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Based on the observation during the survey on 06/24/2015, the facility failed to maintain the construction type, V(111). Findings include:

The facility failed to maintain the 1 hour ceiling rating in the Outside Mechanical Room #129, the surveyor observed unsealed ceiling penetrations around equipment, wires, pipes and HVAC duct.

This deficiency impacted 1 of 5 smoke compartments.
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Review of 2000 NFPA 101, 18.1.6.2 Health care occupancies shall be limited to the types of building construction shown in Table 18.1.6.2. (See 8.2.1.)
Table 18.1.6.2 Construction Type Limitations
Construction Stories
Type
1 2 3 4 or
More
I(443) X X X X
I(332) X X X X
II(222) X X X X
II(111) X X X NP
II(000) X NP NP NP
III(211) X NP NP NP
III(200) NP NP NP NP
IV(2HH) X NP NP NP
V(111) X NP NP NP
V(000) NP NP NP NP
X: Permitted type of construction.
NP: Not permitted.

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Based on the observation during the survey on 06/24/2015, the facility failed to maintain the smoke barriers to resist the passage of smoke and provide a minimum 1 hour fire resistance rating. Findings include:

The facility failed to maintain the following smoke barriers:
1. The smoke barrier at room 501 was observed with 3 conduits with a pipe in each conduit, the ends of the conduits were not sealed.
2. The smoke barrier on "Intake Hallway" to "Involuntary" was observed with the following unsealed penetrations located in the smoke barrier wall to the right of the the smoke doors:
a. An unsealed penetration
b. Unsealed penetrations at the top of the wood joists

This deficiency impacted 2 of 5 smoke compartments.
_______________

Review of 2000 NFPA 101, 8.2.4.4.1 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through smoke partitions shall be protected as follows:
(1) The space between the penetrating item and the smoke partition shall meet one of the following conditions:
a. It shall be filled with a material that is capable of limiting the transfer of smoke.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke partition, the sleeve shall be solidly set in the smoke partition, and the space between the item and the sleeve shall meet one of the following conditions:a. It shall be filled with a material that is capable of limiting the transfer of smoke.b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibrations into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the smoke partitions.
b. It shall be made by an approved device that is designed for the specific purpose.

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Based on the review of facility documentation on 06/24/2015, the facility failed to provide proof of participation of all on duty staff at the time of the fire drill(s). Findings include:
Per documentation provided by the maintenance staff, facility failed to illustrate that all facility personnel are familiar with the signals and emergency action required under varied conditions during fire drills. Per interview with facility maintenance staff, staff confirmed that documentation provided of fire drill participation did not include signatures of all staff in the facility at the time of the fire drills.

This deficiency impacted 5 of 5 smoke compartments.
_______________

Review of 2000 NFPA 101, 4.7.2* Emergency egress and relocation drills, where required by Chapters 11 through 42 or the authority having jurisdiction, shall be held with sufficient frequency to familiarize occupants with the drill procedure and to establish conduct of the drill as a matter of routine. Drills shall include suitable procedures to ensure that all persons subject to the drill participate.

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Based on the observation during the survey on 06/24/2015, the facility failed to maintain the automatic kitchen hood extinguishing system. Findings include:

Per documentation and interview, the facility failed to provide monthly inspections of the automatic kitchen hood extinguishing system.

This deficiency impacted 1 of 5 smoke compartments.
_______________

Review of 1998 NFPA 17A, 5-2.1 Inspection shall be conducted on a monthly basis in accordance with the manufacturer ' s listed installation and maintenance manual or the owner ' s manual. As a minimum, this " quick check " or inspection shall include verification of the following:
(a) The extinguishing system is in its proper location.
(b) The manual actuators are unobstructed.
(c) The tamper indicators and seals are intact.
(d) The maintenance tag or certificate is in place.
(e) No obvious physical damage or condition exists that might prevent operation.
(f) The pressure gauge(s), if provided, is in operable range.
(g) The nozzle blowoff caps are intact and undamaged.
(h) The hood, duct, and protected cooking appliances have not been replaced, modified, or relocated.
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Based on the observation during the survey on 06/24/2015, the facility failed to provide a service opening at the smoke dampers. Findings include:

The facility failed to provide service openings for the 2 smoke dampers in the smoke barrier located at room 501.

This deficiency impacted 2 of 5 smoke compartments.
_______________

Review of 1999 NFPA 90A, 2-3.4.1 A service opening shall be provided in air ducts adjacent to each fire damper, smoke damper, and smoke detector. The opening shall be large enough to permit maintenance and resetting of the device.
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Based on the observation during the survey on 06/24/2015, the facility failed to maintain the electrical wiring and equipment. Findings include:

The following was observed:
1. A microwave was observed plugged into a power strip (extension cord) in the Maintenance Shop.
2. A refrigerator was observed plugged into a power strip (extension cord) in room 813.
3. The Main Electrical Room had storage in front of all the electrical panels - no working space.

This deficiency impacted 3 of 5 smoke compartments.
_______________

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


Review of 1999 NFPA 70, 110-26. Spaces About Electrical Equipment

Table 110-26(a). Working Spaces

Minimum Clear Distance (ft)
Nominal Voltage to Ground Condition 1 Condition 2 Condition 3
0-150 3 3 3
151-600 3 31/2 4

.
Based on the observation during the survey on 06/24/2015, the facility failed to maintain the construction type, V(111). Findings include:

The facility failed to maintain the 1 hour ceiling rating in the Outside Mechanical Room #129, the surveyor observed unsealed ceiling penetrations around equipment, wires, pipes and HVAC duct.

