As per (d) above, these doors are not permitted to open into the enclosure.
Note: In addition, this mechanical room is considered sprinklered but is adjacent to another non-sprinklered mechanical room. There are two large openings in the concrete wall between the spaces which are approximately 8' x 3' each in size. These opening have two large ducts approximately 6' x 2' in size passing through into the adjacent space. These ducts are not equipped with fire dampers, therefore the rooms are considered one large area which opens into the exit enclosure.

5. The basement level stairwell adjacent to the telephone room has an approximate 3" non-sealed hole above the stairwell door. This hole has an approximate 20/25 data line cables penetrating the wall at this point.


B. Based on observations, the facility failed to ensure that exit stairways are in accordance with Section 7.2.2.2.1(b) requiring existing stairways to be at least 44" in width, the minimum headroom to be 6 feet 8 inches, and the minimum width clear of al obstructions, except projections not more than 3 1/3 inches at or below handrail height on each side.

THE FINDINGS INCLUDE:

1. The width of Stair "C" at the 1st floor level reduces to 36 inches.

2. The headroom in Stair "C" at the 1st floor level is reduced to 6 foot 5 1/4 inch from the tread to the overhead.

3. The basement level of East Stair reduces to 37 inches in width.

4. The 1st floor level of Stair "C" East reduces to 35 1/2 inch in width due to the radiator which projects 9 inches off the exterior wall between the first and second floor levels. This radiator also reduces the head room to 5 feet 10 inches.

5. Stair "B" North reduces to 40 inches by the exit door.

These items are not in compliance with Section 7.2.2.2.1(b).

This was acknowledged by facility staff and reviewed during the summary of survey findings.



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Based on observation the facility failed to assure compliance with section 7-1.10.1 NFPA 101(Life Safety Code) states 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.


THE FINDINGS INCLUDE:

1. During the morning hours of 01/09/14, the stair "C East" enclosure between the first floor (discharge) level and the second floor level had the interior window protective bar unlocked and extended into the stair, rendering the stair impassible. A facility maintenance member immediately pushed the window guard into it's designed position.

2. During the survey on 01/06/14 and 01/09/14, the stair "A East" enclosure between the third floor level and the discharge level (level 1.5) , the facility utilized towels and a boom to maintain leaking water from a radiator. The towels and boom were removed on 01/09/14.

This was acknowledged by facility staff and reviewed during the summary of survey findings.

Based on observations, the facility failed to ensure that smoke detectors are properly installed. NFPA 72, Section 2-3.5.1 requires detectors in spaces served by air-handling systems, not to be located where airflow prevents operation of the detectors. Smoke detectors should be located at least 3 feet from air diffusers.

THE FINDINGS INCLUDE:

Observations while touring the facility on the morning and afternoon of 01/06/14 and 01/07/14 revealed smoke detectors arelocated within 3' of air diffusers in the following but not limited to locations.

1. In the first floor corridor near the stair B North door.
2. In the first floor corridor near the Day Surgery exit.
3. In the first floor soiled utility room located in the Day Surgery area.
4. In the first floor corridor by the stair B West door.

This was acknowledged by facility staff and reviewed during the summary of survey findings.

Based on observations, the facility failed to ensure that an accurate municipal water supply pressure could be monitored. NFPA #13, Sections 4.7.7 requires a listed pressure to be installed immediately below the control valve of each system. NFPA #25, Section 2.2.4.1 requires gauges on wet pipe sprinkler systems to be inspected monthly to ensure that they are in good condition and that normal water supply pressure is being maintained. Section 2.2.4.2 requires gauges on dry pipe sprinkler systems to be inspected weekly to ensure that normal air and water pressures are being maintained.

THE FINDINGS INCLUDE:

Observations while touring the facility on the morning of 01/08/14 revealed that a pressure gauge is not installed where the municipal water supply pressure can accurately be monitored. Pressure gauges are installed immediately below the control valves of each (wet & dry) system, however they are installed on the supply side of the back-flow preventer. Back-flow preventers allow water to pass through them in one direction locking the water pressure on the system (house) side of the device. This prevents the water pressure on the system side from going down when the pressure on the supply side goes down, such as during peak use periods during the day. A pressure gauge must be installed on the supply side of the back-flow preventers.

This was acknowledged by facility staff and reviewed during the summary of survey findings.

Based on observations, the facility failed to ensure that an accurate municipal water supply pressure could be monitored. NFPA #13, Sections 4.7.7 requires a listed pressure to be installed immediately below the control valve of each system. NFPA #25, Section 2.2.4.1 requires gauges on wet pipe sprinkler systems to be inspected monthly to ensure that they are in good condition and that normal water supply pressure is being maintained. Section 2.2.4.2 requires gauges on dry pipe sprinkler systems to be inspected weekly to ensure that normal air and water pressures are being maintained.

THE FINDINGS INCLUDE:

Observations while touring the facility on the morning of 01/08/14 revealed that a pressure gauge is not installed where the municipal water supply pressure can accurately be monitored. Pressure gauges are installed immediately below the control valves of each (wet & dry) system, however they are installed on the supply side of the back-flow preventer. Back-flow preventers allow water to pass through them in one direction locking the water pressure on the system (house) side of the device. This prevents the water pressure on the system side from going down when the pressure on the supply side goes down, such as during peak use periods during the day. A pressure gauge must be installed on the supply side of the back-flow preventers.

This was acknowledged by facility staff and reviewed during the summary of survey findings.

Based on record review, observations, and confirmed by staff interview, the facility failed to assure that the automatic sprinkler system is maintained, tested, and inspected as required by NFPA #25. NFPA #25, Sections 1.9 and 1.10 require system components to be inspected and tested in accordance with the intervals specified in the appropriate chapters. Section 9.4.1.2 and 9.4.2.1 requires alarm valves, and check valves and their associated strainers, filters, and restriction orifices to be inspected internally every 5 years.
NFPA 25, 1998 edition. Section 2-2.4.1 and 2-2.4.2 requires gauges on wet pipe sprinkler systems to be inspected monthly and dry pipe sprinkler system to be inspected weekly, to ensure that they are in good condition and that normal water supply pressure is being maintained.
NFPA #25. Section 2.3.2 requires pressure gauges to be replaced or tested every 5 years.

THE FINDINGS INCLUDE:

Record review on the morning of 01/07/14, and observations made on 01/08/14, while touring the hospital's sprinkler risers, revealed that the automatic sprinkler systems have the following deficiencies.

1. Conference Center Boiler Room sprinkler Main.
-No documented date for the 5 year inspection of the two sprinkler main gauges
-No documented date of the 5 year inspection for the internal inspection of the alarm valve.
2. Hood Building Fire Pump Room.
-No documented date for the 5 year inspection of the fire pump sprinkler gauges.
3. Kitchen Sprinkler Room Main.
-No documented date for the 5 year inspection of the sprinkler main gauge.
-No documented date of the 5 year inspection for the internal inspection of the alarm valve.

This was acknowledged by facility staff and reviewed during the summary of survey findings.

Based on record review, and confirmed by staff, the facility failed to ensure that the heating, ventilating, and air conditioning systems (HVAC) are maintained in accordance with NFPA 90A. NFPA 90A, Section 3.4.7 requires fusible links (where applicable) on fire dampers to be removed; all dampers to be operated to verify that they fully close; the latch, if provided, to be checked; and moving parts to be lubricated as necessary, at least every 4 years. Section 2.3.4.1 requires a service opening to 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. Section 2.3.4.2 requires service openings to be identified with letters having a minimum height of 1/2 in. to indicate the location of the fire protection device(S) within.


THE FINDINGS INCLUDE:

Review of the documentation for the maintenance, testing and inspection of the fire dampers on 01/07/14, revealed that the fire dampers were not tested as required. The vendor's report indicates that some dampers were "inaccessible", "no damper installed" or "no access panels." The facility has no plans to correct the identified deficiencies to be in compliance with NFPA 90A.

This was acknowledged by facility staff and reviewed during the summary of survey findings.