This deficiency impacted 1 of 5 smoke compartments.
_______________

Review of 2000 NFPA 101, 18.1.6.2 Health care occupancies shall be limited to the types of building construction shown in Table 18.1.6.2. (See 8.2.1.)
Table 18.1.6.2 Construction Type Limitations
Construction Stories
Type
1 2 3 4 or
More
I(443) X X X X
I(332) X X X X
II(222) X X X X
II(111) X X X NP
II(000) X NP NP NP
III(211) X NP NP NP
III(200) NP NP NP NP
IV(2HH) X NP NP NP
V(111) X NP NP NP
V(000) NP NP NP NP
X: Permitted type of construction.
NP: Not permitted.

.

.
Based on the observation during the survey on 06/24/2015, the facility failed to maintain the smoke barriers to resist the passage of smoke and provide a minimum 1 hour fire resistance rating. Findings include:

The facility failed to maintain the following smoke barriers:
1. The smoke barrier at room 501 was observed with 3 conduits with a pipe in each conduit, the ends of the conduits were not sealed.
2. The smoke barrier on "Intake Hallway" to "Involuntary" was observed with the following unsealed penetrations located in the smoke barrier wall to the right of the the smoke doors:
a. An unsealed penetration
b. Unsealed penetrations at the top of the wood joists

This deficiency impacted 2 of 5 smoke compartments.
_______________

Review of 2000 NFPA 101, 8.2.4.4.1 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through smoke partitions shall be protected as follows:
(1) The space between the penetrating item and the smoke partition shall meet one of the following conditions:
a. It shall be filled with a material that is capable of limiting the transfer of smoke.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke partition, the sleeve shall be solidly set in the smoke partition, and the space between the item and the sleeve shall meet one of the following conditions:a. It shall be filled with a material that is capable of limiting the transfer of smoke.b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibrations into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the smoke partitions.
b. It shall be made by an approved device that is designed for the specific purpose.

.

.
Based on the review of facility documentation on 06/24/2015, the facility failed to provide proof of participation of all on duty staff at the time of the fire drill(s). Findings include:
Per documentation provided by the maintenance staff, facility failed to illustrate that all facility personnel are familiar with the signals and emergency action required under varied conditions during fire drills. Per interview with facility maintenance staff, staff confirmed that documentation provided of fire drill participation did not include signatures of all staff in the facility at the time of the fire drills.

This deficiency impacted 5 of 5 smoke compartments.
_______________

Review of 2000 NFPA 101, 4.7.2* Emergency egress and relocation drills, where required by Chapters 11 through 42 or the authority having jurisdiction, shall be held with sufficient frequency to familiarize occupants with the drill procedure and to establish conduct of the drill as a matter of routine. Drills shall include suitable procedures to ensure that all persons subject to the drill participate.

.

.
Based on the observation during the survey on 06/24/2015, the facility failed to maintain the automatic kitchen hood extinguishing system. Findings include:

Per documentation and interview, the facility failed to provide monthly inspections of the automatic kitchen hood extinguishing system.

This deficiency impacted 1 of 5 smoke compartments.
_______________

Review of 1998 NFPA 17A, 5-2.1 Inspection shall be conducted on a monthly basis in accordance with the manufacturer ' s listed installation and maintenance manual or the owner ' s manual. As a minimum, this " quick check " or inspection shall include verification of the following:
(a) The extinguishing system is in its proper location.
(b) The manual actuators are unobstructed.
(c) The tamper indicators and seals are intact.
(d) The maintenance tag or certificate is in place.
(e) No obvious physical damage or condition exists that might prevent operation.
(f) The pressure gauge(s), if provided, is in operable range.
(g) The nozzle blowoff caps are intact and undamaged.
(h) The hood, duct, and protected cooking appliances have not been replaced, modified, or relocated.
.

.
Based on the observation during the survey on 06/24/2015, the facility failed to provide a service opening at the smoke dampers. Findings include:

The facility failed to provide service openings for the 2 smoke dampers in the smoke barrier located at room 501.

This deficiency impacted 2 of 5 smoke compartments.
_______________

Review of 1999 NFPA 90A, 2-3.4.1 A service opening shall be provided in air ducts adjacent to each fire damper, smoke damper, and smoke detector. The opening shall be large enough to permit maintenance and resetting of the device.
.

.
Based on the observation during the survey on 06/24/2015, the facility failed to maintain the electrical wiring and equipment. Findings include:

The following was observed:
1. A microwave was observed plugged into a power strip (extension cord) in the Maintenance Shop.
2. A refrigerator was observed plugged into a power strip (extension cord) in room 813.
3. The Main Electrical Room had storage in front of all the electrical panels - no working space.

This deficiency impacted 3 of 5 smoke compartments.
_______________

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


Review of 1999 NFPA 70, 110-26. Spaces About Electrical Equipment

Table 110-26(a). Working Spaces

Minimum Clear Distance (ft)
Nominal Voltage to Ground Condition 1 Condition 2 Condition 3
0-150 3 3 3
151-600 3 31/2 4