Based on observations, the facility failed to ensure that Utilities comply with the provisions of Section 9-1. Gas equipment shall be installed in accordance with NFPA #54, #90A, and per the manufacturers specifications. NFPA #54, Section 6.4.3 requires that provisions for makeup air be provided with a minimum free area of one square inch for each 1000 British Thermal Unit (Btu) per hour total input rating of the boiler installed. NOTE: A 100 square inch louvered opening provides approximately 75 square inches of free area. NFPA #90A, Section 2.3.11.1 prohibits using corridors as a supply air system to adjoining areas.
LSC 19-5.1, 18-5.1, & 9-1.1

THE FINDINGS INCLUDE:

At approximately 2:45 P.M. on 01/06/14 it was revealed that the laundry room has a gas fired commercial clothes dryer with a total of 165,000 Btu's. The room containing the dryer is not equipped with any make-up air provisions for combustion. As a result of this configuration, the corridor is being used as a plenum and supplying make-up air to the laundry room. The room is required to have minimum free area of 165 square inches of makeup air.

This was acknowledged by facility staff and reviewed during the summary of survey findings.

Based on observations during the building tour on the morning of 01/06/14, and confirmed by staff, the facility failed to ensure compliance with the restrictions of portable space heating devices. Section 9.7.8 states portable space-heating devices shall be prohibited in all health care occupancies.

THE FINDING INCLUDE:

Portable electric space heaters were observed in the following areas:
- in the Medical Records Department/Health Info Management Office,
- in the Medical Records Department Director/Manager's Office, and
- in patient room # 339 B.

Note: The devices in the Medical Records Department were not in use at the time of observation.

This was acknowledged by facility staff and reviewed during the summary of survey findings.


12268

Based on observations and confirmed by staff, the facility failed to ensure that linen chutes are properly maintained. NFPA 82 Standards for Incinerators and Waste and Linen Handling Systems and Equipment Section 3-2.5.2 states that automatic sprinklers installed in gravity chute service openings shall be recessed out of the chute area through which material travels.

THE FINDINGS INCLUDE:

On 01/06/14 and 01/07/14 a sprinkler pipe and sprinkler head were noted to be installed down the center line of the chute between the fourth and first floor levels.

This was acknowledged by facility staff and reviewed during the summary of survey findings.

Based on observation and confirmed by staff, the facility failed to ensure that smoke dampers were installed as required. LSC Section 8.3.5.1 requires an approved damper designed to resist the passage of smoke to be provided for each air transfer opening or duct penetration of a required smoke barrier. Section 8.3.5.2 requires smoke dampers in ducts penetrating smoke barriers to close upon detection of smoke by approved smoke detectors in accordance with NFPA 72.

THE FINDINGS INCLUDE:

During the morning hours of 01/08/14 while touring the facility, it was observed that the smoke barrier wall on the first floor has duct penetrations above the lay-in tile ceiling that are not equipped with smoke dampers. The following specific ducts are noted but not limited to the following;

- the two ducts which penetrate the first floor corridor wall into the Volunteer Office, and
- the one duct which penetrates the smoke barrier above the smoke barrier doors located in front of the Volunteer Office.

Note: The smoke compartments adjacent to each smoke barrier wall are not fully sprinklered to meet the exception to the code.

This was acknowledged by facility staff and reviewed during the summary of survey findings.

A. Based on record review, the facility failed to ensure that the 1000 gpm @105 psi horizontal electric automatic fire pump is maintained, tested, and inspected as required. LSC Sections 4.6.12.1 & 9.7.5 require automatic sprinkler systems to be continuously maintained in proper operating condition, tested and inspected in accordance with NFPA 25. NFPA #25, Sections 1.9 and 1.10 require system components to be inspected and tested in accordance with the intervals specified in the appropriate chapters. Section 5.3.3.1 requires an annual test of each pump assembly to be conducted under minimum, rated, and peak flows of the fire pump.

THE FINDINGS INCLUDE:

Documentation provided on 01/08/14 was not able to substantiate an annual flow test of the fire pump conducted in accordance with NFPA 25, Section 5.3.3.1.


B. Based on observations during a facility tour on 01/08/14, it was observed that the facility was not in compliance with Section 39.2.4.1. Section 39.2.4.1 requires the number of exits to be in accordance with Section 39.2.4.2. The requirements of 7.4.1.2 shall not apply. Section 39.2.4.2 requires:
Not less than two separate exits shall meet the following criteria:
(1)They shall be provided on every story.
(2)They shall be accessible from every part of every story and mezzanine.

THE FINDINGS INCLUDE:
The Ultrasound Suite, located on the first floor of the Russell Building, Suite 111, is only provided with one exit which is not in compliance with Section 39.2.4.2.


C. Based on observations during a facility tour on 01/08/14, it was observed that the facility is not in compliance with Section 7.1.3.2.. Section 7.1.3.2 Exception No. 2 states 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 which allows existing buildings protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, to allow an existing exit stair enclosures to have not less than a 1-hour fire resistance rating.

THE FINDINGS INCLUDE:The facility is not in compliance with Section 7.1.3.2 due to the 30 minute rated doors on each of the levels to the two exit stairs.


D. Based on observations during a facility tour on 01/08/14, it was observed that the facility is not in compliance with Section 7.1.3.2.3. which requires an exit enclosure to 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.
THE FINDINGS INCLUDE:
The facility is not in compliance with Section 7.1.3.2.3 due to the storage of carpet, boxes of filters, and a metal storage cabinet stored on the ground floor landing of the stair by the Occupational Therapy and Physical Therapy Suite.


This was acknowledged by facility staff and reviewed during the summary of survey findings.



31165

A. Based on record review and confirmed by staff, it was revealed that the facility failed to ensure compliance with NFPA 101. Section 4.6.12.1 states 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 continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction. NFPA 72 (National Fire Alarm Code). Section 7-1.2 states the owner or the owner's designated representative shall be responsible for inspection, testing, and maintenance of the system and alterations or additions to this system. The delegation of responsibility shall be in writing, with a copy of such delegation provided to the authority having jurisdiction upon request. Table 7-3.2 #20 states Off-Premises Transmission Equipment shall be tested on a quarterly basis. Section 7.3.2 and Table 7.3.2 require systems with sealed batteries to have the battery charger tested annually, replace the battery every 4 years, to conduct a 30 minute battery discharge test annually, and to conduct a load voltage test semi-annually.

THE FINDINGS INCLUDE:

During the morning hours of 01/08/14 while performing the record review, it was observed that the facility does not maintain/inspect the fire alarm system as required. The only fire alarm vendor inspection report available for review was dated 12/28/12. As a result of the annual testing, the following items were noted as being deficient:

1. The off-premise testing is not performed quarterly as required.

2. The fire alarm batteries are not dated or documented as being tested as required. There are no line items pertaining to the testing of batteries for either annual or semi-annual tests.


B. NFPA 25, Section 2-3.3 requires waterflow alarm devices including, but not limited to, mechanical water motor gongs, vane-type waterflow devices, and pressure switches that provide audible or visual signals to be tested quarterly. Testing the waterflow alarms on wet pipe systems shall be accomplished by opening the inspector's test connection which simulates activation of a sprinkler head. Section 2-2.4.1 requires gauges on wet pipe sprinkler systems to be inspected monthly to ensure that they are in good condition and that normal water supply pressure is being maintained. Section 9-4.1.2 requires alarm valves and their associated strainers, filters, and restriction orifices to be inspected internally every 5 years unless tests indicate a greater frequency is necessary.

THE FINDINGS INCLUDE:

During the morning hours of 01/08/14 while performing the record review, it was observed that the facility does not maintain/inspect the sprinkler system as required. The only sprinkler vendor inspection report available for review was dated 12/27/12. As a result of the annual testing, the following items were noted as being deficient:

1. The quarterly flow test utilizing the Inspector's Test Valve (ITV) is not performed as required.

2. The facility does not perform monthly pressure readings of the sprinkler system as required.

3. There are no records to substantiate that the 5-year internal check of the main alarm valve was performed.

This was acknowledged by facility staff and reviewed during the summary of survey findings.

A. Based on record review and confirmed by staff, it was revealed that the facility failed to ensure compliance with NFPA 101. Section 4.6.12.1 states 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 continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction. NFPA 72 (National Fire Alarm Code). Section 7-1.2 states the owner or the owner's designated representative shall be responsible for inspection, testing, and maintenance of the system and alterations or additions to this system. The delegation of responsibility shall be in writing, with a copy of such delegation provided to the authority having jurisdiction upon request. Table 7-3.2 #20 states Off-Premises Transmission Equipment shall be tested on a quarterly basis. Section 7.3.2 and Table 7.3.2 require systems with sealed batteries to have the battery charger tested annually, replace the battery every 4 years, to conduct a 30 minute battery discharge test annually, and to conduct a load voltage test semi-annually.

THE FINDINGS INCLUDE:

During the morning hours of 01/08/14 while performing the record review, it was observed that the facility does not maintain/inspect the fire alarm system as required. The only fire alarm vendor inspection report available for review was dated 12/28/12. As a result of the annual testing, the following items were noted as being deficient:

1. The off-premise testing is not performed quarterly as required.

2. The fire alarm batteries are not dated or documented as being tested as required. There are no line items pertaining to the testing of batteries for either annual or semi-annual tests.


B. NFPA 25 section 2-3.3 requires waterflow alarm devices including, but not limited to, mechanical water motor gongs, vane-type waterflow devices, and pressure switches that provide audible or visual signals to be tested quarterly. Testing the waterflow alarms on wet pipe systems shall be accomplished by opening the inspector's test connection which simulates activation of a sprinkler head. Section 2-2.4.1 requires gauges on wet pipe sprinkler systems to be inspected monthly to ensure that they are in good condition and that normal water supply pressure is being maintained. Section 9-4.1.2 requires alarm valves and their associated strainers, filters, and restriction orifices to be inspected internally every 5 years unless tests indicate a greater frequency is necessary.

THE FINDINGS INCLUDE:

During the morning hours of 01/08/14 while performing the record review, it was observed that the facility does not maintain/inspect the sprinkler system as required. The only sprinkler vendor inspection report available for review was dated 12/27/12. As a result of the annual testing, the following items were noted as being deficient:

1. The quarterly flow test utilizing the Inspector's Test Valve (ITV) is not performed as required.

2. The facility does not perform monthly pressure readings of the sprinkler system as required.

3. There are no records to substantiate that the 5-year internal check of the main alarm valve was performed.


C. NFPA 110, Section 6.1.1 requires a routine maintenance and operational testing program of the "Emergency Power Supply System" (EPSS) that is based on the manufacturer's recommendations, instruction manuals, and the minimum requirements of this chapter and the authority having jurisdiction. Section 6.3.3 requires a written schedule for routine maintenance and operational testing of the EPSS to be established. Sections 6.4.1 & 6.4.2 require the EPSS's, including all appurtenant components, to be inspected weekly and to be exercised under load at least monthly for a minimum of 30 minutes.

THE FINDINGS INCLUDE:

Review of the documentation for the hospital maintenance, testing and inspection of the EPSS (generators) on 01/07/14, revealed that the facility was not conducting weekly generator inspections on the two generators as required.


This was acknowledged by facility staff and reviewed during the summary of survey findings.

A. Based on record review, and confirmed by staff, the facility failed to ensure that the heating, ventilating, and air conditioning systems (HVAC) are maintained in accordance with NFPA 90A. NFPA 90A, Section 3.4.7 requires fusible links (where applicable) on fire dampers to be removed; all dampers to be operated to verify that they fully close; the latch, if provided, to be checked; and moving parts to be lubricated as necessary, at least every 4 years.
Section 2.3.4.1 requires a service opening to 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. Section 2.3.4.2 requires service openings to be identified with letters having a minimum height of 1/2 in. to indicate the location of the fire protection device(S) within.

THE FINDINGS INCLUDE:

Review of the documentation for the maintenance, testing and inspection of the fire dampers on 01/07/14, revealed that the fire dampers were not tested as required. The vendor's report indicates that some dampers were "inaccessible", "no damper installed" or "no access panels." The facility has no plans to correct the identified deficiencies to be in compliance with NFPA 90A.


B. Based on record review and confirmed by staff interview, the facility failed to ensure that the "Emergency Power Supply System" (EPSS) is maintained, tested, and inspected in accordance with NFPA 101 and NFPA 110.
NFPA 101 LIFE SAFETY CODE" (LSC), Section 7.9.3 requires written records of visual inspections and tests to be kept by the owner for inspection by the authority having jurisdiction. NFPA 110, Section 6.1.1 requires a routine maintenance and operational testing program of the "Emergency Power Supply System" (EPSS) that is based on the manufacturer's recommendations, instruction manuals, and the minimum requirements of this chapter and the authority having jurisdiction. Section 6.3.3 requires a written schedule for routine maintenance and operational testing of the EPSS to be established. Sections 6.4.1 & 6.4.2 require the EPSS's, including all appurtenant components, to be inspected weekly and to be exercised under load at least monthly for a minimum of 30 minutes.

THE FINDINGS INCLUDE:

Review of the documentation for the hospital maintenance, testing and inspection of the EPSS (generator) on 01/08/14, revealed that the facility was not conducting weekly generator inspections on the generator as required.


C. Based on observations and confirmed by staff, the facility failed to ensure that smoke barrier doors have at least a 20 minute fire protection rating or are at least 1 3/4 inch thick solid bonded wood core or the equivalent in accordance with Section 21.3.7.1.

THE FINDINGS INCLUDE:

During the morning hours of 01/08/14 while touring the facility, it was observed that the smoke barrier door, between the Admitting and Pre-Operation areas, is a non-labeled, non-rated door.

This was acknowledged by facility staff and reviewed during the summary of survey findings.

A. Based on observations, the facility failed to ensure that the automatic sprinkler system is installed per code. NFPA #13, Section 4-1.1 requires a listed pressure gauge conforming to 5-15.3.2 shall be installed in each system riser. Pressure gauges shall be installed above and below each alarm check valve where such devices are present.

THE FINDINGS INCLUDE:

Observations made while conducting the facility tour on the morning of 01/08/14 revealed the automatic sprinkler system to be without pressure gauges.

B. Based on observations the facility failed to ensure that the automatic sprinkler system is inspected and maintained as required per code. NFPA #25, Section 2.2.4.1 requires gauges on wet pipe sprinkler systems to be inspected monthly to ensure that they are in good condition and that normal water supply pressure is being maintained. Section 2.3.3.1 requires alarm devices on wet pipe systems to be tested at least quarterly by opening the inspectors test connection. Section 9.3.4.1 requires each control valve to be operated annually through its full range and returned to its normal position. Section 9.3.5 requires the operating stems of outside screw and yoke valves (OS&Y) to be lubricated annually.

THE FINDINGS INCLUDE:

A review of the automatic sprinkler system records made available on the morning of 01/08/14 revealed the following:

1. The testing of the system's alarm valve by flowing water through the inspector's test connection was conducted once in 2013.

2. There is no documentation to substantiate the annual exercising and lubrication of the system's OS&Y valve.

This was acknowledged by facility staff and reviewed during the summary of survey findings.

A.Based on observations, the facility failed to ensure that an accurate municipal water supply pressure could be monitored. NFPA #13, Sections 4.7.7 requires a listed pressure gauge to be installed immediately below the control valve of each system.

THE FINDINGS INCLUDE:

Observations while touring the facility on the morning of 01/08/14 revealed that a pressure gauge is not installed where the municipal water supply pressure can accurately be monitored. There is no pressure gauge installed on the supply side of the back-flow preventer. Back-flow preventers allow water to pass through them in one direction locking the water pressure on the system (house) side of the device. This prevents the water pressure on the system side from going down when the pressure on the supply side goes down, such as during peak use periods during the day. A pressure gauge must be installed on the supply side of the back-flow preventers.


B. Based on observations the facility failed to ensure that the automatic sprinkler system is inspected and maintained as required per code. NFPA #25, Section 2.2.4.1 requires gauges on wet pipe sprinkler systems to be inspected monthly to ensure that they are in good condition and that normal water supply pressure is being maintained. Section 2.3.3.1 requires alarm devices on wet pipe systems to be tested at least quarterly by opening the inspectors test connection.

THE FINDINGS INCLUDE:

A review of the facilities records conducted on the morning of 01/08/14 revealed the following:

1. There is no documentation to substantiate the monthly reading/inspection of the systems pressure gauges.

2. The automatic sprinkler system is inspected on an annual basis. Quarterly testing of the system's alarm valves via the inspectors test connection is not being performed. Note: Supervisory switches and tamper switches are being tested by the facilities fire alarm contractor at the proper intervals.

This was acknowledged by facility staff and reviewed during the summary of survey findings.

Based on record review and confirmed by staff interview, the facility failed to ensure that the "Emergency Power Supply System" (EPSS) is maintained, tested, and inspected in accordance with NFPA 101 and NFPA 110. NFPA 101 LIFE SAFETY CODE (LSC), Section 7.9.3 requires written records of visual inspections and tests to be kept by the owner for inspection by the authority having jurisdiction. NFPA 110, Section 6.1.1 requires a routine maintenance and operational testing program of the "Emergency Power Supply System" (EPSS) that is based on the manufacturer's recommendations, instruction manuals, and the minimum requirements of this chapter and the authority having jurisdiction. Section 6.3.3 requires a written schedule for routine maintenance and operational testing of the EPSS to be established. Sections 6.4.1 & 6.4.2 require the EPSS's, including all appurtenant components, to be inspected weekly and to be exercised under load at least monthly for a minimum of 30 minutes.

THE FINDINGS INCLUDE:

Review of the documentation for the hospital maintenance, testing and inspection of the EPSS (generators) on 01/07/14 revealed that the facility is not conducting weekly generator inspections on the two generators as required by NFPA 110.

This was acknowledged by facility staff and reviewed during the summary of survey findings.

A. Based on observations and confirmed by staff, the facility failed to ensure that extension cords are used in accordance with NFPA 70. Article 305-3 permits temporary wiring to be used during periods of construction, remodeling, maintenance, and repair of buildings, during emergencies, and for a period not to exceed 90 days. Article 400-8 prohibits flexible cords from being use as a substitute for the fixed wiring of a structure. LSC 19.5.1

THE FINDINGS INCLUDE:

During the morning hours of 01/09/14, strip outlets were mounted on and plugged into wall receptacles on the first floor level "A East" wing corridor wall by patient room #104 and the "C West" corridor walls. These areas were being utilized as charging stations.

This was acknowledged by facility staff and reviewed during the summary of survey findings.


17078

B. Based on record review and confirmed by staff interview, the facility failed to assure that the operating rooms line isolation monitors are tested as required. NFPA 99 section 3-3.3.4.2 , line isolation monitor tests, states that the proper functioning of each line isolation monitor (LIM) circuit shall be ensured by the following:
(a) The LIM circuit shall be tested after installation, and prior to being placed in service, by successively grounding each line of the energized distribution system through a resistor of 200 V ohms, where V = measured line voltage. The visual and audible alarms [see 3-3.2.2.3(b)] shall be activated.
(b) The LIM circuit shall be tested at intervals of not more than 1 month by actuating the LIM test switch [see 3-3.2.2.3(f)]. For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months. Actuation of the test switch shall activate both visual and audible alarm indicators.
(c) After any repair or renovation to an electrical distribution system and at intervals of not more than 6 months, the LIM circuit shall be tested in accordance with paragraph (a) above and only when the circuit is not otherwise in use. For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months.

THE FINDINGS INCLUDE:

Documentation was not available to substantiate the required testing of the Line Isolation Monitors which are located outside each of the Operating Rooms. This was confirmed by interview with the Facility Director.

This was acknowledged by facility staff and reviewed during the summary of survey findings.